[Original Voices: Story]
Thanks to Scandinavia – Creating a Symphony of Global Music Therapy
TTS scholarship at the Louis Armstrong LLA LLA Centre for Music & Medicine at Beth Israel Medical LLA LLA centre – New York
By Sunniva Ulstein Kayser & Britta Vinkler Frederiksen
Abstract
In this essay we will describe our visit at Louis and Lucille Armstrong Centre for music and music therapy at Beth Israel Medical Centre in New York. We were selected as the 2011 Thanks to the Scandinavians scholars. We will describe the music therapy methods in medicine at different units at the medical centre. We will describe our experiences of the music therapist´s work and the special challenges they meet when working in medicine. Further more we will discuss our experiences from a Scandinavian perspective.
Opening
As 2011 selected Thanks to Scandinavia (TTS) scholars at Beth Israel Medical LLA LLA centre in New York, we were provided many wonderful opportunities. We attended from the 25th of July until the 5th of August 2011. Before describing our experiences, we will briefly present the two main factors that have made these experiences possible namely “The Thanks to Scandinavia Fund” and the “Louis and Lucille Armstrong Music Therapy Program”.
The Thanks to Scandinavia fund has its roots from World War Two wherein Scandinavians helped Jews escape from the Holocaust. To give thanks to the Scandinavians, the famous Danish entertainer Victor Borge, who were forced to escape to USA during World War II, founded Thanks to Scandinavia together with attorney Richard Netter in 1963 (Thanks to Scandinavia, 2011a).
One of the main goals of the Thanks to Scandinavia program is to provide educational scholarship to students, medical professionals and teachers to show a continuous gratitude (Thanks to Scandinavia, 2011a). One of the places where their scholarships are offered is at the LouisArmstrong LLA centre for Music and Medicine at Beth Israel Medical LLA centre (Thanks to Scandinavia, 2011b).
The Louis and Lucille Armstrong Music Therapy Program was made possible through generous grants of the Louis Armstrong Educational Foundation, and was established by music therapist Dr.Joanne Loewy in 1994 (The Louis Armstrong Department of Music Therapy, 2006a). Since its birth, the LLA centre, through ground breaking clinical practice and research, have built a platform for how music therapy can be applied and contribute to medical contexts. Through the Thanks to Scandinavia fund, health care professions, among them music therapists are invited to the LLA centre for a two week training to learn more about how music therapy can be integrated and applied in medical contexts. This July 2011 we were the lucky scholars, selected to be given this invitation.
Arriving at Beth Israel Medical LLA centre
Arriving in New York – crossing 59 St Bridge by taxi and watching the fantastic skyline of Manhattan rising in the air was breathtaking. We arrived at Penn station and walked through the streets with a backpack to Union Square along 17th Street approaching 1st Avenue and suddenly the sign on one of the big buildings saying Beth Israel Medical LLA centre lit up. What striked us upon arrival was all the noise at the street level and lack of space – cars and bikes everywhere and people walking in various directions – just everyday life for the inhabitants of New York. At the same time it seemed as though New Yorkers were good at finding small places of more quietness for an example in the small park outside the hospital.
When arriving at Beth Israel Medical LLA centre, the first thing we had to do was to show our identification badge. After that we were met by a long line of people waiting for a very slow elevator, taking us up to the 6th floor where the Louis and Lucille Armstrong (LLA) Program suite for music therapy is located. At the centre we were warmly welcomed by John Mondanaro MA, LCAT, MT-BC, the Clinical Director and Dr. Joanne Loewy LCAT, MT-BC. We witnessed music therapy unfold in diverse contexts in the weeks that followed.
“Music was all Around”
With their carts loaded with instruments, the music therapists filled the units of the Beth Israel Medical LLA centre with music. It seemed like their ears were trained to capture the music in the environment and everything from beeping sounds of machines, to a tiny whistling or humming was embedded in the musical soundscape. Music therapy was applied in diverse contexts, from open areas such as the corridors, waiting rooms and even the infusion suites of the cancer treatment to more closed areas such as the patient`s rooms, the staff`s canteen and during surgical procedures. An example of where we experienced this diversity was the oncology-ward. Here the music therapists, among them John Mondanaro offered group music caring for patients as well as for the caregivers themselves. “The caring for the caregiver”-concept was a concept where the staff was offered music experiences in groups during their shift. Through improvisation, singing familiar songs, relaxation and breathing entrainment, the music therapist provides support, energy and care for those giving care. The idea was that to give care for the caregivers will have a positive influence upon the care the caregivers give to their patients.
