PLAYING THE PRECUNEUS:

MUSIC THERAPY AFTER ACQUIRED BRAIN INJURY

By

Kristen Anderson

Bachelor of Arts, Music, McMaster University, 1994

Major Research Paper

Submitted to the Faculty of Music

in partial fulfillment of the requirements for the degree of

Master of Music Therapy

Supervisor: Dr. Colin Andrew Lee

Wilfrid Laurier University

2010

Kristen Anderson, 2010

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TABLE OF CONTENTS

ABSTRACT .............................................................................................................................. iv ACKNOWLEGEMENTS .......................................................................................................... v

DVD TRACK LIST .................................................................................................................. vi CHAPTER I: INTRODUCTION ............................................................................................... 1

1.1 Background ....................................................................................................................... 1 1.2 The Client ......................................................................................................................... 2 1.3 Purpose of study ............................................................................................................... 3

1.4 Research Questions .......................................................................................................... 3 1.5 Value of the Study ............................................................................................................ 4

1.6 Stance of the Researcher .................................................................................................. 4 2.1 Case Study Research ........................................................................................................ 7 2.2 Consciousness and Identity .............................................................................................. 8 2.3 Introducing the Precuneus ................................................................................................ 9

2.4 Post-Traumatic Stress ..................................................................................................... 11 CHAPTER III: METHODOLOGY .......................................................................................... 13

3.1 Research Design ............................................................................................................. 13

3.2 Procedures ...................................................................................................................... 14 3.3 Research Setting ............................................................................................................. 14

3.4 Data Collection Procedures ............................................................................................ 15

3.5 Data Analysis, Interpretation and Presentation .............................................................. 15

3.6 Ethical Issues .................................................................................................................. 16 CHAPTER IV CASE DISCUSSION ..................................................................................... 18

4.1 Introduction .................................................................................................................... 18 4.2 Consciousness ................................................................................................................. 19

Help! ................................................................................................................................. 19

4.3 Visuo-Spatial Imagery .................................................................................................... 21 Waking Up Blind .............................................................................................................. 21

Confusion in Imagery ....................................................................................................... 23 Spatial Discrimination ...................................................................................................... 24

4.4 Memory .......................................................................................................................... 25

Memory In Words ............................................................................................................ 25 Memory In Music ............................................................................................................. 26 Every Session Is The First Session ................................................................................... 28

4.5 Yawning ......................................................................................................................... 28 Yawning In Music ............................................................................................................ 29 Yawning As Music ........................................................................................................... 31 Yawning Towards Insight ................................................................................................ 31 Yawning As Toning ......................................................................................................... 33

4.6 Self and Identity ............................................................................................................. 34 Am I Dead? ....................................................................................................................... 34

Empathy And Insight ........................................................................................................ 36 Insight And Self Definition .............................................................................................. 37 Music and the Precuneus .................................................................................................. 39

CHAPTER V CONCLUSION .............................................................................................. 40 Figure 3: Music Effect on the Precuneus ......................................................................... 41

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CHAPTER VI REFLECTIONS ............................................................................................. 44 GLOSSARY ............................................................................................................................. 46 APPENDICES .......................................................................................................................... 51 Appendix A: Wilfrid Laurier University Research Ethics Board Approval ............................ 52

Appendix B: Hamilton Health Sciences Participant Consent .................................................. 53 Appendix C: Hamilton Health Sciences Substitute Decision Maker Consent ......................... 56 Appendix D: Hamilton Health Sciences Research Ethics Board Approval ............................. 59 Appendix E: Excerpt from Session Index ................................................................................ 60

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ABSTRACT

This study explores the use of music therapy with an adult having an acquired brain injury

and aims to make connections between the perception of music after brain injury and the brain

regions activated in the process. Much has been studied about how the human brain perceives

music. It is through studies of healthy brains and those with dysfunctions that we begin to

comprehend the effect of music and the regions activated during the perception of music.

Literature about the use of music therapy for clients with acquired brain injury also exists, as

does that with post-traumatic stress. Through a qualitative account of eleven music therapy

sessions presented as a single-case study, the research will demonstrate a link to the

Precuneus region, as demonstrated by the client interaction and supported by the literature.

The study aims to augment a theoretical and practical understanding of music therapy with the

acquired brain injury population and lay the foundation for future investigation into the nature

of music perception in the human brain.

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ACKNOWLEGEMENTS

I would first like to thank you, Chad, for your participation in music therapy and in

this research study. Your continuous positive outlook was inspirational and a reminder that

we are capable of achieving things greater than what we could ever imagine. Thank you for

allowing me to witness and take part in your journey.

To Chads family, thank you for your support and guidance during Chads therapy and

for trusting in me to explore his story further. Your familys devotion is truly moving.

To my supervisor, Dr. Colin Lee, thank you for your steadfast commitment and

invaluable advice. You were key in helping me to maintain direction and positive focus while

I navigated the course of qualitative research.

To the faculty and my classmates, thank you for your precious feedback and guidance

throughout this experience. The diversity of thought and unique perspective allowed me to

see the forest for the trees.

To the rehabilitation team at Hamilton Health Sciences ABI Unit, I thank you all for

your support during my practicum and throughout this research study. Each one of you has

contributed to the knowledge and experience that I have gained in working with this

population.

To my family, thank you for your patience and encouragement as I change direction in

life and pursue goals that parallel my greatest love, music.

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DVD TRACK LIST

DVD Track Session Reference Topic Page Reference

1 Session 1, 12:20 Help! 22

2 Session 6, 41:00 Waking up blind 25

3 Session 3, 41:11 Confusion in imagery 25

4 Session 9, 29:00 Spatial imagery,

blindness 28

5 Session 9, 34:30 Name that tune 28

6 Session 10, 14:20 Yawning 34

7 Session 7, 06:00 Am I dead 38

8 Session 11, 45:00 Final song N/A

1

CHAPTER I: INTRODUCTION

1.1 Background

When I began this research, my experience of music therapy with clients having

acquired brain injury was focused more on a transition from acute care to rehabilitation. The

focus of therapy among all disciplines was prioritized by the treatment of the physiological

and cognitive function necessary for human potential. The examination of consciousness and

ones understanding of the self seemed to be an objective reserved for the future.

What I would soon discover through investigating music therapy with a client named

Chad, is the idea that this process of rediscovery is activated immediately. Despite the

appearance of unconsciousness or reduction in engagement, Chad was experiencing an

evolution of consciousness from alertness through to self-awareness and building a new

understanding of his identity. What will be revealed through the course of research is a

biological thread binding together what appeared to be unrelated presentations of symptoms.

Further still, was the deep effect of music. Initially thought to assist with relaxation or

even be a source of confusion, music became a force that resonated in a specific brain region

responsible for the evolution of this consciousness and recreation of identity. What was

revealed in the study was a relationship between the unique sequelae1 associated with this

clients injury, the effect of music for rehabilitation of function. A stunning finding included

a brain region activated in this journey through evolving consciousness and identity

previously unknown in the context of music therapy.

1 Any abnormal conditions that occur subsequent to and/or is caused by disease, injury or treatment. (Merriam-

Websters Medical Dictionary, 2010, m-w.com.

2

1.2 The Client

Chad is a now 22-year-old male who experienced anoxic brain injury after cardiac

arrest in June 2009. This type of injury occurs when the brain is deprived of oxygen for a

long period of time resulting in diffuse damage to the brain. Because of the dispersed nature

of injury the prognosis for his degree of recovery and rehabilitation cannot be accurately

predicted.

For a period of approximately four months, Chad was relatively unresponsive while in

acute care. At this same time, it was not yet known that Chad was left blind. His injury

resulted in contracture2 of his left leg that was operated on in the fall of 2009. It was at this

time that Chad began to receive music therapy.

