In modern times, the CD has taken its place as the primary music 'product' in a multi-billion dollar entertainment industry but the belief that music is basically entertainment to be enjoyed separately from more serious pursuits of life is a relatively recent concept. For most of human history, music was essential to the communication and sense of connection within a tribe or village. Everyone participated in music that was deeply integrated into the rituals, ceremonies, and celebrations that related to the deepest needs of the community. Although this view of music has largely disappeared from industrial society, it is not entirely gone from the face of the Earth as the following story illustrates:
Felipe Herrara, a Chilean bank president, tells of a tiny Indian village he'd visited on a feasibility study for a proposed hydroelectric dam. Since the village lacked virtually every modern development, Herrara asked the local chiefs what project the bank could fund as a gift in gratitude for their hospitality and assistance. After some deliberation, the chiefs concluded, 'We need new instruments.' The astonished bank president replied, 'Maybe you don't understand. We would like to help you with improvements like electricity, running water, sewers, telephones.' But the chiefs had understood the offer. 'In our village,' it was explained, 'everyone plays music. After we gather to make music together, we can talk about problems in our community and how to resolve them. But our instruments are old and falling apart. Without music, so will we' (Weisman, 1995).
The dominant perception of music as a form of entertainment, produced by professionals for the purposes of leisure, diversion and relaxation, permeates our society right through to our health and rehabilitation institutions. According to Anthony Salerno, founder of the Northeast Center for Special Care, a long-term rehabilitation center specializing in individuals with traumatic brain and spinal cord injury, neurological disorders and ventilator dependency (personal communication, 2007):
The fact is, the vast majority of people who work in our profession, not to mention the Resident-Neighbors, families, advocates, regulators, policy makers, legislators, elected and appointed officials, and the community at large - too often think of music therapy as only a recreational activity and they regard recreational activity as a method of Residents keeping occupied. The fact that this belief is endemic is disturbing, but factual.
Note: At Northeast Center for Special Care, the individuals served are known as the "Resident-Neighbors."
We play music. Music makes us feel good. As such, it appears inconsistent with the principles of serious work. In truth, the effects of music are multi-dimensional, including physiological. Some of these are of particular relevance to those recovering from a brain injury. Negative affect states such as depression, boredom, loneliness and worthlessness have been reported to be the most common post-injury emotional reactions (Gagnon, 2006) and positive self-esteem has been identified as a primary predictor of psychosocial readjustment (Tate and Broe, 1999). Music has been shown to increase dopamine levels that current neuropsychological theories associate with positive affect and feelings of well-being (Menon & Levitin, 2005).
An ever-increasing body of literature indicates a strong and consistent pattern of activity throughout the brain enabling creativity associated with music. Dr. Charles Limb of Johns Hopkins University School of Medicine, quoted in an article in Medical News Today (2008) said, "It is almost as if the brain ramps up its sensimotor processing in order to be in a creative state." Research is uncovering the fact that music is a "whole brain" phenomenon. Music researcher, Daniel Levitan (2006), relates that music listening, performance, and composition engage nearly every area of the brain that has so far been identified, and involves nearly every neural subsystem.
Neuro-researchers have discovered that the brain's capacity for reorganization following trauma, called neuroplasticity, vastly exceeds what was once thought. This suggests to Levitin, "that regional specificity may be temporary as the processing centers for important mental functions actually move to other regions after brain damage" (p.87). And, a major study recently sponsored by the Dana Arts and Cognition Consortium (2008) concluded that an interest in performing arts generates high states of motivation that lead to improvement in other domains of cognition.
Once a client becomes motivated and confident enough to engage in the process, the various stages involved in songwriting and recording — deciding on the content of the lyrics, the emotional quality and style of the music, the group effort involved in its performance — all challenge and strengthen vital personal and community skills essential to community reintegration following brain injury, such as:
*Managing relationships and effective collaboration;
*Handling difficult feelings such as frustration, competition, insecurity;
*Expressing one's ideas within an artistic form;
*Maintaining concentration; and
Generating the musical work, playing it publicly, even potentially marketing the 'product,' is approached from a community arts therapy model, described by music therapist, Dr. Kenneth Aigen (2005), as a holistic understanding of the arts that leads people both inward in exploration of their inner lives as well as outward towards participation and connection within community. Such a framework supports a value system stemming from principles of therapy as opposed to those of the music business, for example:
*Validating and celebrating personal progress, rather than the generation of product;
*Remaining sensitive to personal dignity and privacy issues regarding how a Resident-Neighbor is presented to the public;
*Helping Resident-Neighbors cope with feelings related to the public's response; and
*Developing an ethical plan of how generated revenues, if any, are distributed.
