Familiarity, Comfortableness and Predictability of Song as "Holding Environment" for Mothers of Premature Babies
Comments
After having written the paper Familiarity, Comfortableness and Predictability of Song as "Holding Environment" for Mothers of Premature Babies, I received comments on it from my Doctorate's advisor, in which she counseled me to do some research on music therapy works with mothers of premature babies, purporting to find whether re-creation was the most used musical experience by these kind of patients and the most employed technique everywhere. Therefore, I started researching pertinent literature on a nationwide as well as worldwide level, and by means of such research some conclusions were reached, to wit:
1 – A number of papers was published or is in developmental phase about music therapy with premature babies. Among those we may highlight those presented by Powell (2002); NaaNes (2004); Schwartz (1997); a report from the VII International Music Medicine Symposium (Swan, 1998); as well as that of Health in Hospitals: Intensive Care (2000). All these works describe music therapy treatments as applied to premature babies only [without motherly involvement], during which recorded sounds are employed [like heartbeats, for instance], or lullabies, also on recorded form.
2 – Only two of these papers, one about clinical work developed in France and another in Canada, written, respectively, by Braun (1999), and Bargiel (2004), refer to parental involvement. The first includes mothers and babies. In the first approach, the mothers talk about their babies, maybe because the music therapist is also a psychologist; while the second mentions fathers singing to their babies, including to some belonging in risk groups, but there is no direct mention to premature conditions.
3 – None of the above papers describe music therapy with mothers of premature babies or with mothers and their babies. At most, some mention mothers doing massages on their babies. (Braun).
4 – In Brazil, I had access to four papers, which were reviewed by myself and are listed below: Delabary (1998), de Curtis (n.d.), Fracalossi (2001) and Negreiros (2003). Among these, only the last two describe the music therapy clinical practice with mothers of premature babies and both refer to musical re-creation as the only technique to have been employed in the project.
Therefore, I suppose there may be some other papers published in this area, but if there are any, I had no access to them. In those that I found, there is evidence that the re-creation is almost the only musical experience used by these patients and the technique the most employed by music therapists.
References
Bargiel, Marianne (2004). Berceuses et Chansonnettes: Considérations théoriques pour une intervention musicothérapeutique précoce de l'attachement par le chant parental auprès de nourrissons au développement à risques. Voices: A World Forum for Music Therapy. Retrieved from https://normt.uib.no/index.php/voices/article/view/148/124
Braun, Sylvie (1999). L'Être avec: Relation d'Aide et de Soutien au Service de Néonatologie au Bénéfice du prématuré et de ses Parents. In: La Revue de Musicothérapie. Vol. XIX, no 3.
Curtis, Sofia Camila da Silveira de. (n. d.). O Trabalho Musicoterápico e sua Influância na Comunicação Mãe/Bebâ. Projeto de Pesquisa elaborado para o Hospital Materno Infantil Presidente Vargas. Porto Alegre.
Delabary, Ana Maria Loureiro de Souza (1998). Musicoterapia com Gestantes numa Abordagem Interdisciplinar. Trabalho apresentado no II Encontro Latino-Americano de Musicoterapia. Rio de Janeiro.
Federico, Gabriel (2001). El Embarazo Musical. Buenos Aires: Editorial Kier.
Fracalossi, Renata Del Piero (2003). Música que Embala, Canto que Alimenta: a Musicoterapia com Mães e seus Bebâs Prematuros. Monografia de Conclusão de Curso de Graduação em Musicoterapia. Conservatório Brasileiro de Música. Rio de Janeiro.
Health in Hospitals: Intensive Care (2000). Music Therapy for Premature Babies in Intensive Care. Health in Hospitals: Intensive Care. Retrieved from http://www.internethealthlibrary.com/HealthinHospitals/intensivecare.htm
Naanes, Marlene (2004). Professor Promotes Soothing Sounds for Premature Babies. Retrieved from http://www.2theadvocate.com/lifebefore/sound3.html.
Negreiros, Martha et al. (2003). Projeto MAME: Musicoterapia no Aleitamento Materno Exclusivo [Um estudo randomizado e controlado para avaliar a eficácia da musicoterapia em aumentar a prevalância do aleitamento materno exclusivo entre mães de bebâs prematuros]. Rio de Janeiro.
Powel, Cheryl (2002). Akron Hospital Testing Power of Lullabies. Beacon Journal and Wire Service Sources. Retrieved from http://www.ohio.com
X Simpósio Nacional de Musicoterapia (2001). A Musicoterapia na Hora do Nascimento. Trabalho apresentado no X Simpósio Nacional de Musicoterapia.