Initial sessions took place in Chads room under gown and glove protocol due to

multiple recurring infections. The logistics of this in-room situation, and the fact that a

piano/keyboard was unavailable, meant that my supporting instrument of choice was the

guitar. This carried through our remaining sessions together. In August 2009, Chad had

begun to vocalize outside of music therapy by moaning. His mother confirmed that he then

began to say words that sounded like mom and help.

Rapid changes were observed with regard to Chads recovery throughout his

participation in music therapy. For much of the process I questioned whether what we were

doing together would be considered music therapy given the amount of verbal discourse that

took place. I would come to learn throughout the course of this study how important these

verbal exchanges were, not only in understanding Chads experience of his current situation

but also in understanding Chads experience of music.

2 A contracture is a tightening of muscle, tendons, ligaments, or skin that prevents normal movement

(Hammerstad, 2007).

3

1.3 Purpose of study

The purpose of this qualitative case study is to provide a holistic description of eleven

music therapy sessions with Chad while gaining an understanding of the therapeutic process

for the acquired brain injury population. Wheeler (2005) says, treatment research focuses on

the clinical interventions used in music therapy, or the methods used by music therapists to

induce change in clients (p. 81). The study will examine the following:

Functions of music in therapy, the specific role of the various musical elements, how

clients respond to different music interventions, the therapists contribution to the

therapeutic process, the way a particular method or technique is utilized with specific

populations or problems, the effects of environmental conditions or interpersonal

settings on the therapeutic process, the client-therapist relationship, the client-music

relationship, the dynamics of therapy, and so forth. (p. 81)

The qualitative focus of the study will include events, actions and interactions within music

therapy. This research endeavours to investigate connections between music therapy,

consciousness, identity and trauma, while suggesting links to specific regions of the brain.

Music will be shown to have activated this region, augmenting its ability to integrate

important functions related to ones experience of identity.

1.4 Research Questions

While the initial objective for the study was to examine post-traumatic stress disorder

and the relationship to acquired brain injury, it evolved into a more specific topic of

rediscovery of identity. This experience has been understood to be one aspect of post-

traumatic stress and while I endeavour to lay a foundation for exploration of this

phenomenon, the current study will focus on the following research questions:

1. How does ones evolving identity after acquired brain injury manifest in music therapy?

4

This research question offers the potential for many additional questions regarding the

definition of music, identity and even human evolution not to mention research and duality of

roles. For the purposes of this paper the research focus had to be narrowed considerably.

1.5 Value of the Study

This study will provide an understanding of the course of recovery and rehabilitation

and the subsequent musical interactions that accompany the various stages of this process. It

will allow for the improved design of music therapy interventions for use in a clinical setting

for acquired brain injury.

For the field, the research will offer value by presenting a case study of music therapy

from a unique perspective. While there exists some literature regarding music therapy with

the acquired brain injury population, there is a gap in the body of knowledge relating to the

treatment of trauma relating to this group. The study will lay the foundation for further

exploration into the nature of acquired brain injury and trauma, how these manifest

themselves musically and how music therapy can augment recovery and rehabilitation.

From the perspective of clinical placement, music therapy is a relatively new

discipline and a regular music therapy program did not exist before this work began. The

findings of this study will hopefully provide the management team and clinicians with an

understanding of the rehabilitative potential of music therapy.

1.6 Stance of the Researcher

Music can have a profound effect on the rehabilitation of acquired brain injury clients.

Music has the ability to reach people on many levels and across multiple domains such as

cognitive, emotional, social and spiritual. Music could, in fact, be considered its own domain

5

in our human makeup and there are many examples of music being a force for healing across

all domains.

The debate about the nature of post-traumatic stress following acquired brain injury

interests me as well. Regardless of whether the client is experiencing traumatic symptoms

resulting from the original injury, or the trauma resulting from insight into a radically changed

life situation, the fact remains that this group is living with the effects of trauma.

Through my own experiences with trauma, I have developed a keen interest for the

subject. I recognize how trauma can drastically affect ones sense of identity and relationship

to their environment. Together with my ongoing training in music-centred psychotherapy I

hope to refine my understanding of the nature of trauma, how it affects clients with acquired

brain injury and how music therapy can be an efficacious form of psychotherapy.

When I began the study, I hoped to find that music had profoundly affected Chads

rehabilitation. I thought however, that because I had used my secondary instrument (guitar)

as support, and engaged in lengthy verbal interaction, that the full potential of music in

therapy had not been realized. What I discovered instead, was that I took for granted the

acute effect that I as an instrument of therapy had on Chads recovery.

The recent oral defense of my research helped me to clarify my own understanding of

my dual role of student music therapist and researcher3. It helped me to recognize that there

are benefits to this dual role in addition to its more obvious challenges. Researching my own

clinical work helped me to become more observant and methodical in those observations.

These qualities are what make the work with these clients clinical and help to define the

therapy. Critical observation skills develop over time and analyzing interactions between my

3 Thanks to Dr. Carolyn Arnason for providing Ethical & Epistemological Considerations in Researching Your

Own Clinical Work (Novermber, 2001) adapted from Doctoral Research Course with Kenneth Aigen, 1994.

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clients and me has allowed me to be vigilant in the moment when working with people.

The process of ethical review for the purposes of research was equally profitable in

encouraging me to regularly review my therapeutic relationships and maintain clear definition

of roles in therapy.

I have gained a better of understanding of the data analysis process and in researching

my own work, I recognize the value of data analysis workshops with my peers. I recognized

my egos desire to hang onto the findings and keep them secret until they could be publicly

unveiled but the importance of member checking (Wheeler, 2005) was remembered and the

equally powerful desire to share the excitement of the findings with someone made

supervision an appreciated part of the research process.

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CHAPTER II: LITERATURE REVIEW

2.1 Case Study Research

A brief literature review began with investigation into the design of case study

research. Wheeler (2005) provided a detailed description of this type of study, including

historical overview and the development of the use of case histories to research.

Understanding the difference between publishing a case study and that of case study research

was pertinent to the study. Smeijsters and Aasgaard clarified this context and described

differences between case histories, case vignettes, case examples and case study research (p.

441). The differentiation between case history and case study research for example lies in the

fact that in the case study as research, the goal is to develop the body of knowledge by using

a systematic method of inquiry (Bruscia, 1995, p. 441).

It was suggested that the essential aspects of case study research include:

The use of research method that requires all data to be observed and analyzed;

The use of various forms of data collection and analysis;

Data analyses that are checked by members and peers;

Data analyses that are informed by multiple perspectives. (Wheeler, 2005, p. 441)

Based on the following definition, it was determined that a Qualitative Single-Case Design

was the ideal method of presenting the research.

The researcher does not have a preliminary idea of relationships between events but

nevertheless uses experimentation to see what happens. For instance, without a clear

idea of the effect of singing or playing on instruments, the music therapist might

alternate between them. In assessment procedures we often see that music therapists

use a standard set of musical activities to see how the client reacts. One could say that

the therapist is experimenting without a hypothesis. (Wheeler, 2005, p. 442)

David Aldridge (1996) suggests that an additional dimension of validity resulting from

independent observations (p. 122) can be brought to the research. This was accomplished

through clinical and research supervision as well as a data analysis workshop in which my

peers reviewed the findings.

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2.2 Consciousness and Identity

Kenneth Bruscias (1991) edited collection of case studies includes three chapters that

pertain to acquired brain injury. One that is particularly relevant to this study, is Nancy

McMasters study entitled Reclaiming A Positive Identity: Music Therapy In The Aftermath

Of A Stroke (p. 547). The study describes phases of music therapy treatment and methods

employed including improvising, composing, and singing. The client grieved and protested

what life had brought her, while also finding a way of validating the ability and strength that

still lived inside her debilitated body (p. 547). The client essentially discovered a new sense

of identity. The function of music to feel alive in her situation was similar to this study,

where music activated processes within Chad directly related to consciousness, identity and

self-perception, helping him to feel alive.