The aim in this approach, according to music therapist, Gary Ansdell (2002), is to assist clients in accessing a variety of situations and to accompany them as they move between traditional therapy approaches and the wider social contexts typically involved in music making.
Songs reflect and reveal areas of conflict or concern. In the process of composing, performing, or listening to songs, they transform feelings of inadequacy and isolation into joyously shared communication. The "Blues" idiom is an example of this seeming paradox in action. Playing and hearing "the Blues" — by definition songs about depression — makes people feel good. As a result of this archetypal aspect of songs, the majority of songs, even those on the pop charts, express feelings related to loss, frustration, or anguish. Songs help people manage difficult feelings by:
* Giving form to and enhancing emotional expression;
* Safely containing disturbing or opposing emotions and ambivalence;
* Validating inner experience and ability to communicate with the outside world;
* Stimulating emotional identification and self-awareness; and
* Facilitating group identification and cohesion (Soshensky, 2007).
Speechless — A Case Example
George P. was admitted to Northeast Center for Special Care for rehabilitation following acute medical complications effecting multiple organs, including his brain, that ultimately led to a stroke. Additionally, George was found to have a heart defect that necessitated surgery. Prior to his stroke at age 46, George had been a healthy, single man who was employed full-time doing computer work. He was also an accomplished piano player and singer who played professional engagements and had aspirations for furthering his career as a musician. His musical interests leaned towards jazz and classical and he told me that he sang "like Pavarotti."
At the time of his admission to Northeast Center, George was wheelchair-dependant with severe impairments involving speech, fine and gross motor skills including the use of his hands, and other complications. Emotionally, George was struggling with adjustment issues related to his condition including depression with significant bouts of anger, frustration, and sleep difficulty. George dabbled in some music sessions; however, he was embarrassed by his slurred, labored voice and typically laughed self-mockingly after any efforts at singing. His piano playing was even less functional and he refused to make any serious attempts. George shortly had to endure further medical complications and surgery, returning to the Center in an extremely debilitated condition.
As George slowly regained his strength, he did not want to attend the music program; however, music therapist Peter Bass and I maintained our relationship and continued to encourage George to resume some form of music therapy. As we continued to discuss the matter, George made it clear that he did not wish to take part in group sessions, saying he felt uncomfortable participating with those less musically accomplished than he. That there were, in fact, quite a number of highly talented musicians participating in the program seemed to make no difference to him. George was interested in being musical again; in fact, he began to self-advocate for it, but he would accept only an individual session.
I was able to arrange a weekly co-treatment session with his Occupational Therapist. The original idea was that we would work on some adaptive techniques for George's piano playing. There is evidence pointing to music, as a rhythmically coherent experience of time and space, facilitating improved sensorimotor control, motor programming, and goal directed movement (Hurt, 1998, Dileo, 2005, Aldridge, 2006). We began jamming in an exploratory fashion, with George on piano, usually myself on bass guitar, George's OT helping with his physical positioning and sometimes, another client on congas to provide a rhythmic foundation.
Although there was some progress in George's fine motor control and piano playing, it did not appear significant enough to be sufficiently satisfying or motivating for him. However, his musicality was soon engaged in a more comprehensive manner as George began to compose a chord pattern to accompany his improvisations. It was primarily based on a minor blues progression however it contained several "jazzy" changes that George said were influenced by John Coltrane. The fact that music helps patients cope with the emotional stress caused by sudden severe neurological illness has been borne out by research (Groch, 2008) and I felt the scope of our work was expanding to include psychosocial goals that, to me, are virtually implicit in all music therapy. I suggested to George that he might want to consider composing a complete song including lyrics. George hit on the central idea of "Speechless" almost immediately, referring to his difficulty with communicating clearly. The first verse of "Speechless" came very quickly to George and was finished within one session:
I know what I want to say but the words get in the way
And it ain't no joke when all your words get choked
The next verse took a few more weeks. I was in favor of the song taking a wider view of George's feelings regarding his situation, but George remained adamant that the song was only about his being "Speechless" and needed to remain focused on that. George's strength of character came through as he held fast to his artistic vision, disregarding and overriding numerous suggestions and ideas by me and his occupational therapist until he arrived at a second verse that satisfied him:
I'm so restless
All my thoughts and feelings are still there
I just can't get them in the air
And I need to reveal what I'm forced to conceal
The final section was pure George inspiration. He liked my suggestion that perhaps the song could use a middle section and he spent a brief time in the creative writing program arriving at:
When Moses talked to God
He said, speaking for me is hard
God said, don't worry about it
Your brother will speak for you
Musically, this bridge was applied to a standard blues middle section beginning on the subdominant chord and resolving on the dominant. But if the music of the bridge was rather traditional, it was nonetheless effective as the power and profundity of George's lyric gave the piece a quantum leap into the mythopoeic. George was, of course, referring to the Biblical quotations from "Exodus":
"And Moses said unto the Lord, O my Lord, I am not eloquent; neither heretofore, nor since thou hast spoken unto thy servant but I am slow of speech and slow of tongue."
