Action / Relationship / Communication: A Music Therapy Method for Schizophrenia

By Clarice Moura Costa & Martha Negreiros Vianna

Abstract

The author states that music therapy has an important role in the treatment of negative symptoms of schizophrenia. The article describes the method Action / Relationship / Communication (ARC), its theoretical basis, and the procedures in Music Therapy sessions. Examples of the clinical practice are provided.

Keywords: Music therapy, schizophrenia, method, action, relationship, communication.

Introduction

Our clinical practice began in 1980 with psychotic patients, most of them presenting schizophrenia and undergoing treatment in the Psychiatric Institute of Rio de Janeiro Federal University. While performing our clinical tasks, it has been noticed that patients initially referred only to music and the pleasure they experienced when making it. Later on, they began mentioning the other group members and, even further along the process, speaking about their own feelings, emotions, and conflicts. Therefore it was raised the hypothesis that this would be a regular development of the music therapy process. After an extensive bibliographical survey, nothing was found on this line, what led us to suppose that our patients' evolution was a consequence of our procedures. Between 1980 and 1988 we organized these procedures developed from clinical practice and research, into a method (Action/Relationship/Communication) which is still being currently employed. It was not intended to create a model, which according to Bruscia (2000) always refers to a specific theory, while method doesn't establishes any particular theoretical orientation.

According to Bruscia, definitions of terms like method, procedures and technique can be relatively arbitrary, so it is important to differentiate and clarify the author's understanding about them. We recurred to Lalande (1967) in his Vocabulário Técnico y Crítico de la Filosofía (Technical and Critical Vocabulary for Philosophy), to make clear what we understand as method, procedures, and techniques:

Method: "a path through which some results are reached, even when said path was not fixed on advance in a deliberate, reflexive way." Also, "the use of procedures that can be observed and defined by induction, either to practice them later with more assurance or to criticize the same and render evident their lack of validity."
Procedure: "a means of acting which is usually employed in scientific methods. The word is mostly used in the plural, so as to indicate those steps that must be followed in a regular basis."
Technique: the term is not defined in this vocabulary for philosophy, but we gathered the following definitions for it: "A set of processes found within an art or a science" (Novo Dicionário da Língua Portuguesa [A New Dictionary for the Portuguese Language], n. d.); or "A set of procedures and methods employed by an art, a trade, or an industry" (Petit Larousse [Abridged Larousse Dictionary], 1991).

The terms, method and technique, overlap each other and this may lead into some sort of confusion, therefore we opted for herein using only method and procedures.

A method is not a recipe to be faithfully followed, taking all the steps suggested by it. Each music therapist has his/her own intuitions, his/her own sensitiveness to decide how to proceed according to the moment and the context. We underline that this is a method, not a model of Music Therapy.

As refers to the terms, action, relationship, and communication, the following meanings were adopted:

Action: the capacity of voluntarily performing something (in opposition with the immobilization or the purposeless movements of psychotic people);
Relationship: connection and interaction of the subject with the people around him or with the surrounding environment (in opposition with the psychotic's social isolation);
Communication: The act or effect of emitting, transmitting, and receiving messages by means of conventional methods and/or processes, either through spoken or written speech or by means of other signs, signals, or symbols.

Music is here considered as a specific code that makes up a particular language that allows emitting, transmitting, and receiving messages. Besides, songs simultaneously employ music language and verbal speech, thus helping to transmit the messages one wishes to express.

The Problem of Schizophrenia

Schizophrenia is still a subject for study by psychiatrists, neuroscientists, psychoanalysts, and psychotherapists of different currents of thought, but still no final conclusions were reached about its etiology. Despite all the advancements in the field of neuroscience, the schizophrenic psychosis is still taken to be a complex disturbance that challenges scientific explanations. As long as no particular cause for the onset of this disorder was detected, neither any treatment was found as an effective cure for this particular illness.

Schizophrenia diagnosis was reached by the so-called productive symptoms – delusions and hallucinations – but from the 1980s on was introduced the notion of positive symptoms (delusion and hallucination) and negative ones and the latter were officially included in the DSM-IV [1] criteria, published in 1994. Currently, the negative symptoms are sorted out as primary and secondary. The primary ones include blunt affect, little or no communication, emotional and social withdrawal, poor social skills, alogy - illogic thoughts, anergy - lack of energy, anedony - lack or difficulty to enjoy pleasure, avolition - lack of will, apathy, and cognitive dysfunctions. The primary negative symptoms frequently are manifested in schizophrenia's prodromic or even pre-morbid phases. Secondary negative symptoms are the same as those listed above and so considered when resulting from positive psychotic symptoms or from medication side effects (Elkis, 2000).

Neuroleptics introduced from the 1950s fulfilled an important role in the remission or softening of positive symptoms, but they provoke collateral effects, some of which serious, among them the onset of negative symptoms. In the 1990s, second generation (or atypical) antipsychotics were introduced and these are the choice treatment to date, for their lesser introduction of side effects and for their good responsiveness to some secondary negative symptoms as well. Nevertheless, their effect upon the primary negative symptoms is so far unproved.

