Music Therapy and Acquired Brain Injury
27 Nov 13
Nadine Cadesky, Ph.D, MTA, MT-BC
An acquired brain injury (ABI) is an injury to the brain (that occurs after birth) resulting from a trauma to the brain, cerebral vascular accident, brain tumor, aneurism or similar cause. Not included in this category are brain abnormalities/damage caused by birth trauma, developmental disorders, congenital conditions and degenerative diseases. A traumatic brain injury (TBI) is an assault to the brain caused by a blow to the head, shearing injury, or penetrating foreign object.
Brain injuries of this sort can cause significant, enduring issues with cognition, motor skills, communication and emotional and social wellbeing (Vega, 2013); and can dramatically change the blueprint of one’s life, and ones’ identity as a person.
Vega (2013) does a good job of articulating the specific issues that arise in each of these areas. I am including them here and also including a description of the existential/spiritual issues that also affect clients:
Cognition: “alertness level; attention span; orientation to person, place, and time; short-term memory; and sequential memory” (Vega, 2013, p. 147)
Motor: “fine and gross motor skills, eye-hand coordination, ambulation, and overall motor strength and endurance” (Vega, 2013, p. 147)
Communication: “receptive and expressive language impairments…deficits in articulation” (Vega, 2013, p. 147)
Emotional/Social: “difficulties expressing their emotions and/or navigating social situations” (Vega, 2013, p. 147) and changes in relationships with loved ones and friends.
Existential/spiritual: identity/personhood – issues of loss/grief; changes in sense of self and self in relation to world; issues related to choice, responsibility; autonomy; continued evolution as a human being.
The individuals I work with have sustained severe or catastrophic brain injuries. They are in the rehabilitation phase of their recovery living in a group home setting. I am their music therapist. These clients have deficits in all the areas described above, but they have much strength; and our work together is strength-based.
Music therapists use “clinical and evidence-based…music interventions to accomplish individualized goals within a therapeutic relationship” (American Music Therapy Association, retrieved from http://www.musictherapy.org/about/musictherapy/, November 18, 2013). Music is a natural medium to use in therapy because it has “nonverbal, creative, structural, and emotional qualities” which can be used to “facilitate contact, interaction, self-awareness, learning, self-expression, communication, and personal development” (Canadian Association for Music Therapy, retrieved from http://www.musictherapy.ca/en/information/music-therapy.html, November 18, 2013).
I have found that music therapy with persons with brain injuries progresses at two levels. There is the functional/operational level, where the focus is on cognition, motor skills, social awareness and social interaction, and emotional regulation; and there is a deeper, underlying level where the focus is on those existential issues related to grief, loss, identity and purpose. Functional skills are often the focus with this population, but I do not forget to acknowledge, intuit and work with deeper layers as they fit with a client’s situation and process. I will share two client examples to help illustrate this process.
Bob (pseudonym) is a middle aged male in one of the group homes where I work. He is alert, in a wheel chair with L side neglect due to CV activity and a secondary brain injury. He has impulse control issues and issues with comprehension which affect his ability to purposefully interact. He favors his right side but will use his left hand if prompted. He can recognize and sing song lyrics but likes drumming better. I use drumming and keyboard playing to address his impulse control and motor issues. Drumming is a relief for him. I have used drums to help him to release energy. I have noticed that he self-stimulates with the drum, drumming into a frenzied state…then he stops himself with a big smile on his face. He needs this outlet – to drum without external boundaries and to sing or yell as loud as he can and wants to; and it is the only time that I see him demonstrate variance in his affect. Most of the time his affect is quite flat. At the same time, I realize that he needs to experience balance, so I use the drumming and similar experiences on the electric keyboard to help him experiment with different dynamics. And I find that if he has a few opportunities to fully discharge his pent up energy, he then regulates himself towards a more gentle interaction with the instruments, which builds focus and an experience in the moment of being centered. In the beginning he could not do this, but now he can. Furthermore, he initiates this gentler way of playing, something he did not use to do.
Bob favors using the right hand to play drums, but I work with him to also use his left hand, and I have found that when he does, he does so with intention and does not let the left hand just drop afterwards. This is something the physiotherapist told me she has been working towards with him as well…to use his left hand with purpose and to be able to move it without it just falling to his lap.