In 2009, a neuroanatomist published a vivid personal account of her journey through

the very moments of a stroke and her subsequent eight-year journey to a complete recovery.

What she describes relates to the topic of consciousness, identity and ones understanding of

reality before, during and after such an event. Bolte-Taylor (2009) describes a spiritual

experience in which she felt at one with the universe (p.143). As the left hemisphere of her

brain deteriorated she experienced a time in which her consciousness shifted away from

feeling like a solid, to a perception of [herself] as a fluid (p.143). As the study will reveal,

Chad too appears to feel this blurred boundary between the experience of conscious and

unconscious reality. This revealed itself through verbal discourse and active music making

along with compulsive yawning that I initially misinterpreted after reading this same book.

Bolte-Taylor (2009) lists Forty Things I Needed Most in which an item appears which says,

Honor the healing power of sleep (p.191). While I thought Chads yawning was an

indication of his physiological need for sleep, instead, what was revealed through research

9

was the potential for his yawning to be interpreted as a side effect of the process of becoming

conscious and discovering his identity. Beauregard and OLeary state, consciousness cannot

be directly observed. No single brain area is active when we are conscious and idle when we

are not. Nor does a specific level of activity in neurons signify that we are conscious

(Beauregard & OLeary, 2007, p.109). This appears to be contradicted by the research

findings regarding a brain region called the Precuneus (Vogt and Laureys, 2005).

2.3 Introducing the Precuneus

Throughout the study of music therapy sessions with Chad, distinct phases of musical

behaviour emerged that I categorized as follows:

Blindness

Am I dead?

Memory

Insight

Yawning

Investigation of yawning and its contagious nature, elicited the topic of empathy, which

pointed to existing research conducted on the Precuneus. The main function of this region is

to integrate the following:

Consciousness

Self-Perception

Memory

Visuo-Spatial (Cavanna & Trimble, 2006)

Moreover, this area has been shown to be somewhat hypoactive in mental

states of decreased or abolished consciousness, such as sleep, hypnotic state,

pharmacological sedation and vegetative state. Converging evidence therefore

10

suggests that the precuneus may be involved in the integration of multiple

neural systems producing a conscious self-percept (p. 579).

The precuneus and interconnected posterior cingulate and medial prefrontal

cortices are engaged in continuous information gathering and representation of

the self and external world (Gusnard and Raichle, 2001).

To my knowledge, few studies exist of the Precuneus itself and none relate to music therapy.

A few articles exist that discuss the role of music in activating the Precuneus. A study

published in Japan in 1999 by Nakamura, Sadato, Oohashi, Nishina, Fuwamoto, and

Yonekura, examined the music-brain interaction by measuring regional cerebral blood flow

(rCBF) while simultaneously recording beta rhythms with electroencephalogram (EEG)

during receptive music listening. Their findings suggested:

The premotor-parietal network may include the precuneus as part of the

neuronal substrate for music perception. Thus, there may be an overlap of the

neural networks for musical and spatial processing. Brief exposure to music

led to short-lived improvement on spatial task performance. (Nakamura et al,

1999, p. 226)

The article references another study by Leng and Shaw (1991) that suggests there may be a

common neural firing pattern between musical and spatial processing. Nakamura et al.

therefore concluded the following.

Considering the role of the premotor-parietal networks for spatial processing

and the possible overlap between musical and spatial processing, music

listening may cause priming of the posterior portion of the precuneus, which

may work to the advantage of a subsequent spatial task. Recruitment of the

posterior precuneus during music listening may reflect the interaction of the

music with the mental state, such as in music-evoked memory recall or visual

imagery. (Nakamura et al, 1999, p. 226)

Evidence of the link between the Precuneus and consciousness appears in studies of

those individuals with disruptions in this area including those living with Epilepsy,

Alzheimers and Autism as well as brain lesions and those in a vegetative state (Cavanna,

11

2007). For Chad, evidence of this link appeared in the behaviours that emerged throughout

the course of music therapy.

2.4 Post-Traumatic Stress

A potential disparity exists regarding the nature of the sequelae described above and

how they might instead be associated with post-traumatic stress disorder, which arguably

occurs after neurological trauma. Much of the literature alludes to a broader theme of self-

perception and the loss of identity that occurs after trauma. Examining the literature in the

context of Chads presentation in music therapy, one could interpret musical and non-musical

behaviours as symptoms of post-traumatic stress and adjust the course of therapy accordingly.

There have been numerous case studies published by all disciplines in the field of

neuropsychological rehabilitation after acquired brain injury including that of music therapy.

Research has been conducted with clients of varying levels of consciousness in the areas of

emotional support, behavioural challenges and physical and cognitive rehabilitation. Little

exists in the area of post-traumatic stress and acquired brain injury and nothing was found

pertaining to music therapy and post-traumatic stress disorder (PTSD) after brain injury.

There is a debate among experts about the existence of PTSD after acquired brain

injury. There are those that maintain the brain is not capable of encoding a traumatic

experience due to the nature of acquiring a brain injury. Others feel that coming to terms with

a new way of life after acquired brain injury is the traumatic event resulting in these

symptoms. In an article entitled, Post-traumatic Stress Disorder and Traumatic Brain Injury:

Can They Co-Exist? Richard Bryant addresses this argument. He offers an overview of this

debate, critiques the evidence concerning PTSD following TBI, and considers the possible

mechanisms for PTSD following impaired consciousness (Bryant, 2001, p. 931). With the

knowledge of these articles, I am interested in better understanding the role of music in

12

helping a person to adjust to neurological trauma and the identification of effective music

therapy methods.

Diane Austin (2008) has written extensively on the subject of music therapy for clients

with trauma. She says, common to all traumatic experiences is the rupture to the integrity of

the self and the feelings of confusion, helplessness and terror this rupture evokes (p. 63). A

protective factor for adult clients of acquired brain injury may be the existence of a coherent

ego prior to injury. An ego with seemingly adequately developed defences, which may not be

the case for a victim of childhood trauma as were many of Austins cases. With acquired

brain injury, music can be therapeutic in the recovery from trauma where other treatments are

ineffective due to cognitive challenges.

Additional literature exists relating music interaction with various regions in the brain

and in a study published by Kloet et al (2008) they provide support for the idea that the

precuneus is part of a larger network displaying altered activity in veterans with PTSD

(Kloet et al., 2008). To my knowledge, nothing brings together the elements of music, brain

function and trauma.

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CHAPTER III: METHODOLOGY

3.1 Research Design

The research methodology followed the model of a Qualitative-Experimental

Hypothesis-Generating Single-Case Study. The interaction between Chad and I was essential

to the research. Due to the unique presentations of brain injury between clients, and the

inherent differences between people, the findings of the study cannot be generalized to the

rest of the population. The research was concerned with the quality of the data and the

experience (Wheeler, 2005).

The research is a treatment study intended to focus on methods and interventions used

that were meaningful for the client. Chad had the opportunity to take part in individual music

therapy sessions according to his evolving abilities at varying stages of recovery.

The study focused on events (musical behaviours and interactions) and materials in the

form of video recordings. Video of musical and verbal interactions were indexed4,

transcribed and notated. Refer to Appendix E for a sample of a session index. Chads

experience of therapy was elicited and analysis of patterns and themes were observed

providing insight into these phenomena. I engaged in self-exploration by maintaining a

journal throughout the course of study. Regular reflection occurred throughout all stages of

the process (Wheeler, 2005). My previous experience with this client population together

with further literature review, allowed for an abductive frame within which the resulting data

were interpreted.