Since the 1980s, it came to be accepted that the complexity of psychoses could not be healed exclusively with drug therapy, and that psychotherapies alone could not substitute medication. The controversy, drugs versus psycho therapy, originated a great number of scientific studies and these led to the integration of both lines of treatment. Currently, there are a great number of experts who claim to be important adopting an integrated program, offering for the long-run amelioration of schizophrenic patients medical and psychological treatments, besides other therapies, as well as family support.

The Brazilian Psychiatric Reform, which began on that decade, considers that people bearing mental disorders needs, like any other human beings, a modicum of satisfaction in their emotional, intellectual, social, familiar, and professional dimensions, something that is hampered by hospitalization conditions. This led into a diversification of alternatives to internment, like Day-Care Wards, Psycho-social Attention Centers, and others. These new facilities offer a therapeutic, pluralistic disciplinary intervention targeted to face the complexity inherent to schizophrenia – and music therapists belong in these teams.

The ARC Method

Methods are chosen according to goals and the expected treatment period. The ARC Method was created from clinical work with groups of psychotic patients, most of them schizophrenic. It is a non-directive method, based upon music-making, which is intrinsically interactive, involving the group, each patient, and the music therapist(s) into the music production.

The goal adopted by the method is that of trying to supply by musical activities other ways for the schizophrenic subject to be and to remain in the world, acting upon the negative symptoms presented by the illness – stimulating the capacity for acting out and the pragmatism, alleviating lack of energy, will, and pleasure, fostering new ways for social circulation, and trying to lead into a verbal communication closer to the socially accepted language code.

The method is non-directive in order to grant freedom of choice to the schizophrenic patients who usually suffer of diminished capacity for taking initiatives, resulting from their avolition – lack of will. His freedom for choosing instruments, tunes, and space arrangements (the therapy room is arranged by the patients themselves) will concur to increase their initiative capacity and their pragmatism as a natural consequence. De Backer (2004) states that the clinical design must be developed in response to the patients, rather than the subjects having to comply with a pre-determined design. The freedom of choice, in contrast with the passive acceptation of the therapist's leading, turns out to be important to those people who are greatly limited in their daily activities. Noone (2009) states, "the experience of choice becomes important because it expresses and defines an identity", something jeopardized in schizophrenic patients.

Music induces to movement for its rhythmic aspect and, along with melody and harmony, it can be considered as a language allowing for the expression of feelings and emotions, without requiring coherence in its discourse, as happens in the verbal daily speech. Besides the tunes, the method is supported by sung lyrics or spoken words, its playful features, and on the spontaneity of improvised creation, all of which characteristically enclose the achievement of pleasure. Pleasure and displeasure are pointed out as important factors for the development of the psychic life by authors from manifold areas of knowledge (Freud, Aulagnier, Damásio, and others). Pleasure is also important for its capacity to cope with psychotic difficulty to enjoy anything.

In the ARC Method, the freedom of choice within music-making joins the pleasurable experience, thus contributing to afford the psychotic subject new ways of relating to the other and with the surrounding reality.

Action, relationship, and communication are inherently interconnected, but they will be described in a separate way along the next sections. Music-making is the central axis for this method and around it will spiral-like develop all interpersonal relationships and the communication with one another, so Action deserves a more detailed study and the support of different theoretical approaches whose authors states its importance in human life.

Action

The ARC Method starts by attempts to induce the patient to the action of music-making. Stimulating into action is particularly indicated with schizophrenic patients who often present an important negative symptom, lack of energy, lack of will, and a great loss of initiative.

Some patients present no initiative for playing or singing in the first sessions, or only do it mechanically or repetitively. This was pointed out by De Backer (2004) on his research about music and psychosis, who describes this as "an endless repetitive play of certain rhythms or melodic sequences or a fragmented musical play", stating that to be a characteristic in psychotic patients.

As the ear has no sphincter, the music performed by the group members provokes a vibration on the eardrum for its acoustic qualities and the nerve ends send this information directly to the brain. Therefore, even when a patient apparently is not participating in the session, s[he] is reached by the music and "the most important in the musical experience is not the information […], but that which is being experienced in the presence of music." (Queiroz, 2003, p. 43).

The power of rhythm to stimulate and organize motor action is empirically known ever since immemorial times. Isochronic-rhythmical tunes are used as stimulation for the participation of people into physical activities, like in military marches and work songs, as well as in gyms etc, and that is not by chance. Rhythm makes up a part of our existence ever since intrauterine life, when the fetus listens to both his/her own and his/her mother's heartbeats and visceral noises, as well as to the mother's respiratory rhythm and also captures sounds external to her body. At birth, the baby is already equipped for sound perception, all the while the other senses will take some time to develop into their established forms. In the case of psychoses, the importance of hearing can be ascertained by the larger incidence of auditive hallucinations in comparison to those felt through other senses.

