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llBRARY
Michigan State
University

 

 

 

This is to certify that the
thesis entitled

MUSIC THERAPY IN THE REHABILITATION OF
TRAUMATICAILY BRAIN-INJURED PERSONS:
PROPOSAL FOR THE APPLICATION OF AN

ECOLOGICAL MODEL FOR THERAPEUTIC INTERVENTION
presented by

Rosemary Therese Sergeant Faiver

has been accepted towards fulfillment
of the requirements for

Master Music Therapy

degree in

Win/was:

Major professor

 

 

 

Date June 8, 1988

 

0-7639 MS U is an Affirmative Action/Equal Opportunity Institution

 

 

IV1ESI.J RETURNING MATERIALS:
Place in book drop to
LJBRARJES remove this checkout from
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'7 9.0.49

 

 

 

stamped below.

 

returned after the date

p" (:1; 1:99
ku-~é ‘

see :,> 5 1:35.

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‘ 'HH .
LlHH' {it} 11.3}. ,
1

JAN 2 3 2000

 

 

MUSIC THERAPY IN THE REHABILITATION OF
TRAUMATICALLY BRAIN-INJURED PERSONS:
PROPOSAL FOR THE APPLICATION OF AN

ECOLOGICAL MODEL FOR THERAPEUTIC INTERVENTION

By

Rosemary Therese Sargeant Faiver, R.M.T.-B.C.

A THESIS
Submitted to
Michigan State University
in partial {ulfillment of the requirements
for the degree of

MASTER OF MUSIC, MUSIC THERAPY

School of Music

1988

J

4H0”

545

MUSIC THERAPY IN THE REHABILITATION OF
TRAUMATICALLY BRAIN-INJURED PERSONS:
PROPOSAL FOR THE APPLICATION OF AN
ECOLOGICAL MODEL FOR THERAPEUTIC INTERVENTION
BY

Rosemary Therese Sargeant Faiver

Each year, 400,000 to 700,000 persons nationally suffer
head injuries as a result of accident or abuse. Rehabilita-
tion of these persons is acquiring greater recognition as
knowledge of the brain and its capacity for adaptation is
better understood.

An overview of the literature pertaining to music
therapy with brain-injured persons, neurological aspects of
right-hemisphere dominance for musical/nonverbal tasks, and
issues in families with handicapped members is provided. An
ecological model for intervention is proposed which demon-
strates an integration of these three areas.

There has not been a large amount of documented clini-
cal work in music therapy with this population. Since no
injured person is an isolate, s/he needs to be viewed in
terms of the various systems with which s/he must interface,
e.g., family, health care personnel, community service agen-
cies. The ecological framework offers a tool to facilitate
inclusion of the multiplicity of factors affecting the reha-

bilitation of the patient. Use of this model may assist the

Rosemary Therese Sargeant Faiver

music therapist in developing methods of therapeutic inter-
vention with head-injured patients. Implications for policy

and practice are presented.

Copyright by
ROSEMARY THERESE SARBEANT FAIVER
1988

In loving memory of

Edward A. King, M.S.N

d. October 4, 1987

Sister Mary Charboneau, I.H.M.

d. April, 1935

Beatrice Paolucci, Ph.D.

d. October 1983

ACKNONLEDBMENTS

I have not arrived at this point of achievement alone.
Throughout the elephantine gestatory period of this study
there have been many who have contributed to my knowledge
and growth.

Thus, I offer my deepest appreciation and gratitude to
many -- and most especially to the following:

To the professionals working with the traumatically
brain-injured patients and their families:

Maggie Milz, R.N., for introducing me to the world of
the T81 patient and family and for taking me ”on the
road again" to see the need for a theoretical framework
first-hand.

Edward A. King, M.S.N. (d.l997), for opening so many
doors for me, from the migrant camps in Michigan and
the schools in Mexico City to the hospital in Saginaw
-— a span of over 30 years. He taught me so much about
families of head-injured patients and the lighter side
of wisdom. He taught me to laugh throughout my life
and allowed me to grieve before his was over.

