The Best of What Was There

Development Section: Me

Most music therapy students enter the profession because they love music and want to help people. I became a music therapist because I wanted to know everything.

I started violin lessons, at age 6, in one of the first Suzuki programs started in the United States. While my mother did not learn to play first, as the Suzuki philosophy directs, there was always music in my home. My younger brother and I grew up with wonderful jazz and classical recordings, jazz and classical music radio stations, and my mother’s piano playing.

My parents loved music and were quite knowledgeable about it, but it was not the center of their lives. They had both been English majors in college; my father worked in the printing/publishing business and my mother was a tireless volunteer, working through my growing up years with foster children, the frail elderly, girl scouts, and our church. Later, she worked as a volunteer coordinator in public radio and with a non-denominational church consulting service. Both my parents were voracious readers and our dinner table was a place of discussion and debate. As my brother and I got older, there was rarely a dinner when a newspaper article wasn’t read, or a reference book consulted to provide information or settle an argument. Politics, current events, books, movies and music, history and geography, moral and ethical questions…all were subjects we covered. One evening, when my brother and I were in high school, a co-worker of my mother’s came to dinner. Prior to her arrival, my mother told us that Anne had asked if “her” dinner would be as intellectually stimulating as ours usually were. This was an irresistible cue for my brother and me. Five minutes into the dinner that night, he and I launched into a stimulating (researched and rehearsed) debate on the state of the Soviet state and the impact of …

Laughter was abundant in our house as well. I grew up listening to recordings of Stan Freberg, Mike Nichols and Elaine May. My father was notorious for his shaggy dog stories. We played games; from charades to Twister, Authors (a literary “Go Fish”) to craps.

My brother and I attended an elementary school that continued the eclectic atmostphere of our home. My third grade class studied Japan and made rice paper covers for our reports, studied the pioneers and spent a day in the school’s “Pioneer Room,” a basement space converted into the inside of a log cabin, trundle beds, working fireplace, and all. We incubated eggs, made grape jelly for paraffin-covered jars, worked on a full-size loom one by one and on our own tiny looms, making small rugs. I loved it, and wanted more. In those days, we could walk “uptown” unsupervised and I loved to go to the library. As soon as I exhausted the children’s section, I moved across the hall and more than a few times, I was late home because I had lost myself in a windowseat, reading PG Wodehouse or an Agatha Christie mystery.

And then there was the violin. When I was in second grade, I began taking extra lessons with the local teacher; when I reached junior high school, I was one of the best violinists in a Suzuki program that numbered 200. In high school, I got up before breakfast to practice, played in the orchestra at school (where we also had a terrific jazz band), came home and practiced again, and worked some evenings as the receptionist at a local private music school. Saturdays I was at the same school studying theory, solfege (“do-re-mi” singing), and chamber music. In the summers I attended “music camps” and music festivals where students from around the country came together and played early morning till late night.

Those were great times. It was fun and rowdy and creative. My friends were musicians and we reveled in our abilities and what we could do with them. Everything we played we were discovering for the first time – the Beethoven quartets, Dvorak symphonies, Mozart violin concerti.

When it came time to go to college, I remember that my mother and I read, briefly, about music therapy; I had, through a couple of volunteer experiences, developed an interest in working with children with disabilities. There was never any serious consideration of this option, however – music therapy programs were scarce, and all my energies were devoted to auditions with schools of music. In the end, I also played for Dorothy DeLay , one of the two most prominent violin teachers in the country at the time, and was accepted into a small studio of 6 students she would teach at the University of Cincinnati College-Conservatory of Music (she commuted to this appointment from The Julliard School, in New York City).

Cincinnati was an intense, and mostly thrilling, musical experience. Theory, history, analysis, orchestration, Baroque ensemble, quartets, quintets, orchestra, private lessons, and individual practice for at least 4 hours a day. There were other classes required by the university (English, some sort of math) but I don’t recall them, nor do I think anyone at the conservatory cared whether or not I attended them. Everything was about the music, and preparing us for a professional career. Among the violinists, the six of us studying with Miss DeLay were expected, without question, to go on to performing careers. Each of us had already soloed with a professional orchestra, having won some youth contest or another, and we soloed again with the conservatory orchestras. We all thought we would be, if not soloists, then chamber or orchestral musicians. Everyone else worked for similar goals. At the end of each year, we would play in front of the string faculty (known as “a jury”). When we finished, we all prayed to hear the first of the two possible responses:

“Thank you. See you next year.”

or

“Have you considered music education?”

