2003, Number 4
La experiencia musical como factor curativo en la musicoterapia con pacientes con esquizofrenia crónica
Murow TE, Sánchez SJJ
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Language: Spanish
References: 66
Page: 47-58
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ABSTRACT
This article describes the perception of well-being in a group of schizophrenic patients who attended music therapy. This study also describes the perception of usefulness of the musical experience as a curative factor. The relationship between the perception of the musical experience as a therapeutic factor and the negative symptoms was also examined.The subjects in this study were 15 patients with chronic schizophrenia who attended an outpatients Rehabilitation Program for Schizophrenic Patients at the National Institute of Psychiatry Ramon de la Fuente in Mexico City.
Sixty-six point seven percent of the subjects were male with a mean age of 32.1 years (s.d. + 7.7 yrs.) and 13 years of schooling (s.d. + 2.2). The average age of onset was 24:2 years (s.d. + 6.3 yrs.). Fifty-three percent were single, 20% were married, and 26.6% divorced or separated; 66.7% did not have a formal job.
Patients attended an average of 35.8 sessions (89.5%) out of 40. Sessions were an hour long and took place twice a week. The therapeutic work was conducted by a board certified music therapist.
Music therapy was based on improvisational techniques. The goals of clinical musical improvisation were to improve verbal and non verbal communication, to provide a means for selfexpression, to improve interpersonal interaction, to develop abilities for social interaction, to provide sensory stimulation, and to enhance creativity.
To assess the feelings of well-being and the perception of the musical experience, the authors developed a short self-report form to be filled out by the patients at the beginning and the end of every session. In this self-report they were asked to mark in a continuum from one (really bad) to ten (very well) how they felt at the beginning of the session and how they felt during the past week. There was a section where they could mark some specific feelings.
The second part of the self-report form was filled out at the end of the session. Patients had to mark on a similar continuum how they felt at the end of the session. They also had to mark what the work with the musical instruments had helped them to achieve. They could check several options. They were also asked to rate on another continuum their participation in the session: 1= participation was very poor to 10= full participation in the session.
In order to know if music therapy had any effect on the patients’ symptoms, they were assessed at the beginning and the end of the treatment with the PANSS.
An analysis of the data (comparison of the medians before and after the treatment) shows that there were statistically significant differences on how the patients felt at the beginning and the end of the treatment, showing that they felt better after six months. The results also show significant differences in the report of their participation in the session, which had increased.
One important part of the study was to identify at what point during the treatment did patients start to have a relatively permanent feeling of well-being. In order to find out when that happened, they had to answer a question about how they had felt during the past week. A comparison between the sensation of well-being at the first session and the reported well-being on the first session of each month was made through the six months of treatment. Results show that although patients report an improvement in their well-being from the beginning of the treatment, there are statistically significant differences (p=.001) from the third month until the end of the treatment.
The scores of the PANSS before and after the treatment did not show any statistically significant differences in any of the scales. A correlation analysis between the negative symptoms scale of the PANSS and the well being in the last week of the selfreport was made. Results show that there is a statistically significant correlation (r= -0.623, p=.03) between the feeling of well-being and the negative symptoms scale of the PANSS, between the feeling of well being and the general psychopathology scale (r = -.742, p =.006), and the feeling of well-being and the total score of the PANSS (r =-.714 p =.009). These results may indicate that as negative symptoms decrease, the feeling of well-being increases. In order to find out the perception about the usefulness of the
work with music, the answers to the question “the work with the music helped me to…” were analyzed. The percentages to each answer before and after the treatment were examined. The following are the questions that obtained the highest percentages before the treatment: to relax (80%), to let my feelings out (60%), to have fun (53.3%) and to relate to my peer group (53.3%). The answers with the highest percentages at the end of the treatment were to have fun (80%), to relax and to relate to my peers (60%) and to express myself (66.7%). The highest increases were in the questions to have fun (26.7%) and to find an answer or solution to my problems (26.7%). The answers to some questions diminished: to let my feelings out (-20%) and to talk about my feelings (-20%).
The way the patients perceived their participation was significantly different before and after the treatment (p= .006).
In general, results show these patients report an improvement in their feeling of well-being throughout the treatment. Their answers show that from the third month there are statistically significant differences on how they felt at the beginning of the treatment and through it. The feeling of well-being seems to remain from the third month on.
