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1 Florida State University Libraries Electronic Theses, Treatises and Dissertations The Graduate School 2004 Five Case Studies: 1. CT Scanning with Hearing Impaired Children 2. Music Therapy for Parkinson's, Alzheimer's and Stroke Patients 3. Music Therapy for Non-Patients in a Hospital Setting 4. Review of Pain Assessment Forms and Their Applicability to Music Therapy 5. Guitar Instruction with a Practicum College Student Elena Constantinidou Follow this and additional works at the FSU Digital Library. For more information, please contact lib-ir@fsu.edu

2 THE FLORIDA STATE UNIVERSITY SCHOOL OF MUSIC FIVE CASE STUDIES: 1. CT Scanning with Hearing Impaired Children 2. Music Therapy for Parkinson s, Alzheimer s and Stroke Patients 3. Music Therapy for Non-Patients in a Hospital Setting 4. Review of Pain Assessment Forms and their Applicability to Music Therapy 5. Guitar Instruction with a Practicum College Student By ELENA CONSTANTINIDOU A Thesis submitted to the School of Music in partial fulfillment of the requirements for the degree of Master of Music Degree Awarded: Spring Semester, 2004

3 The members of the Committee approve the thesis of Elena D. Constantinidou defended on December 10, Jayne Standley Professor Directing Thesis Dianne Gregory Committee Member Clifford Madsen Committee Member The Office of Graduate Studies has verified and approved the above named committee members ii

4 This Thesis is dedicated to those people who each and everyone of them contributed in making my dreams come true. To God Who looks after me and constantly gives me strength to reach my potentials. To my wonderful father Dimitris who taught me how to put priorities in life, stay focused on my goals and never give up. To my sweet mother Elpida who taught me what unconditional love is and shaped my personality and character in the best possible way. To my dearest brother Chris whom I ve always admired and had a deep respect of who he is and what he does. To my beloved brother Angelos whom without his endless help and support I would have never had the opportunity to finish the Master s Degree To Professor Gregory whom I deeply admire and without her excellent feedback and support this project would have never been a reality To Dr. Standley whom I deeply respect and whose influence was so strong in shaping my professional career To Dr. Madsen who will always be a role model for me and who has transformed my life into an endless transfer and supported my efforts in any way. THANK YOU! iii

5 TABLE OF CONTENTS List of Tables... vi List of Figures.. vii Abstracts.. iv CASE STUDY ONE: The Integrative Use of Music Therapy with Hearing Impaired Children during CT Scanning 1 CASE STUDY TWO: Music Therapy to Increase Reality Orientation and Cognitive Stimulation for Parkinson s, Alzheimer s and Stroke Patients. 18 CASE STUDY THREE: The Utilization of Music Therapy for Non-patients in a Hospital Setting CASE STUDY FOUR: A Review of Clinical Pain Assessment Forms and their Applicability to Music Therapy CASE STUDY FIVE: Guitar Instruction with an Undergraduate Music Therapy Student doing a Practicum in a Hospital 60 APPENDICES 81 Appendix A: Characteristics of Patients in Each Stage of Alzheimer s Disease 81 Appendix B: Case Study Two - Observation Sheet 83 Appendix C: Case Study Three Song List Appendix D: Case Study Three Observation Sheet. 88 Appendix E: Case Study Three Operational Definitions. 90 Appendix F: Case Study Three Emergency Waiting Room, Session A Appendix G: Case Study Three Emergency Waiting Room, Session B.. 95 Appendix H: Case Study Three Intensive Care Unit Waiting Room, Session A Appendix I: Case Study Three Intensive Care Unit Waiting Room, Session B. 101 REFERENCES iv

6 BIOGRAPHICAL SKETCH. 110 v

7 LIST OF TABLES 1. Explanation of the Decibel Scale Behavioral Research Design 97 vi

8 LIST OF FIGURES 1. Diagrammatic Illustration of the Working of the Ear Response of Hearing-impaired people to sound of varying intensity and pitch Mean number of correct responses for per melodic interval Session A Baseline Session A2 Baseline Session B Intervention Session B2 Intervention Session C Baseline Session C2 Baseline Session D Intervention Session D2 Intervention Mean Reliability of Each Session Shoulder Pain Assessment Group Pain Assessment Form Smile-Sad Faces Scale Visual Analog Scale Verbal Scale CRDI - Baseline 101 vii

9 19. CRDI Treatment CRDI Baseline viii

10 ABSTRACTS CASE STUDY ONE TITLE: THE INTEGRATIVE USE OF MUSIC THERAPY WITH HEARING IMPAIRED CHILDREN DURING CT SCANNING. Abstract In children, as in adults, computed tomography (CT or CAT) scans are an invaluable imaging modality that produces a series of images that can detect many conditions. Like any tool, however, inappropriate use has unique implications for children including a high risk of cancer. Consequently, the fear of anesthesia and sedation along with the high radiation dose a child receives during CT scans, makes this diagnostic approach risky and dangerous. Music Therapy can be used as an alternative mean to anesthesia and sedation thus eliminating any side effects the child may have during this process. Since research has shown that hearing impaired children are able to experience music primarily through the senses of touch, by feeling vibrations and also by actually hearing some tones that are within their limited range, this study discusses the potential use of Music Therapy with hearing impaired children during the CT scans. Moreover, the purpose of this study is to: a) give recommendations (materials, techniques) for facilitation of music therapy during this process and b) lists potential songs that can be used during computed tomography. ix

11 CASE STUDY TWO TITLE: MUSIC THERAPY TO INCREASE REALITY ORIENTATION AND COGNITIVE STIMULATION FOR PARKINSON S, ALZHEIMER S AND STROKE PATIENTS Abstract Alzheimer s or otherwise The Forgotten Disease is a progressive disorder with no known cause, attacking and slowly stealing the minds of its victims. Symptoms of the disease include memory loss, confusion, impaired judgment, personality changes, disorientation, and loss of language skills. Always fatal, Alzheimer's disease is the most common form of irreversible dementia. Music Therapy had always had a dramatic effect on people with Alzheimer s since..music is a battery charger for the brain, and patients will frequently begin to reminisce and verbalize thoughts and feelings in ways thought to be long dormant. This study examines the use of music as a strategy to increase reality orientation and cognitive stimulation. Music Therapy sessions were conducted on an Adult Day Care Facility twice a week of 60 minutes duration, involving elderly people with dementia, post-cva, Parkinson s, and other diagnosis. A behavioral research design ABAB was utilized (A=baseline, B=treatment). During base live sessions, singing of familiar songs, playing simple rhythmic instruments with background music, playing musical games that enhanced active manipulation of the hands and feet and moving/dancing activities were utilized. During treatment phase, these music activities were connected with calendar events and/or community events to reinforce the goals of the Music Therapy program in the Day Care Facility. Graphic data analysis and clinical observations clearly indicated that the coupling of music with a variety of activities along with calendar events and/or community events increased significantly the participation, smiling, eye contact, verbal feedback, social interaction and reality orientation. In the meantime, agitation, wondering and pacing were noticeably decreased during the sessions. Implications of the results for music therapy in such facilities are discussed. x

12 CASE STUDY THREE TITLE: THE UTILIZATION OF MUSIC THERAPY FOR NON-PATIENTS IN A HOSPITAL SETTING Abstract Music therapy is the prescribed use of music and musical interventions in order to restore, maintain, and improve emotional, physical, physiological, and spiritual health and wellbeing. This exploratory study investigated the utilization of Music Therapy and its effectiveness for non-patients in waiting rooms of a hospital setting. Two waiting rooms were chosen, the Emergency waiting room and the Intensive Care Unit waiting room, after consultation with the head nurse of the hospital. A 30-minute session of live music was taken place twice a week in each waiting room. A repertoire list that included songs from a variety of musical genres, was handed to the subjects who happened to be present at the time of the study. Subjects were encouraged to choose songs they enjoyed listening to. Behavioral data were recorded by an independent observer. Observable ontask verbal behaviors were: singing, choosing songs, conversing with the Music Therapists, making comments about music. Observable on task visual behaviors were: eye-contact, moving feet or hands to music, and dancing. Observable off-task behaviors were: conversing with other people, reading newspaper, watching T.V., talking on the phone or any other incompatible or competing behavior at the interval of the observation. Results indicated that Music Therapy in an environment such as the Emergency room, where patients are also present, is not as effective as in waiting room where only nonpatients are there. While overall results of this study were not significant or encouraging, enough variations occurred between the two waiting group populations to warrant further investigation. xi

13 CASE STUDY FOUR TITLE: A REVIEW OF CLINICAL PAIN ASSESSMENT FORMS AND THEIR APPLICABILITY TO MUSIC THERAPY Abstract During the last decade, the use of music as an adjunctive aid to traditional medicine has been acknowledged and patients can now take home sound prescriptions to assist them in regaining health. An ongoing growing interest on the effects of music in medicine has led institutions and research centers to investigate the impact music has on pain management and pain relief. A press release from the National Institute of Health has found that music and relaxation can provide more complete relief without the undesired side effects of some pain medications (Press Release, National Institute of Health, 1999). Despite of fact that music is being utilized in the hospital setting across populations, the author of this study could not find research related to music therapy and pain assessment procedures that identify both problem areas and patient assets for treatment participation and prognosis (Standley, p. 43). Therefore, the purpose of this study is to review clinical pain assessment forms and discuss their applicability to music therapy. xii

14 CASE STUDY FIVE TITLE: GUITAR INSTRUCTION WITH AN UNDERGRADUATE MUSIC THERAPY STUDENT DOING A PRACTICUM IN A HOSPITAL Abstract Guitar. One of the most alluring and expressive instrument with more applications than any instrument known to mankind. From the sedative sound of the Greek Kithara to the atonal sounds of the Flamenco-style Spanish guitar, to the howling solos effortlessly pounded out by George Harrison of the Beatles in the 60s, to the modern Jazz fusion drifting through clubs and concert halls all over the world, there is no instrument as recognized, as versatile, and as expressive as the guitar. The guitar today continues to flourish throughout the globe in its infinite number of applications and styles, growing in popularity and prestige every single year. The value of class-guitar program in schools and colleges is being increasingly recognized throughout the United States. Most colleges have included into their curriculum guitar instruction courses, and students, music or non-music majors, have the opportunity to learn how to play this so popular instrument. For music therapy majors, proficient guitar skills is consider to be the key for successful completion of the music academic curriculum which includes the academic phase and the field-based internship phase, evidencing future successes as a professional in the field of Music Therapy. This study was designed to help an undergraduate music therapy student to successfully meet the requirements and skills needed in guitar while doing a practicum in a hospital setting. Furthermore, this study seek to examine if a relationship exists between guitar skills and the fear of being prepared or having the knowledge, thus being more competent during direct client interaction, hence being an effective music therapist. It was clearly seen that there is a strong relationship between efficient guitar skills, self-enjoyment and being more confident and ready during direct client interaction thus decreasing the fear of failure. Implications of the results are being discussed. xiii

15 CASE STUDY ONE TITLE: THE INTEGRATIVE USE OF MUSIC THERAPY WITH HEARING IMPAIRED CHILDREN DURING CT SCANNING. 1

16 Review of Literature Evelyn Glennie swoops onstage. She takes her place amid a jungle of more than 50 instruments among them the marimba, snare drum, Balinese gamelan and vibraphone and slips off her shoes. Then her arms dart, her hands blur, and the hall fills with a stunning spectrum of sound from the steady tock-tock of rainwater falling on a log to the crash of thunder. As Glennie plays, eyes afire, her body responds dervish-like to the vibrations of her drumming. All musicians speak of vibes, but very few are as sensitive to them and as dependent on them as Glennie. Profoundly deaf since the age of 12, the 30-year-old, Scottish-born virtuoso cannot hear the music she makes. But she can feel it, as she explains, through my feet and lower body and through my hands. I can identify the notes according to the vibrations. The stocking feet are not an affectation but part of her musical antennae (Neill, 1996). How can music mean possibly anything to someone who had never heard his/her own voice? Music for the hearing impaired may seem to be a contradiction in terms but research in the last thirty years unsheathed light to the understanding of a deaf person s musical capacities. Williams in her article The Value of Music to the Deaf explains that the sensation of sound is produced by vibrations which travel through the air in waves. When the cochlea of the ear is stimulated by sound, patterns of electrical pulses pass to the two regions of auditory cortex in the brain. From here the patterns are passed from the date-processing region in the temporal lobes of the brain to the emotional regions in the frontal lobes for analysis (Figure 1). Based on the above, it is easy to conclude that people who are born deaf and have no musical memory to refer (congenital deafness: a person who was born deaf), have no chance of enjoying music. This is a great misconception since approximately only 10% of the deaf population is totally deaf and even that ten percent can respond to music because music can be a series of vibrations transmitted to the brain through other channels than the auditory apparatus (Williams, 1989). 2

