by Kim Arthur
When I interviewed music therapist David Knott to find out how he uses music to help our patients, he naturally turned to his musical instruments to explain… and he even obliged when I asked him to share his beatboxing prowess! So David and I decided that this article wouldn't be complete without some musical accompaniment, and we hope you enjoy "hearing" all about music therapy.
David sings with Austin Rich, the brother of a patient. Photo by Phil Nutzhorn.
Kim: Before I ask you about music therapy, I have to find out how you learned to beatbox!
David: Well, a patient on the Cancer Care Unit taught me a beatboxing pattern about six years ago. I was encouraging him to teach me, which is one of my main approaches with adolescents. I look to them to teach me what they know about music and talk about the music they like. Allowing them to be the teacher helps me get in the back door so we can talk about how music can be used for different purposes, like relaxation. That particular patient taught me to beatbox… but I always call it 'imitation beatboxing' whenever I do it so that patients have an easy way out if they want to tell me I'm not doing it right!
Kim: What is music therapy?
David: Briefly put, music therapy is the use of music to achieve non-musical goals, such as reducing the perception of pain, providing opportunities for non-verbal expression and facilitating relaxation. We use singing, listening to music and playing instruments to help patients. One music therapy intervention is songwriting, where a patient is encouraged to change the lyrics of a song to express anything they like.
Kim: And you're part of our Child Life Department, right?
David: Yes, and my work fits with the Child Life goals as well. Child Life seeks to support the coping of patients through education, procedural support and therapeutic play. One of the fundamental goals of Child Life is to increase our patients' opportunity for choice and control, considering that they're in a hospital environment in which they don't have many choices and there are so many things they have to do, like taking their medicine or having their vitals taken.
Kim: What kinds of choices do you give patients?
David: They can choose the instrument they want to play, for example. One of the instruments I use is the electronic autoharp, and they can choose what sound they want to hear and change the settings. There is one setting called "sustain," which makes the sound last for a shorter or longer time.
Kim: I bet there's a big difference between what you do with kids of different ages. What do you do when you're working with infants?
David: Music therapy has to be developmentally appropriate, and it always depends on why I'm asked to see a patient. When I'm working with an infant, I may use music to help them adjust to being in the hospital or to deal with stranger anxiety. My approach is very improvisational, which lends itself to meeting some of the needs of infants, such as learning through reciprocal interactions.
Kim: What do you mean by "reciprocal" interactions?
David: Infants learn through play and how we respond to them. I echo their vocalizations, incorporating them into an improvised song or use infant-directed singing to describe their actions or objects in their environment.
Kim: What is infant-directed singing?
David: Singing with infants generally involves higher pitches, accentuating vowel sounds and slower tempos. Depending on whether the goal is to calm or to promote play, the singing should be soft and soothing or somewhat alerting, but always mindful not to overstimulate. Infants learn from how they are responded to, so by responding to all of their vocalizations and actions, they begin to learn how to speak and communicate.
Kim: How else can you help infants with music?
David: Music can be really helpful when they're dealing with transitions or a big change in their environment, like getting ready for bed or having a bath. Specific songs for those times can help them anticipate and understand what is happening. The music gives them a kind of heads-up so that they don't have the experience that suddenly something is being done to them, like having a bath or being taken somewhere. One example is the outing song.
Kim: Let's talk about the other end of the age spectrum. What are the main reasons why teens are referred to you?
David: A lot of referrals for teens are because they have a strong interest in music, or because they're having a tough time, either with pain or anxiety. So I treat them like they are the teacher, and through that dialogue we move into the topic of using music for relaxation. I sometimes use a preference-finding exercise where I play samples of music on an iPod and ask them to tell me how much they like them on a Likert scale of 1 to 10. It's a self-report scale, and if I'm getting consistent 5s, I know I haven't found anything that's very meaningful to the patient. There are also times when I get nothing but 1s, and then I know I'm really off-base!