Robert Jones, Ph.D. neuropsychologist and researcher,
for so willingly devoting his time and expertise to the
education of this nouvelle researcher. His personal
commitment to helping me lay a very thorough foundation
for this study has made all the difference. His was a
major contribution, without which I could not have
achieved my goal.

To the chairperson of my master's committee and the director
of this thesis:

Dale Bartlett, Ph.D. Department of Music, for giving me
the opportunity to learn the research process and
exposing me to the research on music and the brain, for
his willingness to allow me to undertake an interde-
partmental approach to a very complex subject, for his
support of the development of a theoretical model which
has already proven to be of value for the profession,
and for his belief in my ability to see it through to
the end.

vi

To the other members of my thesis committee:

Robert Unkefer, M.M., R.M.T. Department of Music, for
strengthening me by challenging me to clarify the
material and to own my convictions.

Linda Nelson, Ph.D. Department of Family and Child
Ecology, for the ability to hear what I was asking,
sometimes while I was still struggling to formulate the
question. It was so very much appreciated. Her
openness to receiving me as part of an ecological
system in which there were influences and obstacles and
supports and implications at each interface, helped me
to understand and to see tools and resources I might
otherwise not have recognized. She made the ecological
process very real. Her editing, feedback and personal
commitment to the completion of this study were an
invaluable education in themselves and helped make my
thoughts a reality.

And to all the members of my family, but most especially:

My husband, Ken -- your belief in me when I no longer
wanted to believe in myself -- saw me through to the
end. Your dedication to reading and typing and
responding to every one of the seemingly hundreds of
versions of this paper while being mother and father
and husband was deeply appreciated, and your attention
to the details of this thesis that you knew were so
important to me meant everything. It was not easy, but
we did it. You've always been here for me and I am
grateful.

My children, Dan, Michelle, Becki, Christa and Maleika
-- thank you --

for the caring notes on my pillow, the flowers,
the pictures for my wall, the laundry done, the
dishes washed, the meals cooked;

for learning about the brain "in case I needed
help", for your interest in my material and the
reports you did on it for school -- I noticed:

for your support and willingness to put up with a
sometimes too tired Mom;

for setting aside your own needs because mine had
deadlines;

for backrubs and hugs and kisses and breakfast in
bed.

vii

You are all very precious to me and I love you.

Both my mother and my father for listening and being
supportive and giving me a life filled with music.

My Dad, Robert Sergeant, for the use of his house,
his car, his refrigerator and his dining room
table during some critical final hours.

My Mom, Virginia Frazier, for mothering me and
nurturing me and letting me think out loud.

My sister Kathy, who has been there for me through it
all, allowing me to laugh and cry and dream and give
up, grieving over my losses and rejoicing in my
successes. Whatever I have achieved or become, in
part, belongs to her.

My sister, Darby, for her generosity in helping me with
my children and my materials and for her encouragement
to achieve my goal.

Juan Marinez, who offered insight and support at
critical times and allowed me to be crabby and stressed
when that was the best I could do.

And most especially Efrain and Frances Marine: and
family whose love and support I never had to earn.

To those friends and professional colleagues who have been
my support system and enabled me to continue my
education:

Sister Josepha Schorsch, O.S.F., R.M.T. who showed me
how to integrate a strong foundation in music therapy
and professionalism with a caring and excitement for
human potential.

Marianne Smith-Beula, M.M., R.M.T, whose gentleness of
soul and insights into the global experience have been
a deepening strength for me.

Charles T. Eagle, Jr., Ph.D., R.M.T., a scholar, whose
vision, prayers, honesty, sense of humor and concern
helped me survive the process.

Teresa Stack, R.N., a role model and treasured friend
whose sense of wonder and love for life have guided my
soul. Her reverence and tenderness for the human
person inside the patient and instinctive belief in the
value of a smile have shaped me both personally and
professionally.

viii

Sister Mary Charboneau, I.H.M. (d. 1985), who nurtured
my soul and taught me to put it into my music.

Beatrice Paolucci, Ph.D. (d. 1983), of the Department
of Family and Child Ecology who insisted that I
experience my experiences so that I might have a deeper
compassion for the life events of others.

