Carol L Shultis, MEd

Faced with the trend toward shorter length of stay in 

, practitioners and patients in need of care face dramatic changes in treatment. Managed care and its related precertification criteria serve as a screen through which few patients can fit. Only those requiring emergency care or those experiencing the most profound limitations can actually meet these criteria-most frequently medically complex patients or those at risk of immediate harm to self or others. Although their responses to treatment are essential data for psychiatrists to justify continued inpatient days or to facilitate discharge, admission assessment and discharge planning occur simultaneously.

Advanced technology, revealing greater detail about 

, has offered another side to current health care practices. Clinical research has provided increased understanding of the mechanisms involved in psychiatric illnesses. Development of new and improved pharmacological agents has opened novel pathways for treating symptoms and syndromes. These advances have also begun to demonstrate how nonpharmacological interventions such as psychotherapy and the creative arts can impact brain function. 

For music therapists this is a time of paradox. On the downside, the steadily decreasing length of inpatient hospital stays requires rethinking and redeveloping, as well as retraining, in order for music therapists to work within a new conceptual model. Decreased financial resources contribute to the pressure to demonstrate the efficacy of music therapy in short-term treatment.

On the positive side, technology and research have identified the physiological benefits of music on the immune system (Lane, 1994; Rider et al., 1985), the benefits of music for relaxation and stress management (Davis, 1992; Fried, 1990), the application of music to memory and attention (Morton et al., 1990), and music-related long-term changes in behaviors in depressed elderly patients (Hanser and Thompson, 1994). Rethinking the application of music therapy has required the development of methodology that is observable and measurable, and can be applied to many different treatment settings. For short-term psychiatry, this is addressed by designing a series of single sessions that focuses on meaningful outcomes in a single session. This was first discussed in 1995 at a national music therapy conference during a training module (Shultis and O'Brien).

According to the American Music Therapy Association, music therapy, the assessment-based use of music to achieve therapeutic goals, is currently provided in over 370 inpatient settings across the United States.  Research studies investigating the use of music therapy with 

 (Hammer, 1996; Scott, 1996) and with geriatric depressived patients (Hanser and Thompson, 1994) have documented viable uses of music therapy. Wheeler's (1983) three classifications of psychiatric music therapy provide a practice theory for applying these research data. Each of the three categories,

 music activity therapy, reeducative music therapy

, requires separate skills and addresses different intervention needs. 

Wheeler's concepts are combined with both Sautter's model (Sautter et al., 1992) that suggests the use of a problem-solving approach to group work, and the qualities of group process that have proved to be most effective in short-term treatment in a study by Hoge and McLoughlin in 1991. This knowledge serves as a foundation for the music therapy program at Allegheny University Medical Centers(AUMC)-Forbes Regional Hospital in Monroeville, Penn. Using music to address specific needs allows treatment to be offered in loosely defined, but somewhat homogeneous, groups. Adults are divided into three groups: those who can think abstractly, those who think in concrete terms and those who are in need of reality testing and grounding. Music therapy interventions include singing; playing both composed and improvised music; creating song lyrics, melodies, harmonies and orchestrations; moving to music; and listening actively to music to facilitate imagery and teach specific relaxation skills. 

Most of the patients in short-term treatment at AUMC-Forbes Regional require music activity therapy or reeducative music therapy. Much of this work is done using a psychoeducational model to structure the groups, a process described by Snelbecker (1974). The bias of these groups is toward the development of knowledge and skills useful in managing emotional states, in coping with life's stressors, in understanding psychiatric treatment and in connecting to other available services. Group sessions incorporate facilitation skills common to the "here and now" approach of gestalt therapy as explained by Korb (1989) and Vinogradov and Yalom's 

In the AUMC-Forbes Regional program, the three most common uses of music therapy are to 1) address anxiety and sleep disturbance; 2) address the need to make reality contact and organize thinking in psychotics; and 3) improve the ability to identify and communicate needs, thoughts and feelings in a productive manner.

Using music as a means to relax the body has been studied for decades (Kibler and Rider, 1983; Rider et al., 1985, Stoudenmire, 1975).  A study in 1994 by Hanser and Thompson investigated using music and relaxation techniques to train depressed elderly people to manage stress and improve sleep. The results demonstrated that when compared with the control group, two experimental groups exposed to direct/indirect music therapy and relaxation techniques were better able to manage stress. This was true both at posttest and nine-month follow-up.

Based on these data, the AUMC-Forbes Regional Music Therapy program provides music and relaxation training in single individual sessions. Follow-up involves periodic checks to offer new music, to gauge use and effectiveness of the intervention, and to answer questions. Despite the absence of specific data, many patients report benefits from the music and relaxation training, and request information about securing personal copies of the music used for continued relaxation after discharge. For the highly anxious, music provided for relaxation needs to be individualized; however, even for these patients, some of the techniques can be taught in groups.

