Voices ResourcesA website for the worldwide community around the journal Voices: A World Forum for Music Therapy

On the Contemporariness and the Challenges of Clinical Practice

The first generation of Brazilian qualified music therapists[1], in which I belong, emerged on the seventies and began to provide clinical practice within the line of the third music production networks conceived by Jacques Attali (1978) – to wit, repetition – that consists in the possibility of sound recording, a recent phenomenon in human history, and in the reproduction and listening to of these sounds in the absence of those who first produced them. Initially, gadgetry involving radio, discs, tape spools and, cassettes, as well as the handling of some of said technological advancements, like "tape clipping", allowing for a larger set of sound possibilities was employed. These afforded us the instruments for creating together sounds designed and mixed along with others, thus broadening our sound-producing tools. Such portable tape recorders were also used to bring in the tunes my patients required or to record their own music endeavors, which is an important source for research to this day.

Vinyl records were played in Long-Playing sound systems and then substituted by the lighter CD players, more practical, easy to fetch along, and presenting to the laymen that which seemed to them a better sound.  Thus, one after another, technology brought us new gadgetry and created increasing differences on the sounds that reach us.

Electronic keyboards have partially superseded piano playing, particularly to the satisfaction of those who want to achieve fast results in musical performing apprenticeship (aided by the ready-made accompaniments). Or else, these are helpful to those who need the feasibility of moving around carrying an instrument, for all that these bring up a great loss on rendering possibilities, like different touchés, sonorities, as well as dynamic and agogical variations, more widely spread before these keyboards became "sensitive." On the other hand these electronic devices brought (and still bring) joy for the autists, who can program and play on them, for all that they keep and increase their isolation when listening to the instrument "play by itself" rhythmical/melodic loops ad infinitum – affording the weaving of "rhythmic tapestries" to feed stereotypes – all the while creating a proven iatrogenic ambiance for conserving and reinforcing the symptoms of their ailment.

Therefore we adapted to the technological progress that marches along with us, though avoiding with a few kinds of patients some of the aforementioned apparatuses. Then the Internet came about and with it, the iPods which, to say the least, make a lot harder the lives of the music therapists, who are not conversant with the current, virtual repertoire and who are supposed to work with teenagers who spend long hours connected to these devices, like those undergoing dialysis treatment.

The portability of iPods allows them to take over most spaces as soon as taken out of the stores that sell them: they are to be found in streets, subways, buses, trains, airplanes, bank queues, gyms, waiting rooms, clinics, hospitals… as well as in the most different hours, from morning to night with the outcome of that which I dubbed an "exhausting contact with songs" (Barcellos, 2010).

We should do better with inverting the question: where the iPods are not to be found? Well, under the showers, while bathing in the sea waves, in swimming-pools… provided the users are not sitting on inflatable seats. And they are all the time present in dialysis wards, where I now practice clinical therapy, a space in which it is the teenagers who most employ them along with notebooks[2].  For instance, this 19-year-old teenager challengingly asking me, raising his iPod with his only available hand, as the other was clamped to the dialysis equipment, "Do you know how many tunes I have here?" Already guessing the kind of answer I'd be getting, I make an effort to keep a deadpan face. After boasting he had gathered 780 tunes, he goes on, "Do you know what I do every afternoon? I download tunes into this computer." This and many other questions and answers mirror and stress my incompetence into dealing with a repertoire including the 780 tunes the teenager keeps in his small iPod, "the dear companion of every hour", as I described it somewhere else. And I refer to this iPod as being "small", both in size and storage capacity, for today the last-generation devices can store up to 40,000 tunes!

But the issue is not limited to not having a repertoire as sizable as the gadget's capacity. It should be remembered that it is impossible for a music therapist to compete with results surfacing from the potency and sound quality of this gadgetry as refers to orchestration, to professional voices, to the singing present in tunes that come from every corner of the world and from the most diverse languages as well. The styles are most varied and presented by the voices of young and old composers/singers who decry everything, including the pain and hopes of these young patients themselves, performers and actors in the stage of their own lives, all which boils down to confirm my thought that patients are the sound/music narrators of their own life histories (Barcellos, 2006).