The many others who asked about me along the way and
whose caring and prayers gave me strength, including
Nuala Clark, Ivy Boduka, Nancy Perry, Lee Anne Roman,
Nancy Cooper, Kelly Brock, Jim and Darcy Greene, Jim
Jenkins, Marta and Jorge Asfura.

To the Department of Anatomy of the Michigan State
University College of Human Medicine for the use of
their brain model.

And to the Michigan Head Injury Alliance for the generous
use of their library materials.

If I may paraphrase the words of Roger Sperry, researcher

in split-brain theory: Hy left brain cannot find the words
for all that my right brain feels.

ix

PREFACE

However autonomous our soul, it is indebted to an
inheritance worked upon from all sides -— before

ever it came into being -- by the totality of the
energies of the earth: it meets and rejoins life
at a determined level.

Teilhard de Chardin (1957, p. 59)

The evolution of our species depends on man's ability,
individually and collectively, to reach his full human
potential. When any one person suffers an insult to that
potential, it affects the whole. Yet, as I see it, the
effect is not only negative in the loss imposed on one
member of our species, but also positive in the challenge
which that loss presents to each of those remaining to find
an alternative way to make a higher quality of life acces-
sible to the injured person. Our responsibility to each
other calls upon us to develop ways and means to create new
methods of communication and responses to life. when one's
ability to seek that for himself has been lessened, he
becomes dependent on others to find ways to help him return
to, and perhaps even exceed, his previous capacity to

function as a human being.

TABLE OF CONTENTS

L I ST 0F F I BURES I I I I I I I I I I I I I I I I I

Chapter

II

II.

III.

IV.

I NTRDDUCT I m I I I I I I I I I I I I I I
Rationale for This Study . . . . . . . .
REVIEW OF LITERATURE . . . . . . . . . .

Music Therapy Studies with Brain-Damaged
Patients I I I I I I I I I I I I I I I

Transition Studies . . . . . . . . . . .

Brain Studies which Support the Use of
Music with Brain-Damaged Patients . .

Family Studies . . . . . . . . . . . . .

Ecological Framework . . . . . . .
Families with Handicapped Members .

PROPOSED INTERFACE OF BRAIN INJURY AND MUSIC

THERAPY WITHIN AN ECOLOGICAL FRAMENORK

Rationale for Use of an Ecological Approach

Proposal for an Ecological Model . . . .
SUMMARY AND RECOMMENDATIONS FOR RESEARCH
Summary and Discussion . . . . . . . . .
Suggestions for Further Research . . . .

Experimental Research . . . . . .

Case Studies: Family and Individual
Practical and Clinical Applications

xi

Page

xiii

23

33
44
4s
51

65

71

82

82

833

GLOSSARY OF TERMS . . . . . . . . . . . .
A. Neuropsychological Terms . . . .
B. Hospital Equipment . . . . . . .
C. Medications . . . . . . . . . .
D. Neurological Tests and Procedures
APPENDICES . . . . . . . . . . . . . . .

A. Informational and Supportive
Head Injury Resources . . . . .

B. Professional Listings . . . . . .
C. Rancho los Amigos Scale . . . . .
BIBLIOGRAPHY . . . . . . . . . . . . . .
A. Selected References . . . . . . .

B. General References . . . . . . .

xii

9O

9O

96

100

101

101

102

105

109

109

115

Figure
1.
2.
3.

4.

EcoMap I .
EcoMap II .
EcoMap III

EcoMap IV .

LIST OF

FIGURES

xiii

Page
74
76
77

79

CHAPTER I

INTRODUCTION

Traumatic head injury (TBI)‘ is an insult to the
brain, not of a degenerative or congenital nature,
but caused by an external physical force, that may
produce a diminished or altered state of conscious-
ness, which results in impairment of cognitive abil-
ities or physical functioning. It can also result
in the disturbance of behavioral or emotional func-
tioning. These impairments may be either temporary
or permanent and cause partial or total functional
disability or psychosocial maladjustment.