***

This was the atmosphere in which I began to realize that I didn’t want to be a full-time violinist. After 14 years on that path, it was a disconcerting discovery, to say the least. I had almost no one with whom to talk about my doubts and my pride kept me focused on the usual auditions for seating placement in the orchestra, and on the repertoire for my other ensembles and lessons – so no one suspected that I was uncertain about my future.

One day, on my way to class, I ran into the wife of the cellist in our school’s resident chamber ensemble, The LaSalle Quartet. Although I can’t remember it, we must have spoken about music therapy at some time because she said, “I’m going over to Mt. St. Joseph College to take a music therapy class next semester. Do you want to take it with me?”

So, in the spring of my junior year, I took “Introduction to Music Therapy” – and was hooked. I shared my enthusiasm with everyone, and got reaction ranging from disinterest (“What’s that? Oh. Ok, see you at rehearsal”) to concern (“it isn’t taking time away from practicing, is it?”) to criticism (“you’re not thinking about that as a career, are you?”). The exception was Miss DeLay. It turned out that she had once considered a career in medicine, specifically psychiatry, and she was fascinated by all I learned in that first class. Tentatively, I told her that I was considering pursuing a master’s degree in music therapy and that I was increasingly sure I didn’t want to play the violin full-time. With all the competition for spots in her studio, it would have been perfectly acceptable for her to wish me well and send me on my way. Instead, she celebrated my plans and helped me create a transition. Because she knew how much I loved chamber music, she arranged for me to spend the summer between my junior and senior years at The Quartet Program, a gathering of 48 string players (12 quartets) in Troy, New York, under the direction of Charles Castleman from the Eastman School of Music. And because I told her that my planned senior year of classes (many, like anatomy and physiology, in preparation for music therapy) would be busy, she helped me plan my senior recital for the fall, and made sure that I truly loved the music I would be playing.

Miss DeLay was a godsend, one of a handful of people who wished me well and helped me along. In 2002, when she died, the longer obituaries briefly mentioned that she once considered medical school; but all described the woman who was interested in and nurtured the person behind the violin.

Music Therapy Stories: John

John was playing the chords to the Doxology for the sixth time when Brian, the transportation aide, knocked on the door of the music therapy office. “Time for physical therapy, Mr. Thomas,” Brian said, poking his head around the door. When John didn’t respond, I put my hand over his, gently, and made eye contact. “Time to go,” I said, while gesturing to my watch and then to the door. I stood up and John slowly pulled his hands from the electronic keyboard. I maneuvered his wheelchair in my small office so that we could open the door completely and then bent down to shake John’s hand and say goodbye. As I took his right hand in mine, he reached up with his left and covered my hand, squeezing it and looking intently at me, tears forming in his eyes. I paused, seeing that he wanted to tell me something.

“My leaf is in your hands,” he said.

***

During the last three years that I worked in physical rehabilitation medicine, my music therapy office was in the same wing as the speech-language pathologists. I think I had moved there from the therapeutic recreation area due to space considerations, but in many ways it made sense from a treatment standpoint; most of the referrals I received were for patients who had difficulties with communication.

I worked in an “acute” rehabilitation facility; patients usually were admitted to our hospital directly from the hospital where they had received care immediately after their stroke, car accident, or other trauma. The chart for my newest patient, John, noted that the cause of his injuries was unknown, that he may have been assaulted but that he had certainly fallen from the rooftop of the business where he was repairing the air conditioning. His most serious injury was to the left hemisphere of his brain, particularly to the temporal and parietal lobes.

The left temporal lobe is, for most people, key to the ability to use and understand language. John had damage to an area called “Wernicke’s” – named for the man who identified its importance – and the speech therapist’s evaluation had confirmed that he had “Wernicke’s aphasia” – an inability to understand language. Normally, this would have been a “contraindication” for music therapy; patients with Wernicke’s aphasia do not tend to respond significantly to music therapy interventions. John, however, had a musical background. He was one of two organists at his small church and at the first staff meeting after his admittance to the rehab hospital, his family had mentioned that music was important to him. These were the days before managed care and severe restrictions on the therapies we could provide, so the physican in charge of John’s care wrote an order for a music therapy evaluation.

As was my custom with new patients, I went to observe John while he participated in another therapy to get an idea of how he performed without the cues and structure he would receive in music therapy. I found him in his room with his occupational therapist, Tim. Tim was working with John on basic grooming skills: combing his hair, brushing his teeth, using an electric shaver. Tim worked on language skills at the same time and this is where John had particular trouble.