At the oncology ward, the music therapists used a blend of well-known songs requested by the patients, staff or relatives, improvisation and meditative music to support the patients breathing, reduce anxiety and give relief to pain. In addition, music therapy seemed to help patients gain strength and belief in themselves to take responsibility in their own treatment, which are highly important at hospitals, wherein patients might often feel powerless.
The factors presented above were also the focus at other units wherein music therapy was offered. One example was the pulmonary unit wherein the LLA centre has done research on their clinical work of music therapy with patients suffering from COPD (Raskin & Azoulay, 2009). We were given the chance to participate in the pulmonary group which seemed mainly to function as an out-patients-service. The music therapist Bernardo Canga MMT, started the session with music to support the breath and improve the breathing-pattern, before moving on to preference-based songs from musicals, operas and the old jazz-scene. Each patient had his or her “own” favorite song, which they stood up and performed to the others in the group. To see the support that the group-members gave each other moved us and we reflected upon the therapeutic potentials that lies in working with groups of patients. One might say that it was the music therapist that facilitated the therapeutic processes to take place through gathering and running the group. Still, the power to help each other was given to the patients. In this way, music therapy could hopefully have ripple effects beyond the 45 minutes that the group met. When one of the patients at the end of his song-performance stated: “Once you hit that high note, you feel like the king of the world” it became clear to us that making music together could give these patients experiences of mastery and self-confidence, seeing that they could manage to use their voice despite their illness and shortness of breath.
One main aspect that we learned during our observation at the different wards was the importance of tuning into the patient`s needs and provide a music therapy offer that addresses these. This might seem obvious, but it is still important to make explicit. In a hectically everyday life setting, using pre-set of activities is maybe tempting, and because our jobs can be stressful, taking the time to listening and tuning into the patient, might be overlooked. To let the world pause for a moment and let our patients feel that we see only them is an important factor that we need to remind ourselves of.
One place where we strongly felt that the world had pushed it`s pause-button, was when meeting a 17-year old girl in a coma. Supporting her struggle of coming back to life, the music therapist used calm vocal sounds, humming on her favorite songs and vocally improvising her name. All around us, alarms went off, there were beeping sounds and nurses running forth and back. In this chaos, the music therapist through her calm singing became a provider of stability, safety and care and hopefully established a tiny “bond” to her former life that the client could hold onto.
Open or Closed Door – The Frames Around Music Therapy ?
One of the first thing that struck us, through the first days at the hospital following the music therapists at the LLA centre, was the lack of space and room they had for making music therapy, and at the same time their creativity in creating space for music therapy to take place. This fostered some reflections in us, particularly about the frames for the music therapy sessions. How do we decide these frames? Is it us, the clients, the institutional rules or the material environment? And not at least, what impact do these frames have on the “status” of the music therapy at the institution? At Beth Israel, the open context wherein music therapy took place clearly made an impact upon the status of the music therapy, mainly because staff, relatives and patients, became aware of its existence and purpose. For example we observed music therapy sessions carried out by Joanne Loewy in the chemotherapy infusion suites of the cancer treatment, wherein several patients were located. The only thing separating the patient and the music therapist from the “outer world” was a curtain, and often this curtain was not even closed. This was for us, a new experience and made us question: What are the advantages and disadvantages of open versus closed music therapy sessions? How can music therapy occur in a chemo suite where closed doors are not an option? Of course, in some context, closed doors are highly necessary for the therapy process to be established and progress and doors was also closed at Beth Israel at some occasions. Still, if appropriate, having the door open might tear down some of the “myths” around what music therapy is and what we do in music therapy. As we observed at Beth Israel, giving the surroundings an opportunity to gain insight into the music therapy was a way of creating bonds between the patients and to make the staff aware of the patients’ musical background and interests.
What we are trying to pinpoint is that it is important not to presume on forehand that the doors should be either closed or open. Rather we can analyze the particular context we are in and ask ourselves; what are the goals of this particular music therapy? What do the client need and what are his or her wishes? Then, based on these factors the client and we together can decide what might be the most appropriate way of doing music therapy.