Though no statistically significant differences were found in the PANSS scores before and after the treatment, there was a tendency towards significance in the negative symptoms scale. A significant correlation was found between the feeling of wellbeing as reported by the patients and a reduction in the negative symptoms. This could mean patients feel better as they experience less negative symptoms. This is congruent with other findings reporting that in the long term negative symptoms are more disabling and that they interfere with the psychosocial functioning of the patients. The reduction of negative symptoms allows them to have a better level of functioning. The patient’s answers to the self-report allows us to conclude that music therapy helps to reduce negative symptoms.
Throughout the treatment feelings of well-being improved in the patients of this study; this may be related to the fact that the therapeutic process made sense to them. If that is the case, the feeling of well being and the fact that therapy makes sense and is perceived as useful can also be related to a better therapeutic compliance and attendance to the sessions.
Participation in the sessions increases through treatment. Informal conversations with the patients indicate that they developed a feeling of belonging to the group, more confidence in themselves and the others, and that the work in the non-verbal realm and in the musical one has helped them to feel better. The former factors may have helped them to feel better and therefore to have a more active participation in the sessions.
The perception of the patients about the usefulness of playing musical instruments remained constant. The main changes were on the answers “having fun”, which increased 26.7% at the end of the treatment, and “find a solution to my problems” (27.7%). It may be that the fact that they feel better allows them to enjoy musical activities more. With this kind of patients, this is very significant since anhedonia is one of the characteristics of schizophrenia and has an important effect on their functioning.
The answer that playing musical instruments allows them to find an answer to their problems may be the result of a learning process along the treatment but also to the possibility of perceiving the musical experience and working with music as a way to feel better. If that is the case, this could be considered as one of the curative factors in music therapy, in which music is considered as the main element and not a secondary one in the therapeutic process.
The decrease in the percentage of answers “playing the instruments helped me to relax” and to “express my feelings” may indicate that working with music goes beyond catharsis, as it may have happened at the beginning of the treatment, and allows for a more purposeful development of social and problem solving skills.
The use of music therapy with schizophrenic patients has produced positive changes in their social functioning. The results form this study show that patients feel better along the treatment period . Patients report they feel better with the treatment often from the beginning. This perception of well-being may result as a factor that facilitates and promotes permanence and an active participation in the treatment process.
One of the effects of music therapy in chronic schizophrenia patients is the improvement of the well-being experience and the decrease of negative symptoms. Also the fact that this occurs gradually and remains throughout the treatment and probably beyond is a result of music therapy.
Also, the fact that many of these patients are able to use the musical experience as a curative factor may have relevant implications for music therapy. On the one hand, it is possible that music therapy promotes several corrective senso-perceptual, interpersonal, and affective changes linked to the musical experience. On the other, clinical observations suggest that patients are able to gradually increase their ability to understand some of their difficulties and to try to find some kind of solution. As mentioned before, anhedonia is one of the symptoms that interfere with social functioning. If these patients are capable of having fun and enjoying the musical experience, it is not unlikely that they may have experienced changes in their hedonic ability.
It is very possible that the experience of musical improvisation in a group situation, in an accepting and non-threatening environment, is a factor that promotes the experience of wellbeing as a starting point to a better psychosocial functioning. In this case, it is important to consider clinical musical improvisation, with all its characteristics and attributes, as the essential curative factor in the use of music therapy with chronic schizophrenia patients.
REFERENCES
HOGARTY GE, ANDERSON CM, REISS DJ, KORNBLITH SJ, GREENWALD P, JAVNA CD, MADONIA MJ: Family psychoeducation, social skills training and maintenance chemotherapy in the aftercare treatment of schizophrenia: One year effects of a controlled study on relapse and expresses emotion. Archives General Psychiatry, 43:633-642, 1986.
MUROW TE, UNIKEL SC: La musicoterapia y la terapia de danza y movimiento expresivo: aproximaciones novedosas al tratamiento del paciente sin esquizofrenia. En: Ortega SH, Valencia CM (eds.). Esquizofrenia, Estado Actual y Perspectivas. Instituto Nacional de Psiquiatría Ramón de la Fuente, México, 2001.