17 How then can hearing impaired individuals perceive the conduction of sound from the ear to the brain? Research shows that hearing impaired children are able to experience music primarily through the senses of touch, by feeling vibrations and also by actually hearing some tones that are within their limited range. A number of studies that examined the effect of vibrotactile stimuli (Darrow, 1992;Darrow, 1991; Ford 1988; Darrow, 1987) on the identification of rhythmic, pitch and timbre changes with hearing impaired offer evidence that the human perceptual system works by the senses since our brain doesn t have access to the real world. Mowers (1986) encourages his students to use a tactile stimulator which consists of a microphone and a vibrator attached to student s wrists. Darrow (1992) employs the vibrotactile device called SOMATRON, a 3

18 platform mattress that channels only the music stimuli in the environment eliminating in this way auditory stimuli from the environment. At this point, it is imperative to mention the two physical properties of sound since these properties help us determine the type and classification of hearing loss. A given pitch is determined by frequency and intensity. Frequency is being defined as the number of cycles per second of the sound waves, these cycles being indicated by the symbol Hz. A young person with excellent hearing can hear frequencies within a range of about 16 Hz to 20,000 Hz. An average adult with normal hearing can hear within the range of 20 Hz to 16,000 Hz, or possibly higher. Intensity or loudness is the second physical property of a pitch or sound usually measured in decibels (db). It is estimated that the lowest intensity level a normal hearing person is able to hear is around -10 to +10 decibels (Fahey & Birkenshaw, 1972). The following figure indicates the approximate intensity level of several environmental sounds (Table 1). 4

19 According always to Williams (1989), severely deaf children should be able to discriminate six levels of loudness, from pianissimo to fortissimo, compare to three levels of loudness that profoundly deaf children may be able to differentiate. The rest of the hearing impaired population has some residual hearing which gives them the capacity for some recognition of music (Figure 2) There are four types or disorders of hearing loss each of which perceives sound apparatus differently based on the location of the damage within the ear. In the article Music Therapy with Children Who Are Deaf and Hard-of-Hearing (Darrow; Gorsuch, Gfeller & Thomas, 2000) the different types of hearing loss are being classified as follows: a) Conductive hearing losses caused by an interruption in the mechanism of the outer and middle ear which conducts sound through the eardrum ossicles and oval window affecting all frequencies of hearing. (Figure 1) Therefore, the loss is mild between 0 and 60 db (Figure 2). b) Sensorineural hearing losses resulting by damage to the inner ear and cochlea. It is assumed that this type of hearing loss has serious consequences for pitch perception because of the handicapped cochlea or sensory hair cells. Consequently, the hearing losses can range from mild to profound deafness. The loss could be between 20 and 130 db (Figure 2). c) Mixed hearing losses caused by outer or middle and inner ear damage. d) Central hearing loss resulting by damage of the nerves or nuclei of the central nervous system either in the pathway to the brain or in the brain itself. The development of the cochlear implants (an electronic inner ear that stimulates the auditory nerve) are used in cases of severe to profound sensorineural hearing losses since the damage exists in the inner ear s structure due to damaged or missing hair cells. Stordahl (2002) points out that the cochlear implant is an assistive device designed to improve speech perception for persons who have bilateral profound hearing losses and who receive little, if any, benefit from hearing aids. One of the earliest recipient of a cochlear implant commended that I don t like rock or hard music because I can t hear rhythm I prefer mellow music because it is easy on the ear. Zinar (1987) Thus, it is assumed that even with a minimal amount of hearing there is up to a certain degree 1) 5

20 localization of a sound or the ability to locate the source of music sound, 2) attention to a sound or the ability to listen to the music sound patterns for a specified amount of time against background activity or noise, 3) differentiation between speech and non-speech or the ability to discriminate between musical and non-musical sounds, 4) suprasegmental discrimination or the ability to differentiate among expressive qualities of music such as tempo, dynamics, phrasing, intonation and contour and lastly 6) auditory memory or the ability to remember melodic and rhythmic patterns from a musical composition. These are six of the ten levels of a hierarchy of auditory processing developed by Derek Sanders used primarily for the development of speech discrimination. Since there are a lot of similarities between components or speech and music, Sposato suggested that this hierarchy can be used to maximize the residual hearing on musical listening for hearing impaired children. In a study conducted by Darrow (1984), the researcher seek to 1) 6

21 compare the rhythm responsiveness of normal hearing and hearing impaired students and 2) investigate the relationship of rhythmic responsiveness in hearing impaired students to the suprasegmental aspects of speech perception that involve rhythm discrimination. Data suggested that hearing impaired subjects performed as well or better than normal hearing subjects with regard to beat identification, tempo change, accent as a factor in meter discrimination, and rhythm pattern maintenance. However, a significant difference was found between the two groups concerning melodic rhythm duplication and rhythm pattern duplication (Darrow, 1984). The use of musical instruments with hearing impaired as a reinforcer to develop auditory skills such as timbre recognition, figure-ground discrimination, and sequential memory has attracted the attention of researchers and clinicians. A study done by Bernier and Stafford (1972) has found that individuals with poor auditory discrimination skills referring to the hard-of-hearing population favor timbres or instruments with less complex tones. In another study, 34 children from a state school for the deaf served as subjects to investigate their preferences for instrumental timbre and musical instrument preferences. Six instruments were selected representing the string, woodwind and bass families. These instruments were the violin, viola, trumpet, trombone, clarinet, and flute. Results indicate the violin and trombone were the most preferred instruments. The author suggests that the preference for the violin is due to 1) the supplementary vibratory stimulation because of their placement on the shoulder and 2) the effortless ability to produce tones (Darrow, 1991). The trombone was widely chosen because of the physical appeal of the instrument (small in size) making the instrument easy to access or use. Results related with timbre preference indicated that the older the subjects were, the stronger timbre preference they had. The most preferred instrument based always on timbre were the clarinet and saxophone and the least was the flute. In conclusion, hearing impaired children should be exposed to timbre variations since in this way it is speculated that they can use their residual hearing to interpret sounds and attach meaning to them, as well as develop listening rules, cues, and strategies (Darrow, 1991). The author of this study could not find research related to hearing impaired children during computed tomography (CT or CAT). After reviewing the literature related to hearing children s musical preferences and musical abilities, literature related 7

22 to musical perception with hearing impaired and literature related vibrotactile communication aids that facilitate auditory skills of hearing impaired individuals, the author felt confident enough to assume that Music Therapy can be used with hearing impaired children as an alternative mean to anesthesia and sedation thus eliminating any side effects the child may have during CT scans. This study discusses the potential use of Music Therapy with hearing impaired children during the CT scans by a) giving recommendations (materials, techniques) for facilitation of music therapy during this process and b) listing potential songs that can be used during computed tomography. Pediatric Computed Tomography Procedure Definition: Computed Tomography, also known as CT or CAT scan, is a type of x-ray imaging procedure which is based on varying absorption of x-rays by different body tissues. In a CT exam, the beam of x-rays moves in a circle around the body providing different views of the same organ or tissue in detail than a conventional x-ray exam. A computer process the imaging information and displays it on a monitor. CT scanning is preferred in children from newborns and infants as well as older children and adolescents. CT scans may be done with or without contrast materials that are taken by mouth or injected into the veins. Some CT scans require using the contrast materials because the picture of certain parts of the body (organ tissue, or blood vessel) is clearer. Two types of contrast materials used are a) barium, which usually is taken through the mouth, and b) iodine, which is usually injected by means of an I.V. (intravenous line). How should a child be prepared for the procedure? If intravenous contrast materials are used, the CT scan staff will need to know whether the child has had any reaction to the contrast materials in the past; the child might be allergic to iodine or seafood; or might have kidney disease. The purpose of asking about allergies is to avoid a possibly serious allergic reaction. 8

23 The child may eat or drink as usual and take needed medication as long as no contrast is given and no sedative (calming medication) or anesthesia is planned. If either of these situations applies, dietary restrictions and/or other instructions will be given by the CT scan staff. The instructions are: 1) Not eat or drink before anesthesia and surgery are for the child s safety. Anesthesia and sedation blunt the protective reflexes that prevent food and stomach contents from getting into the lungs. Digestive acids secreted by the stomach can cause a life threatening pneumonia if they are aspirated into the lungs. 2) The child may have clear liquids up to four hours before the scheduled time for surgery. Clear liquids are: water, fruit juice without pulp, and clear tea. 3) Infants may be given breast milk up to four hours or infant formulae up to six hours prior to scheduled surgery. 4) Parents should not give non-clear liquids or solid food after midnight the night before surgery. 5) If the child requires taking medication, they can be given with a small amount of water. 6) In general children who have recently been sick can not be sedated or anesthetized. If this is the case or if the parent is suspecting that the child may be getting sick, parents should call the CT staff to reschedule the examination. How is the procedure performed? After receiving oral or intravenous contrast materials if needed and a sedative if it s necessary, the child will lie down on the scanner couch and be made as comfortable as possible. The head is supported in a cushion and the exact body position depends on what area is being scanned. Once the child is correctly positioned, the CT staff and the parents leave the room to begin the scan. For the first scan the couch will move through the scanner with the shape of a doughnut, to determine its correct starting position for the rest of the scans. The table will then move more slowly as the actual CT scan is performed. During the procedure the child will hear a slight buzzing or clicking sounds. The child will need to lie quietly as long as several seconds or several minutes, depending on the information needed. Some imaging facilities permit parents or other adults to stay 9

24 in the room when the scan is performed. In this case, the parents or other adults must wear a lead-lined garment to avoid exposure to radiation. Many children are frightened by large machines and the general atmosphere of a medical facility; the presence of a parent, close relative or friend can be very reassuring. If contrast materials are injected into a vein, the child will feel warm all over, but only for a brief time. There will likely be minor pain when the needle is placed into the vein. When the exam is completed and the child if sedated is fully awake, then is allowed to return home. What are the limitations of Pediatric CT? Some of the limitations of Pediatric CT are: 1) Other imaging methods such as ultrasound or magnetic resonance imaging (MRI) can provide pictures of certain areas of the body that sometimes are as good as or even better than those obtained by CT scanning. 2) CT scans do require radiation, although the lowest dose needed to obtain highquality images will be used. As a result, there may be unique implications for child s health including high risk of cancer. 3) The child may require a needle-stick in order to inject contrast material into the vein. 4) The motion of the CT scanner can affect the quality of the CT images even though the child may stay still. Music Therapy during CT Scans Music Therapy can be used as an alternative mean to anesthesia and sedation thus eliminating any side effects the child may have during this process. The CT coordinator will ask the parents to bring the child in a sleep deprived state along with the dietary restrictions and/or other instructions they may get, thus accommodating the efforts of the Music Therapist to put the child to sleep. The Music Therapist will lead the parents to a quiet room, usually sitting in the corner, having the lights off. The Music Therapist will 10

25 sit opposite of the parent who is holding the child while playing the guitar. Once the child falls asleep, the Music Therapist will direct the parent into the CT room. It is extremely important to keep the music going in order to overpower any noise may occur during the procedure (slight buzzing or clicking sounds of CT scanner, any conversation between the CT nurse, radiologist, CT coordinator, parent). The Music Therapist will have to keep playing during the actual CT scanning; hence, it is required to wear a lead apron to prevent radiation exposure. It is noteworthy that since the procedure takes few seconds to few minutes to be completed, a well qualified and skillful Music Therapist will keep the child in the sleeping state until the whole procedure ends. The child is free to go home since he/she did not receive any kind of anesthesia and/or sedation, but more importantly, the child will not be experiencing any kind of side effects. The CT coordinator at Tallahassse Memorial Health Care, Wendy Griner, has included the following three questions after the author s recommendation during the scheduling of a Pediatric CT: 1) Does your child have any kind of disability, for example, hearing impairment? 2) What type of hearing impairment does your child have? Slight Loss = 27 to 40 db Mild Loss = 41 to 55 db Moderate Loss = 56 tp 70 db Severe Loss = 71 tp 90 db Profound Loss = 91 db or more 3) Does your child have hearing aids? If yes, your child must wear them when he/she comes for a CT scanning. 11

26 Music Techniques and Music Materials For Hearing Impaired Children Undergoing CT Scans Characteristics of Hearing Impaired Speaks too loud or too soft Poor speech production Does not pronounce words correctly or distinctly Frequently asks to have things repeated Seems to ignore directions Does not respond to questions asked of him/her Appears to not be paying attention in class Has difficulty locating the direction where sound is coming from Omits parts of words, parts of sentences in speech and writing Looks at the lips of the person speaking to him/her Becomes frustrated when oral directions are given Constantly asks, What? Becomes frustrated and avoids group situations because if noise May complain of ringing or buzzing in the ears Frequent ear infections Limited social interactions and manipulative behaviors feeling of isolation poorly controlled emotions inflexibility egocentricity withdrawal depression low self-esteem Gross motor difficulties Shorter than average memory of auditory stimulus Characteristics of Young Children with Hearing Impairments Intelligence have the same distribution of IQ scores IQ is a function of language development and cognitive ability 12

