-
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
-
ii
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
-
iii
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
-
iv
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.
-
v
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.
-
vi
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.
-
6
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.
-
7
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.
-
8
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.
-
13
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.
-
18
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
-
38
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.
-
39
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!).
-
40
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.
-
41
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