Rhythm controls human physiology and can be found in breathing, speech, heartbeats, in the pace of their locomotion and so forth, for the duration of their existence. Janzen and Ranvaud (2008) quote several neural-scientific studies on rhythm and music. One of the mentioned studies (1982) points out that some activities, like the pace in walking, heartbeats, and others, present a spontaneous tempo and that human beings tend to create rhythms of two or four pulses, less frequently those of three beats, something the authors dubbed subjective rhythm-making. Another research quoted by the above authors (2006) shows that people easily synchronize their movements to regular sound rhythmic sequences, thereby suggesting that they are able to anticipate the rhythmic stimulus and to send out motor commands to coordinate with precision their movements to said stimuli. Other studies quoted by the same survey (2005) underline that synchronization with aural stimuli seems to be more precise and less variable than that with visual stimulation.

These and other studies led to the supposition that there are neurological clocks for the control of time and that these are important in the motor control allowing precise movements in time, something fundamental for the tempo of music performance and, as our purposes are concerned, for stimulating the schizophrenic individual into acting.

Music action, i.e., music-making, core and propeller of all the music therapeutic processes spanned by the ARC Method, must be wrapped in pleasure so as to oppose to another negative symptom, the schizophrenic anedony. During research performed in the Psychiatric Institute of Rio de Janeiro Federal University from 1982 to 1988 (Moura Costa & Negreiros, 1984; Moura Costa, 2010), frequent allusions to pleasure were made by schizophrenic patients, usually immersed into deep mental suffering, during the final comments for the sessions and this called the attention of the researchers [2]. According to Freud (quoted by Laplanche & Pontalis, 1986), pleasure is the regulating principle for the mental functioning and displeasure is present from the beginning of life. He considers that the non-fulfillment of vital necessities provokes a state of high excitement leading into an unpleasant level of stress. The fulfillment of same needs reduces this tension and introduces pleasure. Step by step, as the outer reality is imposed upon the psyche, the principle of reality is built and this offers new, socially-acceptable strategies, to obtain or postpone pleasure, but not to exclude it.

Fechner (quoted by Laplanche & Pontalis, 1986), an author who influenced Freud himself, has stated a "principle of pleasure in the action." He understood that our acts are determined by the pleasure or displeasure propitiated by the mental representation of the action to perform or by its consequences. He observes that this motivation might not be consciously perceived. This postulate presents some similitude to the principle of cognitive-behavioral therapy which states that the operating behavior (i.e., the action) modifies the environment and that the future probabilities for an operant to occur again depend on the consequences which were generated by it (Skinner, 1953). When the action was shown to be pleasurable, there is a greater probability for it to be repeated.

Damásio (1996) states that pain and pleasure are not symmetrical images as refer to their survival-supporting role and that it is the information associated to pain that dissuades us from the imminence of danger. We believe ourselves that, although pain is necessary to activate survival mechanisms, living means much more than surviving for the human being. We live and a large part of human activity and emotions are not motivated by the need for survival. Art, passion, love, sacrifice, heroism, and so on, are actions or emotions that reach much further than the mere survival. For instance, in a very crass level, we do not eat only for feeding – a vital need – but also to taste different flavors.

It is important to observe that a constant pleasurable state would become a "background state", according to Damásio (1996), leading to the loss of the pleasant sensation. Pleasure and displeasure are both necessary for the development of a human being or, like states the author, pain and pleasure are "the levers for development."

Aulagnier (1979) postulates pleasure to be the first investment bringing the baby up to reality. We believe that the pleasurable experience can afford the same meaning to the psychotic patients, immersed in their delusion and hallucination filled world, for it supplies support against the frustrating or unpleasant situations in life (Moura Costa, 1989, 2008).

It was possible to watch in the patients the pleasure in making during the initial moments of therapy, but not the realization that this pleasure derived from their action, i.e., that the music was being produced by themselves. According to De Backer (2004), "the sounds remain outside the patient and do not have any connection to him."

In a second moment, there is an evolution in the music therapeutic process for that which we named, the making of pleasure, when the patients come to realize that it is their own action that is producing the music they are listening to. The pleasure in making felt by the patients in the first moment provides this evolution into the perception that their actions are necessary for this pleasure to come into being.

It has been noticed along more than twenty years of clinical practice with groups of psychotic individuals that even those patients who presented no initiative at all, after two or three sessions began to actively participate in the group activities.

This increase in activity and initiative, which is observed in the very first sessions, will not be immediately reflected out of the music therapy setting. In another research performed in the Rio de Janeiro Federal University Psychiatric Institute (Moura Costa & Negreiros, 1984), it was verified that music therapy patients who had attended up to six music therapy sessions did not show significant changes in comparison to the control group in relation to present the initiative of leaving their wards and going out to the open court. Nonetheless, those patients who attended a greater number of sessions stayed with day care treatment as outside patients after checking out from the hospital in a larger percentage than every other inpatient, which indicates a greater capacity of taking the initiative of commuting from their homes to the day-care ward and longer adhesion to their treatment.

In synthesis, the pleasant action of music-making will contribute to alleviate anergy, avolition, and anedony symptoms presented by schizophrenic individuals.

Relationship

The schizophrenic persons present social withdrawal and poor social skills, as they live in their own private world.