27 HI educational performance is directly related to language deficits. Educational Achievement Reading is the academic area most affected. Social Development are directly related with the degree of hearing loss and the type of impairment. The more severe the problem, the greater the potential for social isolation and the danger of social maladjustment Child complains of frequent earaches or has ear discharges. Poor articulation of speech sounds. Easy questions are answered wrong. Child fails to respond or pay attention when spoken to in a normal manner. Child often ask the speaker to repeat what was just said. Turns volume up unnecessarily. Music Robbins & Robbins (1980) believe musicality is inborn in all children, including the deaf. By musicality, they mean the innate sensitivities and abilities that respond directly to the experiences of rhythmic and tonal order described as music. Therefore, music can be used as a medium through which listening skills can be taught and practiced. And, since music, more intense than conversational speech, employs many more frequencies than normal speech sounds, children with even severe hearing losses are able to listen to and make aural discriminations about the musical sounds they hear (Darrow; Gfeller; Gorsuch; Thomas; 2000). Madsen and Mears (1965) attempted to determine if sound vibrations on the skin have a significant effect upon the threshold of the tactile sense. The researchers reported that sound vibrations does have a significant effect upon the threshold of the tactile sense implying that sound vibrations might also cause the skin itself to vibrate therefore allowing the deaf person to perceive music. A number of studies that examined the effect of vibrotactile stimuli (Darrow, 1992;Darrow, 1991; Ford 1988; Darrow, 1987;Sherrick, 1984) on the identification of rhythmic, pitch and timbre changes with hearing impaired offer evidence that human perceptual system works by the senses since our brain doesn t have access to the real world. A Mower (1986) encourages his students to use a tactile stimulator which consists of a microphone and a vibrator attached to student s wrists. Darrow (1992) employs the vibrotactile device called SOMATRON, a platform mattress that channels only the music stimuli in the environment eliminating in this way auditory stimuli from the environment. Rather than excluding hard-of hearing 13

28 children from music therapy during any kind of medical procedures, CT scans or ECHOS or presurgical procedures that requires the patient to be in a relaxing state, music therapy can become the tool with the use of vibrotactile devices -- through which hearing impaired children can have access to and at the same time enjoy. Instruments Instruments are louder than speech since they transmit large amount of vibrations and can be easily felt if the child places his hand on the instrument. Moreover, instruments are pitched in a wide range of frequencies (from low to high), can be played loudly and may be heard more readily than speech sound which have more limited frequency (pitch) and intensity (loudness) range, allowing the hearing impaired child to experience timbre and rhythm. Preferred instruments are those which can provide tactile and/or aural stimulation to the hearing impaired child during a computed tomography such as electric guitar with amp, electric autoharp or electric keyboard. A new kind of classical guitar that was built with amplification inside creates a bigger sound or sound waves and stronger vibrations that can hit the skin of a deaf child (Madsen & Mears, 1965) and help the child sense music easier. The music therapist can always have the child touch the wooden surface of the guitar while it s being played, giving the hearing impaired individual an extra opportunity to experience music. Singing Singing can often be directly intercommunicative. The mood of the music sets the mood with which the voice is used which created the feeling content that interrelates all those singing. When the singing is, in turn, on a one-to-one basis, a feeling of personal intimacy can develop. The form and character of the song put this closeness in a special setting that both maintains it yet formalizes it. Thus, the closeness is warn but not threatening, the intimacy, enjoyable but not over intrusive. Adults and children can enjoy and respect each other in a singing situation, and also enjoy the ease and naturalness with which their voices bring them into sharing, pleasurable contact (Robbins & Robbin, 1980) Evidently, hearing impaired do enjoy the aspect of 14

29 singing since they respond to the rhythmic element and most of them to the affective quality of the melody (sad, happy affect). In choosing songs appropriate for putting the hearing impaired to sleep before the procedure of CT Scanning, the music therapist should stay within a limited range (from middle C to the octave above) because these tones are close to the children s natural pitch range and among those best amplified by hearing aids (Zinar, 1987). Zinar also suggests using songs that have natural speech accents, with the stress of the music falling on the word syllables that would normally be emphasized. The singing must be in a suitable tempo usually sung in a slower tempo to the hearing impaired child than to a child without hearing problems. As it was discussed earlier, rhythm is easier to perceive, consequently, clearly defined rhythmic strumming while playing a classical guitar with amplification will help the child s perception in regard to melody. It is suggested that hearing impaired children may benefit from early musical experiences in discriminating large changes of pitch. Darrow (1992) employed the vibrotactile device called SOMATRON, a platform mattress that channels only the music stimuli in the environment eliminating in this way auditory stimuli from the environment to test whether hearing impaired children can detect melodic interval changes. The data revealed a greater gain in the identification of pitch change during auditory/vibrotactile condition (Figure 3), also showing that the discrimination of perfect fifth was greatly enhanced (Darrow, 1992) While singing and playing to a hearing impaired child during computed tomography (CT scan) the therapist should have to place the child s feet or hands on the body of the guitar, or the fingers should rest gently across the vibrating strings. If the child is younger than one year, it is highly recommended for the music therapist to hold the child on the therapist s lap while sitting on a swing chair. By putting the deaf child to sleep while singing is speculated to be the best method since the child s back is against the music therapist chest. By doing so, the vibrations coming from the chest (rib cage) will be so easily felt by the hearing impaired child and the music therapist must make sure that she/he is singing with her chest voice and not with her head voice. 15

30 Fig. 3 Reproduced by permission of Darrow, A.A. Potential songs that can be used during Computed Tomography (CT Scans) 1) Kumbaya slow tempo, repetitive words, can be easily sang with a low register voice using chest voice 2) Twinkle, Twinkle Little Star slow tempo, arpeggio guitar accompaniment great to feel the rhythmic pattern, substitute words for the alphabet 3) The Farmer in the Dell Slow tempo, repetitive words, arpeggio guitar accompaniment great to feel the rhythmic pattern, large intervals in the melody 4) My Bonnie lies over the Ocean 16

31 Great waltz tempo, descending melody, large intervals 5) Old MacDonald Had a Farm Slow tempo, wonderful for feeling the sounds the different animals make 6) Ring Around the Rosie Descending melody line, large intervals 7) This Old Man Repetitive words, slow tempo 8) When you Wish Upon a Star Slow tempo, can be easily sang in a low register using chest voice 9) I m Wishing from Walt Disney s Snow White and the Seven Dwarfs Slow tempo, large intervals, melody within middle C and the octave above 10) Look to the Rainbow Slow tempo, melody within middle C and the octave above 11) Hush Little Baby Slow tempo, repetitive words, melody within middle C and the octave above 12) Brahms Lullaby Slow tempo, large intervals, great melody line 13) Wheels on the Bus Descending melody, repetitive words 14) Swing Low, Swing Chariot Slow tempo, great melody suitable to put the child to sleep, can be easily sang with a low register chest voice 15) Oh, What a Beautiful Morning Slow waltz tempo, great melody suitable to put the child to sleep 17

32 CASE STUDY TWO TITLE: MUSIC THERAPY TO INCREASE REALITY ORIENTATION AND COGNITIVE STIMULATION FOR PARKINSON S, ALZHEIMER S AND STROKE PATIENTS 18

33 Review of Literature Barbara Crowe, a past president of the National Association of Music Therapy (AMTA) stated that Music Therapy can make the difference between withdrawal and awareness, between isolation and interaction, between chronic pain and comfort between demoralization and dignity ( Music Therapy is clearly a dynamic approach in the care of young and old but it can be vital and essential for older people whose needs and problems can increase tremendously after the age of 65. With the demographic explosion, it is estimated that senior citizens are the fastest growing portion of the population. Gerontology, or otherwise the study of aging, has attracted enormous attention the recent years and is has been associated with the research of many diseases that most often elder people experience. Among those is Dementia Alzheimer s type which is considered the fourth leading cause of death for older people and is the reason for half of all nursing home admission (Prickett & Moore, 1991). The diagnostic and statistical manual of mental disorders (DSM-IV_R, American Psychiatric Association, 2000) defines Alzheimer s disease as a progressive degenerative brain disease with an insidious onset. Manifestation of this disease is the long and short term memory impairment as well as other problems related with cognitive functioning such as abstract reasoning, judgment, language, visual/spatial ability, and/or personality change which interfere with the individual s daily functioning. As the disease progresses, individuals with the disease unavoidably decline in mental and social functioning (Appendix A) since there is still no cure found for Alzheimer s disease and related disorders. The loss of cognition, language and perceptual abilities in Alzheimer s disease patients may reduce interaction with the environment causing apathy, withdrawal, and social isolation (Pollack & Namazi, 1992). Health care professionals working with Alzheimer s individuals in nursing homes have addressed the need to provide any kind of programs that will maximize and promote restraint-free environments such as activity programs and behavioral techniques, encouraging performance of normal social roles. 19

34 Research on music with regressed elderly persons demonstrates the positive effects of specialized programs on the participation level, orientation, and social behavior of patients suffering from memory loss, confusion, and disorientation (p. 55, Pollack & Namazi, 1992). It has also suggested that music and music activities are useful in helping slow down the progressive deterioration of Alzheimer s patients thus maintaining high quality daily living by enhancing social interaction and relationships but more importantly feelings of achievement (Brotons & Pickett-Cooper, 1994). A plethora of literature in Music Therapy related with programming for individuals with Alzheimer s disease and related disorders reveal five general areas of research that focus on the use of music therapy to improve or prevent current conditions of individuals with Alzheimer s disease. According to Hanson and Gfeller (1995) these categories are (a) cognitive functioning, (b) musical behaviors, (c) social behaviors, (d) physical behaviors, and (e) quality of life. Normal aging often accompanies a weakening in memory but the memory loss can be devastating if it affects the individual s daily functioning and his/hers harmonic survival with family and friends. Prickett and Moore (1991) sought to examine the impact music has on recalling materials. Ten participants with Alzheimer s disease received three individualized music therapy sessions for approximately 20 minutes. Selections of familiar material (sung and spoken) and new materials (sung and spoken) were presented. Songs and spoken material (poems and rhymed speech) were chosen because of their familiarity to patients. The new material was unfamiliar to all participants. Analysis of the data indicates that patients recalled the words of songs dramatically better than they recalled spoken words (including rhymed speech) or spoken information (Prickett & Moore, 1991). This study has important implications to music therapy with Alzheimer s patients since it revealed that such individuals can still be stimulated to respond and participate with the use of familiar songs. More importantly, it was clearly seen that these patients are still capable of learning new songs despite the fact that they could not recall spoken materials. During more advanced stages of Alzheimer s stages, agitation is one of the behavioral disturbances that is most frequently observed. Agitation behavior is defined as an overt behavior that indicates restlessness, hyperactivity, or subjective distress. 20

35 Overt behaviors of agitation can be pacing, hand wringing, inability to sit or lay still, rapid speech, increased level of psychomotor activity, crying, and repetitive verbalizations of distress (Brotons & Prickett-Cooper, 1996). Live music therapy was utilized to examine the effects on agitation behavior of patients with Alzheimer s disease (AD). Treatment sessions included a 30 minutes session twice a week for a total of five music therapy sessions. The music therapy sessions included a variety of music activities adapted to each subject s functioning level (e.g. singing, playing instruments, dance/movement, musical games and composition/improvisation). Brotons and Pickett- Cooper (1996) concluded that the participants were significantly less agitated during music therapy and after music therapy than before music therapy. It was also noted that pacing and crying were significantly decreased. The successful outcome of the study supports previous studies that suggest that music therapy is not only an appropriate therapy method but more importantly a significant behavioral intervention in the management of agitated behaviors exhibited by patients with dementia of the Alzheimer s type. Another area that is greatly impacted as the disease progresses is the social behavior of the patient, consequently affecting the individual s ability to get involve to everyday activities. As a result the patient s interaction with the environment is limited, if any, leading to apathy, withdrawal and social isolation. Music can become the pathway or mean that allows every patient to have the opportunity to make choices, socially interact with others, and experience the joy of making music, contributing at the same time to an increased sense of self-worth and self-esteem leading to a satisfaction of life and better quality of life, reducing stress and anxiety, fostering relaxation and sensory stimulation and increase attention span. A study was conducted by Pollack and Namazi (1992) to investigate the effects pf individualized music activity on social behavior immediately after music sessions. Eight Alzheimer s subjects with moderate or severe dementia were the subjects of the study. Six 20-minutes session were held over a period of two weeks. Subjects participated in one or more music activities, selected according to preferred music response and adapted to cognitive and motor functioning level (Pollack & Namazi, 1992). Data were collected while the subjects were engaged in their activity of choice. Results indicated a 24% increase in social behavior and a 14% 21