National Head Injury Foundation2 (1986, p. 1)

Each year approximately 18,000 to 20,000 persons in
Michigan become disabled by traumatic brain injury, accord-
ing to the Michigan Head Injury Alliance (MHIA, 1988), a
figure that reaches 400,000 to 700,000 persons nationally

(Journal of Neurosurgery, 1980). The National Safety

 

‘ TBI: Traumatic Brain Injury. The term traunatic head
injury will be used interchangeably with traumatic brain
injury, closed-head injury, and neurologic ispairaent, and
is most often abbreviated as TBI. Although in the reviewed
literature the term 781 is sometimes equated with stroke or
cerebrovascular accident (OVA), in this paper it is
generally used as defined by the NHIF (1986).

3 This definition was adopted by the Executive Committee of
the Board of Directors of the National Head Injury
Foundation on February 22, 1986.

Council (1987) estimates that a head injury occurs, on the
average, every 16 seconds in the United States. Nearly
140,000 persons die annually from head injuries in this
country (MHIA, 1988). Over 750,000 head injuries each year
require hospitalization (Barrer and Ruben, 1984), and 50,000
to 90,000 persons annually are left with intellectual and
behavioral deficits that preclude a return to normal life
(MHIA, 1988). These statistics probably represent an
underreporting because many TBIs are undetected.

Two-thirds of all persons sustaining head injuries are
under the age of 30. Young men between 15 and 24 years of
age are more than twice as likely as women to suffer head
injuries because they are typically more involved with
high-risk transportation and sports activities. The elderly
and infants are at high risk of head injury due to falls.

Of the one million children who sustain head injuries each
year, some are victims of child abuse. About 165,000
children will be hospitalized and one in ten will suffer
moderate to severe impairments (MHIA, 1988), ranging from a
period of post-traumatic amnesia from which one can recover
to a persistent vegetative state (coma).

Head injuries are the number one killer of persons
under the age of 44. They kill more Americans under the age
of 34 than do cancer, heart attack and stroke combined. As
many as 1.8 million Americans now have disabilities result-

ing from moderate to severe head trauma. This is three

times the prevalence of disability from cerebral palsy, ten
times more than spinal cord injury, and forty times more
than muscular dystrophy (MHIA, 1988).

Because so many of the victims of TBI are young, the
number of potential years of life lost is great, as also is
the number of potentially useful and active years of life
lost for those who survive. Of all the persons who suffered
head injuries just between 1970 and 1974, 926,000 still
require medical treatment today, according to MHIA. Even
larger numbers are found in subsequent years. Considering
that a majority of head injuries occur to persons between
the ages of 18 and 25, it is predicted that each victim will
require an average of 40 years of some level of medical and
other treatment or support, and the cost of that caring will
total an estimated four million dollars or more over the
remainder of the victim's life after the acute care
hospitalization.

While traumatic head injuries claim the lives of more
people than many other diseases combined, the number of
persons who survive is increasing. The use of seat belts
and motorcycle helmets has greatly increased the chances for
survival of persons who would otherwise have died from head
injuries and other trauma sustained in motor vehicle
accidents. Goldstein (1986), a biologist at the National
Institute of Health in Bethesda, Maryland, said that there
is a critical four- to eight-hour period of time immediately

after an accident in which the brain cells are not yet dead.

The wide dissemination of modern life support technology for
use at the scene of an accident, the highly advanced
medical-surgical management of care for trauma victims, and
the availability of helicopter transport from the scene of
the accident to a trauma center with medically trained
personnel en route, all combine to reduce the critical time

lapse during which additional brain cell damage could occur.

Ratiggale for This Study

Researchers do not yet know if there is an end point in
the rehabilitation of the traumatically brain-injured
patient beyond which they can no longer hope to achieve any
further success. Since success is a relative term and the
potential of the human brain is limitless as far as is
known, it seems appropriate to explore every means that can
be imagined for rehabilitating the injured person.

Since each individual is unique prior to head trauma
and is uniquely impaired by that trauma, it is necessary to
consider a wide variety of individualized therapeutic and
rehabilitative programs. As knowledge grows of what is pos-
sible for the head-injured person, so also does the variety
of professionals who become involved in their rehabilita-
tion. Among these are music therapists, as will be
discussed later; however, in only a few cases of which the

author is aware have their efforts been described and the

results been documented in the literature. This is largely
true among other professions as well.

