Tuesday, February 25, 2014

Using Music as Self Care vs Music Therapy

As I write this, there is growing clinical and professional interest in the convergence of neuroscience and the application of music for clinical and/or therapeutic purposes by board-certified Music Therapists. Close alongside this collaborative effort one finds psychologists and "music psychologists" using music to open new potentials for treatment. These developments, while they have their roots in 19th- and 20th-Century exploration and practice, are primarily 21st-Century fields of endeavor, and, as respected neuroscientist and musician Daniel Levitin has written, are still un-researched:
"There is a great need in the field [of neural correlates of musical behaviors] for research that involves (a) controlled experiments with random assignment, (b) well-matched stimuli and control conditions in order to uncover the mechanisms by which music works, (c) a better understanding of the neurochemical systems involved, and (d) the optimal role of the music therapist in such interventions." (American Music Therapy Association Perspectives, Vol 31 (1), 2013)
On balance, I also want to quote Levitin's more encouraging paragraph which immediately precedes the cautionary concluding one in the same paper:
"The emerging picture is that music can play an important role in bolstering the physical and psychological health of already healthy individuals, and the in the treatment of patients across a wide range of presentations. The advantage of music-based treatments is that they are non-invasive, don't have side effects, are cost-effective, and completely 'natural.'" (op cit)
The over-arching point of Levitin's paper is that, while we know a great deal more today about the measurable effects of music on the brain, we know comparatively little about the vast body of what scientists call "anecdotal evidence" that has accumulated around the use of music for thousands of years. In my view, this results from our Western clinical proclivity to dissect "presentations" down to their component symptomology and then treat the symptoms rather than take a more holistic view of a "presentation" and actually treating that.

In no way to I wish to negate the promise and profoundly amazing clinical research that has been done using music, especially (for example) with respect to its benefits in recovery from brain damage including stroke, intervention with Parkinson's and Alzheimer's diseases and management of autism spectrum disorder. Music Therapists have led the charge in these areas, and are to be commended for doing so.

The point here comes in the form of a question: if we know comparatively little about the effects of music, do Music Therapists not have a clinical and professional obligation for continued rigor before offering music therapy as a credible "treatment?"

For example, imagine yourself with a profound "presentation" that impacts your daily life -- it could be physical, mental, emotional or some combination -- and that no evidence-based music therapy intervention exists for your condition. Let us say that you have tried some drug therapies with moderate results and unwanted side effects. Let us also say that, based on 30 years' experience -- pretty much the entire life span of the practice -- a board-certified Music Therapist offers to treat you with nothing more than his or her professional experience as credibility. You agree that there is a possibility of benefit to you resulting from the music therapy, but you observe that board-certified Music Therapists are not supposed to accept your case because of their commitment to "Evidence Based Practice." For this example, you feel that the offer of music therapy for your "presentation" is genuine and well-intentioned. Hypothetically, do you accept the treatment? Keep in mind that you have no way of knowing which way the therapy will go: to your benefit, neutral, or to your detriment.

Having an experienced therapist as a guide is a plus; knowing that the side effects of music are very few is a plus.(Decibel levels outside the comfortable range can damage your eardrums, for example.) It's great to know that music therapy and neuroscience are working hard to solve the mysteries of the brain, but not enough is known about this now to attempt a cogent diagnosis of your symptoms, so that's a neutral factor in your decision. You could offer to become the subject of a study of how music changes you if at all...but your goal is well being, not becoming Exhibit A of a clinical paper. Even though you might be able to receive "treatment" at no cost if you agree to be the lab rat, you decide this is not in your best interest and contradicts the quality of life you want.

Professionally, your "presentation" is an outlier to the Music Therapist unless it fits into the existing spectrum of clinical study and practice of music therapy. If there isn't enough evidence to support taking you as a patient, the proper thing in your case would be a referral to some other clinician or therapist with more direct experience in whatever your "presentation" includes. There is certainly nothing wrong with giving you music therapy alongside whatever other clinical or therapeutic remedies are employed.

I'd like to suggest a third option.

A little-known pilot study of music as a self-guided intervention was completed by the United States Department of Veterans Affairs in September 2011. Over the course of six weeks of guitar lessons, Veterans with combat-related post-traumatic stress found double-digit reduction of symptoms of depression and improved health-related quality of life. I'll say that again...

Learning to play the guitar reduced symptoms of depression 
and improved health-related quality of life.

Do you see the possibilities here? Your example "presentation" might respond to music that you can give yourself, whether that's playing an instrument, singing, listening, drumming...there is a wide-open potential for you to interact with music to your own benefit. You begin to consider this third option: music as self care.