36 decrease in nonsocial behavior for the group. Of the 255 social behaviors recorded, 96 (38%) occurred before music and 159 (62%) occurred after music. The researchers concluded that individualized music therapy with Alzheimer s patients may facilitate social interaction during music and can encourage further social contact after music. Overall, music therapy activities can promote social behaviors during structured group activities developing peer relationships and increasing participation and social interaction. Almost everyone has some kind of associations with music and can recall when they once heard a certain piece of music in a certain situation in addition to how they felt. Therefore, music can become the it to recall past experiences as well as maintain focus with cognitive impaired adults. Gregory (2002) identified the importance of active listening in engaging cognitive skills for most clients of this population. The researcher points out that for clients whose motor capabilities make performance-based music interventions impossible or improbable, active listening may be the only access to music. Consequently, Gregory attempted to answer whether elder people with cognitive impairments are able to stay focused to music, more specifically to active listening with the appropriate designed interventions and whether attention training has any short-term effects on this population. Participants were asked to move a Continuous Response Digital Interface (CRDI) to the name of the music excerpt or to the word Wait when no music was played, shown on the screen. Gregory (2002) reports that elderly people with cognitive impairments can sustain attention to music across 3.5 minutes listening activity designed for the population. They responded more accurately to music excerpts than to silence excerpts and their responses to both music and silence were slower than responses of younger and well-elderly listener s. The researcher concluded that highly sustained listening intervention for elder people with cognitive impairments can be implemented and learned successfully. She also stresses the fact that active music listening interventions can be considered a successful method in maintaining purposeful selective attention for this population. Although persons with Alzheimer s, otherwise The Forgotten Disease, is a progressive disorder with no known cause, attacking and slowly stealing the minds of its victims, their participation in appropriately selected and adapted musical activities can provide opportunities for cognitive and social development bringing out any positive 22

37 strengths and abilities. Gibbons (1977) in her article Popular Music Preferences of Elderly People supports the idea that music and musical activities may serve to stimulate successful activity which would contribute to self-esteem, aesthetic expression, and gratification. She calls attention to the fact that elderly strongly prefer popular music of their young adult years but states that there were no statistically significant differences in preferences for sedative and simulative music. Under this premise, it is suggested that clinicians should not assume that only sedative music will facilitate the demands and desires of elder people but simulative music as well be utilized to accommodate their needs. Music Therapy activities offer realistic activity options that optimizing fully, the cognitive and social functioning abilities which diminish disruptive and/or agitated behaviors. The importance of choosing and adapting music activities to insure participation, and consequently successful achievement of therapeutic objectives has been mentioned in the literature (Brotons & Pickett-Cooper, 1994). A study was conducted to investigate the preferences of persons with Alzheimer s disease for five different types of music activities: (a) singing, (b) playing instruments, (c) moving/dancing, (d) musical games, and (e) composition/improvisation. Participants were twenty female residents who were at stage 5 and 6 at the time the study was conducted. Each music activity was presented on five different sessions of 30-minutes duration. Preferences for the activities were determined based on the time actively spent as well as based on verbal report. Analysis of the data revealed that there is no relationship between verbal preferences and type of music activity. Therefore, behavior and verbal report do not concur with this population indicating that either they enjoyed equally all music activities or they were not very discriminating at the verbal level. (Brotons & Pickett-Cooper, 1994). The researchers suggest that it is essential for music therapists to have a wide repertoire of activities that stimulate different senses and areas of functioning but at the same time these activities must keep the interest of the participants, hence aiding elder individuals in maintaining attention. The type of the music activities used but more importantly, the relative demand of the specific activity are consider to be two important factors for successful integration of music therapy for persons at all three stages of cognitive functioning. 23

38 Hanson, Gfeller, Woodworth, Swanson and Garand (1996), attempted to compare the effectiveness of three different types of music activities (movement, rhythm, and singing) presented at two levels of difficulty (high and low demand levels). Findings of the study showed that one music therapy activity is not equally suitable for all participants, even though they may all have a diagnosis of the same disorder. Because persons with Alzheimer s and related diseases typically show a reduced ability to tolerate stress or stimuli as these diseases or disorders progress, activities designed to suit the present abilities of the individual are crucial in optimizing purposeful participation and in reducing disruption and agitation. Thus, the effectiveness of the music therapy treatment depends upon accurate assessment of the participant s skills and abilities and the subsequent selection and judicious facilitation of activities that are truly suitable to individual needs and abilities (p. 5, Hanson, Gfeller, Woodworth, Swanson and Garand, 1996). Another study by Groene, Zapchenk, Marble and Kantar (1998) examined the effects of activity characteristics on the purposeful responses of probable Alzheimer s disease participants. A combined 29 sing-along and exercise sessions were presented to a group of seven participants at an adult day care center. Sessions were 24 to 25 minutes long and consisted of live guitar playing and singing by individual music therapists. Since three music therapist and one occupational therapist presented the sessions, the study also examined the efficiency that each music therapist had on the outcome of each session. The researchers found that most of the participants responded better to exercise than to sing-along session. It is stressed that the different demands placed upon the tasks of moving to a model versus singing words to songs, it may be easier cognitively to accomplish the former task. In addition to that, the researchers suggest that to successfully work with clients with probable Alzheimer s, the therapist s professional experience and his/hers personal philosophies can promote the participants self-esteem, enhance participation and increase sensory integration. As a result, the therapist behavioral characteristics (level of musicianship, guitar proficiency and time spend singing and playing guitar) can be possible variations in participant s behaviors. Music Therapy had always had a dramatic effect on people with Alzheimer s since..music is a battery charger for the brain, and patients will frequently begin to 24

39 reminisce and verbalize thoughts and feelings in ways thought to be long dormant ( This study examines the use of music as a strategy to increase reality orientation and cognitive stimulation paired with music activities that are related with calendar events and/or community events to reinforce the goals of the Music Therapy program in the Day Care Facility. METHOD Site Participants and therapist interacted at a major Adult Day Care Facility under Tallahassee Memorial Hospital. The site included the services of nursing, nutrition, recreation, art therapy, speech therapy (based on doctor s referral), music therapy and occupational therapy (based on doctor s referral). The site contained a security locking system for the doors to prevent wandering, loss or injury. Participants Currently there are 37 clients enrolled at the day care. The clients come 1-5 days a week or as needed. Of these, 30% are African-American, 65% are white, 3% Chinese and 3% are other. There are 12 male participants (32%) and 25 female participants (68%). The primary diagnoses of participants are: 50% with Alzheimer s and dementia, 25% post CVA, 8% with Parkinson s disease, and 17% with another diagnosis. Adult children account for 53% of the primary caregivers. Spouses are the primary caregiver for 35% pf the participants. A few participants live alone (3%) and 3% live with another family member. There are three participants funding sources: (1) private pay accounts for 69%, (2) Medicaid Waiver accounts for 25%, and (3) Community Care for the Elderly funding accounts for 6%. Recently, the facility received a Grant providing day care services. No specific criteria were needed for entering the facility. 25

40 Potential participants for the study were those who attended the center on a regular basis and were present on all four sessions during the study. Ages at time of inclusion in the study averaged 75 years, and ranged from 56 to 94 years. The length of attendance in the day care center from admission to inclusion in the study ranges of 1 to 48 months. Design and Procedure A one group, two conditions, one therapist experimental design was used. All participants received contact with the therapist. A total of four sessions were delivered to the group of 11 participants over the course of 4 weeks. It is important to mention that only the participants who attended all four sessions were counted for this study (Figures 4, 6, 8 and 10) show the number of participants in every session and Figures 5, 7, 9 and 11) show participants who attended all four sessions). Sessions were done during the normally scheduled times of music therapy, Wednesdays from 1:30 2:30, that were an established part of the daily program routine of the site. Each session was conducted by the same music therapist/researcher. Two other music therapists were collecting data while the sessions were in progress. For this reason an observational form was designed to aid the observers in the collections of reliable data (Appendix B). A behavioral research design ABAB was utilized (A=baseline, B=treatment). All sessions started with a Reality Orientation Song (When you re smiling) using guitar as accompaniment. Singing of familiar songs, playing simple rhythmic instruments with background music, playing musical games that enhanced active manipulation of the hands and feet and moving/dancing activities were utilized. During treatment phase, these music activities were connected with calendar events and/or community events to reinforce the goals of the Music Therapy program in the Day Care Facility. In addition to that, at the end of each session new movement activities were incorporated, such as the parachute and multicultural music, accompanied with instruments. This was done in order to increase the variety of the activities decreasing boredom, while simultaneously increasing participation and enjoyment. In addition these activities were selected to increase active manipulation of hands and feet thus increasing the idea of here and now. Subjects were 26

41 encouraged to participate and were reinforced periodically by smiling, or by verbally praising their behaviors. When subjects did not participate independently, the therapist used physical and verbal prompts to assure some participation. Results The Data checklist form for the two therapists was designed for analysis. Participation was observed and recorded using a circle for each person s involvement in each activity. It is important to note that any kind of participation whether it was a facial expression (eye conduct or smiling), whether it was a bodily movement (moving feet to music, moving hands to music or playing instruments to music), or whether there were any other signs of participation such as singing, verbalizing or commenting on the songs, were accounted for data collection. Discussion The elderly population is one of the most common populations music therapists work with. When it comes to Alzheimer s dementia type, music therapy is one of the most successful interventions. This study examines the use of music as a strategy to increase reality orientation and cognitive stimulation. Given the structure of the sessions, the differing lengths of the material for each baseline and treatment condition, in addition to the widely varied response level of the participants, the validity of the accuracy of the performance under the these conditions would be questionable. Rather, it was decided that the relative proportions of the responses for each activity could indicate trends and tendencies (See Analysis of each session). Music can serve as a mean of communication especially for those where the function of language has become very challenging or troublesome. The elements of music such as rhythm, pitch, and melody are all being processed differently, in the right hemisphere of the brain and limbic system. By stimulating the limbic system with music, 27

42 emotions are automatically activated thus creating a greater chance of activating intact neurological pathways than with the use of language alone. That is why patients with Alzheimer s have the musical memory since music triggers emotions and emotions triggers memories. Graphic analysis between baseline phase and intervention phase (music activities connected with calendar events and/or community events, new movement activities such as the parachute, new songs and multicultural music) show some difference but not significant. Participation for baseline A and C were 89.4 % and 89.5% whereas during intervention phase B and D they were % and 92.5 % (Figure 12). It is speculated that the small increase may be an indicator of the importance of using activities related with calendar and community events since all of the patients are living in the community and attending the facility solely during weekdays. It is therefore vital to associate any kind of calendar or community events with music activities, thus promoting to the maximum extent reality orientation and cognitive stimulation. Session B or intervention B was coupled with Halloween activities and session D or intervention D was coupled with Veteran s day activities. At the same time, the music that was used during these sessions (B and D) was music of their young adult years since research shows that popular music of their young adult years will most likely promote successful experiences than any other kind of music. Songs like Monster Mash, It s a Long Way to Tipperary and Pack Up Your Troubles in Your Old Kit-Bag were used successfully since these songs were most popular during the 30s and 40s. It is worthwhile to mention that some of the participants were able to recall the name and words of the songs (cognitive stimulation) reconfirming once more the dramatic effect music has on patients with Alzheimer s disease. Another participant (participant 11 in figures 5, 7, 9 and 11) who rarely interacted with the Music Therapist or participated during the session responded in significantly higher rates during session C. It was observed that while singing hymns, ( In the Garden, How Great Thou Art, Old Rugged Cross and Amazing Grace ) the participant exclaimed her preference for this kind of music. At some point, she stood up and conducted the rest of the group while the therapist was playing the guitar. After the song was over, she said to the group that she used to sing 28

43 and conduct these kinds of songs at church. It is clearly seen that music preference is a factor in successful music experiences for this population. It was observed that when music is familiar and pleasing, it will have a greater effect. That is why is very important to set a positive mood from the beginning thus increasing the probabilities for active participation and interaction. An up-beat, age appropriate hello song can become the key for a successful session but the hello song can also be any kind of song that incorporates the participant s names reinforcing once again reality orientation. For the purpose of this study, the song When You re Smiling was utilized since the researcher had previously used this song with great success. As seen, participation rate for When You re Smiling as an opener was extremely high. The researcher decided to also end session B with the same song in order to determine the effectiveness of the song on the participants. Results demonstrate the tremendous positive impact the song had on the patients since during the songs almost all participants smiled and had eye contact with the music therapist or sang along or played their instruments. The staff commented how it created a good atmosphere for everyone as the session began. To successfully work with Alzheimer s clients, one must always take into consideration the professional experience of the therapist and his/her personal philosophy. The therapist musical skills are a good indicator of client s responsiveness and optimum client progress. It is suggested from the literature that significant differences in the amount of time spent singing and playing guitar during sessions by the different therapists might have something to do with the level of guitar playing competency. It is assumed that the more skillful and confident the therapist, the more effective they can be. In this way, the instrument itself does not become a burden between the therapist and the client but a medium which the client can be more easily reached. Equally important is the capability of the therapist to perform memorized music. In doing so, eye contact is reinforced; therapist-client rapport is enhanced thus increasing communication and promoting participation and interaction. Since patients with Alzheimer s dementia type are progressively left with primary somatosensory responses, there is a great need to integrate a broad repertoire of activities that stimulate different senses and areas of functioning. Sing-along activities 29