Given the small amount of documentation on which to
model treatment, music therapists are generally not prepared
to work with the specific needs of this growing population.
Understandably, because rehabilitation of head-injured
persons is yet in its embryonic stage, it is not usually
possible for therapists to be well-enough prepared through
their academic curriculum to work effectively in this area.
Therefore, what literature there is needs to be compiled
from the technical journals and other publications of the
various disciplines and synthesized so that it becomes
available to the music therapist. Typically, literature is
highly compartmentalized within each discipline so that it
is not easily available. The practicing music therapist
cannot necessarily be expected to have access to existing
materials, or time to undertake the search currently needed
in order to locate them. It is the intent of this study to
help make this process easier. Much of the available
knowledge can be pooled and used to develop a helpful model
for further research and treatment of the head-injured
client.

In the literature reviewed by this author, there was no
description of a clearly elaborated model or framework for
use of music therapy in the rehabilitation of neurologically
impaired clients. The contextual approach, here inter-

changeably referred to as an ecological framework, ecosystem

framework, or family ecological framework, can facilitate
the incorporation of relevant factors into the patient
assessment for use in whatever treatment plan is developed
by the music therapist and other professionals.

In addition to having access to the research that has
been done, it would be of great value to the practicing
clinician to be aware of other sources of needed informa-
tion. For example, it would be useful to have a list of the
journals in which one is most likely to find the ongoing
research with head injuries or with music and the brain, or
of the types of professionals who are most likely to be
keepers of the particular information desired. This paper
begins to provide such a listing and can assist future
research by facilitating the creation of a data base
essential to that research.

In view of the above, the purpose of this thesis will

be to provide:

1. a review of the literature that has proven to be
helpful in the acquisition of information pertaining
to research on closed-head injuries, music therapy
with closed-head injuries, the response of the brain
to musical stimuli, and the ecological framework and
its use with families with handicapped members;

2. a listing of types of professionals who, and
organizations which, are most likely to have the

kinds of information needed by clinicians and

researchers working with closed-head injuries;

a definition of terms specific to the fields of
music therapy, neurology and family therapy, as they
are relevant to this research;

a description of the ecological framework and its
application to music therapy with closed-head
injuries; and

recommendations for future research with music

therapy and closed-head injuries.

CHAPTER II

REVIEW OF LITERATURE

The review of literature will comprise four principal

categories:

1. music therapy studies with brain-damaged patients,

2. transition studies,

3. brain studies which support the use of music with
brain-damaged patients, and

4. family studies.

The music therapy studies will be presented in chronological
order, since there are too few to categorize on any other
basis. The transition studies serve to link the literature
dealing specifically with clinical applications of music
therapy to the literature which more directly discusses the
neurological aspects of musical function. The studies
pertaining to the brain will include those which have some
bearing on receptive or expressive musical capacity, its
relationship to speech functions, and its role in communica-
tion. The studies relating to the family are divided in
such a way as to give first an overview of the ecological

model and then to show how that has been applied to families

with handicapped members.

sic Th ra Stu ies wit Brain-Dana P ti nts

Consistently throughout the academic history of music
therapy there has been an expressed need for an organized
body of knowledge and a set of verifiable hypotheses that
will give direction to practice and research (Graham, 1969).
This paper is intended as a partial response to that need,
specifically in the area of music therapy with traumatically
brain-injured persons.

The earliest known examples of the use of music with
brain-injured persons were undertaken by Schneider (1954)
who presented a brief resume of ten case studies with
children. Schneider discussed the brain-damaged child as
one who, before, during or after birth, has received some
injury to, or suffered an infection of, the brain, which
usually results in varying degrees of neuromotor impairment,
mental retardation, and atypical emotional behavior.
Diagnoses and general characteristics were described. There
were ten subjects, five male and five female, ranging in age
from 8 to 19 years. Included within the total group were
two boys and three girls diagnosed on the basis of neuro-
motor involvement as athetoid, and three boys and two girls
diagnosed as evidencing varying degrees of spasticity. All

of the children evidenced some form of atypical speech. The

10

degree of mental retardation of eight of the children placed
them at an age level of one to ten years, based on several
psychological examinations. One child was considered to be
of average intelligence and one of above-average intelli-
gence. Etiology of the brain damage specific to each
subject was not discussed. A control group was not included
in this study.