4 The term Indexing describes the systematic review of session recordings to create a minute-by-minute account

of the interactions that occur. Sessions were analyzed for musical contributions, non-musical contributions

and interpretation or reflection and a chart was created in which to present the detail.

14

3.2 Procedures

Chad took part in weekly music therapy sessions for a period of twelve weeks.

Sessions included verbal and non-verbal interventions according to his needs in various stages

of recovery. It was hoped as student music therapist, that he would have the opportunity to

experience a multitude of music therapy techniques including instrumental playing and

singing, facilitated song writing, free improvisation, re-creation of familiar songs and music

listening although his relatively short stay at the facility meant that not all of these were

possible.

The first four sessions were a period of assessment after which specific aims and

objectives were identified. Sessions were recorded on video so musical interactions could be

analyzed to identify the participants changing abilities in terms of rhythmic, vocal and

instrumental interaction. Session video was reviewed and indexed5 to identify meaningful

moments of progress and assist in determining the course of future therapy.

At the end of the treatment period, I interviewed Chad about his experience of music

therapy and three months after therapy, I interviewed he and his family once again to gain

feedback.

3.3 Research Setting

I am a Master of Music Therapy (MMT) candidate currently completing an internship

at an acquired brain injury rehabilitation centre for adults (16 years old and up). Having been

there for a year, this became the setting for the investigative study. Chad was chosen to

participate based on the receipt of approvals from the research ethics boards at both Wilfrid

Laurier University and Hamilton Health Sciences. There existed no criteria for selection

5 The term Indexing describes the systematic review of session recordings to create a minute-by-minute account

of the interactions that occur. Sessions were analyzed for musical contributions, non-musical contributions

and interpretation or reflection and a chart was created in which to present the detail.

15

beyond the fact that the participant had to be an in-patient on the ABI unit of the rehabilitation

facility.

Chad, and his mother acting as substitute decision maker, were each approached in

person to discuss the purpose of the study and opportunity for participation to which both

consented. Chad had the option of withdrawing from the study at any time without penalty.

Because music therapy was to continue at the facility regardless of the study, the participant

would continue to have the opportunity to engage in music therapy if he had withdrawn from

the study. It was and remains the expressed intent of the researcher to provide quality music

therapy for these clients regardless of the objective of case study research.

3.4 Data Collection Procedures

The data naturally occurred throughout sessions. Primary data included the verbal and

musical interactions between client and therapist as recorded on video throughout eleven

sessions. Secondary data included indices, transcriptions and notations of these same sessions

as well as an in-person, semi-structured interview with the participant and his parents about

their experience of music therapy. This interview followed a Biographical-Interpretative

Method based on principles of open-ended questions for the purposes of eliciting stories

(Wheeler, 2005).

3.5 Data Analysis, Interpretation and Presentation

Data analyzed included video, interview results, indexing6 and narration. Data were

coded and analyzed with subsequent categories being formed according to the principles of

adapted Grounded Theory where the purpose is to discover theory from data (Glaser &

Strauss, 1967, p. 1). Musical interactions were indexed and notated for further analysis.

6 The term Indexing describes the systematic review of session recordings to create a minute-by-minute account

of the interactions that occur. Sessions were analyzed for musical contributions, non-musical contributions

and interpretation or reflection and a chart was created in which to present the detail.

16

Verbal discourse was transcribed and these events were consolidated into graphs that

provided a visual representation of the context of events and relationships between them.

This data was then coded to form seventeen categories to which each action or interaction was

assigned. These categories were then consolidated and related according to their similar

context or topic such as Insight or Playing instruments. This data was then graphed to

provide a clear visual representation of the relationships between events or categories such as

Instrumental Playing and Yawning.

Data will be presented in a format that traces the chronology of Chads recovery

through a comparison to the literature. References to session examples will be coded with the

session number and time of occurrence. For example, when describing an event that occurred

in session three at 5 minutes and 13 seconds it will be referenced as: (S3, 05:13).

3.6 Ethical Issues

Because the study involved a human participant, the potential for ethical issues

immediately became apparent. In addition to practitioner, I adopted the role of researcher

near the end of treatment, which naturally suggests intrinsic bias. A reflexive process and

clinical supervision helped to identify and control excessive bias during the study and helped

me to understand external influences during the course of therapy and the data analysis

phases.

The qualitative nature of the study ensured that results were revealed throughout the

data analysis allowing the therapy to proceed uninhibited by the requirements of the research.

This allowed Chad to exist as client rather than participant throughout the therapy thereby

directing the course of his treatment according to his unique needs.

My value system as therapist reflects a client-centred approach. The fact that I had a

number of supervisors at various levels (placement supervisor, research supervisor and

17

clinical supervisor), prevented any negative impact on the participant resulting from the study.

These ensured the design of therapeutic interventions focused exclusively on the rehabilitative

needs of the client and not those of the therapist as researcher.

Because I acted as the primary instrument of data collection, analysis and

interpretation I understand that I had an effect on the resulting data. Every choice that I made

had an effect on the study at every stage of the process. As therapist choosing the direction of

music therapy then as researcher in the selection of meaningful interactions for subsequent

analysis, the fact remains that a duality exists around my role.

A duality also existed for Chad. Because of the cognitive impact of his injury, I

ensured that Chad understood that he was not only taking part in music therapy, but also in

case-study research. While I recognize the dual role of participant and client to exist, it

did not have a negative impact on his course of therapy. Every means of protecting Chads

privacy were adopted until it was determined that anonymity was no longer warranted.

Finally, due to the size of the facility, and the narrow timeframe for scheduling music

therapy, the possibility existed that other in-patients and their families would question why

they had not been invited to participate in music therapy. The issue did not arise, however,

the team was prepared to explain the circumstances surrounding the therapists placement at

the facility and those individuals would have had the opportunity to participate in music

therapy.

In conclusion, although ethical issues that accompany case-study research are

unavoidable, I am confident that potential conflicts were prevented and the client was treated

in an ethical manner.

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CHAPTER IV CASE DISCUSSION

4.1 Introduction

The initial topic of study pertained to post-traumatic stress in clients with acquired

brain injury. However, after indexing7 and analyzing eleven music therapy sessions with

Chad, a different process of recovery was revealed. Symptoms of post-traumatic stress

disorder fall into three broad categories frequently referred to as Intrusion, Avoidance and

Hyperarousal. While Chad experienced symptoms that could be classified this way, they

appeared in a different context.

Chad experienced intrusive memories but not about the instant of trauma. Intrusive

memories manifested as hallucinations of past experiences including the pet dog and the

family pool. Chad, to my knowledge, never exhibited avoidance behaviour in the strict sense

of post-traumatic stress disorder or in terms of therapy. Chad frequently initiated

conversation about his injury. He was always a willing participant in music therapy and never

hesitated to talk about his feelings. Chad did experience what could be considered symptoms

of hyperarousal including sensitivity to light, touch and sound although these are not

uncommon for clients with acquired brain injury.

For this reason, the research became more focused on the change in identity that

occurs after neurological trauma. Tracing Chads journey back to consciousness in the

context of music therapy resulted in the following categories for discussion:

Consciousness

Visuo-Spatial Imagery

Memory

Yawning

Self and Identity

7 The term Indexing describes the systematic review of session recordings to create a minute-by-minute account

of the interactions that occur. Sessions were analyzed for musical contributions, non-musical contributions

and interpretation or reflection and a chart was created in which to present the detail.

19

These categories evolved from consolidating musical and non-musical interactions based on

these themes.

4.2 Consciousness

Help!