44 can be cognitively stimulating but persons with more severe stages of decline will not maintain this involvement for long periods of time. It is known that participation in instrumental rhythmic activities, especially when vibrotactile stimulation is provided, elicit greater responses and help the elderly to participate purposefully. Other materials such as scarves, parachute and theraband can easily substitute for the rhythmic instruments hence increasing active manipulation of hands and feet thus increasing the idea of here and now while decreasing boredom. It was quite surprising that during the parachute activity used during intervention sessions B and D, the entire group s attention and interest was maintained and people who were asleep throughout the session opened their eyes and watched, even though they did not participate. It can be inferred that new activities can attract and maintain this population s attention, proving that repetition of the same activities and same songs can shut responses and meaningful communication with the environment. Similarly, the use of new songs can be additional stimuli for reality orientation. It was interesting to see the faces of the participants when a Greek song was played during the intervention phase D. The music therapist/researcher was eager to see whether the patients were aware of what they were listening, therefore reinforcing the idea of here and now. Many of them were looking at each other with eyes wide open and moving their heads from one side of the room to the other. Some of them, the higher functioning patients, realized what was going on and decided to play along. Later on more patients joined in and interestingly enough, everybody kept up with the tempo of the music as it became faster and faster. When the song was over the therapist asked a participant if she liked the song. Her face was grimacing when she said No. What a great way to orient people in reality and cognitively stimulate them! Music therapy is clearly a dynamic approach in the care of people with Alzheimer s dementia type problems. With easy force it opens all the cells Where Memory slept. Wherever I have heard A kindred melody, the scene recurs, And with it all its pleasures and its pains. Such comprehensive views the spirit takes, That in a few short moments I retrace 30

45 (As in a map the voyager his course) The windings of my way through many years. -excerpt from the poem Music and Recollection by William Cowper, p.201 Limitation of the study As it was pointed out earlier, given the structure of the sessions, the differing lengths of the material for each baseline and treatment condition, in addition to the widely varied response level of the participants, the validity of the accuracy of the performance under the these conditions would be questionable. Rather, it was decided that the relative proportions of the responses for each activity could indicate trends and tendencies. One critical issue is the collection of data with the most reliable way. Observers need to be trained ahead of time in order to ensure that each of them knows exactly what needs to be done. Each observer needs to be collecting data individually and not in cooperation with the other observer, but more importantly each of the observers has to realize the importance of being as objective as possible. The researcher has to make sure that criteria, procedures or expectations are being clarified and well understood from the observers so as to be as reliable as possible. Being an observer is not an easy job since everyone tends to be biased. Despite of that, it is under the code of ethics that as music therapists we have to be able to conduct research in the most reliable and most professional way. 31

46 Analysis of Each Session Session A Baseline Participants: 15 Reliability % (all participants for that day): 88.9% Reliability % (11 participants-those who attended all 4 sessions): 89.4% Activity Activity 1 Hello Song: When You re Smiling Activity 2 Movement Activity with rhythmic instruments Background Song: Hit the Road to Jack Activity 7 Play and Sing-along In the Good Old Summertime Activity 11 Play and Sing-along Rock Around the Clock Activity 12 Play and Sing-along When the Saints Go Marching In Activity 15 Play and Sing-along This Little Light of Mine Activity 17 Play and Sing-along Someone to Watch Over Me Number of People Participated in activity Observer 1: 15 Observer 2: 15 Observer 1: 14 Observer 2: 13 Observer 1: 11 Observer 2: 13 Observer 1: 12 Observer 2: 12 Observer 1: 13 Observer 2: 14 Observer 1: 12 Observer 2: 13 Observer 1: 9 Observer 2: 11 Reliability of each activity between the two observers 100% 93.4% 86.7% 86.7% 93.4% 93.4% 80% 32

47 Session B Intervention Participants: 16 Reliability % (all participants for that day): 91.5% Reliability % (11 participants-those who attended all 4 sessions): 90.09% Activity Activity 1 Hello Song: When You re Smiling Activity 2 Movement Activity with rhythmic instruments Background Song: Monster Mash Activity 7 Play and Sing-along I ll Fly Away Activity 11 Play and Sing-along Getting to Know You Activity 12 Play and Sing-along In the Good Old Summertime Activity 15 Play and Sing-along This Little Light of Mine Activity 19 Play and Sing-along When You re Smiling Activity 20 Parachute Background Song: Let Me Fly Number of People Participated in activity Observer 1: 16 Observer 2: 15 Observer 1: 14 Observer 2: 14 Observer 1: 12 Observer 2: 12 Observer 1: 11 Observer 2: 11 Observer 1: 12 Observer 2: 12 Observer 1: 13 Observer 2: 12 Observer 1: 10 Observer 2: 11 Observer 1: 14 Observer 2: 10 Reliability of each activity between the two observers 93.75% 100% 100% 87.5% 87.5% 93.75% 93.75% 75% 33

48 Session C Baseline Participants: 16 Reliability % (all participants for that day): 91.1% Reliability % (11 participants-those who attended all 4 sessions): 89.5% Activity Activity 1 Hello Song: When You re Smiling Activity 2 Movement Activity with rhythmic instruments Background Song: Hit the Road to Jack Activity 7 Play and Sing-along Moon River ** New Song Activity 11 Play and Sing-along This Little Light of Mine Activity 12 Play and Sing-along In the Garden Activity 13 Play and Sing-along How Great Thou Art Activity 15 Play and Sing-along Amazing Grace Activity 16 Play and Sing-along My Wild Irish Rose **New Song Activity 17 Play and Sing-along In the Good Old Summertime Activity 18 Play and Sing-along Oh, What a Beautiful Number of People Participated in activity Observer 1: 11 Observer 2: 14 Observer 1: 12 Observer 2: 13 Observer 1: 11 Observer 2: 11 Observer 1: 10 Observer 2: 11 Observer 1: 12 Observer 2: 12 Observer 1: 11 Observer 2: 10 Observer 1: 11 Observer 2: 11 Observer 1: 10 Observer 2: 9 Observer 1: 11 Observer 2: 9 Observer 1: 13 Observer 2: 12 Reliability of each activity between the two observers 81.2% 93.75% 87.5% 93.75% 100% 93.75% 100% 93.75% 87.5% 75% 34

49 Morning 35

50 Session D Intervention Participants: 16 Reliability % (all participants for that day): 93.5% Reliability % (11 participants-those who attended all 4 sessions): 92.5% Activity Activity 1 Hello Song: When You re Smiling Activity 2 Movement Activity with rhythmic instruments Background Song: It s a Long, Long Way to Tipperary and Pack Up Your Troubles in Your Old Kit-Bag Activity 7 Play and Sing-along Let Me Call You Sweetheart Activity 11 Play and Sing-along Multicultural Music ** Fast Greek Song Activity 12 Play and Sing-along Everywhere You Go ** New Song Activity 15 Play and Sing-along Getting to Know You Activity 17 Play and Sing-along Amazing Grace Activity 18 Parachute Background Song Lift Every Voice and Sing Number of People Participated in activity Observer 1: 15 Observer 2: 16 Observer 1: 15 Observer 2: 13 Observer 1: 10 Observer 2: 11 Observer 1: 10 Observer 2: 12 Observer 1: 10 Observer 2: 10 Observer 1: 11 Observer 2: 10 Observer 1: 12 Observer 2: 11 Observer 1: 11 Observer 2: 11 Reliability of each activity between the two observers 93.75% 87.5% 93.75% 87.5% 100% 81.2% 93.75% 100% 36

51 # of Activities Session A - 10/22 - Baseline Observer 1 Observer Participants Figure 4 Session A2-10/22 - Baseline Observer 1 Observer 2 # of Activities Participants Figure 5 37

52 Session B - 10/29 - Intervention Series1 Series # of Activities Participants Figure 6 Session B2-10/29 - Intervention Observer 1 Observer 2 # of Activities Participants Figure 7 38

53 20 15 # of Activities Session C - 11/05 - Baseline Participants Series1 Series2 Figure 8 # of Activities Session C2-11/05 - Baseline Observer 1 Observer Participants Figure 9 39

54 Session D - 11/12 - Intervention Series1 Series # of Activities Participants Figure 10 # of Activities Session D2-11/12 - Intervention Participants Observer 1 Observer 2 Figure 11 40

55 Mean Reliability of Each Sesssion % of R eliability Reliability % (all participants for that day): Reliability % (11 participants-those who attended all 4 sessions) Sessions Figure 12 41

56 CASE STUDY THREE: TITLE: THE UTILIZATION OF MUSIC THERAPY FOR NON-PATIENTS IN A HOSPITAL SETTING 42

57 Review of Literature There is no doubt that the power of music can affect the mood and physical state of human beings since for ages music and medicine were inseparable in the minds of men. To the ancient Greeks music was considered to be essential in the education of youth and God Apollo embodied the aspiration of harmony through medicine and music. Aristotle in Politics wrote of the power of music, declaring that the emotions created by some music can excite the soul to mystic frenzy.. Most of us are aware that music can affect our moods. We know that sometimes it can make repetitive work less tedious, make us feel more relaxed or cheerful, in addition to less tense or bored. At times, it can start feet tapping and hands moving, or cause nostalgia, longing, and feelings of tenderness. At the same time that our feelings are being affected, other things happen to the body which we do not realize. It has been shown, for example, that music can affect blood pressure and heartbeat and can even restore pupil size of eyes fatigued by exposure to light. Respiration rate increase with strong, lively music such as Liszt s Hungarian Rhapsody, Number Two, and posture is different when people listen to stimulative music than when they listen to sedative music. Zinar (1987) For many years researchers, philosophers, psychologists and musicians attempted to explain reactions to music and which factors influence musical preference. In an effort to explain reactions to music, some investigators have attempted to control differences in the influence of musical selections on human subjects by categorizing their music as stimulative or sedative (Taylor, 1973). Taylor indicates that this kind of classification clearly incorporates not only the differential properties of the music, but also its effects on listeners. Traut and Davis (1993) seek to find whether the influence of subject-selected versus experimenter-chosen music will have any impact on affect, anxiety, and relaxation. It was clearly seen that neither the presence or absence of music nor the choice of music appeared to make a difference in the relaxation response. On the other hand, Walworth (2001) found that there was a statistically significant difference in the anxiety levels between the no music control group and the other two experimental 43

58 groups (Experimental group one marked their preferred genre and/ or artists. Experimental group two marked specific songs used for relaxation purposes). Despite controversial results, studies have also investigated the relationship the degree of liking and self-reported relaxation while listening to music. Stratton and Zalanowski found that the most important factor in relaxation was the degree of liking for the music. They pointed out that significant correlations occurred between liking and relaxation, pleasure and not thinking. In another study by Hammer (1996), the researcher investigated the effects of Guided Imagery through Music and relaxation techniques on state and trait anxiety levels. On the whole, the results indicate that Guided Imagery through music may be of some benefit to persons with chronic stress and anxiety. Much research in the nursing field has dealt with the needs of families and interventions to provide better support for them (Donnell, 1989; Carmody, Hickey & Bookbinder, 1991) Jarred (2003) identified the need to utilize live Music Therapy in surgical waiting rooms to determine the effect on anxiety level of non-patients (family or friends). According to Jarred, anxiety arises in family members when hospitalization, whether it is planned or an emergency, is required for one of its members. Because anxious family members cannot be as supportive and can pose a threat of projecting anxiety onto the patient, there is a great need in the medical field for intervention that successfully reduces family anxiety. She reports no significant differences in anxiety, stress, and worry levels among the three groups but underlines that subjects in the direct music group (subjects were encouraged to request songs) and indirect group (subjects in this group had no control over music provision) exhibited greater relaxation levels than did the control group. Equally important was the positive response of all subjects participated in this study to include live music among the services the hospital should offer. Hargreaves, Messerschmidt and Rubert (1980) reviewed the existing literature and found five categories of main factors influencing people s preferences to music therefore affecting in one way or another, their physical, psychological, emotional or mental state. These categories are: 1) age, intelligence, musical experience and training and socio-economic status, 2) personality factors such as extraversion-introversion, 3) familiarity and repetition on affective responses to music, 4) prestige and propaganda and 44