The study was concerned with the observable effects of
music on the total behavior of each child while listening to
recorded instrumental music and while performing simple mo-
tor tasks to the accompaniment of this music. The effects of
different types of recorded music under different sequences
of presentation were studied in relation to the child's
overall behavior of the day. The actual motor tasks were
not described in detail; the reader is told only that they
were performed with music as a background framework which
seemed to this author to provide orientation in time and
space and, therefore, structure to the activity. Schnei-
der's work with these patients was based on Altshuler's iso-
moodic or "iso-" principle (1945). This principle suggests
that, by matching the music to the patient's present level
of tension or relaxation as the starting point, the thera-
pist can then gradually, by altering the music, move the
patient into the desired structured state of relaxation
facilitated by the music. Children diagnosed as spastic
responded best to stimulative music, while those children

diagnosed as athetoid responded best to sedative music.

11

Schneider concluded that music can be used with pa-
tients who have similar diagnoses to improve motor control,
enhance various psychological processes, and influence
emotional behavior by inducing a state of relaxation which
allows them to be receptive to the task at hand. Schneider
stated, however, that, although each child benefited from
music in quite similar ways, therapy should continue to use
a patient-specific approach.

Fields (1954) discussed the use of music as an adjunct
to medical treatment with adult brain-damaged patients. It
appears that the patients were generally classified as
having cerebral palsy, with no further clarification or
definition of brain damage. Treatment was directed specifi—
cally toward an increase in motor coordination which can be
demonstrated and measured objectively.

Of the four patients discussed by Fields, three had
been assumed to have reached their final plateaus of effi—
ciency, for which reason other therapies had been termina-
ted. The fourth was considered unsuitable for occupational
therapy because of the extensive nature of the disability,
but was retained in physical therapy for attempted training
in ambulation. The individual circumstances of these four
patients, therefore, eliminate, to a large degree, a discus-
sion of the value of music when used concurrently with other
treatment.

In Fields' study, the use of music was focused less

upon its value as a stimulus to effect emotional changes,

12

than as a stimulus to promote muscular activity and coordi-
nation. Music was used to determine its value: (a) as a
changing stimulus, (b) as a stimulus to subcortical activi-
ty, (c) as a security-inducing device, and (d) as a timing
element necessary in coordinated activity. Manipulation of
pitch, rhythm, intensity, timbre and form in music was
studied to determine methods for its application to meet the
problems presented by the disabilities of these patients.
Two features of music were described that make it different
as a stimulus from other stimuli, such as the direct verbal
command to activity. One of these features was that music,
correctly selected for the individual patient, may be varied
in intensity to overcome a sluggish stage of the reflex.
Another feature is the infinite variety of change possible
in the pitch, rhythm, tempo and style of music, thus
avoiding the dulling of a reflex that can occur with an
unchanging stimulus.

The ages of the patients in this study were 20, 24, 24,
and 52. One was male. The physical disabilities ranged
from mild hemiplegia to severe quadriplegia. The neuro-
logical symptoms included spasticity, athetosis, rigidity,
ataxia, and tremor, as well as speech, auditory and visual
defects. 'The range of ID was reported to be between 70 and
110. Psychological characteristics due to organic
pathology, as listed by Fields, were: (a) distractibility,
(b) disassociation (sic), (c) perseveration, and (d) rever-

sal field tendencies.

13

Fields believed it was impossible to employ control
groups with brain-damaged patients as no two subjects are
exactly alike. Therefore, the treatment value was
determined by quantitatively measurable factors such as any
increase in motor coordination over previous attempts by
that particular patient. An increase in the number of
fingers used, or any increase in range of motion, was a
measurable indication of success. The degree of relaxation
and reduction of tension was determined by a reduction of
"overflow" motion in some patients, and by an increase in
the use of an extremity.