Wernicke’s aphasia also is known as “receptive aphasia” because while the patient with Wernicke’s may be able to speak and write, he will have difficulty being able to understand what is said to him, or to read. In addition, he will have problems evaluating his own speech.

The areas that produce, control and evaluate speech and language in the left hemisphere are quite close together. It is not unusual, therefore, for an injury or stroke to cause problems with both expressive (talking, writing) and receptive (listening, reading) language. John’s injuries had affected the receptive areas primarily, but his expressive abilities weren’t perfect. An example of the problems this presented arose when John asked for his comb. Because of the expressive damage he had, he substituted another word for comb, saying “Give me a cat”. Unable to understand what he himself had said, John expected Tim to hand him the comb. When Tim said, “I don’t understand” (another thing John couldn’t comprehend) and failed to follow John’s instructions, John became frustrated. When I arrived at the room, John and Tim were well into their session, and John was well into aggravation. Within a couple of minutes of my arrival, John threw his brush at Tim’s head.

After the session, Tim and I talked. “John’s having trouble with the sequencing of his grooming routine,” Tim said, “so it would be great if he could understand and use language as a cue. So far, though, he‘s just getting more and more frustrated and angry. Repetition will help, of course, so we’ll press on.”

Conversations with Kate, John’s speech therapist, and Phil, his neuropsychologist, confirmed that John was demonstrating a fairly clear picture of Wernicke’s aphasia and that his frustration was affecting his ability to benefit from therapy.

I knew, from case studies and research, that music therapy likely would not have a significant impact on John’s verbal communication abilities; he would be able to repeat things I sang to him and probably be able to sing familiar songs, but without comprehension. I had treated a patient once who had been able to sing, with perfect clarity,

“Yes! We have no bananas! We have no bananas, today!”

and yet, when presented immediately afterwards with a photograph of bananas next to a photograph of a towel, he not only could not pick out the bananas but seemed to have no idea why I’d shown him the pictures. So in John’s case, I didn’t expect that I would be able to help him significantly with functional communication.

Nevertheless, it was obvious that John was discouraged and I wanted to find out if he could participate in music in some way. Perhaps the opportunity to hear his favorite music would provide some relief from the stress and frustration. That was the perspective I had when John came to my office for a music therapy evaluation.

Knowing that John would have a difficult time understanding anything I said to him, I decided to try and start our session non-verbally. I set my electronic piano to reproduce a pipe organ sound and when the transportation aide brought John to my office, I had him rolled right up to the keyboard. I did not greet John with words, but instead smiled at him and gestured to the keys. John did not immediately respond, so placed one of my hands over his right one and gently lifted it to the keys, keeping it elevated so that just one of his fingers pushed down on a key. The instant John heard the “pipe organ,” he lifted his hand from mine, pulled his fingers apart slightly, and using his thumb, index and ring fingers, played a C chord.

The instant that chord sounded, he lifted his index and ring fingers and added his second finger and pinkie to his thumb for an F chord (C – F – A).

John had immediately begun to play the most familiar “progression” of chords, based on the notes C, F, and G. The transition from the C chord to the F chord was a fairly simple one, but the G chord would require him to change all three notes. On his first attempt, he correctly shifted his fingers for the upper two notes, but left his thumb on the C instead of moving it down one note to the B where it belonged.

And then, something interesting happened. John heard his error, and corrected it, moving his thumb down to the B. Where he was unable to hear and correct his speech, he was able to hear and correct his playing.

John continued to repeat this familiar, C, F, G, C progression of chords for a minute or so and then tentatively lifted his left hand to the keys and added lower versions of the same notes to his playing. Within a few minutes, he moved into the Doxology. As before, John demonstrated that he could correct errors of one note. He did get confused when more than one note was wrong, but was able to follow my fingers as I pointed out the correct notes and usually was able to continue on from that point. The latter skill was notable because it meant that he was not playing the entire refrain automatically, but rather with some deliberation.

***

Conscious, deliberate movement is different from the automatic action generated from motor memory; some of the brain activity is the same, but some is different. That is why, after people have a stroke, or other traumatic injury to the brain, they often are able to perform a routine movement or task, like waving, brushing hair or singing. If you interrupt the sequence of their movements, however, or ask them to consciously follow a specific set of instructions, they may have a much more difficult time.

In his music therapy evaluation, John demonstrated that he could be interrupted in the middle of something he probably had committed to motor memory (the Doxology is played in almost every church service) and still was able to continue from that point to the end. He had the ability to play deliberately, a skill which meant that some of his self-evaluation and initiation skills were intact – but obviously much more so for music than for verbal communication.