As stated above, people attending a music therapy group hear the sounds that are being produced by that group. However, psychotic patients, often caged in their private worlds, despite the fact that their aural channels are impressed by the produced sounds, do not listen to them, that is, no meaning is thereby attributed by them, not even acknowledging the presence of other people in the room or anything else exterior to themselves.

The person that looks for music therapy must be listened so that s[he] may be cared for and this is the music therapist's task. But the possible changes within the patients only can occur when they listen, instead of only hearing. The music therapist's role is that of leading them into listening to themselves and to the others around them (instruments, tunes, and people). De Backer (2004) states that in the beginning of the therapy "there is an absence of shared playing and inter-subjectivity with the therapist in the sense that the patient does not engage in the joint music." Whenever listening is begun, music begins to be shared, and music-making stops being a self-centered action growing into an acting with that affords the awakening to the others, the interest for relating (interaction of the subject with the people around him/her and with the surrounding environment), and for the communication, three aspects that are intrinsically interconnected.

Group music living favors re-socialization. Playing, singing, listening to oneself and the others, choosing tunes, some music instrument, the way to play it, and then having one's expressivity welcomed by both the music therapist and the group render interpersonal relationships easier. A psychotic tends to avoid direct contact with other people and the use of music mediates this contact. According to Gold, Heldal, Dahle & Wigram (2005), music therapy helps people with serious mental illness to develop relationships they may not be able to using words alone.

As highlights Barcellos (2009), re-creation, that is, the reproduction or interpretation of tunes, is the predominating musical experience in Brazilian music therapy clinics. According to Queiroz (2003), "In a song the delimitation of the lyrics and the flowing unity of music notes act together. […] A tune's therapeutic power surfaces from this sum of qualities shared by music and verbal speech." We have observed that frequently during sessions some of the patients welcomed other group members (including music therapists) with songs that they had figured as representative of them.

We also verified from the above mentioned research (Moura Costa & Negreiros, 1984), that social interactions experienced by schizophrenic patients during music therapy sessions have allowed for the amplification of their social circulation inside other environments at the hospital. After only six music therapy sessions, a meaningful difference was perceived among the subjects included in the music therapy group in comparison to those in the control group as refers to social interactions. This was confirmed both by the patients' answers to a questionnaire elaborated for the research purposes and by the music therapists' own observations, noticing that the music therapy patients while in hospital court could be seen in company of other people more often than the control patients. Results have shown that music therapy significantly influenced in the sense of increasing interpersonal relationships during the internment period and later into a longer adhesion to the day-care ward treatment.

Communication

Little communication, little mental organization, and illogic thoughts are some of the negative symptoms for schizophrenia. According to Gold et al. (2005), music therapy is a psychotherapeutic method that uses musical interaction as a means of communication and expression.

An important task to be undertaken by the music therapist working in the mental health area is that of trying to establish a path for communication with the psychotic person. Communication can be defined in a simple way as the exchange of messages between people. Communication sets in when the receiver(s) understand the message sent by the emitter. For this to happen, it is necessary the existence of a common code. An example can be taken from warfare, when codes are created to prevent the enemy side to access messages exchanged by allies. Each schizophrenic person individually alters the social code, thus rendering harder the comprehension of messages sent. Therefore, it is necessary to find a way to decode them.

Music is a specific code, a language made up by sounds and silences, as well as by pitch, tone coloring, intensity, texture, and rhythm. Tones presented in an orderly sequence, subjected to rules and laws of music composing, possesses a meaning which will be attributed by either the performer or the listener, according to the moment and the private history of each one (Moura Costa & Negreiros, 1984). Music bears within itself several expressive or significant possibilities. Sense-giving by the subject is broader than in verbal speech, but not limitless, for it is intrinsically bound to the music's formal structure and to the tune's fabric (Moura Costa & Negreiros-Vianna, 1984).

As states Barcellos (2009), "whatever the experiences the patient was compromised with while active in his music-making, these can be taken as metaphors for his/her inner world and, thus charged with meaning, they may permit the music therapist to develop a greater comprehension of their histories." According to this author, whatever is expressed through music is lived and interpreted as an expression of the patient's psyche and whatever can be observed outwardly corresponds to their inner experience. She employs the term, "narrative", for that which the patient shows and expresses out of his/her inner world and she believes that music narratives, as producing meanings, can alleviate the stress provoked by the most diverse kinds of suffering.

Each schizophrenic subject can use music as a means for self-expression (a socially non-codified way to manifest their own contents) of conflicts and feelings. Since music language, other than verbal speech, connects does not a significant to a signifier, the subject can express contradictory feelings and thoughts without any contradiction. This detachment from the word's logical meaning is adequate to the alogy found in schizophrenic individuals.

Music affects us by bringing up emotions, making memories to surface, in such a fashion that corresponds to no physical properties of the sounds themselves. Although reactions to each tune will depend on personal idiosyncrasy, on former experience, on memories, lived by each individual, music connects these reactions in a relatively strict way for a culturally homogenous population. In the quoted research (Moura Costa & Negreiros, 1984; Moura Costa, 2009) it was verified that both normal and schizophrenic subjects assigned similar emotions to four music excerpts previously recorded by the therapists, despite presenting little familiarity with them. As the only lyrics were sung in German, there was no possibility for same lyrics to induce the awakened emotions and this comes as a further corroboration to the thesis that music can in itself give hints to that which the patient feels or intends to express. The active music-making within which the patient is involved can as well express his/her inner world as a metaphor and the music narrative is charged with meaning, as states Barcellos (2009).