Schwartz, Fred (1997). Music and Perinatal Stress Reduction. Retrieved from http://www.birthpsychology.com/lifebefore /sound3.html
Swan, Norman (1998). Music Therapy. [transcript of a radio program] ABC Radio National: The Health Report. Retrieved from http://www.abc.net.au/rn/talks/8.30/helthrpt/stories/s13132.htm
About Lia Rejane Mendes Barcellos
Biography
Lia Rejane Mendes Barcellos graduated in Piano and Music Therapy. Master in Musicology. Doctorate student in Music at Rio de Janeiro State Federal University – UNIRIO. Coordinator of the Music Therapy Post-graduate Program at Brazilian Conservatory of Music in Rio de Janeiro – University Center; Music Therapy Professor in the undergraduate and post-graduate Music Therapy Programs and Coordinator of the Social Music Therapy Clinic "Ronaldo Millecco" at the same institution. Music Therapy Invited Professor in several Post-graduate Programs of Federal Universities.
I am a psychology undergraduate student with a minor in music therapy and I read this music therapy journal article that I wanted to comment on and analyze. The article, Familiarity, Comfortableness, and Predictability of Song as "Holding Environment" for Mothers of Premature Babies, documented and analyzed the treatment methods of music therapy within the NICU. The researcher, Barcellos (2006), attended to the various ways in which the music therapists used music in their sessions with the mothers. The therapists used popular songs or lullabies for the mothers to sing to their babies, or had the mothers create and sing a song for their infant that was a personal tribute to their child. Because the mothers ,were in an unfamiliar and sterile environment, the songs they knew well, such as popular music, seemed to give them a sense of well-being and shelter from their harsh surroundings. Barcellos (2006) believed it helped the mother’s anxiety because the music held them in a safe environment which made them feel good and protected. The role of the music therapist was also to give this sense of a holding environment because these mothers were so worried about their babies and needed support to be nurturing to their child. The strong relationship between the mother and music therapist encouraged the mother to connect with her child and create a sanctuary of sound that would keep the baby safe. When the mothers composed their own songs, the emotional content about the infant’s future and dreams was gratifying to the singing mom because they were able to break the plastic barrier between them and their baby and touch them with their love and words (Barcellos, 2006).
An important thread throughout the entire study was the way the music was used as a tool to achieve a holding environment where the mother and child could feel safe. I have experienced the way music can change the mood, feeling, and behavior of the listeners and the environment by creating a secure space for people to connect. For instance, in my psychology internship this summer, I co-led a play group of 5 children with autism for one and a half hours each day. It was a challenging process because these children were uninterested in playing with their peers and were very easily agitated and aggressive when provoked by seemingly small stimuli. When I introduced my guitar and singing to the environment, all of the activity stopped and all eyes were on me. The children sat next to each other, which was unbearable a few moments earlier, and were able to sing along and feel safe within the music. The other therapists and I noted this abrupt change and created an almost completely musical play group where the music followed the mood within the room and would manage the intensity by using soothing songs to bring the children back to center. There was a greeting song that set the stage for the day and a soothing goodbye song that created peace and a sense of safeness within them that they took home. When the music was used, the children interacted with each other more and had more instances of rich engagement. Thus, music created the familiarity and the protective environment that these children with autism needed to be able to connect with one another.
Through my experience with music and its uses, I believe that music therapy should be used for people that need the outlet, the safety, or the familiarity of music to keep them safe and centered in their life. Anyone who has experienced loss, trauma, disability, or a difficult change could benefit from this holding environment (Barcellos, 2006) and give them the strength to move through their obstacles. Clearly music therapy can be used in many different areas, but I respect and agree with Barcellos (2006) in that people who need consistency and a medium to turn to, music is the puzzle piece that can aid them in their reconstruction.
My name is Anna and I am a second year music therapy student from Katowice, Poland. The article titled Familiarity, Comfortableness and Predictability of Song as "Holding Environment" for Mothers of Premature Babies by Lia Rejane Mendes Barcellos brought up a few topics that refer to my interests, therefore I would like to share some thoughts.
Barcellos writes about the clinical practice with mothers of premature babies, and about familiarity and predictability of songs, which result in increased comfort on both sides – mothers and babies. I have never had any occasion to work with premature children, but I am interested in the relationship between mother and child in general.