A week after his first music therapy session, John did something else that was, at first glance, startling. He had started picking out melodies on the keyboard with his right hand – primarily hymns. One day, however, he began to play a fragment of a melody that I recognized, but could not name. John was struggling to get past the first few measures (groups of notes), but he kept getting lost. I felt sure that the printed music for the song would be in one of the many large music books on my shelf, but I needed to know the name of the song. John, of course, couldn’t help. So, I did what I had done occasionally since I’d started working in a hospital without other musicians around: I called my mother. Fortunately, she was used to these long-distance “name that tune” calls and after I quickly explained my dilemma and hummed the first few notes, she said, “Fly Me To The Moon” and “we’ll talk to you on Sunday! Bye!”

“Fly Me To The Moon” was indeed in one of the books on my shelf and I opened the book and placed it on the keyboard stand in front of John. It seemed to me that he recognized that the page was filled with music notation, as he looked from the notes to the keys; but he couldn’t seem to figure out how to translate the printed notes into keyboard keys.

I decided to show him the purpose of the book by playing the melody and I reached across him and started to play the opening notes of “Fly Me To The Moon” – but as soon as I began the first note, he put his hand under mine and continued on his own. Further, he looked at the music as he played and it was evident that he was “reading” it, because he was able to get past the measures he’d played over and over and play through to the end of the song. The grin on his face as he finished was infectious and we laughed together.

It became evident, as I turned to the pages for some other songs I thought he might know, that John couldn’t start any of the songs on his own; but that once I played the first note, he was able to read the rest of the music with minimal assistance. While he was playing, I went around the corner and found his speech therapist, Kate, and had her come and watch John’s playing. We realized together what was happening.

***

Music notation is a symbol system, in many ways like the letters and numbers we write. Once you learn the code, you can read any piece of music. Music notes are named by letters from A to G; and the notes on the page, which appear on a staff, proceed in order as they appear on a line of the staff, then a space, then a line, then a space.

When people first learn to read music, they memorize the placement of the notes. Perhaps you took piano lessons and learned the names of the notes on the lines of the staff with “Every Good Boy Does Fine.” At the very beginning, you read each note and thought, “that’s an A, that’s a C” and so on. After a while, however, you began to recognize the relationships of the notes to one another. You realized that successive notes on lines meant that you should skip one note (the one that would have appeared on the space between the lines). So if the first note was E and it was followed by a note on the line above, you simply “skipped” over F (the space) to G. And after a while longer, you began to hear what that interval sounded like. So every time you saw a similar distance between notes (line to line), you made an equivalent skip on your instrument. You learned the same thing about successive notes on spaces and about lots of other combinations. Quite soon after you learned to read music, you weren’t labeling each note as you played (“A, C, F, D") but rather recognizing the visual patterns -- the intervals – between notes. You learned the association between those visual spaces and the changes in fingering or breathing you needed to make with your instrument to play the notes you were seeing.

Reading words can be a matter of recognizing patterns as well. Many people learn to read by learning the sounds of the letters and the rules of pronunciation, but soon they recognize whole words and don’t stop to “sound them out.” Some children with cognitive impairments, who are not able to learn the rules of phonics, are nevertheless able to read by recognizing whole words on sight, like their names and other familiar words: stop, walk, school, police, food, phone.

***

What Kate and I realized was that John was reading music spatially. He needed help with the first note, because that note had no spatial relationship to a note before it: he had to read it as a symbol, and that was something (due to his receptive aphasia) that he could not do. Once he had his finger on that first note, however, he was able to recognize and interpret the visual intervals between notes and using that, and his memory of what the song should sound like, he was able to play a song from printed music.

John and I tried using printed music for unfamiliar songs, but this was not as successful. He needed a context (the memory of a familiar melody) in which to play. Music is, after all, more than melody and John was not able to concentrate on reading an unfamiliar melody and rhythm and harmony. After all, he wasn’t in a situation in which he wanted to learn something new; he was already spending all his energy trying to regain what he had lost. Despite John’s ability to illustrate for me the ways in which the brain processes music, the purpose of his music therapy wasn’t to provide me with information – it was to improve John’s quality of life and ability to recover all he could after his injuries.

That goal was met. John clearly enjoyed his twice-a-week music therapy sessions and his treatment team (doctor, nurses, therapists) reported that his cooperation improved immediately. While we couldn’t find a way to translate his musical abilities into improved verbal or written communication, his increased enthusiasm gave him the chance to get the most out of his time in our facility. John would always have difficulties with communication and would always need care, but he was more independent when he left us for a long-term care facility in a neighboring state.