Environmental Music Therapy (EMT)
Another question that came to our mind when observing the lack of space discussed above, was whether or not this factor might be a reason why Environmental Music Therapy (EMT), processed in open area at the wards and waiting rooms, has become one of the main trademarks for the LLA centre. EMT has its origin from work at the Neonatal Intensive Unit (NICU) in 2000 at Beth Israel Medical LLA centre wherein it was used as a technique for addressing and modulating external stressors and observed to have a positive effect on staff, babies as well as parents. From these experiences EMT has expanded to other units. Especially those units where a state of “near medical emergency” is constant, EMT has been observed to be effective (Loewy et al., 2005, Mazer, 2010, Stewart, & Schneider,2003). Andrew Rossetti, MMT, MT-BC working at the LLA centre, was one of the music therapists that recently had been employed to, among other tasks to further develop EMT.
Rossetti`s working definition of EMT is:
the intentional use of live music and sound to modulate the soundscape of a given area or room to convert this environment into one more conducive to healing and wellbeing by means of interactive process between the person(s) actively providing EMT and those actively receiving it (Rossetti, 2011. *)
The clinical reason for applying EMT in medical contexts, are findings from research studies suggesting that high levels of noise at hospital units are a stressor for patients and prolong their recovery period. In fact a study show that people recovering from cardiac surgery used significant less amount of time at the Intensive care Unit when music was used (Schwartz, 2009). The method of EMT was to create and improvise music that matches the sounds in a unit. In this way EMT incorporates the aural characteristics of hospital unit and modulates them to form a non-toxic soundscape, and by that lower the stress effect of noise on the patients. An important aspect of EMT was thereby to integrate with the environment and avoid that music becomes just another factor adding noise to the soundscape.
Already on the 2nd day of our stay we were asked to participate in providing EMT. Together with music therapist John Mondanaro we went to the unit for intensive care (ICU), where people are severely and in a critical medical state. In the middle of the unit just next to the nurse station and right were patients were lying in beds, we created a musical space through improvising music. It was a very special experience which fostered a lot of thoughts in us – first of all being shy, feeling awkward and afraid of bothering people and we asked ourselves “are patients/relatives ready for such an experience which might bring them in contact with feelings around a critical situation?” Even though EMT was not meant to be intrusive you cannot know how the patients perceive the music or if it was the right timing. We were also insecure of which cues to use when creating the music. We had discussions on this topic with the music therapists at the LLA centre, and through verbalising and discussing our thoughts, it became clearer to us which cues to use. These cues were: the base sound level, aural events such as loud or intrusive talking and laughing, cries, shouts of distress, mechanical sounds as ventilators, ventilation systems, door slams and sounds made by moving equipment. The mood state of those present was also a cue observing facial expressions, gait, body language, speech patterns and volume, exhibited behaviour, collective energy of the space as well as the energy of each individual in it (Rossetti, 2011). We realised that to use this EMT music therapy method was challenging and practise was needed in order to assess the environment of the unit very quickly and then create music which addresses the needs of patients as well as relatives and staff.
The questions that aroused when observing EMT, made us wonder what role the cultural aspects played in fostering this uncertainty in us. We were both unsure how EMT would fit into Scandinavian hospitals. Both of us felt that it would be more challenging to convince staff about the benefits of this approach in our home countries. The differences in cultural aspects are both related to the fact that music therapy seems more integrated in the medical system in USA and thereby the hospital environment is more used to the music therapist` presence than in Scandinavia. In addition we questioned whether we in general are a bit more reserved and afraid of trying out new, unfamiliar procedures in Scandinavian countries and that this might foster resistance among staff? This was off course only speculations based on our observations and reactions. Still, it was interesting to reflect upon by the fact that both us were experiencing music therapy in another culture than our own. The staff at the LLA centre investigate on this method – at the Sugical Intensive Care Unit they are collecting data from clients and staff on their impressions of noise, live music and EMT. These impressions from the clients and staff are very helpful in order to perform EMT.
Through discussing and verbalizing the backgrounds, intentions and the way of performing EMT, its intentions became clearer to us and somehow helped us to develop our own EMT skills. We experienced the importance of dialogue with the music therapist at the LLA centre about EMT, in order for us to understand EMT. It made us think that at dialogue and agreement about EMT – its medical purpose, background and intensions - with staff and leaders of the units was crucial to prevent resistance among staff and clients.