In session one, Chad appeared to be asleep so I chose to quietly strum guitar chords

(open E in various positions on the fret board) and sing syllables. Chad rolled onto his back

sideways in the bed and lifted his head and upper body to reach for his foot. He appeared to

be examining his body more than responding to the music. I began to sing words including

Hes awake, Chad, Good morning. Approximately twelve minutes into this improvised

greeting song Chad began to cry out help (S1, 12:20) (DVD Track 1). The volume of the

cries made me wonder if he realized anyone was there. I considered the possibility that

hearing impairment might explain the volume of his outburst. I waited, and eventually

requested the assistance of a rehabilitation therapist to reposition Chad in a less contorted

position in the bed. I continued to strum the guitar quietly and vocalized pre-composed songs,

omitting the words. Chads cognitive state became evident in the following entries that

appeared in the medical chart the day following the first music therapy session.

I love you mom.

I love you dad.

I love you [friend].

Get me out of this world.

Am I dead?

Who is that? (October 22, 2009)

Because the radio was often left on in Chads room it is difficult to know if he was

aware of my presence and that I was the source of the music. In that moment there was

already a felt sense of confusion and I questioned the role that music would play in his

recovery.

20

In this session, Chad was beginning to expand his own spatial awareness by

investigating his body with his hands. At that stage he did not venture farther than his own

body and that included experiencing instruments. Although Chad pushed his foot against the

guitar (S1, 09:10) it appeared to be more of a stretch from inside out rather than outward

exploration. When I suggested that he play the guitar with his foot, he curled his toes. I took

hold of his foot and strummed the guitar. (S1, 10:00)

Session two occurred a week later and the chart indicated that Chad had been

repeatedly crying out help throughout the week. Chad was once again in bed. I played the

same open E chord progression from the previous week. Chad appeared relaxed and listened

attentively, occasionally vocalizing the syllable oh. During the session, the rehabilitation

therapist entered the room to stretch Chad and I requested that he do so while I continued with

the music. According to the rehab therapist this impromptu collaboration resulted in the most

quiet and relaxed stretching session to date. Chad did not call out Ow! or Help! as he

normally would.

Music seemed to be encouraging relaxation. Live music in a therapeutic context

offers a benefit unique from playing pre-recorded music for relaxation and that is the

flexibility to respond to the unique biological rhythms of the client in that moment.

Vogt and Laureys (2005) describe consciousness as:

a multifaceted concept that can be divided into two major components: the

level of consciousness (i.e., arousal, wakefulness or vigilance) and the content

of consciousness (i.e., awareness of the environment and its relation to self)

(Vogt & Laureys, 2005, p.205)

According to this definition, I interpreted Chads presentation in those moments as being a

lower level of consciousness on both fronts. Examination of the index data and literature

offered a different perspective. Conscious awareness involves a continual stream of self

21

reflection and an effort to relate the self to its sensory environment (Vogt and Laureys, 2005,

p.7). Chad was becoming more conscious in this regard and music served a greater purpose

in addition to relaxation.

The song Times Like These by The Foo Fighters was introduced during the stretching

with vocal melody and guitar accompaniment (S2). The open E improvisation and Times

Like These were recurring musical themes throughout therapy and were being imprinted in

Chads memory from this early beginning providing a consistent environment for Chads self-

reflection and exploration.

Chad responded by raising his eyebrows when I sang higher pitches or the ah

syllable, bobbed his head to the music and clasped his hands together in front of his face,

blowing into his thumbs as one would if they were to play a blade of grass like a whistle. In

these first two sessions Chad was confirmed to be visually impaired but hearing intact and

demonstrating a beginning awareness of his environment through appropriate responses to

music. Music was stimulating movement toward consciousness in the sense of awake

versus asleep and self-awareness in the context of identity.

4.3 Visuo-Spatial Imagery

Waking Up Blind

Chad told me about a nightmare he had of his family being killed and sought

reassurance that they were safe. This verbal exchange revealed to me the extent of Chads

experience of waking up blind. Chad would sleep and have dreams in which he was able to

see. Then when he would awaken, he was without sight and might therefore interpret that

experience as sleeping. These are intrusive images that made it difficult for Chad to

comprehend internal versus external imagery and conscious vs. unconscious reality. Study of

the literature shows the Precuneus is involved in this process. Being close to the primary

22

visual areas, the activation of this region is often interpreted as reflecting visual mental

imagery (Demonst et al., 1992; Grasby et al., 1993; Fletcher et al., 1995). The contribution

of the cuneus/precuneus to tasks involving visual material has been demonstrated (Corbetta et

al., 1993).

Chads blindness was one of the broadest reaching symptoms. It was central to

challenging his recovery on so many levels: his sense of self, his consciousness, his ability to

form memories and his physical and environmental awareness. His vision began to return

soon in our time together. It was described as being a tiny window and he demonstrated

while sitting upright in bed with the guitar lying flat on his lap. He indicated that he could see

the neck of the guitar even though he was looking straight ahead at the wall.

On occasion, Chad had to be reminded that he was beginning to see albeit mostly in

the periphery. The return of his eyesight helped to reduce the confusion between internal

mental imagery that he was experiencing and the real imagery of the external world.

C: Were alive, right?

K: Yes, we are alive.

C: pauses

C: I thought

K: Mm. Hm.

C: that I was dead.

K: Now that youre starting to see a little bit more, does that make it easier?

C: Yah.

K: To believe that youre alive?

C: nods and pinches himself. (S6, 41:00) (DVD Track 2)

An interview post-treatment revealed that Chad had also experienced hallucinations that were

based on past memories.

When Chad was introduced to the snare drum his playing was facilitated by hand-

over-hand interaction. Due to challenges with coordination and vision impairment, Chad

appeared to exert a tremendous amount of concentration while playing the drum. Initially

23

playing with his hands without sticks; he began to gain a new understanding of spatial

orientation. When he began to use drumsticks to play the snare, he learned to manipulate his

surroundings using objects thereby offering a unique understanding of his affect on the

environment. Once again, the literature revealed a link between music and the Precuneus.

Considering the role of premotor-parietal networks for spatial processing and

the possible overlap between musical and spatial processing, music listening

may cause priming of the posterior portion of the precuneus, which may work

to the advantage of a subsequent spatial task (Nakamura et al., 1999, p.226)

Confusion in Imagery

Chad seemed to be bombarded with confusing imagery. During receptive music

therapy he often interrupted the music with questions as if he was aware that I was in the

room, but not that I was the source of the music. A radio frequently playing in his room likely

added to this illusion. It is a challenge to understand how much of a role music may have

played in adding to this confusion. Symptoms of post-traumatic stress include disconnected

images that intrude upon on our understanding of our reality. At the time, I struggled with the

effectiveness of using music without accompanying verbal interaction. Because Chad was

having visual images in his sleeping state and very confusing visual images, if any, in his

waking state music also had the potential to be an intrusion. That being said, I do not believe

that music was counterproductive to Chads recovery. Music helped to initiate images then

integrate them, with the support of verbal intervention.

Session three included repeated calls for help although by this time Chad was

conversing with the staff and his family. Chad was able to comprehend others speaking to

him, provided their rate of speech was slow with pauses between words. His first verbal

acknowledgement of my music appeared when he said, Turn this off its keeping me up

(S3, 41:11). When he made the statement he looked away from me and reached out with the

24

hand opposite to me into the air as if the sound were coming from that direction. He was not

yet able to discriminate the source of the sound I was making. (DVD Track 3)

It is my believe that live music was beginning to engage Chads brain, in the

Precuneus region, helping to develop the ability to discriminate the location of sound and

become more self-aware and conscious although it is impossible to know for sure.

Spatial Discrimination

Engaging with instruments served to challenge Chads visuo-spatial understanding in

a number of new ways. When first offered a snare drum and some instruction, he

experimented by playing with his hands, examining the dimensions of the drum and playing

with a lilting rhythm. Chads spatial awareness was challenged, as was his coordination.