Bob’s echolalia gives the impression that he is repeating what is heard to help him comprehend what is being heard. Yet it limits his purposeful engagement in an interaction through language, so I stop him when he is repeating what I have said, and I help him to learn to respond to what is said. I also use call and response song lyrics to help him relearn this skill. I see this area, and the increased practicing of gentle interactions in musical contexts, as an area of focus in our continued work together.
Thomas (pseudonym) suffered a catastrophic brain injury when he was 19 years old. He is alert, in a wheel chair, living in another one of the group homes where I work. Thomas has good receptive communication, but some issues with his expressive communication. So he can interact meaningfully through language, but sometimes struggles to make what he is thinking fully clear through his words. Thomas loves to sing. He has excessive vocal tension and issues with tuning and vocal placement. He is quick to recognize cues which allow him to self-correct. Thomas has right side neglect but an incredible amount of motivation which shows itself in his constant attempts to use his affected hand in our music-making.
Thomas plays the guitar. He holds the guitar on his lap and plays it with the unaffected hand. His playing is rhythmic and melodic, because he makes full use of all strings on the guitar. When he is frustrated, this frustration is channeled into his playing, and changes the character of the music played. Thomas moves his affected arm towards the guitar and tries to relax it onto the guitar surface. Twice he has surprised himself when this has unexpectedly caused him to strum the guitar.
Thomas loves to sing. He has some difficulty keeping lyrics straight, but this does not deter or frustrate him and he likes it when I help him correct his words. Sometimes the singing is an enjoyable way for us to interact together. Sometimes it is a channel to release his pent up energy. We use singing to work on Thomas’ intonation and to help him learn to relax the muscles used in singing and articulation.
Thomas loves to use the harmonica. When we first started he could only play in a very limited way, mostly pushing his breath into the harmonica and producing the tonic note of a scale. Then I worked with him to help him expand his use of the harmonica so he could experience what it might be like to play more than one note and to control his breathing in and out to produce different notes. Now Thomas moves up and down the harmonica, breathing in and out, in a manner that fits with his mood and level of relaxation or tension on a particular day. I have the sense that the harmonica playing allows him to breathe and make sound without the complications of vocal tension and articulation/intonation difficulties. And recently I noticed something very interesting. The use of Thomas’ arm has been limited because of the spasticity in that limb – his arm, hands and fingers. Yet lately I have noticed that Thomas’ hand and fingers have begun to move in rhythm with his harmonica play and this suggests to me that his brain is starting to coordinate the movement of the hand and fingers as he is immersed in the harmonica playing. This is very exciting.
Thomas and I write songs together. He writes the lyrics and I write the music. Thomas’ lyrics communicate his philosophy of life, and they are often profound. And Thomas expresses feeling proud of his lyrics. One song is included here:
There’s nothing more beautiful
Than holding on to what you have
Even though it was forgotten or knocked away…
Holding on to what you have left
To find happiness and strength
Along with another person
That inspires you on the same note…
There’s nothing more beautiful
Than to hold on to what you have left
Even though it was forgotten or knocked away
… (Thomas [pseudonym], 2013)
Thomas’ life as he knew it (as those who love him knew it) was knocked away in one split second. Yet Thomas holds on to what he has left and finds happiness and strength in his day to day living, in his rehabilitation, in his interactions, and in his music. He often ends his or our music by saying that it was ‘more beautiful than beautiful,’ and by commenting that the most beautiful part was how we came together or how he came together on the last note, in perfect harmony, in sync and in tandem. Thomas was a snowboarder, and I cannot help but see this image of a snowboarder making that perfect landing on the mountain. It was an imperfect landing that ended the life that Thomas knew but it is his daily ‘perfect’ landings in moment to moment engagement with life, with others, and with his music that give him joy and purpose. And isn’t that what it’s all about?
I hope this article has given you a bit of a picture of the lived experience and meaning of music therapy in work with individuals with brain injuries. I continue to be inspired – and to learn from my clients, moment to moment, day by day – as a professional and person.
Vega (2013). Adults with traumatic brain injury. In Allen (Ed.), Guidelines for music therapy practice in adult medical care. University Park, IL: Barcelona Publishers.