Music Therapy with the Premature Babies
One unit where the goals for music therapy were very obvious was at the NICU (Neonatal Intensive Care Unit) where premature babies as young as 25 weeks were hospitalized. One might say that these babies are already in a type of musical modality – the tempo of the heartbeat, the tempo of respiration, the tension and power they use when sucking. These babies meet the world and all the sounds of the real world before they are ready to cope with all these impressions and stimuli. One might think that music therapy just adds more stimuli to their world, but the fact was that music therapy helps to structure the stimuli and make it less stressful for the baby.
At this unit we followed Angela Ferraiuolo-Thompson MA, MT-BC in her work. Playing mainly with instruments such as ocean disc (specially designed for them by Remo), the gato box and vocalization she made musical interventions with the babies and the parents. One example was to play a pulse in half speed of the babies heartbeat which simulates how the heartbeat of the mother sounds like for the baby when being in the womb. The heartbeat of the mother is crucial in the process of bond making between the baby and mother. When the baby was stressed because of medical procedures such as needle sticks, the music therapist tried to calm the baby down singing or playing a lullaby like improvisation that integrated the energy, dynamic and tempo of the baby in the music. The music therapist also supported the babies sucking by resonating with the babies own tempo and stabilizing it, and by that support the baby to keep on sucking. In addition, music therapy at NICU was meant to help parents to use music as a modality to support their bonding with the baby. One technique was to turn the parent’s favourite songs into a lullaby like song and help and support them singing it when holding the baby.
It was truly inspiring to observe the work being done with these small vulnerable human beings. When considering the importance of this work upon the babies and the parents, it is strange that it isn’t more implemented at units with premature babies. There is no music therapists employed at neonatal units in Denmark. In Norway, as far as we know, two hospitals have music therapy at their neonatal units.
Why might it be that music therapy at the neonatal unit is not more integrated in Scandinavia? One reason might be that staff are afraid that it would provide too much stimuli for the babies, which is a very natural perception to have by the fact that music by its very nature is a sound-creator. Here we want to highlight what we observed at the NICU during our TTS scholarship, namely that music therapy actually created structure to all the stimuli these babies meet. This observation also resonated with the staff and the music therapist ‘experiences and intentions of applying music therapy at NICU. At Beth Israel Medical centre music therapy at NlCU´s has been offered for 16 years and all around USA a lot of music therapists are employed in this field. This work has been documented in clinical research, in clinical trials of 10 mid Atlantic US hospitals, and will be published in near future. Hopefully this publication will help in convincing more hospitals globally that music therapy with premature babies makes sense and are highly important for the babies’ development.
The Peter Krueger Clinic
Another interesting area of observation was music therapist Melanie Acosta MA, LCAT, MT-BC. Her services are offered at an ambulatory clinic for children and adolescents infected with seriously infections. At the clinic the children’s medical status were measured and help were provided to support them in coping with psychosocial issues. The music therapy we observed at the clinic was focused on supporting communication and expression, and through that get in contact with psychosocial issues. We observed how nicely the music therapist applied her music therapy approaches in order to regulate affect by balancing structure and freedom. We were lucky to meet two clients – one being very extravert and having problems with focus and concentration, while the other client being almost without any tension – and very quiet. In the first case the music therapist had to be very structured both in her attitude but also in the music to make sure the music became meaningful. Too much freedom –for an example “do whatever you want” would only have kept him in the chaotic stage, without focus in the contact. On the other hand, too much structure or rules wouldn’t have provided him with room enough to bring in to the therapy important issues in his life at the moment. The first client wanted to play at various instruments at the same time, and Melanie used it as a starting point. She provided the structure mainly through frame working around this client`s expression to establish and maintain contact between them. This frame-working was also used as a method when the client did sing-along to a pre composed song. The music therapist then sat in the background playing the beat of the song on a drum.