You realize you listen to music throughout your day: you wake to music each morning, sometimes have it playing as you prepare for the day's activities, listen in the car and sometimes use your smart phone and ear buds at work between meetings. You're always working out to music that powers you up, even with the "presentation" you've been fighting for months. Sometimes you sing along to the music; there's a concert by a favorite performer coming up soon and you're looking forward to it. You've even tried apps like Pandora and Spotify and the mood-based suggested playlists in Songza, and of course you buy new music on iTunes or CDBaby whenever one of the emerging bands you like releases their latest CD or EP. Usually, you relax to something soothing in the evening or before bed. Surprising yourself, you start to examine the soundtrack in your life and begin to wonder what effect it might have on you....

Not surprising to think that there might be a correlation between your music and your "presentation." There's enough neuroscience to suggest it's worth a look. You decide to vary just one song in your daily routine: the one that wakes you up. As much as you love waking up super-energized, you decide against all reason to wake up to something more subtle. You've done your research and made your choice of a new song and what the heck? If this new tune doesn't wake you up there are plenty of others to choose. You find, for example, a string quartet (?!) that looks intriguing (do Classical musicians really dress like that?!) and change your wake up tune, then you observe what happens. After a few days, you notice a change. You still wake up with energy, but less agitated. It takes a little longer to get out of bed because the music isn't so energetic, but you set the alarm a little earlier to give you time to hear more of the music before actually leaving the bed. You've started to engage in the process of music as self care.

Gradually, you being notice the effects of different types on you. You've always known that workout music needs to pump you up -- now you discover how there's more to it than a just high number of powerful beats per minute. You learn how you can modulate your breath to the pulse of music, whatever speed that pulse may be. You begin to notice the paradox between music that feels one way and lyrics that feel the opposite. You begin to sense that there is a lot more going on than a plainly obvious and simple physical, emotional or mental effect. You begin to engage with music in a different way. Even high-energy music has new meaning for you now that you are beginning to parse the polyrhythms and balance of each voice and instrument in the mix. You start to reverse-engineer what the producer had in mind in the various pop songs you love; begin to play around with equalization to hear interior sounds that aren't obvious in the airplay mix. You decide to listen less to sampled music -- most digitized music compressed to make it more portable but winds up missing quite a bit of information that our brains "fill in" for us -- and you haul your CD collection out of storage to see if you can really hear everything in a given song. As your ears become accustomed to wanting more depth in the music, you start to change all your compression settings from "normal" to "high" or "studio quality"...and you quickly run out of space on your mobile device.... You come across the old flute you used to play in the high school marching band and try some tunes you still remember....

Are you getting the picture? I'm not suggesting that we all become audiophiles, or start taking music lessons, but the small-and-growing mound of evidence for music as a "self-guided intervention" -- what I call "music care" -- supports the notion that you, with whatever your symptomology or "presentation," might be able to give yourself a form of relief that simply isn't available any other way.

The World Health Organization calls stress the "health epidemic of the 21st Century." Debilitating stress, depression and anxiety are a leading cause of "years lost to disability" worldwide -- more so than even cancer or AIDS. The world needs better health care for depression, stress and anxiety. You deserve better health care. If you had the opportunity to give yourself care -- care that could be effective, is definitely safe and free of side effects, and that is available for free worldwide -- why would you wait for a therapist?

It's just a suggestion, but I believe that it's time to get busy and listen.

Tuesday, February 18, 2014

Veterans Not Victims

The latest statistics on post-9/11 members of the Armed Forces estimate that 20% will experience combat-related post-traumatic stress. The number for Vietnam Veterans is closer to 30%, but perhaps more than any other conflict in history, our current wartime era has brought attention to the injuries our fighting men and women must overcome, including post-traumatic stress...an injury that is a normal human response to trauma, be it wartime or peacetime.

Human beings are innately equipped to process post-traumatic stress. Our physical bodies and psyches seem to evolve -- even transform -- through such injuries, and we become more resilient and resourceful as a result. The Wounded Warrior Project has helped countless Service members find a new mobility after battleground injuries -- physical, mental and emotional. Terms such as "neuroplasticity," unheard of during the Vietnam conflict, are now accepted medical lingo for describing the brain's own ability to re-wire itself around physical damage, including traumatic brain injury, whether suffered on the battlefield or the playing field.

There are thousands of government and non-government organizations, professionals, non- and for-profit organizations dedicated and willing to meet the needs of the most at-risk Service members and Veterans in every possible way. Injuries suffered by those who defend their homeland deserve treatment without delay; injuries to those deployed abroad by the homeland may be more difficult to justify, but those injured in the line of duty deserve the very same standard of care. This is the right and honorable thing to do, and we can thank Vietnam era Veteran advocates for their political sacrifice that paved the way for today's post-9/11 Service members and Veterans to receive better health care and services.