What is lacking in the study is a clarification of the
nature and etiology of the damage to the brain in each of
the subjects. This becomes a significant piece of informa-
tion when attempting to do comparative studies, for example,
between a person who has suffered a cerebral thrombosis
(stroke) and someone who has survived an automobile accident
where there is considerable contra-coup damage (i.e., damage
to the brain on the opposite side of the point of impact to
the head). For this reason, careful research design which
would control for relevant variables is essential. Such
design should include a control group, preferably randomly
assigned, so that important threats to validity may be
effectively minimized, including history, maturation, selec-
tion and interaction (Campbell and Stanley, 1967; Cook and
Campbell, 1979). To make comparison groups more homogeneous

or to facilitate use of statistical methods for controlling

14

certain variables, it will be necessary in future research
to identify and document patient and treatment characteris-
tics which could affect the outcome.

Later, in a paper published by Obaldia and Best (1971),
the subject of music and brain damage was approached from an
educator's point of view. Their definition of brain damage
concerned those problems associated with personality disor-
ders, learning disabilities and various forms of emotional
instability that might interfere with learning in the tradi-
tional classroom. The brain damage seemed to be congenital
in nature. They presented ten case studies of children
between the ages of ten and fourteen with an IQ ranging from
untestable to 133. Personality profiles were taken from
school records which indicated a history of brain damage
since birth. The research focused on improvement in one or
more of the following areas: (a) environmental behavior
(school, home and community); (b) academics (formal
school-learning characteristics); (c) human relations; and
(d) self-assurance, self-confidence and self-respect. These
appear to represent various aspects or dimensions of
resocialization. Since the subjects were already at a high
level of motor and speech functioning, it was not necessary
to use music as a facilitator in these areas, although
individual improvements were made. Without exception,
however, dramatic and positive behavioral changes in each of
the subjects were reported which, according to the authors,

were the result of being involved with music.

15

Other factors which should be considered, but which
were not discussed, include: (a) the level of expectation
for client performance on the part of the educator doing the
study, which was perhaps higher and more positive than that
of the classroom teacher; (b) the added individual attention
inherent in the case study method; and (c) the emphasis on
the process of enjoying music according to one's own
ability, instead of in a manner competitive with another's
ability. Though the authors of the study did not address
these issues, this writer suggests that these be important
considerations in determining the relationship between
overall behavior and reinforcement through music. Care
should be taken concerning cause and effect implications.

The actual music techniques employed were very simple,
using the piano, bongo drums and Spanish guitar. Achieve-
ment of rhythmic ability and melodic ability had already
been established, though they were at a very elementary
level. With the use of the three named instruments, each of
the subjects was given a two- to three-measure excerpt of
music to learn. Each excerpt was taken from a musical
selection to be performed in ensembles of two or three
members. The task was to provide each subject an opportu—
nity to learn music individually and then to play that music
learned as part of the ensemble.

The results of the study initiate additional and
continuing questions. By definition, these subjects differ

from the types of subjects referred to specifically in this

16

thesis. Though the subjects in the study by Obaldia and
Best are categorized as brain damaged, the nature of their
disorder does not coincide with those whose injury was
incurred later in life as the result of a direct insult to
the brain. How much can we hope to retrieve or reconstruct
if it was not there in the first place? Does the person who
suffers a traumatic injury to the previously healthy brain
stand a better chance of rehabilitation to a normal level
than do those with similar lesions who have carried their
injuries since birth? If yes, why? If not, what are we
able to generalize from our studies of brain-damaged persons
with differing etiologies?

Observing that the neurologically impaired child often
seemed to develop functional understanding of musical
concepts more readily than concepts in other areas, Pirtle
and Seaton (1973) devised a study to investigate musical
experiences designed to develop specific musical concepts.
The purpose was to observe the effect of music on the
neurologically impaired child's improvement in spatial,
temporal and ordinal concepts and in his ability to relate
these concepts to their verbal symbol.

The study was undertaken at the Institute of Logope-
dics, a residential center for the habilitation of communi-
cative disorders. Fifteen pairs of children with mental
ages of six years or younger participated in the study.
Actual chronological age ranged from 4 to 12 years. All of

the children selected for the project participated in music

17

classes twice a week, daily classroom activities, individual
speech therapy three times a week, art programs, and physi-
cal education programs. All had hearing sensitivity for
pure tones and speech that fell within normal limits, and
none had complicating motor disabilities.