With the other client, music therapist Melanie was aware of not being too directive in her musical approach, and very sensitive to give the client a chance to take the lead when improvising. In example the therapist choose a Dorian scale at the piano – as a focus point for the client who played the xylophone in a repetitive and almost meditative way. All though they were small, he took some musical initiatives during their playing. The main thing was that he was able to play for a long time giving him an experience of “getting lost in the music” as he himself expressed afterwards. The inner world of this client became audible in the music, at the same time the client´s music resonated with the music of the music therapist. Maybe this musical experience was the first step out from his quiet and maybe lonely state, and a starting point for developing his skills in being in contact and dialog?
Integrating Music Therapy – A Collaborative Process
Six music therapists working full or part time at the LLA centre seemed fantastic for music therapists from Scandinavian, where two music therapists working at the same place is luxury. Still, it is important to mention that music therapy was not a fully integrated part of all the units at the Beth Israel Medical centre. In the beginning phase it was funded by only one foundation and through the years supplemented by several of other funds. Slowly, different units of the hospital have started to put music therapy at their budget and pay directly to the LLA Centre to have music therapy services at their unit. At these units, the LLA Centre offers both clinical work with patients, caring for the caregivers and research-studies. At the time of writing, there are six on-going research studies at the LLA Centre. At the pulmonary units, a research study called The Music for AIR is soon to be completed, investing the effect of music therapy upon patients with COPD (The Louis Armstrong Department of Music Therapy, 2006b). In addition, the LLA centre hosts a Clinic for Children with developmental delays and for musicians in NYC. The LLA Clinic is runned by Joanne Loewy and their medical director Stephan Quentzel MD. They see patients of all kinds-from “Broadway to subway.” Other research studies include a protocol for children with Asthma; the Asthma Initiative Program (The Louis Armstrong Department of Music Therapy, 2006b). For patients with cardiovascular diseases the LLA Centre has developed the Music for CAIR program and a study upon music therapy as a complementary approach for those undergoing cardiovascular rehabilitation is under progression (ibid.). At the cancer treatment, the Centre is running a study on Clinical Music improvisation at the infusion suites investigating the effect of singing and/or music improvisation upon the resilience of the patients (ibid.). In addition a study on effect of music therapy in the recovery of patients undergoing spine surgery (ibid.). The NICU study is also under progression (The Louis Armstrong Department of Music Therapy, 2006b), as is a new study for those undergoing simulation in radiation therapy. To offer research studies at the wards wherein the therapists are doing clinical work, was according to the LLA centre, a highly important integration strategy, namely because the music therapist are able to document the possible effect and thereby the importance of music therapy upon patients lying on the units.
An important philosophy developed by the LLA Centre was how to approach a new area or unit – inviting to cooperation where the staff feel like being a part of providing music in the care of the patients. One strategy is to examine whether or not the unit already has been using music before, and if they have use this as a starting point for contact and collaboration between the unit and the music therapist. This has made it easier to establish a good collaboration with the staff and the patients from the beginning. The music therapists at the LLA centre believe that collaboration also increases the chances of developing good ways of using music to therapeutically support the patients’ recovery.
These two points described above could be useful for music therapists in Scandinavia to have in mind when trying to implement music at a hospital or unit. Funding might be necessary in the starting phase of implementing music therapy. The next step will then be to operate this funding in a way that could provide growth and development for the profession. To succeed in this process it might be a good thing for Scandinavian music therapist to collaborate in developing formal strategies for how to integrate and develop music therapy offers in new contexts. Maybe one way of doing it is to cooperate in groups were one person is responsible for raising money? “Money makes the world go around” – as a famous phrase from a musical puts it and enough money helps music therapists feel more secure in their working situation. Feeling more secure in the working situation might then further help music therapists in being open and facilitate cooperation and integrating other ways of using music in the care and treatment of clients.
Grand Rounds – Global Sharing of Knowledge
After a week of learning, observing and reflecting upon the various and profound work, the time had come for us to share some experiences and knowledge from our own work as music therapists at the Grand Rounds. The fact that Britta was a well-experienced music therapist working in the field for 20 years, while Sunniva was just about to begin her career as a music therapist was reflected through a relatively large diversity in our presentations. Britta told about her work at the forensic psychiatric ward and her Private clinic through two cases using both music and sound-clip. Britta`s work in the psychiatric field is also the ground stone for her phd research at Aalborg University which she will begin with autumn 2011. Sunniva`s presentation was based on research-findings from her recently submitted master thesis wherein she has done a modified grounded theory research upon music therapy in COPD-rehabilitation. Her research upon music therapy and COPD clients is the first of its kind in the Norwegian music therapy field. To present and get feedback from the staff at Beth Israel Medical Centre and the medical community wherein this topic was better established and developed, was a unique opportunity to develop more knowledge and foster ideas that can be used to further develop this field back in Scandinavia.
