Experience lends us some assurance. We think that, when we have a long life of clinical practice we can feel confident whenever we begin a job within a new field of performance. On the other hand, we also know about the challenges to face in any new area we ingress, but we can count on the knowledge of our peers and, standing on their former work, we can find a point from which to depart.
That is why we accept to develop a job within a new field, even when we know it is on something unknown to us or, more exactly, because it constitutes a challenge. Our first attitude is that of doing a survey on Brazilian and foreign literature in the area and search for contact with music therapists who might have worked in said area, either on national or international level and who have reported on their experiences.
It was sheltering such hopes that, on July 2008, I accepted an invitation from The Kidney Foundation (Fundação do Rim)[1], an institute that, as a pioneering approach, decided for including music therapy in the treatment of seven renal disease-bearing children who are being taken care of in a Dialysis-Treatment Unit at Renal Diseases Clinic (Clínica de Doenças Renais) of Rio de Janeiro[2] during their dialysis process. Nonetheless, due to institutional and personal problems, this work only began on March 2009. Being allowed some time to prepare, I started by doing a survey on the literature available in Portuguese and asking such music therapists I keep contact with and whom I knew had worked in the chronic renal-disease area, to forward me some materials on their own experience. I was sent copies of five papers on clinic music therapy with adults under hemodialysis. Some applied music therapy before the dialysis sessions, others at the end, a few while the treatment was being applied, but nothing was available on children and teenagers.
Therefore, my hopes were diverted toward foreign music therapists. To begin with, I asked for the help of Latin-American therapists I had had contact with: from Colombia I was sent a report on music therapy work performed with adults after their dialysis sessions. I asked the help of professionals from several countries. Then I received a paper from Canada approaching performances with adults and referring to the inexistence of literature on music therapy in the area. I started to search on the web sites and found two papers from Korea and one from Norway, all of them describing therapy given to adults.
Thusly given almost no information about what is done in music therapy with children and teenagers during their dialysis treatments, being myself the representative of the Music Therapy Social Clinic (Clínica Social de Musicoterapia)[3], a department of the Brazilian Conservatory of Music (Conservatório Brasileiro de Música), I decided to face the challenge and start on the job, something that was done after several meetings with the Kidney Foundation personnel and with the female medical doctor in charge of the Renal Diseases Clinici[4].
Then I visited the Renal Diseases Clinic before starting on the job and I took note of the challenges imposed by the institutional conditions, as well as those inherent to the illness and its treatment, such as the physical space, to wit, a small, cluttered room with seven couches connected to dialysis machines and disposed in an L-shaped format that does not allow the patients in the ends of the "L" to see each other; the personnel movement, always intent into their own procedures, like taking stock of pressure and reaching to the machines anytime a beep tells them something is not working as it should; the movement of other staff bringing in materials; and that of parents accompanying the children; also the alarms emitted constantly by the machines to call for the nursing staff attention; two TV sets playing all the time; iPods, also on all the time, brought in by the older patients; their different age brackets – spanning from three to twenty years, something that makes for rather different music preferences and repertoires; the limitations imposed by the treatment itself, that is, the impossibility of full movement for the patients, who are connected to their machines and the unfeasibility of moving both their arms, for one of them is kept immobile, all of which hampers the playing of music instruments by them; and my own limitations, which were mainly represented by the difficulty of dealing with a repertoire belonging in the sound history and preferences of a generation "turned on" all the time to iPods which bring them daily contact with all kinds of music, both Brazilian and foreign.
To bypass my most important limitation I invited in a young music therapist[5], who was prepared to play on her guitar a large part of the repertoire now belonging in the teenager sound and musical world. Together, we slowly created strategies for the best facing of all these challenges.
Right away I realized that two aspects are fundamental for therapists involved in this kind of work, i.e., flexibility and creativity. Thus we were led into adopting more than a strategy to work with – individually, in duos, or in groups, including in this last format, whenever possible, both the nursing staff as the patients’ mothers, who participated by singing along and dancing. We also realized that we had to present sufficiently alluring suggestions so that our proposal could be more attractive than the iPods, the TV features or even the patients’ sleep (for some of them sleep away a large part of their dialysis sessions).