"And the Lord said ... thy brother Aaron will be thy prophet."
In discussing his imagery, George said that Moses had been one of his major heroes even prior to his stroke. The fact that Moses was someone who, like George, was considered to have had a speech impediment and yet became known as the greatest prophet of all time signified to George that his disability did not preclude his ability to do important work. George believed he had a purpose yet to be revealed.
When George's song was finished, he wanted it to be recorded. This necessitated moving out of the individual session format and into a wider community context. Peter and I thought it would be a profound statement for George to challenge the content of the lyric by singing his own song but he refused. He insisted that it would sound "horrible" and no argument about how the therapy involved in singing it himself outweighed conventional aesthetic considerations could change his mind. George's choice of vocalist for the song — his "Aaron" — was Adam, another resident and recovering TBI survivor and fellow jazz and blues lover. Adam was emerging as a stunningly talented singer although he had never known this about himself and had virtually never sung prior to coming to Northeast Center. A group of resident-musicians assembled to begin working on the song with George as musical director. As the rehearsal started to take shape and then transition into a recording session, the energy and ambiance generated by the music of this little group caught the attention of the Center's Public Relations Director. She wanted to take a picture to document the session but George disallowed it. He wanted no pictures of himself. Although George's song explored a wide-ranging coping response to his current life crisis, some of his real-life emotional conflicts related to his trauma were clarified. A talented singer, he refused to sing (although we were able to encourage him to provide a little backing vocal part) and a proud and handsome man, he refused to be photographed. Nevertheless, the recording of his song proceeded well and George was extremely pleased with the results.
With the success of his musical vision behind him, George seemed happier and more comfortable with himself. We began to discuss the possibility of filming a music video to accompany his song. At first, George said no, until he had an idea for an image that appealed to him — throwing a rod down on the ground and having it turn into a snake, as Charlton Heston did playing Moses in "The Ten Commandments." We considered this possibility but realized it did not seem realistic to bring a snake into the Center. However, George remained interested in the project, developing cinematic ideas and allowing himself to be filmed, something he would not permit less than a month previously. George donned a makeshift Moses costume for the shoot and later said that he felt honored having the opportunity to play Moses. He said he felt as if he connected with the spirit of Moses during the filming, who represented to him perseverance as well as accepting the loss of royalty to achieve a higher purpose. George said, "Moses was someone who was willing to walk through the desert until he couldn't walk anymore and like Moses, I will fight to the very end."
As George began to make plans for his upcoming discharge, it was apparent that his self-esteem, self-acceptance, and sense of empowerment were improving. He became willing to attend open group music sessions and he sang "Speechless" and other songs publicly in groups and performance situations within the Center on multiple occasions. Historically, some music therapists have argued that therapy requires privacy and is about process, not product. However, music therapist Gary Ansdell (2005) has countered that performance within a music therapy context can keep the focus on process while also balancing individual and communal needs. In his live performances, CD recording and video-making process, George came to express pride in himself and his accomplishments rather than simply self-derision as he had done earlier in his treatment. To paraphrase social therapist Fred Newman (in Holzman, 1999, p.129), people can learn to perform beyond themselves. They break out of habits and discover, not who they were, but who they were not. Although performance in healthcare must never be a requirement or an expectation, carefully considered, it can function as an epiphany of sorts that reflects, not where we are, but where we can go.
In preparing to return to community life, George would certainly require some special services and he reflected on his future and the changes he'd been through. Formerly a self-described arrogant, independent person, he accepted people taking care of him more then he allowed before. "The World is my brother," he proclaimed. "I'm more humble and pious than I was before. It's OK that I need help. I've made some peace with what has happened to me and an important part of this healing came from being taken seriously as an artist. I wasn't ready to sing on "Speechless," but I do hope to get back to my singing. I want to sing in local opera, maybe even The Metropolitan. I want to be the first wheelchair impresario!" "Well," I said, "that would be about as far away from being speechless as one could go." And George just laughed.
The fact that music is so identified with the entertainment industry means that, in writing and recording original songs, the client is doing something that's culturally idealized. In this way, as music therapist David Ramsey (quoted in Aigen, 2005) points out, the perception of being an invalid can be almost instantly transformed.