At the PACC centre wherein the Grand Rounds took place, life was busy. It was a large medical centre in the middle of Union Square in New York where people come for examinations during daytime. We had both witnessed how busy the environment at this centre were and was therefore a bit uncertain how much people would come. In addition, there were two conferences running parallel with ours. But all uncertainty was brought to shame, wow what a crowd! It was not easy to say whether it was the centre that was good at promoting their events or if it was a generally large interest for hearing about music therapy in medicine, but the fact was that we were both overwhelmed by the large and various crowd that had come to listen. Doctors, professors, music therapist, nurses, and administrators, all of them were there, listening to our presentations! Afterwards we were met with a large interest and curiosity for our topics which fostered some good discussions and reflections. To present our work at the Grand Rounds became an opportunity to give something back to the LLA Centre and fostered a room for global exchange of knowledge and experiences in the medical music therapy field.
Thanks to Scandinavia
Our two weeks at the Louis and Lucille Centre for Music and Medicine at Beth Israel Medical Centre have been a life-time experience for us. It has provided us with knowledge, concrete strategies for how to integrate music therapy in medical contexts, new angles and ideas for how to do music therapy and not at least, it has given us the opportunity to meet lots of wonderful and inspiring people. One of the intentions of the Thanks to Scandinavia program is to build bridges between Scandinavians, Jews and Americans through providing opportunities for global contact, friendship, sharing and learning about different approaches in music therapy (Thanks to Scandinavia, 2011a). Because music therapy is a relatively small profession around the world it is crucial that creating opportunities can foster international contacts and exchange of knowledge. TTS is a great way to support this exchange. Through our two weeks at LL A LLA centre for Music and Medicine, life-long contacts have been established, creating a symphony of global music therapy and care. We own a huge thanks to all the patients, caregivers and staff, to Joanne Loewy, John Mondanaro, Melanie Acosta Po, Bernando Canga, Andrew Rossetti and Angela Ferraiuolo-Thompson for sharing of your profound knowledge and experience and to Marie Grippo for making our trip to New York possible. Not at least our largest gratitude to the late Victor Borge and the late Richard Netter for the establishment of the “Thanks to Scandinavia foundation.”
References
Loewy, J. et al (2005). The role of music therapy in care for the caregivers of the terminally ill. In C. Dileo (Ed.), Music Therapy at the End of Life (pp. 239-250). Cherry Hill, NJ Jeffery Books.
Mazer, S. (2010) Music, noise and the environment of care: history, theory and practice. Music and Medicine 2010 (2)
Raskin, J. & Azoulay R, (2009). Music therapy and integrative pulmonary care. In R. Azoulay & J.V. Loewy (Ed.), Music, the Breath and Health: Advances in Integrative Music Therapy (pp. 69-86). New York: Satchnote Press.
Rossetti, A. (2011). Thought on EMT nonpublished working paper. LLA Centre.
Stewart, K., & Schneider, S. (2003). The effect of music therapy on the sound environment in the neonatal intensive care unit – A pilot study. In J.V. Loewy (Ed.), Music therapy in the neonatal intensive care unit (pp. 85-100). New York, Satchnote Press.
Schwartz. Fred. J.,MD (2009). A pilot study of patients in postoperative cardiac surgery. Music and Medicine, vol. 1(1)
Thanks to Scandinavia (2011a). About us. Retrieved September 1, 2011, from: http://thankstoscandinavia.org/about-us/.
Thanks to Scandinavia (2011b). Our Programs in the U.S. Retrieved September 1, 2011, from: http://thankstoscandinavia.org/our-programs/scholarships/in-the-u-s/.
The Louis Armstrong Department of Music Therapy (2006a). Retrieved August 28, 2011 from: http://www.musicandmedicine.org/.
The Louis Armstrong Department of Music Therapy (2006b). Current Research Projects. Retrieved September 14, 2011, from: http://www.musicandmedicine.org/.