After approximately one minute playing the snare drum, he began putting his finger in his

ears and nose, which I believe was a form of self-examination and an attempt to understand

his position within his environment. This movement toward understanding lead to a change

in how Chad presented verbally and vocally in music.

During instrumental playing Chad said a number of times that the music was too

loud and frequently said shhh (S5, 29:49). He also indicated that the room was too

bright. I believe these statements to be an indication of possible over-stimulation of his brain

in coordinating multiple inputs of information, a phenomenon that could only occur through

such a multi-faceted stimulatory experience such as playing instruments. Acoustic guitar and

voice, aside from the obvious logistical convenience, offered a minimally intrusive experience

with a gentle timbre to support Chads music at this stage.

An additional point of interest with regard to Chads processing of musical experience

is evident in the fact that the speed with which perception occurs (i.e. instrumental playing

and reaction after listening to music) is accelerated in comparison with that of verbal

25

interaction during the same period. When speaking to Chad one had to speak very slowly in

order for him to comprehend. In the music, Chad was able to mouth the words to songs in

tempo with no delay.

In session nine, as Chad moved to playing the snare drum, he looked at my face with a

startled expression of what I thought to be recognition as though he was suddenly able to see

me (S9, 29:00) (DVD Track 4). At the time it appeared to be random, however with the new

understanding of the Precuneus role in integrating various areas of the brain, it might be said

that exercising this area through instrumental playing contributed to the recognition of a

visual representation of the external world different from that of the mental imagery he had

experienced during receptive music therapy.

4.4 Memory

Connections exist currently regarding the role of the Precuneus in episodic memory

retrieval. A large body of literature pertains to the use of music therapy for the purpose of

exercising memory. Music therapy with Chad was no different. The manner of memory

storage and connections for retrieval presents an interesting discussion concerning Chads

experience of music therapy.

Memory In Words

Session five was the beginning of our discussions about music, artists and preferred

musical styles and Chad was observed to have mouthed the words in the chorus to the song

Times Like These. When asked whether he recognized the song, however, he said that he did

not. This was my first introduction to the manner in which Chads memories had been stored

and were being retrieved. It appeared as though various components of songs (artist, title,

melody, lyrics) were being stored separately with no unifying link between them. This same

phenomenon would appear later in session seven. I asked Chad whether he could imagine a

26

song in his mind and hear it playing in his head, which he said that he could (S5, 07:42).

This demonstrates memory retrieval as well as the ability to create mental and auditory

imagery. An impromptu intervention of Name That Tune revealed stored memory but

disconnection in paths for retrieval (S9, 34:30) (DVD Track 5).

Chad and I began with a verbal introduction at the start of every session together with

a brief orientation where I would determine whether Chad was able to remember my name.

The retrieval of the information was blocked if asked the question, Do you remember my

name? however on one occasion when I began to spell it, Chad said the name after only the

first three letters demonstrating that the memory had been stored but retrieval was context

dependent. On later occasions, I waited to prompt Chad for my name until part way into the

session to determine whether the context of making music was a trigger for the memory

retrieval. These occasions resulted in immediate retrieval of the first syllable matching my

name, and then further prompting was required to finish the task. Examination of the session

indices demonstrates that physical memory of the music experience is being stored and

accessed from session to session, and a disconnection exists in the mental realm linked to

visual and mental imagery.

Understanding that Chads storage of song information included a separation of the

various components of a song, turned out to be a microcosm of a larger disconnection that

existed in Chads storage and understanding of the various components of his external world.

In this phase of therapy, music served to engage these various components at once thereby

creating new connections. Music acted as an integrating force.

Memory In Music

In session one, Chads ability to respond to external stimulation was impaired and he

did not appear to be engaged with the music being played live. Although my vocals consisted

27

mostly of syllables, there were moments that included words like Chads awake, Good

morning, Hes awake, Time to wake up as well as various syllables. A partial

representation of the chord progression and vocal melody are provided in Figure 1.

Figure 1 Session One Guitar/Vocal Excerpt

Because Chad did not appear to be actively responding to the music in the first session, it was

difficult to assess how much he was absorbing, and how much damage had occurred

regarding his ability to construct short and long-term memories. Upon close examination of

the pitch and contour of Chads yawning in later sessions, it appears as though a foundation

was laid in these first sessions for Chad to remember new melodies. A repetitive pattern of

descending vocal contour reappeared in the episodes of yawning.

In session ten, at 29:17, Chad begins to yawn the first three tones that match the pitch

and contour of the melody I sang in session one. Also in this session, at 33:20 the tonality of

Chads yawning matches the tones that I had sung earlier in that same session. It appeared as

though he was imitating what I had done thereby demonstrating his ability to learn and

construct short-term memory. This is an area that presented as a deficit in other contexts.

Recruitment of the posterior precuneus during music listening may reflect the

interaction of the music with the mental state, such as in music-evoked

memory recall or visual imagery. Activation of this area during memory

retrieval [1] and through visual imagery as a mnemonic [2] has been reported

(Nakamura et al., 1999, p.226)

28

Every Session Is The First Session

Throughout the course of therapy there was a pervasive sense that Chad was

experiencing each session as if for the first time because of his memory impairments. The

implication of this means there would naturally be nervousness on the part of the client to

participate in music therapy. In particular the fact that Chad was blind, redeveloping

coordination, rehabilitating memory and relearning the basic activities of daily living would

inevitably amplify the nervousness on the occasions that he was then encouraged to play

instruments and sing. Chads family indicated that the frequency of yawning increased when

he was anxious which also began to occur around the same time that Chad was beginning to

explore the boundaries of his environment through instrumental play. By session eleven,

Chad was becoming more adept at playing instruments and the yawning behaviour decreased

compared to the previous two sessions. This shows memory construct and expanded

environmental awareness.

4.5 Yawning

About Yawning

Considerable debate surrounds the phenomenon of human yawning and its cause and

evolutionary purpose. From an evolutionary standpoint, many believe that yawning and its

contagious nature serve a group purpose by keeping members of the group alert. There are

those hypothesizing that yawning serves to keep the brain cool and regulate body temperature.

Still others maintain that yawns might be caused by a lack of oxygen in the bloodstream and

studies exist that contradict one another as to the affect that yawning has on oxygen levels in

our systems. Humans are not the only species that yawn. Dogs, cats, apes and even herring

gulls yawn. Because of its contagious nature, even in some animals, researchers are

investigating a possible connection between contagious yawning and ones empathic ability.

29

Biologically, scientists do have an understanding of the neural substrates that are

activated during the act of yawning and one of those regions is the Precuneus (Cavanna &

Trimble, 2006).

To my knowledge, very little exists in the way of literature pertaining to the

phenomenology of yawning in therapy and nothing specifically relates to the context of music

therapy. The International Journal of Child Psychotherapy published an article in 1973 where

a case was presented of a non-communicative thirteen-year-old patient whose incessant

yawning constituted his principal expressive response during a phase of treatment lasting

many months (Marcus, 1973, p. 1). Dr. Marcus initial reactions to the behaviour were to

interpret it as resistance to the therapy process. My first impression of Chads yawning was

that it was exhaustion; a natural symptom of recovery from brain injury. When it began to

occur alongside active music making, it took on a new meaning that continued to evolve

throughout the study.

Yawning In Music

Chad experienced the spontaneous onset of yawning in session six and the behaviour

increased in frequency and duration throughout music therapy. The yawning occurred outside

of music therapy as well as in sessions however the quality was different. When it occurred

in music therapy sessions, I asked Chad if he was tired and in need of rest. For the majority

of occasions he indicated that he was not tired and preferred to continue and that the yawning

was something beyond his control even referring to it as an entity separate from him, saying,

It does this all day (S10, 33:58).