Brazilian music therapists lend priority to songs, as their therapeutic power springs from the sum of qualities both of music and verbal speech. Song lyrics often translate the patients' state of mind, thus making them clearer for the music therapists to interpret, who then can help the former to accept as their own the feelings and thoughts expressed.

Procedures

The group is wide open, that is, when a patient leaves it for a reason or another, s[he] will be substituted by another. Ideally, it must be constituted by eight people, to a maximum of twelve, so as to allow the music therapist pair a vision of both the group and every subject within it. The ideal group must have approximately the same number of men and women. Groups presenting a variety of ages can be very rich for the acceptation of diversity in music preference, habits, and thoughts, but is not interesting, for example, to accept one teenager in a senior group, or vice versa.

The music therapy room must be large enough to easily accommodate the whole group and also be furnished with sufficient benches or armless chairs for everybody to grab his/her own seat. Patients are encouraged to help in the organization of space, placing the benches or chairs as they best please. Instruments are selected by the therapists and they are made up by percussion elements corresponding to the local culture and at least one harmonic instrument [3]. Wind instruments are avoided for hygienic reasons. All music instruments should be exposed in an open surface for the patients easily to choose them. It is interesting to keep an open space in the center of the room for the execution of free bodily movements or dancing. However, it is up to each music therapist to choose the layout of his/her own clinical setting, according to the goals the treatment is targeted to.

Sessions are coordinated by pairs of therapists, without any role hierarchy. One of the therapists can present proposals aimed toward supplying some group need, intervene into the group dynamics, observe the group as a whole, while the other can take care of some patient that is felt to be discarded by the group or who presents trouble into following group activities, whenever s[he] considers this attitude pertinent. For instance, whenever a patient presents the need for a rather individualized attention, the therapist more connected to (s)he can take immediate charge of him/her, while the other handles group activity.

It is important to stress that the therapist pair must adopt a similar way of thinking and acting, and discuss what happened after each session, so they can most effectively work together.

Sessions

Sessions should be held twice or three times per week for the better continuance of the treatment. If fewer sessions are held than the number appointed above, when a patient misses a session, there will be a larger space of time between them leading into discontinuity. Each session takes from 60 to 90 minutes (depending on the number of participants) and is set up into two moments. The first is that of the sonorous-musical expression, lasting from 45 minutes to an hour and the second, taking 15 to 30 minutes, will be devoted to comments aimed to clarify whatever was done by each patient in the first part of the session.

The Session's First Part – The Sonorous-Musical Expression

Music therapists do not plan the sessions, but develop activities following that which is spontaneously brought in by the group. After the room is set up, one of the music therapists invites: 'Shall we begin?' and signals at the instruments. Both wait for a few minutes, until each patient has elected their instruments and freely tried them. If some patient shows no initiative to go and look for one, a music therapist offers him/her two or three of those left, to allow them a free choice. It is not rare that a patient belonging in the group for a longer time takes the initiative to bring some instrument to his/her fellow patient.

Musical resources employed are re-creation, improvisation and, more rarely, listening to some recorded tune when this is required by a patient, but never proposed by the music therapists. The latter participate as equal members in the group, playing, singing, or dancing with the other members.

The initial moment is centered in the music-making action and it falls on the music therapists the task of stimulating each patient to play, even when they are exclusively tuned to their own inner worlds. Departing from the subjects' proposals, a music therapist may include new activities considered pertinent to the therapeutic method.

In the ARC Method, the action of the music therapists is similar to that of a music game, in an improvised way, considering this concept as anything that is spontaneously done by a patient or the group taken as a whole. All the members produce sonorities and this leads to effects and reactions in all those present (the group, each individual by himself, and the music therapists). A patient's music, is here understood as any organization of sounds or movements performed by him/her. The patient can play an instrument, mouth pre-verbal sounds, employ his/her body as a percussion instrument, even if all that might seem incoherent. Music therapists unconditionally accept this patient's music, all the while trying to shape it into a somewhat more organized way or, as states Barcellos (2009), "the music therapist supports the patients into placing themselves within the music flow and exploring all possibilities of change in that music, for changes is the fitting goal for any kind of therapy. For Smeijsters (quoted by Barcellos), one of the premises for music therapy is, '[…] a patient changes when his music changes' ".

The group tends to spontaneously organize his music action by means of rhythmic improvisations. When after the passage of a little time this does not happen, one of the music therapists intervenes, preferably setting up a pulse or starting a rhythmic activity. The sound organization through the music therapist's intervention may bring pleasure to the patients and thus lead them to try to organize themselves. As stated Fechner, the current pleasure in the action, even when unconsciously perceived, motivates new actions.

