A Personal Experience in the Process of Implementing Music Therapy in a Hospital in Brazil

By Cristiane Ferraz

Introduction

In Brazil, until the mid 1990's, the use of music therapy in a medical setting was more concentrated on psychiatric hospitals. When music therapy entered general hospitals, its use was to provide diversion and nurturance to the patients. Music therapy served humanization purposes. Its integration in a medical setting as part of a multidisciplinary team is still new, gradually taking form and adjusting to the needs of a general hospital.

When I was asked to write a paper on music therapy and medicine, I examined my personal process in the development of my practice as a psychologist and a music therapist. In Brazil, the work psychologists do in hospital settings is called psicologia hospitalar,^[1] so it felt natural to me to consider what music therapists do in a hospital setting "musicoterapia hospitalar": a modality that integrates medical music therapy, music psychotherapy and music medicine. It seems to me that each one of those approaches can make a therapeutic contribution to a hospital setting; nevertheless, they work differently according to the unit (surgery unit, neurology unit, oncology unit, pediatric unit, intensive care unit, etc.) and the patients. In the following paragraphs, I will share, according to my experience, the contributions each one of those approaches can offer to patient's medical treatment in a general hospital.

In São Paulo,^[2] at Albert Einstein Hospital, music therapy is a new modality, part of the Mental Health Department, which consists of psychologists, psychiatrists, neuropsychologists, music therapist, and interns in psychology and neuropsychology. Since I am back in Brazil, after my experience in New York, I have concentrated on the integration of music therapy in a hospital setting.

The Beginning of my Music Therapy Journey in New York

Medical Music Therapy

I attended a masters program at New York University (NYU) and did my internship at Beth Israel Medical Center where I learned from Dr. Joanne Loewy and Jeanette Rodriguez. Dr. Loewy developed medical music therapy validating the idea that medical goals can be reached through the incorporation of psychotherapeutic principles into medical practice through music therapy (Loewy, 1997). The work we did in New York was focused on the use of live music with special attention to the use of improvisation to promote integration of the hospital experience, well-being and healing. During that phase, I focused on pediatric patients, developing a great interest in music therapy working with pain and palliative care, based on the premises of Dr. Loewy's approach. After that, I worked at Mount Sinai Medical Center, also in New York, learning about child life interventions and developing my work with music therapy in a pediatric setting.

There, I worked mostly with critical patients in the Intensive Care Unit, and chronic patients who frequently were in the step-down unit. There were a lot of painful procedures involved in both cases, but in different contexts. The goals with chronic patients were usually focused on facilitating the integration of the hospital experience in their lives, providing ways for them to strengthen their egos, face the disease and better cope with the situation. Whereas the goals with patients in acute care were more concentrated on reducing the traumatic impact of the hospital stay by fostering safety and a means to express their feelings about their difficult experiences through music.

Music Medicine

In the pediatric intensive care unit for cardiac patients, we frequently attended babies. The nurses were very attentive to the importance of humanizing the environment for patients and families. Comforting the babies with recorded music seemed efficient not only to foster safety and nurturance to them, but also to reduce the level of noise in the unit I was consulted to select appropriate music for the babies. I consider this type of intervention music medicine, where the relationship therapist-patient is not primary, but secondary to the music's capacity to create a special environment. The focus is the use of music and its properties in order to provide physiological change and to promote general well-being.

Music Psychotherapy

During the masters program at NYU, I began studying music psychotherapy, which combined making and listening to music in order to evaluate and treat specific issues. It seemed to me to be an efficient approach with chronic teen-age patients during long and/or frequent hospital stays. There were always many aspects to deal with in the process of the illness and the treatment that it was not only important to facilitate the painful procedures and reduce the impact of trauma, but also crucial to provide means for the elaboration of the experience patients were living in a way that would strengthen their egos and help them face the disease.

The Continuation of the Journey in Brazil

Medical music therapy and music psychotherapy have been the focus of my work. Live music-making either with or without the active participation of the patient (and family members) is the center of the sessions. The patients, their treatment plans and the goals of music therapy guide me in developing an approach focused more on the medical aspects or on the psychological aspects of each case. Obviously, the power of the properties of sound and music are always considered in the interventions of medical music therapy and music psychotherapy.

The instruments used in the sessions are: acoustic guitar, xylophone, shakers, tambourines, drums, gato drum, bells, Tibetan ball, chimes, guiro, rain stick, ocean drum, "shrudy" box, and cowbell. The instruments, cleaned before and after the sessions, are taken to the patients' rooms when they cannot go to the music therapy room.

After returning to Brazil, I worked for one year in a neurological intensive care unit, at Hospital da Beneficência Portuguesa, (HBP). There I was able to stretch my learning experience and work with adults going through critical medical conditions. This was the beginning of the challenge of bringing what I learned in New York to Brazil and adjusting it to the reality of the hospital. This process included introducing the team to music therapy and earning their respect by obtaining results with the interventions. I believe that the meetings with doctors and nurses in which they explored musical instruments, and felt the benefits of music making were very valuable to the process of implementing music therapy. The fact that they could experience music therapy and find their own conclusions reinforced their opinions about providing this service to their patients.