59 lastly 5) social determinants such as musical taste cultures. Leblanc (1982) in his article An Interactive Theory of Music Preference highlights that Music preference decisions are based upon the interaction of input information and the characteristics of the listener, with input information consisting of the musical stimulus and the listener s cultural environment. Leblanc expresses the opinion that For music therapists, the theory offers an approach to the analysis of music listening preferences, and thus a potential for greater sensitivity in the use of music listening as a therapeutic tool. METHOD Purpose Music therapy is the prescribed use of music and musical interventions in order to restore, maintain, and improve emotional, physical, physiological, and spiritual health and well-being. This exploratory study investigated the utilization of Music Therapy and its effectiveness for non-patients in waiting rooms of a hospital setting. Procedure This study was conducted at Tallahassee Memorial Health Care. Two waiting rooms were chosen, the Emergency waiting room and the Intensive Care Unit waiting room, after consultation with the head nurse of the hospital. A 30-minute session of live music was implemented twice a week in each waiting room. In order to make the study as reliable as possible, the two sessions in the Emergency waiting room occurred the same days (Monday and Friday) and same hours (1:00 p.m. and 11:00 a.m. respectively) as the two in the Intensive Care Unit. A repertoire list that included songs from a variety of musical genres (See appendix C), was handed to the subjects who happened to be present at the time of the study. Subjects were encouraged to choose songs they enjoyed listening to or request songs they liked. Behavioral data were recorded by an 45

60 independent observer (See appendix D). Observable on-task verbal behaviors were: singing, choosing songs, conversing with the Music Therapists, and making comments about music. Observable on task visual behaviors were: eye-contact, moving feet or hands to music, and dancing. Observable off-task behaviors were: conversing with other people, reading newspaper, watching T.V., talking on the phone or any other incompatible or competing behavior at the interval of the observation (See appendix E). Results This study was conducted to retest previous research related with the effectiveness of Music Therapy in other non-patient areas for example waiting rooms. Results of the data (See Appendices F, G, H and I) suggest that music had negative acceptance and impact in the Emergency but had more positive effect on the Intensive Care Unit waiting room. Many reasons contributed to the controversial outcome (see discussion section). Discussion Comparison of the effects that Music Therapy had in both the Emergency and Intensive Care Unit waiting rooms yielded several significant findings. Results indicated that Music Therapy in an environment such as the Emergency room, where patients are also present, is not as effective as in waiting room where only non-patients are there. A patient with a strong migraine, seizure or even fever is not in a condition to redirect their attention from their physiological state to music. Incidental conditioning of the listener greatly influences the listener s ability to accept any input from the environment and in the case of music, to transfer that input into a pleasant and relaxing experience. Extensive research in Music Therapy has been done to determine whether music can facilitate or help in pain management and relief (analgesia). Despite the encouraging outcomes with certain populations, it is extremely hard to transfer or 46

61 apply these findings in the Emergency rooms where a variety of situations and health problems needs to be addressed at the same time. Under these circumstances one type of music may be helpful ease the pain for one patient but will create anxiety to another patient. As a result, as Leblanc points out, the Music Therapist must be very sensitive in the use of music as a therapeutic tool. Hargreaves, Messerschmidt and Rubert (1980) reviewed the existing literature and found five categories of main factors influencing people s preferences to music therefore affecting, in one way or another, their physical, psychological, emotional or mental state. These categories are: 1) age, intelligence, musical experience and training and socio-economic status, 2) personality factors such as extraversion-introversion, 3) familiarity and repetition on affective responses to music, 4) prestige and propaganda and lastly 5) social determinants such as musical taste cultures. All these factors contributed in one way or another to the final outcome that this study had. The age, intelligence and socio-economic status are three variables that can affect directly the outcome of any study. People, patient or non-patient, with a variety of age range, come and go in hospitals. How can an eighteen year old focus his attention to music if the Music Therapist is playing In the Good Old Summertime or Oh, What a Beautiful Morning? The young man will only respond to music once he hears an upbeat, fast music(r&b, Rap), but the environmental conditions in a hospital setting will never allow the Music Therapist to satisfy the young man s desire. Socio-economic status is another important factor that contributes indirectly to the successful implementation to Music Therapy in non-patient areas. Diverse populations from different socio-economic status attend hospitals every day. Similarly, it is difficult to assess five or ten different people within 30-minutes frame if those people come from different socio-economic status, with different educational background and different cultural orientation. As Leblanc (1982) underlined in his article An Interactive Theory of Music Preference Personality characteristics can influence an individual to be more or less receptive to different musical styles and the influence of various aspects of the cultural environment. Under such circumstances, it is hard for the Music Therapist to conduct an effective and constructive session and at the same time it is tough for the diverse audience to benefit from it. 47

62 It is worthwhile to mention, that the last part of the research conducted in the Intensive Care Unit, was thought to be the most successful session among the four. Many reasons might have contributed to this success, (Music Therapist s previous experience, Independent observer s comments, Staff s recommendations and comments) but these findings can not be generalized. Further research is needed by manipulating different variables in order to clearly understand the usefulness of Music Therapy in such non-patient areas. Another issue that needs to be addressed is the ethnic and musical background of the Music Therapist. Based on the Therapist s observations, she concluded that the ability to create a bond with the audience in order to increase responsiveness, thus increasing effectiveness of the session is more demanding when language barriers exits and when the Therapist and the listeners don t share much of the same ethnic and musical experiences. The Therapist assessment about what people want to hear can not be as accurate hence affecting the results of the study. Particularly, during the third session of the study the Music Therapist played a lot of Spirituals thinking that the audience will enjoy since all of them were African Americans. At the end of the session the independent observer asked the therapist/researcher why she decided to do that. Then the independent observer commended I am Hispanic in origin and if you would have played Tejano music I would have stepped out. What makes you think that coming from a certain ethnic background, automatically you must like listening to that ethnic group music? Research shows that people enjoy listening to music that comes from their immediate environment while growing up. Assuming that, the researcher s assessment led her to use more Spirituals. Maybe the independent s observer s strong music background affected his appreciation to his ethnic music. This is another topic that needs to be investigated. While overall results of this study were not significant or encouraging, enough variations occurred between the two waiting group populations to warrant further investigation 48

63 CASE STUDY FOUR TITLE: A REVIEW OF CLINICAL PAIN ASSESSMENT FORMS AND THEIR APPLICABILITY TO MUSIC THERAPY 49

64 Review of Literature Ever since the birth of music therapy as a profession during the late years of World War II, , in addition to the tremendous development in the last half of the 20 th century, music therapy has repeatedly proven the healing powers music can have on any aspect of human development and functioning whether physical, physiological, psychological, cognitive, emotional or social. Today, hundreds of reports and articles are being published to scientifically support how music can be a powerful stimulant in restoring qualities and abilities in people. During the last decade, the use of music as an adjunctive aid to traditional medicine has been acknowledged and patients can now take home sound prescriptions to assist them in regaining health. A medical veteran officer who suffered from neurotic depression expressed accurately the role of music in his recovery: Although I have always appreciated music and held the belief that music therapy would be beneficial to the neuro-psychiatric patient, especially in the stage of convalescence, I now am convinced from actual experience that these psychotherapeutic effects are more real than theoretical. This form of therapy gives the patient an opportunity of acting out his emotions instead of submerging them deeply into sub-conscious strata. Because of the numerous items that one must think of while studying music, i.e. breath control, memorizing words, music, etc. the patient has very little time to dwell on his deleterious complexes and thus gradually establishes a tendency to become more extrovert. Another important factor is the relaxation that the patient experiences, thereby increasing his self-confidence. Music, as it is applied and taught daily to patients at the Walter Reed Hospital, also affords an opportunity to socialize with others in an area of mutual interest. 50

65 All of the above mentioned factors tend to eventually (and I believe successfully) remove the feeling of inadequacy which is constantly grasping the neurotic patient (Rorke, 1996). Standley (2000), in the article Music Research in Medical Treatment reviewed existing literature in the utilization of music in medical settings. She provides a metaanalysis that synthesizes data from separate studies generalizing the effects of music in medical treatment. Clinical applications in the medical setting are being presented which are categorized according to the types of other medical or therapeutic techniques paired with the music activity. Each music therapy technique cited includes a description of intended function of music, the possible therapeutic objectives, target populations with probable treatment duration, suggested means for clinically documenting results, and specific music therapy procedures (Standley, p. 21). An ongoing growing interest on the effects of music in medicine has led institutions and research centers to investigate the impact music has in pain management and pain relief. A press release from the National Institute of Health found that music and relaxation can provide more complete relief without the undesired side effects of some pain medications (Press Release, National Institute of Health, 1999). Michel and Chesky (1995) conducted a survey among music therapist to investigate the use of music/music techniques in pain relief. Results indicated that there is a growing number of clinicians using music specifically for pain relief pointing out that there is an apparent need to further explore the field of pain management through music, including music used as and with vibrotactile stimulation. Music therapy has been proven to be effective in a variety of groups within the medical arena. Among those, is the pediatric population whose perception of pain and overt responses to pain are drastically different from any other population. Malone (1996) investigated the effects of live music on the distress of the pediatric patients receiving intravenous starts, venipunctures, injections and heel sticks. It was clearly seen that music as a distraction during invasive procedures appears to be beneficial for all age groups (Group 1: 0 to 1 year, Group 2: 1 to 3 years and Group 3: 3 to 7 years) during preneedle and post-needle stages. When comparing age groups, children 0 to 1 years showed significantly less distress during the music conditions than did the other two age 51

66 groups. It was concluded that the more relaxed and distracted the child is, the less behavioral distress will eventually exhibit during the later stages of the procedure. The effects of music on sensation and distress of pain in women during the active phase of labor was investigated by Phumdoung and Good (2003) and others (Walters, MacLaren, Clark, McCorkle, & Williams). One Hundred and ten participants were randomly assigned to a music group and a control group. Women in the intervention group listened to soft music without lyrics for 3 hours starting early in the active phase of labor. Results indicate that soft music can decrease both sensation and distress of active labor pain in the first 3 hours and it can delay increases in distress of pain for an hour. The findings of the study supported once again that music can ease severe pain. Experimental research in music therapy was conducted by Wolfe (1978) to demonstrate the effectiveness of music therapy in inhibiting the perception of chronic pain, as expressed through verbal complaints. Wolfe proved that verbal conditioning which would seem to support the effective modification of patient verbalizations can be achieved with the use of appropriate music. Curtis (1986) investigated the effect of music upon the perceived degree of pain relief, physical comfort, relaxation and contentment of the terminally ill. Even though no significant results were documented statistically, graphic analysis of individual responses had demonstrated the efficacy of music as an intervention tool with this critically ill population. Music therapy can serve as an effective tool in alleviating and remediating the problem of sensory deprivation with burn patients (Christenberry, 1979) It can provide sensory and visual stimulation and help the patient to redirect thoughts from the hospital routine, elevate mood, encourage relaxation thus reducing anxiety and lessening pain, express feelings, built self-esteem, augment physical goals and many more. Despite the fact that music is being utilized in the hospital setting across populations, the author of this study could not find research related to music therapy pain assessment procedures that identify both problem areas and patient assets for treatment participation and prognosis (Standley, p. 43). Therefore, the purpose of this study is to review clinical pain assessment forms and discuss their applicability to music therapy. 52

67 Review of Clinical Pain Assessment Forms and their Applicability to Music Therapy Assessment can become a time consuming, problematic issue when incorrect tools are used to evaluate the current conditioning of patients. Validity of the information collected can become a controversial issue when the patient is not in a healthy cognitive mental state. Recently, a view has been adopted that interdisciplinary assessment must exist in order to better evaluate the patient so as to meet his/her needs in a more efficient and effective way. When discrepancies occur between professionals about the diagnosis or prognosis of a patient, how reliable do these assessment tools need to be considered? While conducting research in collecting clinical pain assessment forms, it was found that accessibility to these forms was difficult since most clinical settings offered by different facilities were either reserving the rights for accessing these forms, or actually selling the forms for use. Charging individuals to use these forms decreases the ability of other paraprofessionals to frequently use them, consequently limiting communication between professionals and thus poorly evaluating patients. Most often music therapist can successfully conduct an initial assessment of any patient admitted in a hospital setting. As a result, it would be beneficial for music therapists to have access in using these forms anytime. Is should also noted that music therapist are not associated with pain in the same way that nurses, doctors or physical therapists are, therefore under such nonthreatening atmosphere the patient-therapist relationship is being enhanced hence more reliable assessments are being done. Even though pain assessment tools usually include information about the intensity, character, frequency, location, duration, aggravating and alleviating factors, they greatly vary from facility to facility and of course from population to population. With such a wide variety, it is speculated that professionals are not reliably assessing the patients since different criteria are being utilized and different approaches used --Checklists (figure 13, Illustrated Manual of Orthopaedic Medicine James & Patricia Cyriax), versus Likert Scales (figure 14, Excerpted from American Medical Director s Association Clinical Practice Guideline: Chronic Pain Management in the Long-Term Care Setting), versus pictorial assessment scales (figure 15, From the University of Wisconsin Hospitals and Clinics Home Health Agency. Permission granted to modify or 53