Recently I took up a job – I am an instructor providing children ages 0 to 4 with music centered activities, considering general development as a goal. During meetings that I lead, mothers work and play with their children using popular kids' songs and lullabies. They also learn new games for children, which they can repeat at home. Observing the sessions I lead, I see different mothers with their children. I also observe children interacting with others who take care of them: fathers, grandparents, older siblings. The difference in the relationship between mother and a child and other significant person and a child seemed to be always very clear to me…
This experience made me willing to raise a question referring to one of the sentences by Barcellos: "Contrary to what is generally thought, the relationship between mother and baby has to be created." Does it mean that the maternal instinct is completely a myth? Is this statement a general, scientifically proved fact? Does it concern only a specific situation of mothers and premature children? I have always thought that the specific relationship between mother and child is determined by the nature and such emotions like confidence or unconditioned acceptance on mothers side result from biological conditions. Do mothers really have to create the relationship with children? Observing my sessions - am I projecting my own belief or do I see natural phenomenon? If I do project something that is not scientifically correct – how often do I / we do this? How many misunderstandings can be caused by such situations? These are just questions to think of…
The second thing I would like to share is a reflection connected with the advantages of using popular, familiar songs in the course of music therapy. Barcellos writes about these songs being used to comfort newborn premature babies and their mothers. I had a contradictory opportunity to work with elderly people with different problems. We were mostly singing popular songs because it was the activity they liked the most. Popular songs helped them recollect memories and created a sense of belonging.
Barcello’s article made me think that these familiar tunes can be with us during the whole lifetime, but their great potential reveals especially strongly in the beginning and by the end of our lives. The same words and melodies comfort infants facing the wonder of life and older adults closing to the mystery of death.
Barcellos’ (2006) discussion of music therapy for the mothers of premature infants provoked a strong emotional response in me. Last year, my daughter was born at a gestational age of 34 weeks and 2 days. She weighed 4 pounds 11 ounces and seemed unbelievably small and fragile. Though she was quite healthy for a premature infant, she spent her first 23 days of life in a Level IIB Neonatal Intensive Care Unit (NICU) so she could learn to take in food by mouth, grow, and maintain steady weight gain. This was a physically and emotionally exhausting time for me and my husband, and we would have benefited greatly from the support and education that a board-certified music therapist could have provided.
Barcellos (2006) described mothers of premature infants as “people in distress” (para. 6). I whole-heartedly agree with this description. Though the level of distress varies widely based on the health of the infant and mother and the support systems in place, I believe that any mother who is discharged from the hospital and has to leave her baby behind is going to experience a certain amount of distress. Mothers of premature infants are exposed to stressful situations before, during, and after labor and delivery. When we found out that I had severe pre-eclampsia, which required prompt induction of labor, my husband and I were shocked! I had trouble sleeping that night due to concerns about my daughter’s health and my body’s ability to handle the upcoming induction. Labor and delivery were also more stressful than I’d anticipated. I was confined to bed during labor because of a need for an IV and constant monitoring of my daughter’s heart rate and my blood pressure. Though I’d planned to listen to music to reduce my stress and pain perception, I was unable to do so, which was very disappointing. The medication I was on to control my blood pressure caused an intense headache, so I only wanted quiet in the room. When my daughter finally arrived, I was only able to spend a moment with her before she was taken to the NICU. My husband went with her, but felt torn since he wanted to be there to support me, as I was facing some post-delivery complications.
Following labor and delivery, the NICU environment contributed to the stress we experienced. Infants in the NICU are connected to numerous machines and it seems as though alarms are constantly going off. Privacy is minimal and there are often strict limits on the number of visitors, age of visitors, and length of visit. My three brothers didn’t get to meet their niece until she came home because they were all under the age of 18, the minimum age for NICU visitors. Another stressor was attempting to breastfeed, a feat made more challenging than usual by the fragile state of my daughter. Because of all the stressors that NICU parents face, I believe that Barcellos (2006) came to an accurate conclusion when she proposed that most mothers of premature infants would be good candidates for receptive methods of music therapy, rather than techniques like songwriting and improvisation that require a higher level of participation. This may be particularly true during the first part of the NICU experience, when parents are flooded with information about their child’s condition and what they might expect while trying to acclimate to the NICU environment.
It was interesting to follow Barcellos’ (2006) thought process as she tried to decide on the best type of music and intervention for mothers of premature infants. I agree that considering the fragile emotional state of mothers of premature infants, music that creates a ‘holding environment’ would be ideal. Barcellos noted a number of musical characteristics of popular music that may help to create that ‘holding environment.’ However, I believe that one of the most important elements of popular music is the familiarity it brings to the unfamiliar, unpredictable NICU situation. If popular music is to be used in this setting, it should be limited to music that is familiar to the mother. Barcellos discussed the use of lullabies to facilitate bonding between mother and infant. This can be a very powerful experience. For me, the act of singing to my daughter was a very emotional experience, particularly early on. I chose to wait until she was at home before I sang to her. Since I didn’t have a ‘container’ or ‘holding environment’ for the intense emotions, I didn’t feel as though I could express them in the NICU.