When John left, I sent a list of instructions and music with him, hoping that there would be someone among his caregivers who could help keep him involved with music. As with so many of my patients, I was unable to keep track of what happened to John, but knowing and learning from him certainly enhanced my “leaf” – and my ability to treat others.

What is Music Therapy?

What is music therapy? Among music therapists, the question itself is a bit of an inside joke; we anticipate it, plan for it, and then never feel that we’ve given a perfect explanation. There are definitions and descriptions in therapeutic books and journals, and famous lines from literature that end up at the start of newspaper articles or on inspirational posters. None of them adequately express the totality of the music therapy experience.

What is music therapy? Music therapy is the process that occurs when a music therapist and client share musical experiences in order to help the client focus on non-musical goals. Music therapy is about the processes of healing and learning, coping and creating – not about a product, like musical performance or a test score. Music therapy also is about communication between the therapist and the client, with music as a language. Music therapy does not occur without this interaction, because each person’s relationship and responses to music are unique.

The music in music therapy might be in the style of classical, country, rock ‘n’ roll, rap, jazz; it may be original or familiar, melodic or atonal. It is almost always “live,” but may be composed or chosen ahead of time – or improvised on the spot. Music therapy sessions may include singing, playing instruments, listening or moving to music, and creating or writing music and songs. Each session is focused on the clients’ specific goals, with the therapist constantly evaluating the clients’ responses to the musical interventions and adjusting them as necessary.

The music therapist has a music therapy degree from a school accredited by the American Music Therapy Association and is certified to practice by the independent Certification Board for Music Therapy. He or she is an accomplished instrumentalist or vocalist who -- in addition to studying privately, participating in ensembles, and taking music theory and history classes -- has also studied psychology, anatomy and physiology, and research methods while learning and practicing music therapy skills in health care and educational settings. At the conclusion of training, the music therapy student has spent several months working full-time under the supervision of an experienced “MT-BC” (board-certified music therapist) before taking the national certification exam.

The music therapy clients, on the other hand, do not need to have any musical skills to participate and benefit from music therapy. The music therapist will find ways to take whatever abilities they have and make them a part of musical experiences. Who are these clients? Who needs and participates in music therapy? The list is long and includes both children and adults with developmental, cognitive, or physical disabilities; mental illness; and temporary impairments due to illness, stress, or trauma. People with Alzheimer’s disease, cancer, autism, and chemical dependencies can receive help from music therapy, as can mothers in labor, premature infants in intensive care, people with motor impairments due to diseases like Parkinson’s, and those who are incarcerated in juvenile detention or adult prison systems.

The clients’ “non-musical” goals may be to increase or improve something: strength, communication, attention span, self-esteem – or they may be to decrease something: stuttering, “off-task” behavior, the perception of pain. When the client is fighting a debilitating disease, the goals may be to maintain skills or activities.

Some music therapists are full-time or part-time employees, others are self-employed as private contractors with one or more agencies. Many music therapists work with private clients; some of those therapists have their own clinic space and others travel to their clients’ homes. Music therapy is provided one-on-one (therapist and client); in small groups; in co-treatment with other types of therapists; and as a consultant service, in which the music therapist helps another therapist or teacher incorporate music therapy strategies into a classroom, therapy session, or healthcare environment.

The person who asks for a definition of music therapy may be talking to a self-employed music therapist with a clinic space in her home where she sees children with developmental disabilities. It is just as likely, however, that the music therapist is a full-time employee of a gerontology facility, seeing small groups of patients with dementia, Alzheimer’s disease, and communication impairments – or that the music therapist has one contract with a hospital, working on the oncology (cancer) unit, and another in which he works at a community mental health facility with people in addiction recovery.

What is music therapy? It is art, it is science. It is innovative, it is familiar; it is precise and creative. It is finding the music in people as they are, and finding and creating music that will help them be more of themselves. It is sharing music for someone else’s benefit and discovering that the experience changes you, as well.

I'm in a mood today!

My music psychology students hardly knew what to make of me today. Correction: my non-music therapy major-students hardly knew what to make of me; my regular students just laughed and made "yup, that's Betsey" faces at each other.

I was just in that sort of mood today. I had a delicious dream just before waking up, the pants that I recently brought out of the back of the closet fit just as well, if not better, than the first time I wore them, and there was a great song on the radio on my way to school.

So I grabbed my Commitments CD and started class with the volume turned way up for "Mustang Sally." I even danced my 44-year old self around the room. I, apparently, was the only one with soul. Kids today.

Move On

A beginning...