I also try engaging them actively with one of my cool instruments, like the air synthesizer. You move your hand over the instrument and it reads your hand position to produce a sound, which will often engage patients.
Kim: Do you ever run into challenges because a teen is interested in music with lyrics that are violent or inappropriate for a hospital setting?
David: We don't provide any of that music, but there are some pretty interesting resources out there that are still "hip." I actually have a CD of kids' rap and I had a teen who was really "tough," and into some pretty extreme rap, and he actually liked the kids' rap. That isn't always the case, but I just try to help them understand why we can't provide music like that. Sometimes I find that patients will choose a song to do lyric analysis and they'll be completely surprised by the lyrics.
Kim: What is the goal of lyric analysis?
David: The goal is to identify emotions, using music as a way to talk about feelings in a non-threatening, non-personal way. We listen to a song and try to discover the meaning that the artist intended. If a patient is in a difficult emotional state, then I don't push them. I leave it to the patient to disclose what they're willing to disclose, and it's a very positive way to engage with patients because it's non-personal.
Kim: What do you do to help patients with pain?
David: When I'm asked to see a patient in a lot of pain, I first explain why I was asked to be there, and then suggest that sometimes music can help you to relax and breathe more deeply. I play music for them, usually with the guitar, observing their movements and their breathing. I use the iso-principle, which involves starting out by matching their mood. If they're feeling energetic, or their breathing is fast, then I'll play something up tempo to match that mood. Then I look for signs that we are sharing our attention on the music, for example, if their body is calm, if they are watching me, making eye contact, or looking at my hands, then I try to slow the music very subtly, hopefully imperceptibly. I may move further away from the bridge toward the middle of the guitar so the notes become softer. I've actually seen patients' eyes get heavy, and they sometimes drop right to sleep.
Kim: And what if a child needs motivation?
David: In that situation, I might start with quiet music to match their mood, and then move in a more energetic direction. I definitely pull out the different instruments and see what will motivate them, like the electric drumstick, or the electronic autoharp.
Kim: Can you remember a particularly special time when you were able to connect with or motivate a patient?
David: Once there was a 3-year-old girl on the Rehab Unit who had posterior fossa syndrome, which involves a constellation of symptoms that occur after removal of a tumor in the posterior area of the brain. It causes irritability, dramatic mood swings and difficulty engaging with others. I was actually working with a different patient at the time, and the 3-year-old looked interested in what we were doing. But whenever I looked toward her, she would look away.
When the other patient was done, I offered her the electric drumstick, and she took it and played and played for 15 or 20 minutes. I supported her by playing songs on the guitar at the tempo of her playing. She moved her arms so vigorously that one of the nurses had to protect her head. One of the staff members told me that it was really remarkable because she hadn't been holding onto anything. Whenever she was given a toy in therapy she would just throw it. But she responded really well to the electric drumstick, and didn't want to let go.
Kim: What do you think it is about music that allows it to have a therapeutic effect?
David: Both listening and playing music has a unique effect on the brain. Participating in music activates numerous structures responsible for timing of movement, memory and emotion. From subcortical structures all the way up to our frontal lobes, music affects our brain, and so it can be applied for certain outcomes.
Kim: Thanks so much for sharing the sound of music therapy! I have one last question for you… what's this I hear about a musical hand sanitizer dispenser and a songwriting contest?
Austin Rich helps paint the musical hand sanitizer dispenser. One of Austin's songs was recorded on the dispenser to play whenever someone puts their hands under it to get gel. Photo by Phil Nutzhorn.
David: Well, it started as a poetry and songwriting contest for patients in order to educate families about the importance of hand hygiene and help improve the hand hygiene compliance of families and visitors.
You can listen to entries by patients Emily Talbot, Veronica Flynn, Alexandria Chapin, Breannah Kanaly, Sam Thomas and Zachary Bloudoff and by staff members Rebecca Vest, Nicole Holmer, Ashleigh Singer and David Knott and his family.
All photos by Phil Nutzhorn from the Paint Shop.