And all that happens within a ward in which the music therapist threads his/her way in with only his/her guitar!

Well, accepted this new reality, absorbed its impact, some strategy must be endeavored to face the situation. Should we dive into the Internet and ceaselessly download new tunes?  Learn by heart everything that we can?  Deeply study everything that falls into our hands or reaches our hearing? All these could be ways. But they are impossible within some sets of circumstances. Thus, considering the urgency for these interventions, other venues can and must be chosen. The easiest way out would be requiring that all iPods were disconnected while we're there. Simple as that. But this does not seem to me the best solution for two reasons. First, because I understand patients should have a chance to make their own choices and, secondly, because I adhere to Virginia Axline's line of thought when she states that "every change worth the effort will spring from inside out" (1972, p. 125).

About the Strategy we Created

We already know that music therapy techniques ("methods", according to Bruscia's terminology, 2000) go beyond the exclusive employment of the re-creation of songs created by other composers, something that exacts a large repertoire knowledge from the music therapist and that will afford the patients the possibility of expressing their internal contents, although through the voice of somebody else — the original composer.

We have noticed all along our clinical practice the importance of the patients' usage of musical re-creation experiences and the music therapist's taking advantage from it as a music therapy technique. We are aware that popular songs end up by existing in everyone's experience, for this is phenomenon spread throughout all ages and cultures, thus considered to be one of the truly universal features in human life (Finnegan, 2008).  Therefore, in my opinion, singing accomplishes manifold functions and lends itself to different applications within the area of music therapy: because it grants a strong musical experience for the patients, for its laying roots into common cultural grounds on which both music therapist and patient can step, as well as allowing for "a natural and unrestricted running over of human expression", again quoting Finnegan (2008, p. 16).

As far as my own experience goes, I consider that the use of songs should be frequently followed by interventions intended to lead patients into expressing themselves by using their own musical voices.

All the same I realize, with some amount of worry, that oftentimes re-creation is employed within situations where other techniques could be more potent and bring over best results. If only this technique will be employed where others could as well be, we might perhaps lose a great deal of opportunities for gleaning, impacting, and "activating a psyche-enhancing system", (Fiorini, 1995, p. 37) which could become a source of empowerment for the patient to face a pathology that asks for an anxiety-producing treatment, depression, and other stress-inducing factors.

Therefore, not to allow them to sing time and again, sometimes in a "mechanical fashion" whatever they listen to or read from pages where the lyrics of songs were printed and prepared exclusively for them, all the "while [the patient's] musical preference is important we [the music therapists] must also have the potential to provide other musical avenues that will balance and make the therapeutic process more directed, potent, and esthetically powerful" (Lee 2003, p. xvi).

Thus, as a response to the challenge introduced by iPods, we created a strategy that coincides with Attali's fourth network – composition – mainly leading teenager patients to compose, all the while staying aware of the difficulties inherent to this activity and with no initial concern with esthetics (for all that this is acknowledged as being important), according to the viewpoint that the process is more important than the final product.

About Composition in Music Therapy

 I define composition in music therapy as "the creation of music by the patient or patients or by these together with the music therapist(s) which is registered (in many ways) and can therefore be repeated, in which it differentiates from improvisation not only by the register, but mainly by the process and the intention of creating". The patient leaves its mark on this musical experience, his/her footmark, so as to say, working upon that which s(he) makes, sometimes along several sessions, simply expressing the wish to "invent" a tune or departing from other stimuli presented by the environment.

As to the treatment of patients on dialysis, composition was the choice strategy adopted to provoke and engage them into an interacting musical experience so as to bypass iPods' lure by substituting for them something more potent within a relational space – to wit, creation.