Isochronic-structured rhythm induces movement and fulfills a persuasive function into acting together in an organized fashion, which aids into the group organization. A number of other activities (like songs, body movements…) can be introduced along with the music therapist's perception of need and adequacy during this first moment.

Rhythmic cells created and performed by individual members in the music therapeutic groups coordinated by us were predominantly simple binary structures, repeated without variance. It is important to try to enhance such improvisations thereby to offer new music resources and to broaden the patients' expressive possibilities thus breaking up the constant, stereotyped formats. Occasionally, ternary and composed-binary paces were created, confirming the mentioned neural-scientific hypothesis stating that the subjective rhythm-making is organized mostly in binary paces and less often in ternary ones. Besides, syncope-divided binary beats reproduce the usual rhythmic elements inherent to Brazilian musical culture, and their utilization favors group integration.

Departing from the initial rhythms, new activities may be introduced by the subjects, like singing and dancing and these can or cannot lead to new interventions by the music therapists. The latter can modify the patients' suggestions or suggest themselves something different when the group needs or those of some particular member are felt as necessary.

The very fact that the tunes are chosen by the patients themselves, who bring into play tunes dear to them, is one of the reasons for the sessions to be pleasurable. These songs are generally known by the majority of the group members and can bring satisfaction to all. Obviously, not everyone in the group will appreciate them, but these can present their criticism and later initiate their own choices.

During our clinical practice, we observed that popular songs are the tunes most re-created, with emphasis set on Brazilian popular music as broadcast by media and it is possible that lyrics induce the choices, instead of the tunes themselves. Songs, uniting as they do tune and lyrics, are particularly useful to give the music therapists some understanding into that which the patient wishes to express. Then, to give back to the patients that which the therapists have understood before, the latter can introduce other songs considered adequate to the situation according to their own judgment.

Folk music, including children's tunes, those from the popular festivals celebrated in Brazil during June holidays, as well as Christmas songs, both popular and religious, are also present. Children's tunes, in a general way, report to regressive situations or are connected to playful needs necessary after moments of great tension within the group and those can be inserted in by the therapists to bring about a relief for this tension whenever it is felt to be excessive.

The capacity for reproducing song lyrics was shown to be preserved, without the emerging of such disturbs observable within the schizophrenic discourse, which points toward the maintenance of musical bonds with culture, even in patients who show a deep loss on other bonds, like hygiene habits, for instance. This preservation is important because songs are dynamically connected with words and thus it affords clearer indications about what the patient is trying to communicate.

During the session, music therapists can employ assorted strategies, depending on the situation. If, for instance, a member of the group insists into singing or playing in opposition to the others, it is necessary to sort out whether s[he] presents a real difficulty to follow or is instead intending to sabotage the group production. In the first case, a music therapist can come closer to that particular patient and help him/her out, making, for instance, clear gestures to show him/her how to handle the instrument or singing near him/her the lyrics and tune that are being performed by the remainder of the group, so as to present a model easy to follow by that member. In the case of sabotage, or when the group is not well structured, a music therapist can take up a leading instrument and mark a strong pulse or else start singing a song (s)he knows to be well known by most or that was shown as pleasant to them in prior sessions so as to lead the group into the desired integration.

Music therapists' interventions are not designed only to solve problem situations, but also to reinforce positive acting. When some individual creates a new rhythm or melody or modifies the lyrics of known songs, this member is trying to modify that which s[he] knows well, that is, to introduce new facets into the already known. Creative attitudes open the opportunity for re-signifying data from the individual's personal history, i.e., for trying to find new responses to those situations that limit that person's life, leading toward a possibility for changing and experiencing new roles. Music therapists must support and stimulate creative attitudes, which might thus be transferred into other situations in the patient's life. The return of the material proposed by the patient is musically done, but sometimes a verbal intervention becomes necessary and adequate.

According to Molino (n.d.), music, a phenomenon or a musical fact as he prefers to state, presents a triple mode of existence – simultaneously it is the production of a sound object, an arbitrarily isolated object, and a perceived object.

Music therapeutic setting is a space of specific listening, not directed to music alone as a finished product, i.e., a perceived object – the music therapists must direct their hearing to the other aspects mentioned by Molino, that is, the product itself, the way the patient produces it, and the effects this production has caused upon him/herself, the group, and the music therapists as well.

Music therapists share listening with the patient but beyond sharing it they should interpret for themselves the way by which the patient employs or does not employ the material available (musical instruments, voice, and body percussion sounds); also whether they keep silence, whether they are creative or stereotyped, whether they show spontaneity or inhibition. They also must musically joke with the patients, to take away their inhibitions toward music-making and the use of instruments so as to lead them into the music-making action, which is the core of the ARC Method.

The music therapists' listening must be free of any prejudices on what good music should sound like. They have to develop a skill for vibrating along with the patient, thus to understand whatever the patient intends to express, and then going all the way toward him/her to help the patient on shaping up this expression.

After the beginning of music-making, the music therapists try to awake the patients to making with, a process in which music passes to include the others. Interpersonal relationship begins through music. Music therapists try to help the subjects to realize that the other or the others surrounding them are playing and/or singing. When this proposal is adhered to, then the group begins to jointly sing or play. It is important to render subjects conscious to the fact that they are relating to each other by means of the music and to make explicit this relationship which sometimes is not clearly perceived.