Music is a time-based link to reality. While it is true that music will have a physiological impact without conscious listening, it is not possible to purposefully respond to music without listening over time. For psychotic patients, this listening over time is a means of reconnecting with the external world. Music and rhythmic experiences can help the psychotic establish contact with reality and respond appropriately.

Rhythm is the element of music that distinguishes it from other auditory stimuli (Scartelli, 1989). Wertheim (1977) hypothesized that rhythm may have an impact on the whole cerebral cortex and large subcortical areas. This information reaches the medial geniculate by way of the ascending reticular formation that activates the limbic system and cortex. This brain activation can be incorporated into the group first through listening to rhythmic music. While listening, patients may be encouraged to begin to keep the beat with a part of the body.

Once the brain is activated, anecdotal evidence suggests that the psychotic patient is more able to organize thoughts and communicate with the group. According to Gaston (1968), "Rhythm furnishes a non-verbal persuasion not only to act but to act together," and as the psychotic patients become more connected to the external world, it is then possible for them to engage in interactive improvisation with instruments, to do group singing or to compose simple lyrics. Though the results are not always permanent, engagement in these music therapy experiences can stimulate brain functioning and facilitate reorganization.

Addressing Emotional Management and Expression

Patients admitted to short-term psychiatric units often experience difficulty expressing what led to the admission. Once they are in the safe environment, this difficulty may include what they are now thinking or feeling. "I don't know," "I just let the stress get to me," or "I was forced to come here, there's nothing wrong with me, it's everyone around me," are common responses.

Studies in 1971 by D'Zurilla and Goldfried, and in 1987 by Schotte and Clum, found that psychiatric patients lack the ability to generate solutions or to use viable alternatives and have a tendency to focus on the negatives of problems. This paucity of problem-solving skills, combined with an inability to define and describe emotional states, can severely impede the patient's ability to communicate with the staff. This inability can jeopardize even the most appropriate treatment.

Group and individual treatment interventions that focus on learning to think in new ways, shift perspective, develop a vocabulary for describing emotion and practice new modes of self-expression can contribute to the patient's treatment. When the patient gains the ability to communicate present state and to respond to the doctor and the treatment team, more applicable treatment plans can be devised.

Music therapy fits these needs naturally. Konovalov and Otmakhova (1983) and Jausovec (1985) demonstrated integrative brain function in response to music. This activation allows for learning new ways to respond to life's events in group work where patients can learn to identify and name feeling states, practice new modes of self-expression and communication, and explore obstacles to changes in life patterns. 

In a group of depressed patients who have few words to describe response, music therapy can begin to open the door to the development of a descriptive vocabulary. Words that match an emotionally charged experience are more likely to be committed to memory and used again. So, by responding to music-recorded or improvised-and describing it in concrete or feeling terms, group members learn descriptors from one another.

Group members may also be asked to improvise individually, using sound to describe the extant feeling and allowing the sound to shift out of that feeling state. Helping the improviser to describe that feeling again contributes to the building of vocabulary. More important, however, is the experience itself, of giving sound to what is within, hearing that sound and responding to it as the improvisation happens over time.

This process of taking an internal state, making it audible and conscious, responding to it and then reintegrating the response is a fundamental principle in creative arts therapy work. This principal was outlined by David Read Johnson at the National Association for Creative Arts Therapies Conference in 1985.

When patients experience difficulty with this process, the music therapist can modify the intervention to assist the patient. Helping to project or imagine a response by instructing the patient to play "how you would like to feel if it is different than your current state" often frees the improvisation. When the patient is unable or unwilling to engage in making the music, the therapist can serve as the instrumentalist, thereby allowing the patient to conduct the sound.

In addition to the improvisational and listening experiences, groups may also engage in song writing, singing, drawing or imaging to music. In response to a sound or orchestration, they may also compose poetry or write other creative works to reflect emotional states, practice modes of communication, develop vocabulary, refine music-listening skills and develop greater self-understanding. Music therapy can be efficacious in a single session; it can make a difference. According to E. Thayer Gaston (1968), the modern-day father of music therapy, "Aesthetic experience may be one of the best devices to help [man] adjust and adapt to his environment."

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Articles

Faced with the trend toward shorter length of stay in inpatient psychiatric units, practitioners and patients in need of care face dramatic changes in treatment. 

Carol L Shultis, MEd

Articles

Music Therapy for Inpatient Psychiatric Care in the 1990s