Finding the Client in Their Environment: A Systems Approach to Music Therapy Programming
[Editors note: The article presented here is republished from the Canadian Journal of Music Therapy Vol. IX, no. 1 2002 with the kind permission from the publisher and the author.]
Abstract
Most extended care environments are fraught with noise pollution, resident distress, and staff busyness. The continual clamour of random sound events such as call bells, public paging systems, TVs, loud conversations, kitchen clatter and continuous foot traffic contribute to an alarming sense of frenetic activity and impervious indifference. The Emergent Voice is the sum of all sounds we hear. It is the qualitative and identifiable personification of health or illness in a system. An Emergent Voice that reveals disturbing sounds and disruptive behaviours can be influenced towards health through the experiencing of the aesthetic, temporal and structural properties of music. This perspective introduces an environmental approach to music therapy programming in institutional facilities and necessitates a basic understanding of systems and field theories, the physiology and phenomenology of sound, and a willingness to engage in, and listen to, the environment in a new way.
Résumé
La plupart des établissements de soins prolongés sont aux prises avec la pollution sonore, la détresse des résidants et du personnel débordé. La présence continuelle d'événements sonores hétéroclites tels les systèmes d'appels et de diffusion publique, les téléviseurs, les conversations bruyantes, le vacarme des cuisines et le bruit continuel des pas se conjuguent pour donner une impression alarmante d'activité frénétique et d'indifférence impénétrable. La Voix émergente correspond à l'ensemble des sons que nous entendons. C'est la personnification qualitative et identifiable de la santé ou de la maladie dans un système donné. Une Voix émergente révélatrice de sons troublants et de comportements dérangeants peut être influencée dans le sens de la santé par l'expérience des propriétés esthétiques, temporelles et structurelles de la musique. Ce point de vue présente une approche environnementale des programmes de musicothérapie dans les milieux institutionnels. Elle nécessite une compréhension minimale des théories sur les systèmes et sur l'environnement, de la physiologie et de la phénoménologie du son, ainsi qu'une volonté de s'engager dans l'environnement tout en l'écoutant, d'une façon nouvelle.
Introduction
Throughout mankind's history humans learned to make sense out of the environment by observing it, listening to it, absorbing it, testing it and using it. It has nourished us and provided natural resources for development and shelter. Our deep involvement with and our co-creative dependency on our environment are often taken for granted, and yet this relationship has inspired songs, symphonies, concertos, and poetry throughout our history. It is safe to say that we cannot - intentionally or otherwise - live apart from, or totally disconnected from our environment.
As music therapists we are perhaps cowed by the austerity, the largeness, the hierarchical structure and the medical predominance of hospital environments. We can be overwhelmed into losing our own aesthetic in the medical hub of such places. We are called upon to create relationship experiences and healing processes through specifically determined music therapy techniques. In so doing, we create ambience, texture - and sometimes - tension in the environment whether it is our intention to do so or not. It is for this reason that, with conscious intent, we are professionally well placed to work with the environment rather than in conflict with it. Who, other than music therapists, can - or would - address this complex sound system of chaos?
Over the past eight years I have worked within an extended care population, and found similar sound environments across four different sites and 500 -bed case load. One three-floor facility with 200 beds, is the focus of this study. Staff and nursing efficiency are maximized by routing traffic through the dining rooms. The long, wide corridors with four beds to a room remind one of the impersonal hospital rather than of a home. There are no spaces for activities, quiet moments, or visiting, other than the dining room. Because there is little space, two activities often take place simultaneously in the dining rooms.
I questioned how I could work effectively in shared open spaces where random interruptions, call bells, public announcement systems, disruptive, agitated residents and busy staff continually sabotaged the therapy sessions. I was alarmed at the consistent exposure of residents to these same intrusions in their environment - their home. In nursing homes, which are often constructed with medical imperatives in mind, there is often no sanctuary - no quiet place to find a moment of grace for residents or staff. The underlying value systems in such an environment seemed to place the schedule above all other activities of caregiving. It seemed that the most disturbing sounds of resident agitation were overlooked, ignored or rationalized as part of the dementia process. Staff were quick to blame resident behaviours for the general chaotic environment and personal/professional stress. And yet, at both instinctive and objective levels, there appeared to be more behind these behaviours than degenerative etiology.