Finnegan (2008) states that a popular song ends up by existing in everyone’s experience for it is a phenomenon diffused down all the times and through every cultural environment, something that can therefore be considered as one of the true universal phenomena in human life. That is why, in my opinion, it fulfills different functions and is adequate to be applied in diverse forms in music therapy.
In a former paper published by Voices (Barcellos, 2006) I made reference to those musical characteristics of popular songs that can render them familiar and predictable, a fact that turns out into comfort feelings and a holding environment for the mothers of premature babies, something that leads into their own re-creation, for they are then submitted to a situation of emotional frailty and risk, almost always of a temporary character, but driving them into a need to be sheltered so that they can strengthen themselves to care for their babies. I acknowledge this emotional risky situation as mainly provoked by the situational unpredictability and understand as well that the musical predictability is an extremely important aspect to be taken into account on this and in many other contexts of similar nature.
In relation to patients bearing chronic renal ailments it appears to me that the opposite happens to be true. I consider that the lives of such patients are, on the first hand, highly predictable for the fact that they spend twelve hours per week "connected" to their dialysis machines, depending on this for their very survival and that, on the other hand, such lives are subjected to unpredictable, risky aspects, like the several clinical interventions and even a premature death, for all that the latter are to be somewhat expected for their natural belonging into the pathological developments and, by the same token, partially predictable.
That is how, not only for the predictability originated by their connection with the machines but also by their daily contact with recorded pop songs, I consider that, along with the ‘empowerment’[6] granted to these patients, one of the goals – configured as the "clinical heart" to lead patients to the creation of a new discourse able to organize "new frames of meaning", as said Fiorini (1995, p. 20) – is that of provoking and activating a human capacity which is preserved: their capacity to create, where the herein creative object is music as approached by referential or non-referential improvisation as well as composition. Within this context, an effort is to be made to believe in this capacity, for their respective diseases are as visible as unstoppable and may induce us not to take into account such aspects on the health orbit that are to be considered as necessary to allow for a minimally normal life. On this line, Sartre is to be trusted in his statement that "In every human suffering there is hidden some capacity for enterprise" (apud Fiorini, ibidem, p. 24).
Based on former experiences and open to any sound or musical manifestation from the patients, I realized that whenever everyone sings together, including almost always the addition of the nursing staff and the patients’ kin, the popular song is the choice type of music and the most adequate technique. However, during those moments in which patients are individually cared for, improvisation and composition are the most employed experiences and the most appropriate technique to be employed by music therapists.
Oppositions and tensions are seen by Fiorini (1995) as characteristic to the creative way of thought which is not to be understood either as a principle of reality or a primary or secondary thought process, but really inserted into the order of creative process, that is, belonging in the tertiary processes[7]. Certainly to echo his internal oppositions and tensions, a 17-year-old patient "takes over" and changes into song lyrics some ideas presented in a text by an unknown author[8], who employs the rhetorical form of the oxymora, so as to "compose" new frames of sense related to his own life history.
Such a composition must be "read" within the time and space in which it was created, that is, in a day and moment during which the dialysis room was shaken by a clinic episode with the three-year-old patient, who reacted and soon recovered after the nursing staff intervention, but an incident that certainly was seen as threatening by all the patients present.
The title and the lyrics in that song (by R. C. C., April 2, 2009) are:
Nada de nada
Já passava da meia-noiteE o sol raiava no horizonte.
Vacas pulavam de galho em galho,
Enquanto o homem dizia, calado:
"Melhor morrer do que perder a vida".
Nothing out of nothing
[It was past midnight
And the sun broke the horizon.Cows jumped from branch to branch,
While the man said, keeping his silence:
"Better to die than losing your life".]
This was followed by the spoken sentence,
"Na verdade, eu prefiro perder a vida, porque posso encontrar."
["Actually, I’d rather loose my life, because I can find it back".]