68 adopt provided written credit given to Institutionalizing Pain Management Project, University of Wisconsin - Madison), versus Visual Analog Scales (figure 16, Excerpted from the American Family Physician, October 1, 2001), versus Verbal Scale (figure 17, From the University of Wisconsin Hospitals and Clinics Home Health Agency. Permission granted to modify or adopt provided written credit given to Institutionalizing Pain Management Project, University of Wisconsin Madison). Music therapist should be familiar with the above assessment tools and be very confident of using them since these assessment tools are more often used by medical personnel. Music therapists must also be aware that when it comes to patients with cognitive, language or sensory impairments, patients should be assessed with scales that are tailored for their needs and disabilities. Another important aspect in reviewing pain assessment forms is the classification of the forms into two main categories. These categories are 1) forms based on population addressed to (Figure 14) and 2) forms based on assessing different body parts or pain origin (figure 13). Music Therapists should always review and take into serious consideration any available information in order to set appropriate goals and objectives. For example song writing could be most beneficial with a severe burn patient since music will allow the patient to discuss his fears or frustrations and build his self-esteem. Likewise, a variety of live instead of recorded music activities can be more effective with pediatric patients before or after surgery. Pain assessment tool can be lengthy with a great number of medical terms that neither the patient nor the close relative will be able to understand. Evidently, filling in lengthy forms can be frustrating and stressful thus increasing the anxiety of the patient and family. Music Therapist can provide a pleasant environment while assessing the patient eliminating any unwanted tension. Lastly, it is necessary and significant for Music Therapist to review existing literature in pain management so as to keep themselves updated and well informed. Transfer of knowledge from one situation to another is necessary so as to facilitate and serve patients needs successfully. 54

69 Figure 13 55

70 Figure 14 56

71 Figure 15 57

72 Figure 16 58

73 Figure 17 59

74 CASE STUDY FIVE TITLE: GUITAR INSTRUCTION WITH AN UNDERGRADUATE MUSIC THERAPY STUDENT DOING A PRACTICUM IN A HOSPITAL 60

75 Review of Literature The Guitar is not only one of the most alluring and expressive instruments, but one that has more applications than any instrument known to mankind. From the sedative sound of the Greek Kithara to the atonal sounds of the Flamenco-style Spanish guitar, to the howling solos effortlessly pounded out by George Harrison of the Beatles in the 60s, to the modern Jazz fusion drifting through clubs and concert halls all over the world, there is no instrument as recognized, as versatile, and as expressive as the guitar. The guitar today continues to flourish throughout the globe in its infinite number of applications and styles, growing in popularity and prestige every single year. Actually, the guitar includes an entire family of modern instruments: the nylon-string classical, the steel-string acoustic, the archtop and the electric guitar. The value of class-guitar program in schools and colleges is being increasingly recognized throughout the United States. Most colleges have included in their curriculum guitar instruction, and students, music or non-music majors, have the opportunity to learn how to play this popular instrument. For music therapy majors, proficient guitar skills are considered key to the successful completion of the music academic curriculum which includes both the academic phase and the field-based internship phase. In a study conducted by Petrie (1993), while the researcher presented an evaluation of the National Association for Music Therapy Undergraduate Academic Curriculum, he brings back the question that was raised at the Seventh Annual Conference of the National Association for Music Therapy (NAMT, 1956), concerning what music therapy knowledge and skills the Clinical Training Directors expect from the beginning music therapy interns to have developed during the academic phase of their program. Petrie also included Gault s findings (1978) that revealed that fifty-six percent of the practicing music therapy professionals believed that music therapy training during academic work was not sufficient as a base of knowledge on which to begin internship. Madsen (1999) points out that An obvious and important aspect of music therapy academic training is to prepare prospective therapists with the necessary skills, attitudes, and knowledge base necessary for successful progress through the music therapy internship. Based on the above, Petrie strongly believes that it is important for the 61

76 music therapy student/intern and the future professional clinician to be aware of the taxonomic levels of learning. According to Petrie, there are three levels of learning, which are: (1) Learning concerns cognition which are conceptual knowledge: ideas, facts, concepts, and generalizations learned through the educational process, (2) Cognitive skills which add to cognitions the student s ability to apply his or her own ideas, to use previously learned knowledge to solve problems, to interpret data or situations, and to generate new questions and (3) Affective understanding which focuses on the student s ability to be aware of self or to interact with others. Level three is considered the most important learning level. Clifford Madsen, a professor and prominent researcher in the School of Music at Florida State University, was one of the first people who realized the necessity of making transfers as students, interns, professionals, researchers and clinicians. In his article Research and Music Therapy: The Necessity for Transfer (1986) he proclaims that Transfer appears to be the key to achieving greater meaning from research reports as well as from all other reading. It has been suggested that until each of us as professionals is capable of answering the important question of How does this information relate to me? it is probably fruitless to attempt to provide any easy solutions to our many problems. Gregory (1978) considers the identification of competencies which are required in music therapy and the refining techniques for shaping these competencies as the primary task of educators and clinical training supervisors though few published research has dealt with the clinical effects of different music therapists and those competencyvariables that result in optimum client progress. In a study conducted by Groene, Zapchenk, Marble, Kantar (1998) with Alzheimer s disease patients, the researchers tried to determine the client and individual therapist s variables that result in optimum client progress. Among those variables were the guitar skill level of each therapists and how this variable affect the client s responses. It is worthwhile to point, that there was significant differences in the amount of time spent singing and playing the guitar during sessions by the three different music therapists. Each therapist self-rated his/her ability to successfully lead exercise sessions, sing-along sessions, and to perform on guitar during sing-along sessions. MT1 rated his guitar ability 10 out of 10, MT2 rated her guitar ability 4 out of 10 and MT3 rated her guitar ability 7 out of 10. Each therapist s primary 62

77 instrument was guitar, piano and voice respectively. MT1 has been in the field of Music Therapy for fifteen years and working with dementia patients for 4 years, MT2 for six years and working with dementia patient s for six years and MT3 for fourteen years and working with dementia patient s throughout her career. It was observed that there was a significant difference in Participant s 6 response level during exercise sessions and singalong sessions. It is seen that MT1 spent significantly higher singing percentage during sessions and a significant difference in the proportion of time spent playing guitar. A post hoc Newman-Keuls multiple comparison procedure showed significant differences in guitar playing percentages between all therapists. It is suggested that the indicated significant differences in the amount of time spent singing and playing guitar during sessions by the different therapists and client responses, might have something to do with the level of guitar playing competency. If this is the case, if any, unique skills, behaviors, or characteristics could music therapists bring to the activity of exercise that would ensure the finest quality of care in a shrinking healthcare budget? Further research and discussion of this question may be warranted at all levels of music therapy training and practice (Groene, Zapchenk, Marble, & Kantar, 1998) Is there anything we need to be doing that can optimize the purposeful and pleasurable responses of clients that we are not presently doing to help strengthen therapeutic efficacy? Is there a correlation between the number and/or specific nature of a person s fears that may indicate a level of confidence and/or success? (Madsen, 1999). One indicator of the importance and success of a class-guitar program is the number of students who play the guitar inside as well as outside the school environment but more importantly, the relationship that exists between being a competent guitar player in promoting therapeutic relationship and therapeutic results. This present study was designed to help an undergraduate music therapy student to successfully meet the requirements and skills needed in guitar while doing a practicum in a hospital setting. Furthermore, this study seeks to examine if a relationship exists between guitar skills and being more competent during direct client interaction, hence being an effective music therapist. 63

78 METHOD Site and Design The individual sessions of this study were conducted in an available room in the School of Music at Florida State University. Sessions were held twice a week, on Tuesdays and Saturdays, with each session lasting for an hour. A total of eight lessons were delivered over the course of four weeks. Participant This study was designed to help an undergraduate music therapy student to successfully meet the requirements and skills needed in guitar while doing a practicum in a hospital setting. While this study was being conducted, the undergraduate student was a senior in the department of music therapy and was finishing the academic phase of the program, getting ready for the field based internship. It is important to mention that the participant had successfully completed a beginning and an intermediate class guitar courses and volunteered to take part in this study. The student was originally from Venezuela and Spanish was her native language whereas the therapist who conducted the study was originally from Cyprus and Greek was her native language. Lessons were delivered in the English language. Procedure This study contained five conditions (Table 1): assessment phase or baseline with video tape (Figure 1), treatment phase, post-treatment phase A or baseline with video tape (Figure 2), post-treatment phase B or baseline with no video tape and post-treatment phase C or baseline with video (Figure 3). 64

79 Table 2 The participant was assessed during the first lessons to identify areas that needed to be addressed during the treatment period. In addition to that, the music therapist watched the final presentation of the participant while taking intermediate class guitar. This was the assessment phase or baseline with video tape (Figure 2). During treatment phase, the participant attended one hour guitar sessions twice a week over the course of four weeks. The music therapist had set three long term goals for the treatment phase and few short term objectives for each session. The 3 main goals were: 1) formation of barre chords, 2) correct movement of the right hand and 3) arpeggio pattern strumming. The objectives of each session are listed under the individual lesson plan where all sessions are presented in details. As soon as the treatment phase was over, the instructor/music therapist video taped the participant in order to assess the participant s improvement. This was the post-treatment phase A or baseline with video (Figure 3). Post-treatment phase B or baseline with no video tape followed where the participant and instructor had no lessons scheduled for the course of two weeks. Immediately after post-treatment phase B, a post-treatment phase C or baseline with video followed (Figure 4). Basically during this session the instructor/researcher/music therapist reassessed the student s guitar skills so as to determine whether the progress increased, declined or remain steady. The CRDI was used to evaluate all performances of the participant. For reliability reasons, the researcher watched the three video tape segments twice, in two different times of the day. It is important to call attention to the fact that the participant was not aware of the whole design of the study, since the researcher speculated that the 65

80 participant would have been less biased about the study thus practicing and performing in the usual manner like in the past. Results and Discussion This study was designed to help an undergraduate music therapy student successfully meet the requirements and skills needed in guitar while doing a practicum in a hospital setting. Since the participant had successfully completed a beginning and an intermediate class guitar courses, it was deemed necessary to assess and evaluate the student s guitar skills so as to set goals and objectives for each lesson during the treatment phase. The two main areas of development for this student are technical, particularly of the right hand playing a variety of rhythmic strummings and facility of movement in the left hand playing open position and barre chords. As it is seen in Figure 2, the participant was capable of performing a variety of strummings and picking patterns with the right hand, (i.e. Travis Pick, Alternate Base), but it was clearly observed that the hand movement was totally wrong (the fingers were moving outwards instead of inwards.) This is a crucial issue since it sets the foundation for the remainder of the students study. An area of improvement for the left hand was the formation of barre chords and the facilitation in playing those barre chords. The student had only 25% success playing barre chords while singing the song Little Help From My Friends and even those times the tone quality of the guitar was quite displeasing. As a result, she could not maintain eye contact with the group and strumming was not as steady and accurate. The treatment phase which followed, covered the largest portion of the study, four weeks (see Table 1). While in treatment, the participant attended one hour guitar sessions twice a week. Each session is presented in detail (see Lesson Plans) specifying the objectives addressed each time. Immediately after the treatment phase, the researcher reassessed the student to determine in what areas any improvement was made. Figure 3 shows a more consistent and steady guitar playing while barre chord formation and facilitation is quite evident. At this time the student was very comfortable with the right 66

81 hand freedom to move across the strings from the elbow and the correct movement of the right hand thumb, anchoring of hand with correct wrist position. The beginning right hand training is the most important element in beginning guitar study as everything that follows is built upon this cornerstone. A student must understand that the physical act of playing the guitar is not a natural muscular activity, nor even intuitive. Rather, it is, in fact, a set of carefully formed habits that may seem awkward at first. Everything a student does on the guitar becomes a habit and habits are much more easily formed from the beginning than replaced at later stages of development. Significant improvement was not seen in maintaining eye contact with the group. One explanation might be that assimilation of the new material can not happen overnight or over the course of four weeks. New habits, especially when old ones are being replaced, take time to be engraved especially when those habits need to be transformed into a well coordinated external stimuli and motion. The design of the study was such that when the instructor/researcher/music therapist reassessed the student s guitar skills, progress that increased, declined or remain steady could be determined. It was clear that the student s performance ability had declined but the decline was not significant. The participant had again difficulty forming barre chord (see Figure 3) but she could successfully form and play those chords 75% while singing I Got Rhythm. It is worthwhile to mention that the student s technical skills were improved since the right hand was moving correctly in a very comfortable, relaxed and controlled motions and the left hand would easily form simple and complex chords. The researcher asked the participant to rate her confidence level in playing guitar during a practicum session using a Likert scale before treatment and after treatment. The participant rated her confidence level while playing the guitar during a practicum session before treatment as 5 out of 10 and as 9 out of 10 after treatment. There is no doubt that a relationship exists between guitar skills and being more competent during direct client interaction, hence being an effective music therapist. Further investigation needs to be done in this area to statistically determine if indeed a relationship exists between being a well qualified guitar player and the effect on therapeutic relationship and therapeutic outcome. 67