Mapping out the occurrences of Chads yawning with other vocalizations,

verbalizations and instrumental play revealed connections worth further examination. I

created a graph (Figure 2) of the co-occurrence of yawning alongside other events such as

30

Instrumental Playing, Singing, Music Talk and verbal discourse around Blindness, Insight and

Humour/Sarcasm. Instrumental refers to Chad actively playing instruments. Singing

includes the act of singing by definition as well as mouthing words without vocal sound (i.e.

lip-synching). Music Talk refers to any verbal discourse relating directly to music such

as instruction for how to play instruments, discussion regarding Chads preference for musical

styles and bands as well as verbal interventions involving memory of band names, specific

songs and song lyrics. Verbal discourse relating to Blindness included Chad relaying details

about what he was able to see or read and the effect that losing his vision had on his life.

Insight refers to verbal discussions in which Chad demonstrates knowledge about his injury

and life situation and Humour/Sarcasm includes verbal exchanges during which Chad made

a joke appropriate to the context of the situation.

Figure 2: Correlation Between Events

The graph revealed what appeared to be a direct correlation between the onset of instrumental

playing and that of yawning. Early sessions (1 4) consisted of Chad listening to live music

for relaxation and pain management as well as verbal discourse surrounding the nature of his

31

injury and insight into his situation. In session five, Chad began to demonstrate more

acceptance and understanding of his situation and was motivated to engage in discussions

about the music being played.

Yawning As Music

Alongside this increase in instrumental playing was an increase in yawning. With the

exception of session eight, all instrumental play included a related amount of yawning. No

other events occur in such direct correlation. Chad was encouraged to sing throughout music

therapy in an effort to rehabilitate both his long-term and short-term memory.

Chad was able to remember the lyrics to songs that were favourites prior to injury and

he demonstrated this by mouthing the words together with me as I sang. He did this without

any audible voice. At different times, Chad would yawn with a loud audible voice and often

at length. In session six, I left the room to refill Chads water bottle. With the camera still

recording, Chad once again yawns, but this time with no one else in the room, it occurs

without sound and for a short duration (S6, 10:35).

Subsequent occurrences of the yawning when I am in the room are loud and longer in

duration. Some occurrences lasted 20 seconds or more. In these moments, I felt as though

Chads vocalizations should be considered singing because of the quality and duration. A

number of ideas arose with regard to the intention behind the yawning (DVD Track 6).

Yawning Towards Insight

Two sessions are of particular interest regarding these parallel occurrences.

Examination of the graphical representation of index data showed a cluster of events,

including Music Talk, Blindness, Insight and Humour; occurred alongside the highest

occurrence rate of Chads instrument playing. In sessions nine and eleven, there is a close

32

relation between verbal discourse about Chads blindness, level of insight into his situation

and humour/sarcasm. With those events comes a notable increase in Music Talk.

After examining transcripts of conversations, the talks about music pertained less

about instructing him how to play instruments and instead revolved around song lyrics and

Chads ability to remember them and make connections between lyrics and bands. In that

span of time, the events seem to be related and together with the cluster of conversations and

the instrument playing is also the yawning behaviour.

Session ten appeared to be set apart from the surrounding sessions when looking at the

frequency of events. There is an acute drop in discussions involving Insight,

Humour/Sarcasm and Blindness. Music Talk also decreases, as does Instrumental Playing.

What occurred instead was a change in the nature of Chads instrument playing. The

instances of playing instrumentals lasted longer without interruption. Especially interesting in

this session, was the relative consistency of the occurrences of yawning with the previous

session. It demonstrates improved coordination to be able to yawn while playing the drum

kit. Then in session eleven there was a marked increase in the occurrences of instrument

playing at the same time as a decrease in yawning. Chad appeared to have some form of

memory of playing instruments showing that nervousness had lessened and he had an

improved visuo-spatial understanding of his environment regardless of his vision impairment.

He appeared to have a consciousness acceptance of himself and continued to build upon his

identity. Occurrences of instrumental playing reach the maximum level throughout the course

of treatment here, as do the talks of music. He was quickly becoming more engaged in the

music therapy process and music seemed to help him feel alive.

In the final session, Chad once again engages in voiceless singing. He mouths the

words to the songs, in a voice that is inaudible. It is possible that a neural disconnection

33

existed between Chads ability to sing with words and without. He appeared to be able to

recite song lyrics, and to vocalize, often in tune with the music however these two functions

never appeared together. It is difficult to understand how much was conscious choice and

how much was cognitive deficit. Chads mother relayed a story very early in his treatment

about him singing the national anthem at a football game. This would lead one to believe that

he possesses the ability to sing with words and has made a conscious choice to do otherwise.

Although I have referred to Chads vocalizations as yawning because they most

closely resemble that action, there is an important difference that sets it apart and leads me to

believe that it could be considered singing or vocalizing. People recognize relatively early in

life that yawning has an infectious quality. Mirror neurons in our brains have been thought to

be the cause of this imitative urge. In all the occurrences of Chads yawning throughout

music therapy sessions, there was not one instance of my own yawning reflex being triggered.

This leads me to believe that Chads yawning served the purpose of vocally engaging with the

music. The Precuneus is an area of the brain that is activated when yawning (Platek et al.,

2005) so it could be argued that music was activating this part of the brain and yawning was a

by-product of that process.

Yawning As Toning

Music provided a context in which to safely engage in this extended yawning

behaviour, which was evident in the fact, that when outside of music therapy, Chad would

still yawn frequently but frequently without sound and for shorter duration. The vocal quality

that accompanied the yawns during music therapy could be compared to a Toning exercise.

Diane Austin describes Toning as the conscious use of sustained vowel sounds for

the purpose of restoring the bodys balance. Sound vibrations free blocked energy and

resonate with specific areas of the body to relieve emotional and physical stress and tension

34

(Austin, 2008, p. 29). She discusses how natural sounds, such as sighing and yawning, can

act as a warm-up for Toning and as a result the immediacy of toning can provide clients with

a musical encounter in the here and now that is physical, emotional and spiritual (p. 31).

While I initially wondered if Chads yawning was resistance, I believe it was instead a

means of bringing himself into the present and into a waking consciousness. Toning in the

form of prolonged yawns offered him a pleasurable way to experience his body and music

therapy offered a safe environment in which to prolong the encounter.

In conversations with Chad, he did not appear to hold back presenting his thoughts and

feelings and could be described as anything but shy. When invited to sing however, he

frequently refused. Initially I thought that perhaps the refusal to sing was due to a lost ability

until his mother disproved this theory by sharing the national anthem story. In sessions, Chad

mouthed the words to songs in a very clear and pronounced manner as if to demonstrate that

he could do it but was choosing not to. Exercising control of himself in his environment

demonstrates conscious awareness and insight.

4.6 Self and Identity

Am I Dead?

This innate pursuit of consciousness manifested verbally for Chad in a single repeated

question. Am I dead? Still without sight, but already demonstrating improved

comprehension of faster rates of speech, Chad began to ask this question both within music

therapy and outside of music therapy. In the context of music therapy, after examining the

factors that lead into and out of each of these questions, we see that various actions occurred

synchronously. The Am I dead question occurs at the same time as either music talk or

music making, is accompanied by frequent yawning and eventually disappears as the yawning

increases in duration and frequency.

35

In session six, with Chad in his room in bed, he began to ask the question Am I dead

approximately every ten minutes. The first instance occurred after he played the snare drum

for the song Good Riddance by Green Day (which he had indicated previously was a

favourite band and song prior to injury). In this session, Chad once again mouthed the words

to the chorus without audible sound. He reached out with his left hand, and interrupted the

music with Hey. Am I dead? leading us into a discussion about what he is experiencing to

elicit this question.