I am speaking of oppositions and tensions not only in the lyrics, but also extant, to a certain degree, in the tune: it was a Funk Melody, as requested by the patient, on andante tempo, the first phrase introducing syncopes and contretemps which contrast with the regular rhythm present in the third phrase, on Dorian mode (a primitive Greek D minor scale sporting a natural C).
To Fiorini, "all therapies are broad works aimed at the activation of a creative system within the psyche" (1995, p. 37), something that can be, according to my own viewpoint, a source of empowerment for the patient to face a pathology that asks for a treatment generating anxiety, depression, and other highly stressing factors.
We are aware of the need of further research and studies on the employment of music therapy in this field, but we believe, adopting a ‘transportation’ metaphor introduced by Tia DeNora (2000), that music is an experience that might take us from an (emotional) place into another and that, through it, all those patients might, beyond expressing their internal contents, live or experiment a risk-free unpredictability.
[1]Francisco Santino Filho Kidney Foundation (Fundação do Rim Francisco Santino Filho), whose home office is seated in Rio de Janeiro, is a non-profit organization that gives care to children and young people in social-risk status who are the bearers of chronic renal diseases requiring dialysis treatment throughout a network of 48 clinics in Rio de Janeiro State. This institute is sponsored by the Else-Kröner-Fresenius-Stiftung [Else Kröner-Fresenius Foundation] from Germany and by the Fresenius Medical Care (Brazil) and directed by Livia Guedes and Ana Maria Motta who, in a pioneering approach, have inserted music therapy within their project, besides physiotherapy care, school tutoring, and food support.
[2]This is an enterprise seated in Rio de Janeiro specialized in the treatment of renal disease-bearing patients.
[3]"Ronaldo Millecco" Music Therapy Social Clinic was created by the Brazilian Music Conservatory University Center [Conservatório Brasileiro de Música – Centro Universitário (CBM-CEU)] in 2002 with the stated goal of tending to low-income people who cannot afford a music therapy treatment as well as facilitating internship for the Music Therapy College graduate students, a university-level school also maintained by the Conservatory. The care supplied in the Renal Disease Clinic is an outside care project supported by the Music Therapy Social Clinic.
[4]The nephropediatrician, Dr. Fátima Bandeira.
[5]The music therapist, Mariana Florenzano Barcellos.
[6]Ruud defines music therapy as "an effort to increase the possibilities for action" and explains that "to increase a person’s possibilities for action would mean not only to empower her but also to alleviate […] some of the material or psychological forces that keep her in a handicapped role". (1998, p. 52).
[7]The "tertiary process" references appear in several authors, like Winnicott (1971), Green (1972), and Arieti (1976), but what we are employing here is Fiorini’s thought, who defines such phenomenon as "a special kind of thought processes activated during the creative work". (1995, p. 15).
[8]A Madman's Diary. http://nebulosadereflexoes.blogspot.com/2009/01/dirio-de-um-louco.html
Barcellos, Lia Rejane Mendes (2006), Familiarity, Comfortableness, and Predictability of Song as a ‘Holding Environment’ for Mothers of Premature Babies. Voices: A World Forum for Music Therapy, retrieved on November 2, 2009 from http://www.voices.no/mainissues/mi40006000205.html.
DeNora, Tia (2000), Music in Everyday Life. Cambridge: Cambridge University Press.
Finnegan, Ruth (2008), O que vem primeiro: o texto, a música ou a performance? [What comes First: Text, Music, or Performance?]. In: Matos, C. N., Travassos, E., Medeiros, F. T. (Editors). Palavra cantada: Ensaios sobre poesia, música e voz [The Word in Song: Essays on Poetry, Music, and Voice]. Rio de Janeiro: Viveiros de Castro Editora.
Fiorini, Hector Juán (1995), El psiquismo creador [The Psyche as a Creator]. Buenos Aires: Paidós.
Ruud, Even (1998), Music Therapy: Improvisation, Communication, and Culture. Gilsum: Barcelona Publishers.
Barcellos, Lia Rejane Mendes (2009). Challenges on Music Therapy Clinical Practice. Voices Resources. Retrieved January 09, 2015, from http://testvoices.uib.no/community/?q=colbarcellos141209