Unfortunately, our system of care in America is victim-based. That is, we diagnose issues as a "disorder" or an "illness" rather than an "injury" and treat these issues as if they must be "cured" rather than integrated into our psyches and day to day lives. Our helping programs are designed to find and treat the most at-risk members of society which is noble...except that many of those at-risk folks may not actually be "victims" of anything.

The combat infantryman who gets blown up can be severely hurt, yes, but that's part of the battle. In no way does getting blown up suddenly turn a soldier into a victim; getting blown up is not the same as being the target of some premeditated crime or random accident. It was the soldier's choice to be on the battlefield, and it's his mission to win that battle, even if he returns from it -- or to it -- with physical, mental or emotional injuries. Battle scars? Cost of doing business. No pro football player leaves the field on a stretcher thinking of himself as a victim -- I hope....

So this blog is not about victims. It's about the Veterans no one seems to be is talking about.

With great respect for the 20% of post/9-11 Veterans and 30% of Vietnam era Veterans with diagnosable post-traumatic stress, we have to ask ourselves: What we are doing for and with the 80%?

The 80% are the Service members who leave active duty and engage successfully with life as a civilian. Some become leaders, true, but the vast majority settle into lives, careers and marriages with a level of success that takes them out of the at-risk pool, at least for a while.

The 80% are the Service members, now civilians, who take their active duty service into their new roles as fathers, mothers, businesspeople, researchers, administrators, entrepreneurs, coaches, mentors, counselors. They quietly -- in most cases -- become a part of the fabric of their community, church, office, school, business or service organization.

The 80% are sometimes first responders -- they have the training. They are sometimes team leaders, just as they were in combat. They are machinists, software or civil architects, tow truck drivers, government bureaucrats or elected officials. They have the skills to engage opportunity, at whatever level, and they take it.

The 80% are the Veterans we hear and see in "hire a Vet"advertisements.

The 80% may not be the youngest rising stars, but they are the ones with experience and savvy beyond their years.

The 80% -- less than one million people -- are the ones quietly doing exceptional things in civilian life. They are working hard -- sometimes to climb the ladder of achievement, sometimes to stay out of the at-risk pool -- to make a contribution to the rest of us. They know how to make a contribution and they are unstoppable.

Some among the 80% are also living with unseen injuries; some have learned how those injuries have changed them forever and some have yet to learn it.

With so much of the country paying attention to the 20%, are we missing what's happening with the 80%? What could we learn from them?

More importantly, how would we learn it?

The 80% like to merge into civilian life. For some, the medals and stories and tools of war are put aside but never forgotten, but never a part of civilian life. The qualities of being a Service member remain, but the tools of the new trade are not battlefield weaponry. Getting a Veteran to help the rest of us connect the dots between the qualities of being in Service and the sound of those qualities in the music of civilian life is a difficult thing...Veterans aren't generally built like that.

We aren't going to be able to do an evidence-based study on the 80% -- many institutions of higher learning and research think tanks like to try, but the truth is that funding for studying the "normal" isn't as rich as funding for studying the "abnormal" so we are missing much opportunity to understand what makes the 80% work.

Although it's "unscientific" as a method, if we want to learn from the 80%, we can simply watch what they do. We can confirm that Veteran qualities which "work" in civilian life have merit. We can use this "anecdotal" evidence to help all of society benefit. We can model the successful character traits as parents, business leaders, professionals, and teachers -- from elementary to university -- and watch for a performance boost in academics and in life.

Yes, it won't work for everyone, but I believe we do have a shot at some real change here. By making a real effort to learn from the 80%, we may be able to make a wider collective change in society at large than targeting all our resources on the 20%. The truth is, we don't presently have the sorts of organizations we will need to help the 80% serve us. True, there are a few non-profits in the Veterans sector with a clear civic opportunity mission instead of a crisis-driven response mission, but we will need more institutions that support things like entrepreneurism, purpose-driven businesses and adult development, if we are to really capitalize on what today's Veterans have to teach us.

Let's reach the 80%, not so much with services, but with open, teachable minds. Let's learn what's working for the 80% and use that knowledge to re-inspire our existing programs and help us create new ones. Let's reframe our response to the opportunity today's Veterans present. Instead of a focus on woundedness, let us encourage a focus on wonderfulness. A Veteran that succeeds in civilian life doesn't do it alone; civilians are a part of that trajectory, too.

Military service is not an easy choice in a world where military strength is so politicized.

I suspect the Veteran who enjoys success in civilian life gives and receives respect from his or her colleagues, gives and receives honor, gives and receives teamwork, gives and receives friendship. I suspect that the qualities and character of a successful Veteran inspire his or her civilian peers -- not because of the ribbons and medals of valor but because we civilians understand that taking the oath of military service can be an exceptionally humbling, difficult and powerful promise. The 80% of Veterans who have made that promise are people I want to know.  

How about you?