Communication skills are amplified by the opportunity of exploring the several ways of using the available instruments, as well as of singing and playing. The communication mediated by music, a significant non-verbal model, brings to the individual the possibility of surfacing his/her inner contents, shape them up and acknowledge them as his/her own.

Another research (Moura Costa, 2009a) has shown that feelings and emotions attributed to music by the schizophrenic are similar to those assigned it by normal people. Music is a cultural product, a language common to patients and music therapists. The music therapeutic listening (to the produced music, to the way the patient produces it, and to the effect it has provoked) supplies the music therapists with an understanding, even when partial, of that which the patient means to express. From this understanding on, the music therapists' intervention aim towards sharing that which they have realized in the moment they think adequate.

The possibility of understanding what music communicates is broadened for the emerging of a musical interaction between the patient/group and the music therapists. As states Barcellos (2009), this interaction may help the patient to understand some of the aspects that are necessary to alleviate his/her suffering.

To traverse this path, the most employed resources will be those of improvisation, mainly the rhythmic one as well as those of re-creation, mostly of popular songs, with modifications on the accompaniments, sometimes on the lyrics and, more rarely, on the tune itself.

The Session's Second Part – Comments

One of the music therapists signals for the end of the sonorous-musical expression and waits for the patients to spontaneously start to talk. When this does not happen, s[he] will intervene with the question, "How did you like our meeting?"

As states Nattiez (n.d.), "we can verbalize the effects music provokes within us and formulate that which it invokes." So as to understand the signification attributed by the listener to a musical sequence, it is possible to study the verbalization it has given rise to, independently from its title or even from the spoken or sung sentences belonging in that work.

To understand that which the patients have lived, we think to be necessary to give them voice, that is, to hear them out in whatever they have to say about their own performance, feelings, emotions, or inhibitions face the results produced and listened by them. Instead of restraining ourselves to the inference of that which they lived through by observing their attitudes, we listen to their own words and these sum up into new indicators about their living processes.

Each subject is encouraged to freely speak up whatever they think, never hearing any criticism from the music therapists. If someone doesn't talk, the music therapists try to stimulate this person, but finally must accept his/her denial of presenting an opinion. The music therapists, in the verbal part of the session, must drive their listening not only to that which is enunciated by the patients, but also to the way in which their comments were presented. They are supposed to listen to the music of the speech of the patient, in the same way they have listened to music during the first part of the session. The motivations for their verbalizations are sought in the wording and attitudes presented by the patients, that is, what led them toward the meaning assigned by them to the musical production, so as to clarify whatever was said.

This clarification consists in leading the subject to lend a deeper dimension to his/her comments, escalating from any innocuous statement to that which s[he] effectively thought and felt. For instance:

Patient: "That was good."
Music therapist: "What was it you felt good?"
Patient: "The sound;"
Music therapist: "Which was the sound you enjoyed?"
Patient: "The samba tunes."
Music therapist: "Why was that?"

And so on and so forth until the subject can maximize the signification assigned by him/her to that which was experienced. Here the goal is that of trying to lead the subject into becoming conscious of his/her emotions and/or conflicts, as the latter were musically expressed and to help him/her to communicate them verbally as well.

Any clarification has to be made on the individual level when dealing with schizophrenic patients, who are characterized by their loss of identity. Speaking of that which was done as being group actions may be damaging to these patients.

In the session's final moments, there is an attempt to try bringing out into verbal speech all that was produced during the sonorous-musical expression. Then the music therapists present their own opinions and end the session.

Evolution

When therapy starts, sounds produced are poor and repetitive, as De Backer also noticed, and in the final of the session, patients limit themselves to innocuous, meaningless comments, like "it was good", "cool", apparently without realizing the origin of the sounds they had heard. Some never utter a word. All the while, the number of patients who leave the room before the session ended or present negative comments ("It was boring", "I didn't like it") is insignificant, indicating that the situations experienced in the music therapy session, if not pleasant, were at least acceptable.

In a second moment, when the first signs of the perception that the pleasure is coming from some outer element appears, the patient comes to the clear attribution of said pleasure to the music. Examples:

"The piano was good."
"The music was cool."
"The tunes were nice."

From the perception that the musical pleasure has an existence in the outer world, the person begins to recognize the need for his/her musical action, i.e., to place him/herself as the subject of same action and then seeks to better explore the available instruments. The sonorous expression becomes richer. The wish for playing, singing, and making music begins to be more clearly expressed. Though often this pleasure is still turned only toward oneself, the pleasure of music-making is no longer experienced as bound to hearing and movement, but also to the desire of producing it. The avolition and the anergy begin to diminish. Examples:

"I'm gonna try several instruments."
"I can play loud or softly."
"It was cool today. I loved singing "Boom-boom, baticoonboom"[4]."
"I played the drum, it is my favorite instrument."

The first references to the other members in the group appear, firstly in impersonal, indirect fashion, mentioning the tunes performed by the others, without inclusion of the subject him/herself as part of the group. Examples:

"They never finished that tune."
"They played far too loud."