82 Conclusions The value of class-guitar program in schools and colleges is being increasingly recognized throughout the United States. Most colleges have included into their curriculum guitar instruction courses, and students, music or non-music majors, have the opportunity to learn how to play this popular instrument. For music therapy majors, proficient guitar skills is a key element in successfully completing the music academic curriculum which includes the academic phase and the field-based internship phase, evidencing future successes as a professional in the field of Music Therapy. It is suggested that class guitar sessions should be designed for only music therapy majors so as to have a closer monitoring of each student s progress and areas that need to be addressed. It is also critical to incorporate into the class guitar curriculum the instruction of technical issues such as sitting position, right and left hand movement. Moreover, well qualified instructors who have either experience in teaching class guitar or have a background in classical guitar playing should become the instructors of these students. As it is said a good beginning is half way through success (Greek Quote), that is why it so important to consider the fact that proficient guitar skills may be the key for eliminating some of the pre-internship fears leading to a successful completion of the music academic curriculum, but more importantly, acquiring a life-long skills as promising professionals in music therapy. 68

83 Figure 18 69

84 Figure 19 70

85 Figure 20 71

86 LESSON 1 DATE: 10/04/2003 Instruction Time: 1 Hour ASSESSMENT SESSION Technique (Right and Left Hand) Chords Singing Other Right hand movement: Right hand was moving out instead of in 7 th chords: Could not hold any 7 th chords Voice quality: Voice volume was too soft compare to the guitar playing Voice not well supported Sitting position problems Back not straight, one leg on the top of other, shoulders up: tension on shoulders, Barre chords: Impossible to hold any barre chords Volume of guitar: Guitar not clearly played Guitar was too loud compare to voice volume New Chords Taught: B7, G0, D0, E0, D7 Pick up 5 new songs to get the student ready for the next practicum Songs: 1) Love me Tender 2) In the Good Old Summertime 3) Let Me Call you Sweetheart 4) Oh! What a Beautiful Morning 5) I ll Fly Away 72

87 Lession 2 Date: 10/07/2003 Instruction Time: 1 Hour OBJECTIVES: 1) Need to explain arpeggio (how the right hand moves correctly) 2) Need to know 3 barre chords 3) Right hand moving wrong for 2/4 or p-ima. The hand is going out instead of in 4) Hand shape is bad. Must change the wrist move out instead of in or closer to the wood of the guitar. Technique (Right and Left Hand) Chords Singing Other Love Me Tender: Alternate Base practice. Explain and showed the correct movement of p ima. Learn which base strings to play with each Chord. You Are My Sunshine: Work on changing from B7 to E, from B7 to A, from B7 to D Taught a new rhythm In the Good Old Summertime: Clarify the melody I ll Fly Away: Work on rhythm (more base) I ll Fly Away: Work on chord progression In the Good Old Summertime: Taught G7 chord Let Me Call You Sweetheart: Talk about diminished chords Showed Em barre chords Go through chord progression Oh, What a Beautiful Morning: Clear the melody In the Good Old Summertime: Taught ¾ rhythm, waltz rhythm Work on the dynamics of the song Enjoy the music or feel the waltz rhythm Let Me Call You Sweetheart: Talk about phrasing, breath, breath support, ritardando at the end Work on waltz tempo Oh, What a Beautiful Morning: 73

88 Review D chord Learn how to change from E7 to Dm Learn how to change from A to E0 74

89 Lesson 3 Date: 10/11/2003 Instruction Time: 1 Hour OBJECTIVES: 1) Work on right hand movement p-ima 2) Go through five new songs Technique (Right and Left Hand) Work on p-ima (alternation of p with ima of right hand) Chords Singing Other Review the 5 songs above. Pick up the next 5 songs which are 1) I Got Rhythm 2) Summertime 3) When the Saints Go Marching In 4) Soon and Very Soon 5) Edelweiss 75

90 Lesson 4 Date: 10/14/2003 Instruction Time: 1 Hour OBJECTIVES: 1) Review alternate base right hand movement. 2) Introduce arpeggio Technique (Right and Left Hand) Chords Singing Other Work on p-ima right hand technique Introduce arpeggio Soon and Very Soon: Work on G chord (new fingering) Work on chord progression Soon and Very Soon: Work on melody When the Saints Go Marching In: Work on 2/4 rhythm Soon and Very Soon: Work on the rhythm Edelweiss: Work on chord progression Learn Em7, Am7 and Dm6 Edelweiss: Work on waltz rhythm, feel the music, ritardando on the word forever. 76

91 Lesson #5 Date: 10/18/2003 Instruction Time: 1 Hour OBJECTIVES: 1) Work on right hand movement for arpeggio 2) Review alternate base Technique (Right and Left Hand) Chords Singing Other Review p-ima Play through Soon and Very Soon : Work on correct Strumming Play through I Got Rhythm: Work on G6, C7, F7, A9 Play through Summertime Work on the melody, chord progression, changing chords on time Listen to the 5 songs taught last week. Play through When the Saints Go Marching In : Work on the rhythm (locked right hand) Edelweiss: Work on feeling the music and correct tempo. 77

92 Lesson #6 Date: 10/21/2003 Instruction Time: 1 Hour OBJECTIVES: 1) Play alternate base with I-IV-V chord progression in different keys. 2) Learn five new songs. Technique (Right and Left Hand) Technique: Practice on p-ima Play very slowly chord progression A-D-E7-A. Chords Singing Other My Girl Temptations Listen to the song and work on chords and rhythm I Got Rhythm: Work on chord changes. Learn 2 new chords: E7 and Em7 Work on the following progression: - G7, C7, G6, F7, E A9, D7, G6 Summertime: Work on chord progression No more problems with B7. Great changes. Your Cheatin Heart F major - Barre chord practice. Work on chord progression practice. 78

93 Lesson #7 Date: 10/25/2003 Instruction Time: 1 Hour OBJECTIVES: 1) Work on arpeggio pattern with I-IV-V chord progression in different keys. Technique (Right and Left Hand) Work on arpeggio pattern with I-IV-V chord progression in different keys. Chords Singing Other Listen to the 5 songs taught last session. 79

94 Lesson #8 Date: 10/28/2003 Instruction Time: 1 Hour OBJECTIVES: 1) Introduce different kinds of strumming 2) Learn at least 5 new songs Technique (Right and Left Hand) Introduce different kind of strumming: 1)p-i-m-i a 2)p-i-m-i-a-i-m-i 3)p-a-m-i Chords Singing Other Learn 6 new songs 1) Wonderful World 2) Over the Rainbow 3) Fly Me to the Moon 4) Can t Help Falling in Love with You 5) Getting to Know You 6) Hey Good Lookin 80

95 CASE STUDY TWO APPENDIX A CHARACTERISTICS OF PATIENTS OF EACH STAGE OF ALZHEIMER S DISEASE 81

96 82

97 CASE STUDY TWO APPENDIX B OBSERVATION SHEET 83

98 84

99 CASE STUDY THREE APPENDIX C SONG LIST 85

100 SONG LIST COUNTRY: ] 1) King of the Road 2) Crazy 3) Hey Good Lookin 4) Georgia On My Mind 5) Rocky Top 6) Could I Have This Dance 7) Blue Suede Shoes GOSPEL: 1) Soon and Very Soon 2) Swing Low, Swing Chariot 3) I ll Fly Away 4) The Old Rugged Cross 5) When the Saints Go Marching In 6) This Train 7) This Little Light of Mine 8) Joshua Fought the Battle of Jericho 9) Down by the Riverside OLDIES: 1) When You Are Smiling 2) Let Me Call You Sweetheart 3) In the Good Old Summertime 4) My Wild Irish Rose 50s: 1) Rock Around the Clock 2) Moon River 3) Blue Moon 4) Love Me Tender 5) Can t Help Falling In Love With You 70s 1) I Can See Clearly 2) You ve Got A Friend 86

101 : 1) My Heart Will Go On 2) Wind Beneath My Wings 3) Hero JAZZ: 1) Strangers In the Night 2) Don t Get Around Much Anymore 3) Unforgettable 4) Someone to Watch Over Me 5) Summertime 6) Ain t Misbehavin SHOW TUNES: 1) Getting To Know You 2) Oklahoma 3) Over the Rainbow 4) Oh, What a Beautiful Morning 5) Edelweiss\ 6) Memory from Cats 7) Give My Regards to Broadway 8) I Got Rhythm 9) Wonderful World 87

102 CASE STUDY THREE APPENDIX D OBSERVATION FORM 88

103 89

104 CASE STUDY THREE APPENDIX E OPERATIONAL DEFINITIONS 90

105 OPERATIONAL DEFINITION Sympol: Definition: + (On-Task Verbal) Person(s) must be on-task for the duration of the observation unit. (singing, engaging in conversation with MT for example requesting a song) M (On-Task Visual) Person(s) must be on-task for the duration of the observation unit. (trying to find MT, eye-contact with MT, moving feet to music, moving hands to music, dancing) N (Non-musical activity) Person(s) spent time in non-music activity such as reading newspaper/magazine, talking to friends or relatives or TMH staff. O (Other) Person(s) engaged in any incompatible or competing behavior at any time during the interval of observation. 91

106 CASE STUDY THREE APPENDIX F EMERGENCY WAITING ROOM OBSERVATION SHEET SESSION A 92

107 93

108 People not looking were either starring into space(4) or looking at magazines (4 people clapped consistently) 4 people consistently slapped, 1 person tapping foot in I got rhythm at the 10 minute interval someone requested Tenderly During time 4 and 5 all left so that only two were present. One consistently watched the performance the other left at 5 people came in at time 7, People left and entered so that at the end of time seven two were left with two children 2 children looking at performance for last 2 observations 94

109 CASE STUDY THREE APPENDIX G EMERGENCY WAITING ROOM OBSERVETION SHEET SESSION B 95

110 96

111 Time 1-19 people, 3 people within eye contact looked at MT - 4 people left at 4:42, mostly foot tapping and swinging 2 nd song 7: 01 Over the Rainbos 13 people, 1 person looking intently, however most with eyes closed (5) 10:35 Wonderful World 13 people observation at 12:00 had 5 people sleeping 14:53 You ve Got a Friend -observation at 14:00 had 3 people engaged in loud conversation most off task sleeping talking to each other one on phone other s starring into space 17:40 Moon River (15 people) - Most people concerned with injuries talking to each other 19:51 Falling in Love with you (15 people) Observation at 20:00 all people quiet 21:55 Love me Tender (16 people) No conversation, sleeping 26:05 My Heart will go On 26:00 observation-talking to each other some sleeping 29:55 (13 people) Wind Beneath My Wings at the 30:00 observation one person asleep, 2 in conversation, all others starring into space 32:00 observation 6 people in conversation 32:59 10 people 3 starring, 1 sleeping, 3 pairs in conversation 97

112 CASE STUDY THREE APPENDIX H INTENSIVE CARE UNIT OBSERVATION SHEET SESSION A 98

113 99

114 00-01 What a Beautiful Morning 3 people Head nodding and foot tapping Head nodding and foot tapping wonderful world person left, 2 people now, head nodding and foot tapping, the two people study the list of songs for requests Somewhere Over the Rainbow One person arrives, three people now engaged in conversation Moon River the same three people talk people talking person answers telephone, 2 read newspaper in the Garden 3 people person gets off phone One person arrives, now 4 people, Oh when the saints All 4 engaged in conversation more people arrive, 6 people in waiting room now I ll Fly Away two people left, 4 people in waiting room one on phone again Swing Low Sweet Chariot person back, doctor comes and talks to one member others listen, 5 in waiting room now Another family member arrives, two groups of 3 engage in conversation two in conversation, 1 reading, two in conversation all engaged in conversation arrive, 3 leave, 4 people in waiting room all leave except for one on cell phone one comes back 2 people in room one person engages MT. Asks for a song, sings My heart will go on with the MT different person on phone in background person is still singing with MT, 3 previous people are conversing 100

115 CASE STUDY THREE APPENDIX I INTENSIVE CARE UNIT OBSERVATION SHEET SESSION B 101

116 102