Music therapy theory, processes in music therapy, general systems theory and quantum physics contribute to this environmental perspective which I first integrated within a hermeneutic inquiry (1998). Building on the work of Kenny (1989), who describes the environment as a "resource pool" for aesthetic reciprocity and transformation, and Sears (1968/1977), who provides a framework for behaviour-altering experiences within music therapy processes, I will describe the concept and rationale for developing an "environmental attitude" in music therapy treatment planning and provide an example of one environmental music therapy program.
Other research perspectives also contribute to this particular approach. World traveler and sound environmentalist Murray Schafer (1977) challenges us to be pro-active in the composition of our own sound culture and cites technology and the frenetic pace of living as the cause of a chaotic "soundscape"1. My thesis (1998) explored aesthetic bankruptcy and disruptive behaviours in the institutional setting. Several qualitative perspectives in human aesthetic experiences, such as the work of Idhe (1983), Berleant (1970) and Dissanayake (1992) speak to the phenomenology of sound, the totality of sensory experience, and our primal, aesthetic biological imperative.
Quantitative researchers, such as Tomatis (1991), Berard (1993) and Weeks (1991) have contributed prolific research and commentary in the relationship between behaviour and auditory processes. Tomatis maintains that sounds are either "charging" (positive) or "dis-charging" (negative) and are responsible for increasing or decreasing healthy brain activity and behaviour. Bentov (1977) uses the physics of sound as a fundamental premise for activities in consciousness and spiritual connection.
This environmental approach centres on a theoretical construct called the Emergent Voice. The Voice is the textured mosaic of all sounds, motion and aesthetic sensibilities present and missing in the institutional environment and it contains important dues about those who live there, and those who work there. In short the Emergent Voice is a subjective measuring stick that offers information as to the health or illness in the environment through its sound. This construct emerges from a Gestalt perspective. Gestalt therapy looks to the wholeness - or integration - of experiences, personality, or environment. In my approach I asked, "Is the Emergent Voice whole?"
For me the answer was "no". The Emergent Voice contained a sense of neglect -- as though no one (staff, residents and visitors) felt validated or heard. There was an absence of listening and the entire "whole" seemed to be pathos of disempowerment. There was illness in the system. The resident voice was not present - mostly because it wasn't invited to be there. Given the systems thinking perspective that all events and systems are related I concluded that no one was listening, and no one (at any level) was being heard in this environment. Perhaps hidden realities2 created and maintained by complex inter-related human systems were driving and habituating the behaviour of not listening. And so, the absence of "listening" - rather than the ensuing consequences - became the focus for my environmental treatment planning.
Figure 1. The Emergent Voice.
Developing an Environmental Perspective
Developing an environmental awareness requires seeing, hearing and understanding the physical space, the residents, the staff, ourselves and the administrative processes as one whole field of inter-related and complex human activities. Three fundamental notions assist the music therapist in understanding and clarifying her own relationship to her environment.
- All things are always in relationship
- All events - large and small, known and unknown - impact on the environment.
- It is a physiological fact that we are vibrational beings in a vibrating universe.
General systems theory is about relationship and is a fundamental premise towards developing a global perspective for healing in the institution. Those who think in terms of general systems theory engage in a certain kind of thinking called systems thinking. The systems thinker interprets experience through the notion that all things are related - and that all things known and unknown impact in our functioning systems (e.g. Capra, 1995; Leonard, 1997). According to systems thinking there is no foundation nor hierarchical order in the network of human experience. For example, the systems thinker understands that the basis of physics is not fundamental to life processes any more than biological or psychosocial realities (Capra, 1995). The General Systems World View is a magnificent web of inter-relating systems and realities.
Hidden realities such as conflicting value systems, cultural assumptions and non-listening patterns create tension in the system. The philosophy of systems thinking then, would suggest that this tension will have a domino effect throughout the psychosocial systems in shared living/working spaces, and it will likely be manifested at the weakest link - the client population. That is to say, the human cacophony of agitation, anger and disempowerment reveals a pervasive dysfunction in all the systems. The author proposes that the miscreant behaviour of non-listening is the dysfunction, and a marginalized environment is the consequence. Participants in a marginalized environment will also behave in a marginalized manner. This is the nature of systems. "When the rhythms of the landscapes become confused or erratic, society sinks to a slovenly and imperilled condition" (Schafer, p.237).