If a friend, family member, visitor, caregiver, or peer hears you singing or playing on a CD, doing something they may think only 'stars' do, something they might think they couldn't do, that person may also think of you differently. It expands the context of your relationships, of your self-perception, and of your community's perception. Your talent differentiates and also connects you to the community.
Beyond their influence within a healthcare system, CDs circulate in the general public. Their function is to share music with strangers throughout the world, creating an opportunity for people from all walks of life to experience people's musical talents. The artist's musical talent, the artist as musician, becomes the persona, and that persona is not defined by injury or disability, but by the music they create — music to which all people can relate. The fact that the performer may have a disabling injury becomes irrelevant to the experience of the music. This is the value in challenging people, not just to make music, but to transcend limitations by becoming musicians, musical artists.
In this context, contemporary brain injury rehabilitation methodologies stress the principle of 'inclusion,' meaning the individual is incorporated into the community, irrespective of actual or perceived disability. This is differentiated from the idea that people need to be alike, 'fit in,' or reach for similar standards; in the contemporary music business, to be "commercial." According to Condeluci & McMorrow (2004):
Inclusion brings people to the community regardless of their differences. It does not try to change or alter differences against a person's will or capacity. It does not try to create forced similarity. Inclusion suggests that people join in as they are. Inclusion respects differences, honors diversity, and invites full community participation. It is a term that implies a welcome to all (p.24).
As the internet and the availability of technology begins to whittle away at the mainstream music industry's control of product, through the easy accessibility of cheap or free music, and of all kinds of homemade and idiosyncratic music, the global music community is becoming more 'inclusive.' Writer, Melvyn Bragg (2007) quotes artist Yinka Shonibare commenting on the role of "disabled" individuals in the arts as "the last remaining avant-garde movement." Bragg also refers to Ju Gosling, artist in residence at the National Disability Arts Collection, who points out that such work helps people to understand that we can only really be happy when we accept the reality of the human condition as being vulnerable and imperfect.
In participating in musical activity that has been restored to a context more worthy of its essence, we are all renewed. Music therapist Alan Turry (2005) has discussed the healing journey of a (previously non-musician) woman named Maria who, upon being diagnosed with a serious form of cancer, chose to write songs in music therapy and, ultimately, to record and release them. In the liner notes of her self-released CD, writer, poet, and musician Gary Keenan (2002) wrote the following:
This is soul music of the highest order. The songs are acts of witness to the ordeal of living ... All of them express a transformation of the soul, from passive victim to creative artist, and of the body from sickness to health. Her discovery of her true voice is recounted in these songs, and their real power is not that they portray a personal confession but that they enact a fundamental spiritual process. In order to be whole, each of us must find our true voice, whether we are singers, poets, accountants, or bus drivers. By so boldly stepping forth in an act of faith, Maria not only changes herself but is the agent of change in her audience. She has chosen to face death singing her particular duende, the flamenco singer's fierce devotion to life in spite of loss — and by doing so transcends the fear that silences too many of us daily.
As our clients discover for themselves, as they recreate themselves in fact through their creative music-making efforts, our musical community — a community that embraces all, gives up on no one, excludes no one, and with it, the songs on a public release CD — cannot be considered merely entertainment. Nor do they strictly represent a form of treatment, although they are, in some sense, both of those things. But, really, the songs bear witness to the faith, the optimism, and the indominability of the human spirit in, seemingly, the most afflicted and traumatized among us. Dr. Kenneth Aigen (1991) writes: "All creative acts have as their archetype the creation of the world and our presence in it. Very simply, then, to embrace creation, and hence creative activity, is to embrace life" (p.94). In this courage, our Resident-Neighbors have much to teach us. Again, in the words of Anthony Salerno, founder of the Northeast Center for Special Care (personal communication, 2007):
Artists recreate reality for themselves, and for us; they reinvent their world, our world, the world. They redeploy reality. Artists rediscover reality in their own way, on their own terms, and then they let us in. When they do this, they have awesome power, the power to reshape, to transform, to express, to convey their reality. At its best, this is a discovery for the artist and the audience. When that art is attainable by us, it becomes our reality as well. Artists bridge the gap between self and other when they make art.
Whether only a few or a million people hear any recordings released to the public is not the point. Their reality is enough. As we help to empower those who might otherwise be marginalized to project their voices proudly into the world, we not only have the privilege of assisting them in their heroic personal journey but we also, to quote music therapy pioneers, Paul Nordoff and Clive Robbins (2005), give the art of music "a new moral reality in the world."
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