Many aspects gravitate around the employment of composition in music therapy, but there is no space here for a detailed description of them all. Although, I highlight among these: goals and ways to lead a patient into composition; ways for register a composition; who registers a composition and how this is done and  how I do it myself; and, finally, how do I make a "music therapeutic reading or analysis" of that composition.

A Composition by iPod-using Patients

Below you will find the lyrics for a composition made out of the curiosity of two adolescent patients bearing a chronic renal illness, relating to the suggestion that the music therapist gave that each patient asked by singing whatever it was the gift they wanted for Christmas.

P. and N. composed a rather simple melody, employing only adjoining scale notes and a regular rhythm, while singing lyrics related to their illness, thus pointing to the fact that music eases the expression of living or charges the lyrics with a weight that would hardly be exclusively told by verbal means only.

Final Considerations

Many are the challenges faced in clinical practice with chronic renal diseases, but perhaps the greatest among these are the existence of physical and psychic scars these patients have to bear along and the necessary creativity and flexibility for the music therapist to face the possibility of music therapy chronicity in relation to the chronicity of the very illness.

I understand the need for research in the employment of music therapy within this particular area, but before that strategies have to be devised to help us utilize this potent tool we are already endowed with – music itself – a means to afford us a musical experience that can lead a patient from an (emotional) stance to another – so as to adopt a !transportation" metaphor first employed by Tia DeNora (2000). When we open "new music venues" to these patients we can lead them into experiencing new paths to express their internal contents and to live out new emotions without running any risk, while activating a preserved human capacity: that of creating, where the creational object here is the very music, surfacing by means of improvisation, be it referential or not, and by composition.

Notes

[1]Those graduated from specific courses for the training of music therapy.

[2]This clinical work is performed by the music therapists Lia Rejane Mendes Barcellos and Mariana Barcellos at the Clinic of Renal Diseases (Rio de Janeiro – Brazil), supported by the Kidney Foundation, an institution directed by Lívia Guedes and Ana Maria Mota, who introduced music therapy in their project in a pioneering attitude.

References

Attali, Jacques (1978).  Bruits: essai sur l'économie politique de la musique [Noises: an essay on the political economics of music]. Paris: PUF.

Axline, Virginia Mae (1972). Ludoterapia [Play Therapy]. Translated into Portuguese by Ângela Maria Valadares Machado Coelho.  Belo Horizonte: Interlivros.

Barcellos, Lia Rejane Mendes (2006). O paciente como narrador musical de sua[s] história[s] em musicoterapia. [The patient as musical narrator of his/her story[ies] in music therapy]. Cadernos de Pós-graduação. Instituto de Artes. Unicamp, Campinas, SP – Brasil. Vol. 8(1), pp. 187–195.

Barcellos, Lia Rejane Mendes (2010). La composición musical en musicoterapia: aspectos teóricos y prácticos [Musical composition in music therapy: theoretical and practical aspects]. IV Latin American Congress of Music Therapy. Bogotá, Colombia.

Bruscia, Kenneth (2000). Definindo musicoterapia [Defining music therapy]. Rio de Janeiro: Enelivros.

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 is it that comes first: text, music, or performance?]  In: Matos, C. N., Travassos, E., Medeiros, F. T. (Eds.) Palavra cantada: ensaios sobre poesia, música e voz [Lyrics in song: essays on poetry, music, and voice].  Rio de Janeiro: Viveiros de Castro Editora.

Fiorini, Hector Juán (1995). El psiquismo creador [The creative psyche]. Buenos Aires, Argentina: Paidós.

Lee, Colin A (2003). The architecture of aesthetic music therapy. Gilsum: Barcelona Publishers.

How to cite this page

Barcellos, Lia Rejane Mendes (2011). Contemporary Challenges: Music Therapy in Dialysis Wards on the time of iPods. Possible or Not?. Voices Resources. Retrieved January 12, 2015, from http://testvoices.uib.no/community/?q=fortnightly-columns/2011-contemporary-challenges-music-therapy-dialysis-wards-time-ipods-possible-or