Environmental transformation, therefore, requires transformation of listening behaviours within the whole culture of workers, residents and management. By changing this undesirable behaviour at residential and staff levels, aesthetically meaningful relationships in the psychosocial system will contribute to a healthier environment - one in which fewer disruptive behaviours will occur. Music therapists are well trained, and suited to creating a more balanced reciprocity of voices for all participants in the environment. A question this paper attempts to answer is how do we change the behaviour of non-listening in large institutional environments? The relational nature of systems can be likened to the ripples of water moving outward, and so, in environmental program planning we can do much to influence the appearance of beneficial behaviours into the system.
Kenny (1989) was the first music therapist to apply General Systems Thinking and Field Theory to the clinical experience and to develop a theory that described the immediate environment as a "resource pool" (p. 41) for therapeutic activity. Although her work concentrated on the one -to -one therapeutic relationship, she conceptualized the "musical space" (pp. 79-82) as a partner in the treatment process. It was a palpable place that therapist and the client contributed to, participated in, and emerged from transformed. Moving away from the traditional psychology paradigms (but not excluding them) to explore General Systems and Field Theory frameworks, Kenny's theory (1989) has broadened the "playing field"3 and pioneered new possibilities for Music Therapy.
The Physiology and Phenomenology of Sound
"Sound pervades my world and invades my being" (Idhe, 1983, p. 30).
Sound seems to dominate the senses because it transverses four dimensions - and possibly more. Idhe speaks of the phenomenology of auditory experience as spatial, temporal and physical. It is temporal because it comes into our awareness and passes out of it. It is spatial because it surrounds us and enters the centre of our being. We can avoid visual stimulation by closing or averting our eyes, but having no ear-lids, we cannot escape the spatial quality of sound. There are aesthetic qualities to sound as well. The qualities we assign to each sound are consonant with our internal referents - our personal context (Kenny, 1986; Langenberg, 1996, chap. 6; and McMaster, 1996).
Sound is the effect caused by any disturbance in the air around us and is generally perceived when vibrations occur within the range of frequencies that can be heard by human ears and is transmitted to the central nervous system via our bones, soft tissues and auditory channels. The normal hearing range for the adult human is from about 20Hz to 18,000Hz. Our experience of sound may be the result of input from many sources. For instance, busy staff members moving quickly through the dining room create sound systems.
In fact, through evolutionary paths, humans are biologically wired for sound. According to Weeks (1991, p. 41), ear neurology shows that almost all cranial nerves lead to the ear - including the Vagus nerve which comes in direct contact with the ear drum. The Vagus nerve travels throughout the body and innervates areas such as the larynx -which allows us to speak, sing or scream; the back muscles; the lungs and the heart. It eventually reaches down through the diaphragm to sensitize the internal organs and the intestinal tract. The evolutionary significance of this may be found in the "fight or flight" reflex, or the coined term "gut feeling." Survival may have been related to the ability to discern subtle qualities of sound present in the immediate environment. That is to say, sounds deemed "unsafe" would require ongoing vigilant behaviours. The absence of those sounds or the presence of others may induce relaxed behaviours. It may be that our agitated and withdrawn residents do not feel safe in this environment.
Our physiological "wiring" suggests that we are programmed to transmit and receive sensory information about ourselves as well as sense physical phenomena. Three supporting pieces of information may support this notion. Our solid bodies are actually composed of millions of oscillating fields in waves of rhythm. Added to this is the known fact that contained within the nucleus of atoms are the protons - entities which have existed since the beginning of time. Leonard (1978) and Bentov (1969) propose that since we are comprised of such entities, we contain all known and unknown information that has ever existed in the universe. Leonard states that we are intimately connected with the world of sound vibrations. If it were not so, we would be out of "sync" with the universe because all matter vibrates (p .68). And since we are matter, we are unable to escape the vibrational reality of ourselves. Thus, the immobilized resident with decreased hearing function is as susceptible to "sound" vibrations and their inferred meaning as her 'hearing' neighbour. Finally, Leonard (1978) speaks of an "inner pulse"4 as an essential aspect of our being that finds expression in our everyday life of walking, talking, singing, writing, or shaking hands. So understanding the relationship between the physiology of sound, auditory functions, and aesthetic meaning is critical in understanding how we relate, or do not relate, to our environment.