It is only when the subject starts to realize that music is a joint action performed along with the other group members that s[he] begins to include him/herself as a subject, the relationship begins to be established. Examples:

"I found it wonderful because I participated, I wanted to follow the others."
"It was a gathering through singing and its poetry."
"I enjoyed everything, it was good, I felt good. What matters is the participation."

Then criticism about the music that was performed surfaces and a number of references to the need for a better execution reveal the beginning of esthetical concern. It becomes important to organize the sound, both to achieve pleasure and to communicate with the others. Examples:

"Some instruments overcome the others."
"It is necessary to level the sound."
"I think it is good, but still not well organized."
"I guess the sound was hard, everyone was playing to themselves and nobody was playing for anybody."

Concern with the results of music production indicates the starting point for the assignment of a meaning to the produced music. It then begins the perception that the patient's own feelings are being channeled out through music-making. This modification leads into a new phase, when every patient commences to talk about themselves, their feelings, and their interpersonal relationships by means of verbal language. Examples:

"If not for music therapy, I would never leave my bed."
"I enjoyed it very much, for you get to communicate through the instruments."
"Music therapy helps us to externalize our nervousness, our frustration. Music calms us down."
"Music therapy helps to cure through music, it unchains our wills a little."
"This therapy makes us express feelings that had been pent up for a long time."

As an example of this evolution we can present the case story of a young man who never left his ward bed where he stayed in total silence:

His psychiatrist asked us to invite him to the Music Therapy group. I went to the ward and found him lying in his bed completely motionless. I invited him to come for music therapy. He stayed silent, without any attempt to budge. After asking him up with a number of different phrasings, I silently reached out my hands to him. After a while, he put his own hands over mine. A few moments further, I began to raise my hands and pulled him into a sitting position. He stood up from the bed, keeping his hands on mine and we left the ward step by step, me walking backwards and him shuffling toward me until we arrived to the music therapy room. Meanwhile, the session had been opened by my partner. He sat on a bench close to the door and I sat beside him. We remained there in silence to the end of the session. Next time, as soon as I neared his bed, he raised and followed me to the music therapy room. The group called him in and he sat close to the others, but only listened and watched the proceedings. During the third session, someone handed him an instrument and he timidly started to play on it. In the comments part, he limited himself to answer to a couple of questions addressed him by the other patients. Ever since then he began to attend and to participate few a few in the activities, using the instruments, singing, until further on he not only communicated in the sonorous-musical fashion but also verbally.

We believe that most of schizophrenic people need therapeutic support during a long period or even for their lifetime.

As an example, a forty years old man, with a story of several internments in psychiatric hospitals, joined the group of music therapy while he was an inpatient. After discharged, he continued in medical treatment and music therapy as an outpatient for almost one year. During this period he lived alone in his apartment, had a professional activity and got a girl friend. The direction of the hospital considered that he was cured, and discharged him of all treatments. Less than a month after the discharge, he suffered a serious crisis needing a new internment.

Conclusions

The treatment of schizophrenia claims for a multidisciplinary set of approaches to take up all the symptoms the disorder presents – medicine administration, different kinds of psychotherapy, family therapy, and art therapy.

The specific contribution of music therapy is that music is at the core of the music therapeutic processes and, in the ARC Method, the pleasurable music-making leads into the development of interpersonal relationships and communication with each other. The procedures used can induce through rhythm the schizophrenic subject to act. Schizophrenic people tend to avoid direct contact with other people and the use of music mediates this contact. Rhythm in the method is used to fulfill a persuasive function into acting together, favoring interpersonal relationships. Music also offers a language allowing for the expression of feelings and emotions without demanding coherent discourse in contrast to verbal speech, thus fending off the subjects' illogic thoughts. The method is also supported by sung or spoken words, by its playful features, as well as by spontaneity and creativity that are characteristically pleasure-inducing. The clinical case reported and some examples of comments of the patients show that the ARC method can alleviate negative symptoms and contribute to a better quality of life of schizophrenic people.

We agree with Gold et al. (2005), who states that music therapy as an addition to standard care is very helpful to schizophrenic people improving their quality of life and their mental state, but further research should be done on the long-term effects of it.

We above considered "method" as the usage of procedures that can be observed and defined by inductive means, either to practice them with greater assurance or to criticize them. After reading over decades of clinical practice, the existence of a transmittable method containing procedures which can be observed and replicated to treat people, fully closed within their inner worlds is undeniable.

Notes

[1]Diagnostic and Statistical Manual of Mental Disorders, by the American Psychiatric Association (Author's note).

[2]The authors of the present paper and the psychiatrist, Leonardo Azevedo e Silva. (Author's Note).

[3]In our usual practice, the instruments employed were a piano, a guitar, a banjo, an atabaque kettledrum, a tambourine, a tabor, a rattle, an agogô set of bells, a maraca, a set of castanets with handles, a notched-bamboo reco-reco, clubs, ganzá and afoxé gourds, an orchestra triangle, and a loaded cocoanut shell coco. (Author's Note).

[4]Brazilian samba

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