Reading this discussion of music therapy for mothers of premature infants made me curious about the amount research attention this topic has received. While there are numerous studies about the use of music with premature infants, a search of the Medline database revealed few studies that used music to improve outcomes for mothers of premature infants. Lai et al. (2006) found that the use of music during kangaroo care (skin to skin contact between infant and parent) resulted in significantly less state anxiety in mothers, while infants spent less time crying and more time quietly sleeping. Kangaroo care was one of the few relaxing experiences I recall having in the NICU, and I can imagine how music could enhance that experience. Whipple (2000) educated parents in the use of music and multimodal stimulation for their premature infants. Parents who received this education experienced more positive interactions with their infant and spent more time visiting their infant. Infants receiving music and multimodal stimulation experienced greater daily weight gain and were discharged sooner, though neither finding was statistically significant. Cevasco (2008) studied the impact of music on mother-child bonding and maternal coping in both full term and premature infants. Mothers of premature infants who were assigned to the music group valued music significantly more than either control group or the full term music group. Once again, premature infants in the music group were discharged sooner (an average of 2 days) than those in the control group, a finding that was not statistically significant.
Though the findings of Whipple (2000) and Cevasco (2008) related to discharge date were not significant from a statistical standpoint, I would argue that the practical significance should not be dismissed. Recalling my daughter’s NICU stay, weight was an important measure of progress, and I looked forward to seeing the new daily weight on her chart each morning. Also, as a music therapist I’m certainly biased, but I believe I would have eagerly accepted any offer of intervention that might get my daughter home sooner and posed minimal risk. Finally, it would be interesting to know how much money could be saved if premature infants were able to return home two days sooner. Administrators may pay more attention to ‘insignificant’ research findings if they save enough money!
I don’t believe there is one particular music intervention or genre that is best suited for the NICU. Part of this is due to the NICU itself. Level III NICUs, for infants born at very young gestational ages (“micro-preemies”) or those with serious health concerns, are strictly regulated. Unless music therapy was provided for parents outside of the NICU, not all music interventions would be appropriate. Mothers of premature infants have a wide variety of experiences, both in terms of their NICU time and their prior experiences with music. My experience was that education and contact with other NICU mothers was the most helpful. The hospital where I delivered offered infant first aid training to parents in the NICU. Attending this class made me feel more comfortable bringing my daughter home and allowed me to make connections with other mothers. These connections reduced my feelings of isolation, helping me realize that other mothers experienced similar frustrations and feelings of guilt and helplessness. Finally, some type of follow-up music therapy support for parents would be beneficial. My daughter is now nearly 9 months old, and though she’s small for her age, she is healthy, active, and thriving. However, this is not the case with all premature infants. Many parents of premature infants have to deal with long-term feeding issues, as well as concerns about physical and cognitive development, and sometimes additional procedures and surgeries. Music therapy could be an effective way to address the complex emotions these parents experience.
Though music interventions may vary widely, I believe music therapy is an important part of the NICU experience and the impact on parents can be just as important as the impact on the infants. Familiar music can comfort and support parents in a very challenging time, enabling them to care for their infants more effectively. Music therapists can be helpful by providing music that allows for safe emotional expression, and can provide education to empower parents and facilitate positive parent-child interaction.
References
Barcellos, Lia Rejane Mendes (2006). Familiarity, Comfortableness and Predictability of Song as "Holding Environment" for Mothers of Premature Babies. Voices: A World Forum for Music Therapy. Retrieved from https://normt.uib.no/index.php/voices/article/view/243/187
Cevasco, A. M. (2008). The effects of mothers' singing on full-term and preterm infants and maternal emotional responses. Journal of Music Therapy, 45(3), 273-306.
Lai, H. L., Chen, C. J., Peng, T. C., Chang, F. M., Hsieh, M. L., Huang, H. Y., & Chang, S. C. (2006). Randomized controlled trial of music during kangaroo care on maternal state anxiety and preterm infants’ responses. International Journal of Nursing Studies, 43(2), 139-46.
Whipple, J. (2000). The effect of parent training in music and multimodal stimulation on parent-neonate interactions in the neonatal intensive care unit. Journal of Music Therapy, 37(4), 250-68.