The Role of "the Aesthetic5" in the Environment
Human tribes, cultures and societies may have evolved and survived through time because we are biologically organized with an imprinted aesthetic template. Dissanayake (1992) states that social organization and order comes from aesthetic activities and that the appetite for art is, and always has been, fundamental to human existence. She theorizes that an aesthetic sensibility cannot be understood apart from other biological systems and functions, and argues that humans have aesthetically determined needs that are imprinted and inherited as part of our human biological template. If her theory is correct, our aesthetic (sensibility) is biologically imprinted in our DNA and each person is aesthetically organized in a unique manner. The point to make here is that there are multiple perspectives on what aesthetic sensibilities can be. This is important to music therapists because of the way people relate to music or do not relate to music or their environment.
Figure 2. The Aesthetic Continuum, a linear representation of multidimensional layers of experience refers to the full scope of aesthetic meaning of relationship to the environment. At the far left and up to the centre the institutional environment is primarily concerned with meeting basic needs. In order for our clients, or ourselves, to be engaged and connected in the environment, the environment must be responsive and provide a meaningful context for positive participation.
The "aesthetic continuum" is a construct to describe the full meaning of aesthetic sensibility (Woodward, 1998, pp. 57-59). The function of this linear model is to amplify the concept of aesthetic uniqueness. In the context of environmental strategies, aesthetic experiences require a meaningful connection to the environment - whatever that may be for any given individual at any given time. Many institutionalized elders spend most of their time at the left end of the continuum where there is no apparent awareness of the external environment. In the middle of the continuum, participation in the environment occurs in a pragmatic and logical manner. At the far right of the continuum there is co-creative participation in aesthetic experiences between the external and internal environments of the individual (Amir, 1997). The continuum moves through the resident's personal level of motivation, and or ability, to be engaged in a meaningful way with her environment.
Without relevant aesthetic meaning in the environment our residents will not connect to it. They will not reach beyond their inner focus of despair and depression to engage with an environment that is sterile or reflects neglect and ambivalence. Aesthetic survival is bound together in two interdependent human potentials - the aesthetic and the biological. Although many of our clients are physically and/or cognitively compromised, their aesthetic, creative and imaginal systems often remain functional. These intact systems are the material music therapists typically work with to bring integration to the whole.
Environmental sounds must fit into a contextual framework that resonates with internal referents - for all participants in the field. The Alzheimer patient gradually loses the ability to contextualize random sounds in the environment. He or she cannot appropriately rationalize unrelated external stimulants with internal referents - especially in large, shared open spaces. Through music and intentionality, music therapists can - and do - offer immediacy, context and reciprocity to the sound experience.
Sears (1968/1977) proposes three kinds of experiences that occur in the process of music therapy: experiences within structure; experiences of self-organization; and experiences of relating to others. These experiences are facilitated through properties inherent in the music itself, listening to music, having music in the environment, and the making of music. The structure inherent in music influences time-ordered behaviour, reality-ordered behaviour, and ability-ordered behaviour. These defined experiences within music therapy processes helped to establish a framework for this particular environmental approach.
Implications for Practice
Programming for the environment requires consulting the material identified in the Emergent Voice. The Emergent Voice6 revealed that agitated, withdrawn and disempowered behaviours were prevalent in the environment (see figure 1) while active listening behaviours were absent. It was clear that specific programming could address each of the elements in the Emergent Voice while collectively addressing the underlying behaviour of "not listening." The four main program types are: SunDowning Groups; Expressive/Creative Music-Making Groups; Listening to Music Groups; Meal Time Music.
The Sundowners Group uses music with aesthètic intentionality for self-organization (Sears, 1968/1977) for agitated and disruptive behaviours. The agitated resident is unable to self-organize, particularly in the afternoons and evenings. Through a process called "conscious therapeutic feedback loops" (Woodward, p.84) the music therapist influences the environmental field through the structure of the music and her therapeutic aesthetic intentionality. From an environmental perspective, the desired outcome is a sense of cohesiveness and relaxed awareness amongst the participants, a place where all behaviours can exist together in acceptance. The structure inherent in the music and the shared aesthetic experience provides affectively ordered behaviour (Sears, 1977).