C: Hey. Am I dead?

K: No. Youre very much alive.

C: Promise?

K: I promise.

C: K.

K: Do you feel like youre dead?

C: No.

K: No. Are things just a little bit foggy in your head?

C: A little bit. (S6, 02:30)

After the discussion, we resume the song, picking up where we left off in the chorus and Chad

once again mouths the words in tempo with the song. After the chorus, he stops singing and

resumes his drumming finishing the song without interruption. This sequence of events

occurs a number of times throughout this and the next session.

C: Hey.

K: Yah?

C: Am I dead?

K: Nope. Youre not dead.

C: Promise?

K: I promise.

C: Okay.

C: Hey.

K: Yah?

C: Coma?

Further discussion regarding our ability to have a conversation if he was in a

coma. (S7, 06:00) (DVD Track 7)

36

These discussions were interspersed with instrumental playing which research has shown is

influential on the Precuneus region, also associated with self-awareness and consciousness

(Vogt and Laureys, 2005).

Music appears to have triggered an event in the brain that revealed a biological

connection between the perceiving of music both actively and receptively and the movement

toward self-awareness and as I would soon discover, the ability to empathize. Music without

verbal interaction could have been a confusing experience for Chad and it will be shown that

some aspects of the dysfunction only appeared through verbal discourse.

Empathy And Insight

In session seven, Chad became irritated by noise being made by his neighbour in the hall.

The following discussion ensued when Chad interrupted the music by yelling at that person:

C: Yells neighbours name.

K: Do you want to talk to (neighbour)?

C: No. I want to tell her to shut up.

C: Help!

K: Whats the matter?

C: Nothing.

C: yells neighbours name

C: A bitch.

K: Pardon?

C: What a bitch.

K: chuckles. Thats not very nice.

C: So.

K: I wont tell her.

C: Hey.

K: What.

C: Do.

Further discussion about his relationship with [neighbour]

K: I think shes scared. You probably know better than anybody how she

feels.

C: Why.

K: Because youre both going through very similar experiences.

C: How so?

K: Well youre both in the hospital. Recovering from brain injury.

C: True.

K: Thats something huge that you have in common.

C: Yah. (S7, 10:26)

37

The discussion demonstrates Chads inability to empathize, a capacity that had not

been challenged prior to injury. Not only was Chad not aware on his own of the perspective

of another, but once it was pointed out to him he still appeared unmoved.

Chad continued to engage in music therapy for another twenty minutes, listening and

responding vocally to various pre-composed songs such as Trouble by Coldplay, Times Like

These by The Foo Fighters, hand-over-hand guitar improvisation, and mouthing the words to

songs, when he once again heard his neighbour in the hallway. Rather than yell in frustration

he instead said calmly and quietly, Hi [neighbour] (S7, 30:26). It appears as though his

engagement in music had a calming effect and may have stimulated his ability toward

empathy.

Had Chad been in a group music therapy situation this type of interaction may have

manifested differently but through individual music therapy this disability revealed itself

instead in conversation alongside music. The fact that Chad demonstrated the beginning of

empathetic attunement shows that he has a developing sense of self as one must understand

oneself before one is able to understand an other.

Insight And Self Definition

As Chads engagement in music making increased a direct correlation appeared

between yawning, which also increased dramatically, and Chads occurrences of insight into

his situation. Prior to session nine, Chads mother had indicated that he seemed to be having

a bad day in terms of his abilities yet in music therapy things transpired differently.

Throughout the session Chad explored the penny whistle, the snare drum with sticks

and the tambourine. He appeared to have a mental image of the penny whistle even though he

was unable to see it. When offered to him, he immediately took it and held it correctly

although he admitted that he had never seen one before and didnt know what it was. I

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described it to him as a recorder and we discussed how many holes it had in it, which he tried

to feel with his fingers. Once Chad successfully produced a sound, he was able to experiment

with different ways of holding the instrument. Through this fine sensorimotor experience

Chad was able to extend his focus on musical exploration and discussion about the penny

whistle, which continued for approximately eight minutes before he interrupted by saying It

would be easier if I could see the holes (S9, 08:07). We launched into a discussion about

what Chad was able to see and it appears as though he can see the colour of the instrument but

could not distinguish the holes.

We resumed our playing and a couple of minutes later he interrupted the playing again

by saying, cant find the friggin holes (S9, 10:15). With a description of the different sized

holes he attempts once again to feel them but Chads frustration is apparent when he says, it

sucks not being able to see (S9, 11:29). After a brief discussion about what it is like to have

impaired vision, we improvise together in the key of C, which leads into Good Riddance by

Green Day; a band and song that Chad had indicated previously was a favourite. Chad

continued to play the penny whistle and was focused once again on trying to navigate the

instrument.

When the song finished, I offered verbal encouragement regarding the positive

changes that I had seen in Chad over such a short period of time. Chad demonstrated the

ability to imagine the future and introduced his positive outlook regarding his recovery by

saying when I can see and when I can walk until then, this sucks (S9, 14:50). The ability

to imagine future demonstrates an ability to form and retrieve memories, as this is required to

create our projection of the future and our understanding of our self in relation to our

environment. It would have been difficult to determine, without the verbal discourse that this

was happening.

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Music and the Precuneus

In sessions nine and eleven Chad demonstrated increased insight into his situation.

This included many occurrences of instrumental playing coinciding with a cluster of events

relating to insight including talks about music; talk of blindness/vision, insight as

demonstrated by statements of awareness and humour including sarcasm. To me, this

demonstrates an intricate sense of self-awareness and improved episodic memory; both of

which are Precuneus functions (Cavanna & Trimble, 2006).

Because of the correlation between active playing and these clusters of events, one

could argue that playing instruments as an intervention for music therapy is effective in

stimulating this area of the brain and therefore assisting in the rehabilitation of important

cognitive functions such as visuo-spatial imagery, self-awareness, consciousness, empathy

and memory retrieval. In Chads case music may have been the integrator as evidenced by his

yawning, what I believe is the voice of the Precuneus. Chads presentation of the question

Am I dead? stopped occurring in music therapy sessions providing evidence to the fact that

music was helping him to feel alive and awake (despite the yawning!).

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CHAPTER V CONCLUSION

The study supports the ability of music to first initiate then help to actualize and

integrate disconnected components of our psychological experience. It causes me to wonder

if music has a similar integrating function to that of the Precuneus. If music affects this brain

region, then there is a case to be made for the efficacy of music therapy to rehabilitate the

functionality handled by this region including memory, visuo-spatial ability, visual and

mental imagery, perception of self and consciousness.

The implications to music therapy of working with Chad and having him participate in

this case study research are significant. Finding this critical link between brain function and

music perception and processing provides validity and reliability to the use of music therapy

for the rehabilitation of the acquired brain injury population and others. It offers an intimate

understanding of the meaning behind both verbal and non-verbal communication. It is said

that as we move deeper in the direction of the interior of the brain that we are travelling back

in human evolution as these are the oldest areas of the brain. In that core, is the Precuneus,

which seems to be activated by music suggesting an evolutionary aspect to music that could

lead to a better understanding of the efficacy of music therapy. The study demonstrated a

profoundly integrated course that our brains follow to perceive music.

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Figure 3: Music Effect on the Precuneus

In terms of music therapy interventions, my work with Chad sustained my belief that

conversation about music is as important as making music. Verbal dialoguing provided

insight into additional images Chad was experiencing. Music therapy has the remarkable

benefit of combining many rehabilitative properties within each intervention. Playing

instruments and singing at the same time requires specific coordination. Chads ability to

multi-task in this way improved throug