The neurological intensive care unit at BPH contains 9 beds. Three times a week, I would come in, talk to the doctors, talk to the nurses, learn about the patients' conditions, set priorities concerning which patients should be seen and in what order. In consultation with the team, I would develop strategies to work with these patients. Depending on their conditions, I would focus on pain relief, sedation, promotion of security and comfort, or appropriate music stimulation for patients emerging from coma. The instruments used were an acoustic guitar, small percussion instruments (shaker and bells), and an ocean drum.

Subsequently, I went to Albert Einstein Hospital and the Mental Health department, where the challenge got bigger: to integrate music therapy into the hospital setting, as an approach that could be used in collaboration with other modalities (physical therapy, neuropsychology, psychology, speech therapy, etc.), focusing on treatment to provide recuperation and healing. The goals for music therapy in this setting were not based on humanization. Music therapy was considered a modality included in the treatment plan and in the medical bill as a therapeutic session.

The strategies developed to reach this goal included offering in-service training for medical staff, participating in multidisciplinary meetings, and developing music therapy groups for patients and families.

My first concern was that music therapy should be respected as a serious modality, with its unique contributions. The two floors elected by the department for music therapy to be more present were the oncology and the neurology floors. Psychologists and neuropsychologists were the first to refer patients to music therapy, followed by doctors and nurses. It felt like a sign of support and encouragement to have my first referrals coming from my department colleagues.

The process of educating and introducing the teams to music therapy, in combination with the results we were getting after the patients sessions, expanded the area music therapy was serving. Other units (dialysis, neonatal, pediatrics, intensive care unit) began to request music therapy services through referring psychologists on each unit. Music therapy group projects were developed to address needs that could be better addressed with music therapy. In addition, the pediatric unit was requesting music therapy to provide individual sessions for children in pain and/or traumatized by the impact of the hospital stay and/or to help patients with invasive procedures. And doctors responsible for the Programa de Álcool e Drogas, (PAD),^[3] started requesting music therapy services for patients attending their treatment program.

With only one music therapist in the hospital, the department agreed that groups would be a more effective way of providing music therapy to the patients on other floors. Individual sessions are offered based on referrals by the multidisciplinary team from the 6th and 11th floor (oncology and neurology). When staff members identified a patient who might benefit from music therapy, they usually call the department or they request a psychological evaluation in order to determine which intervention would be more appropriate. When requests come from the ICU, Intensive Care Unit, PAD or pediatrics, the cases are discussed and if they fit the schedule they are seen on a priority basis.

After the first session, which is focused on an evaluation of the patient (that usually follows a model developed by Dr. Joanne Loewy - "Tour of the Room" - adapted to the context of the hospital), goals are set and a treatment plan is developed. The sessions are registered in the charts, in order for the medical team to be aware of the music therapy processes their patients are going through.

Music medicine is also part of the process of "Hospital Music Therapy." At Albert Einstein Hospital, we are developing a program centered on the needs of family members who have dear ones in the Intensive Care Unit. The program is called "Centro de Atenção aos Familiares."^[4] This will be a space where the family can find comfort and security. A music selection developed in order to provide general well being will be playing three times a day, around the visiting scheduled hours, helping to decrease anxiety levels, fostering calmness and patience.

Final Considerations

It seems to me that when music therapy enters a general hospital environment, it encourages the contribution of music medicine, medical music therapy and music psychotherapy. Each medical department, each patient, each situation is unique and requires a particular approach to the work. It is not a matter of only using a certain approach. It is a matter of knowing the institution, the people we are working with (patients and staff), the needs they present, and our goals. According to that and based on our therapeutic and music principles, we can develop a plan of intervention, attending to the requests we have for ourselves as music therapists, our commitment to our work, and the demands of the institution.

I believe that the course of music therapy in Brazil is unfolding and expanding in a very creative and committed way. The role music therapists are taking in general hospital settings can still be very different; some are more focused on humanization purposes, some more integrated in the use of music medicine, and some more concentrated on medical music therapy. It seems to me that we are going through a transition phase. It is a time in which we can design, in a more organized and structured way, the function of music therapy in a medical setting. This could contribute to the treatment of the patients, not only with the idea of providing a distraction, but especially with the concept that music used as a therapeutic tool can provide more than a humane environment. It can provide recuperation and healing.

For me, this time of implementing music therapy at Albert Einstein Hospital has been a time of defining what I was used to calling "musicoterapia em medicina."^[5] From my perspective, "musicoterapia hospitalar" seems to be a name that defines the work music therapists do in a general hospital setting in Brazil. It is an attempt to design our role in an institution centered in the disease of the body and how we can serve the patients, connecting body, mind and soul, bringing health and a unique contribution for the medical setting.

Notes

1) Psicologia hospitalar: hospital psychology. Musicoterapia hospitalar: hospital music therapy

2) São Paulo is the second biggest city of Latin America with approximately 10.500.000 habitants according to the census of 2000.

3) A program developed to assist patients suffering from alcohol and drug addiction.

4) Centro de Atenção aos Familiares: Care Center for Family Members.

5) Musicoterapia em medicina: Music therapy in medicine.

Reference

Loewy, J., MacGregor, B., Richards, K., Rodriguez, J. (1997). "Music Therapy and Pediatric Pain Management: Assessing and Attending to the Sounds of Hurt, Fear and Anxiety." In: J. Loewy. Music Therapy and Pediatric Pain. Cherry Hill, NJ: Jeffrey Books.