The Expressive, Creative Music-Making Group (called "The Troubadors" in this instance) infuses the environment with the aesthetic of the elders and addresses the disempowerment portion of the Emergent Voice. Disempowerment and anger are often the result of not being heard, not having a means of making a difference, and not having a process in place to make choices. There is also the awareness that there is no future - nothing to project today's actions into. This program works on communication, leadership, emotional expression, mastery and group process. The Troubadors often perform for other residents at special events and have been asked to perform annually for the Hospital Foundation AGM meetings as well as for HRH Prince Charles during His Royal visit in 1998. In short, the elders are being heard in their own environment.
Receptive listening groups can profoundly influence the environment because they create a palpable listening zone that is modeled by the residents themselves. Listening is infectious. It is also visibly and palpably sacred. The quietude from listening is different from the lassitude often witnessed in ECU. The act of listening is in itself a sacred connection to the environment, to the self (Sears, 1968/1977) and to "other". After observing the responses by the residents to this program, one nurse related to the others "It was as though the hand of God touched them on their shoulder." This deeply meaningful group can be experienced and shared by residents at all levels of awareness and functioning.
The mealtime music program addresses withdrawn and isolated behaviours by infusing the environment with aesthetic influences. It also speaks to the aesthetic bankruptcy of institutional environments and the spartan functionality of mealtimes. Compact discs (CDs) were compiled with attention given to the order and choice of elements in the music. Consideration was given to what might relax the staff because their behaviour in the dining room was also critical to creating a relaxed environment. If staff were calm, it increased the likelihood that the residents would also be calm. The CDs were to be played 30 minutes prior to mealtimes to allow the aesthetic influence to have affect prior to the kitchen staff arriving. The CDs are useful tools to restore aesthetic normalcy to the environment after a special event. The vacant let-down that follows high energy events can be softened by putting on one of these CDs 5 minutes after the event has been cleared away.
Many staff were supportive and appreciative. Nurses reported that they were particularly helpful to calm agitated residents in the special care wing. At the time of this writing, nursing and rehabilitation staff in six of the dining rooms ensure that the music therapy CDs are on at mealtimes. The successful outcome of this program is that staff began to take responsibility for, and an interest in, the sound environment. Their "aesthetic" was now assisting environmental healing.
Environmental programs fit very well into client-focused practice because the intentional use of music is tied to a reciprocating process between resident and environment. The use of the organizing principles in music the contextual placement of music, the aesthetic qualities in music, and processes in consciousness are no different for the environmentally conscious music therapist than they are for the client-focused music therapist. Intentionally placing these fundamental properties in the participating field provide organizing elements and "meaningful relationship for the self and for the whole" (Sears, 1968). In terms of the environment, the aesthetic nature of music contributes to a shift from disinterest in, withdrawal from and conflict with the environment towards a shared conscious aesthetic experience.
Figure 3. The Transformed Emergent Voice During Treatment Sessions.
Transformation in disruptive behaviours such as agitation, withdrawal and anger is an undebatable outcome for treatment planning. A transformed Emergent Voice may indicate that healthier listening behaviours and awareness are present in the system. There is more purposeful activity and participants are physically, emotionally and/ or cognitively involved in their environment. In this representation, the Emergent Voice has become more balanced with new behaviours.
Other types of programs
Spontaneous music happenings in common areas and rhythm bands create an immediacy in the environment that is infectious. "Listening zones" in varying areas of the residence (kitchens, wards, common areas, traffic areas) can be established periodically to invite new listening behaviours to emerge in the environment. Some music therapists play live music in the dining areas at meal times. They feel they are better able to sense the emotional climate of the residents and can adjust their music accordingly.
Music therapists might be inspired by the open and inclusive format offered by Baines (2000) or the more structured model for choir groups used by Summers (1999) - in building a sense of community. Baines uses a feminist perspective, and proposes that music therapists are the catalyst in how connective, and therefore how transformative, sing-a-longs (for example) can be. In Summer's model, choir members develop a sense of belonging through their participation and their contributions to the global experience of all.
Reiteration
We cannot determine how each resident processes auditory stimulus and we cannot blame a marginalized environment for all disruptive behaviours, but we can rationalize that behaviours of withdrawal or agitation might be measured against global listening behaviours in the environment and the quality of the Emergent Voice. My perception is that the global habituation of "not listening" contributes to undesirable behaviours and a generalized disconnection from external events. There are other realities that drive some behaviours in any given system and this paper cannot conjecture about the reciprocal nature of those realities. But the behaviour of "not listening" at staff levels radiates outward and permeates the everyday quality of life issues of the resident. Systems thinking does not look for a culprit or perpetrator. Boundaries between systems are illusions and so, the ripples of these realities are felt everywhere.
Ultimately, it really is the responsibility of all participants in any given field to contribute to a healthy sound environment. The question that music therapists need to ask of themselves is what part do they want to play in the transformation of the environment? It takes one ripple to begin the flow. Schafer (1977) regards the soundscape of the world as a huge musical composition in which we are simultaneously the composers, performers and audience (p. 205). So the final question may be: is the soundscape of the institution an indeterminate composition over which we have no control, or are we its composers and performers, responsible for giving it form and beauty?
References
Amir, Dont (1996). Experiencing Music Therapy: Meaningful Moments in the Music Therapy Process. In Langenberg, M., Aigen, K. & Frommer, J. (Eds.). Qualitative Music Therapy Research: Beginning Dialogues (pp.109-129). Gilsum, NH: Barcelona Publishers.
Baines, Sue (2000). A Consumer-directed and Partnered Community Mental Health Music Therapy Program: Program Development and Evaluation. Canadian Journal of Music Therapy, Vol. VIII, no. 1. pp.51-70.
Bentov, Itzhak (1977). Stalking the Wild Pendulum: On the Mechanics of Consciousness. VT: Destiny Books.
Berleant, Arnold (1970). The Aesthetic Field. Illinois: Charles C. Thomas.
Berard, Guy (1993). Hearing Equals Behaviour. New Caanon, CT: Keats Publishing mc.
Capra, Fritjof (1995). The Web of Life. New York: Doubleday.
Dissanayake, Ellen (1992). Homo Aestheticus: Where Art Comes From and Why. New York: The Free Press.
Idhe, Don (1983). Sense and Sensibility. Atlantic Highlands: Humanities Press Inc.
Kenny, Carolyn B. (1989). The Field of Play: A Guide for the Theory and Practice of Music Therapy. Atascadero, CA: Ridgeview Publishing.
Langenberg, Mechtild (1996). Fusion and Separation: Experiencing Opposites in Music, Music Therapy, and Music Therapy Research. In Langenberg, M., Aigen, K. & Frommer, J. (Eds.). Qualitative Music Therapy Research: Beginning Dialogues (pp.131-160). Gilsum, NH: Barcelona Publishers.
Leonard, George (1978). The Silent Pulse. New York: E.P. Dutton.
McMaster, Nancy (1996) Music Therapy: A Partnership of Listening Using Sound and Silence to Restore and Expand a Resonance of Being. Unpublished thesis, New York University, New York.
Sears, William (1996). Processes in Music Therapy. The Nordic Journal of Music Therapy, 5 (1), 33-42. (Original Work published 1968).
Schafer, M. (1977). Our Sonic Environment and the Soundscape: the Tuning of the World. Rochester, VT: Destiny Books.
Summers, Susan (1999). A Tapestry of Voices: Community Building With a Geriatric Choir Reflected in a Music Therapy Model of Practice. Unpublished master 's thesis, Open University, Vancouver, British Columbia, Canada.
Tomatis, Alfred (1991). Chant: the Healing Power of Voice and Ear. In Campbell, D.G. (Ed.). Music Physician for Times to Come (pp.11-28). Wheaton, IN: The Theosophical Publishing House.
Weeks, Bradford, S. (1991). The Physician, the Ear and Sacred Music. In Campbell, D.G. (Ed.) Music Physician for Times to Come (pp.29-54). Wheaton, IN: The Theosophical Publishing House.
Woodward, Alpha (1998). The Emergent Voice: A Systems Theory Perspective for Environmental Music Therapy Strategies in an Extended Carefacility. Unpublished thesis, Open University Vancouver, British Columbia, Canada.