According to Pirtle and Seaton, there are no standard-
ized musical perception tests available to evaluate essen—
tially speechless children. The researchers, therefore,‘
designed a test of musical development and two corresponding
language tests. The first, a vocal integration test, was
used to investigate the development of aural concepts in a
non-musical situation. The second, a verbal comprehension
test, was employed to examine the child's ability to trans-
fer aural concepts to spatial, ordinal, and temporal con-
cepts. The tests were designed to provide the children with
a means of response not dependent on ability to verbalize,
such as playing a drum, making appropriate motions, or
indicating a choice between two diagrams or pictures. Five
subtests were devised, one for each basic conceptual area of
music: melody, rhythm, harmony, expression, and form. The
assumption was that for each conceptual area of music there
exists a corresponding conceptual area of language.

The purposes of the language test were: (a) to test
comprehension of concepts taught in a musical context when
presented in a non-musical situation, (b) to determine the
degree of conceptualization attained within each area, and

(c) to provide a means of measuring the effect of musical

18

experiences on verbal comprehension.

The purpose of the experiment was to determine if music
could facilitate the development of auditory memory and
conceptual understanding in the neurologically impaired
child and thereby enhance the child's ability to develop a
language and increase appropriate social behavior. There
was a positive correlation between the use of music and the
development of the desired skills.

An operant definition of the term neurologically
iepaired was not provided. It is assumed from the context
that these children were impaired since birth severely
enough to require institutionalization. It is also sur-
mised, from the types of expected responses implied in the
test, that the children were capable of at least a moderate
level of physical and mental functioning prior to the study.

Boyle (1985) studied the use of music in operant
procedures for the comatose patient. Her purpose was to
determine whether the use of music as a contingent
reinforcer would increase the frequency of specified motor
behaviors of vegetative comatose patients in response to
verbal experimental directions. Coma is defined as those
states in which cognitive functions are diminished and the
patient is unresponsive to all outside stimuli (Posner,
1978). The vegetative state denotes a state in which the
essential component is the absence of any evidence of a
functioning mind which is either receiving or projecting

information, in a patient who has long periods of

19

wakefulness (Jennett and Plum, 1972). Boyle briefly dis-
cussed the standardized procedures that have been developed
for testing responsiveness of the comatose patient to
external stimuli. The Glasgow Coma Scale (Teasdale &
Jennett, 1974; Teasdale, Murray, Parker, & Jennett, 1979)
was used to examine the best eye-opening, verbal, and motor
responses occurring in given time periods. The Munich Coma
Scale (Brinkmann, von Cramon, & Schulz, 1976) used additive
scales to rate susceptibility to stimulation and reactivity.
Stimulation in these testing situations refers to use of
electrical, tactile, acoustic, and optic devices. Reactions
to this set of stimuli include motoric, mimic, orientating
or communicative responses. These procedures do not measure
operant responses but rather the application of technology
to the experimental analysis of behavior to test the
responsiveness of comatose patients.

The patients in Boyle's study were considered comatose.
A distinction was made in the study between the “vegetative
state” of the coma patient and the "vegetative state" of
profoundly retarded individuals. While they are similar in
their lack of responses, their conditioned reinforcers may
be different. Without special reinforcement conditioning
procedures, only primary reinforcers generally are viable
for many profoundly retarded individuals. Comatose
patients, however, have had many conditioned reinforcers
prior to trauma. Primary reinforcers (e.g., food) are often

difficult to use with comatose patients because of the

20

involvement of mechanized life-support systems and the
patient's tentative and often precarious condition.

Music was selected as a contingency because it seemed
suited to the limitations of the patients while simultane-
ously tapping their potential to be controlled by condi-
tioned reinforcers from their own unique histories. Music
can be non-intrusive, unobtrusive, easy to administer, less
likely to produce satiation, and less likely to create
resistance from caretakers, medical personnel, or members of
the patients' families.

Three case studies were described. All three subjects
were diagnosed as comatose. Dependent variables were estab-
lished based on the patients' present ability to respond.
Procedures involved standard direct observation techniques.

In a more recent study, Lucia (1987) extended the defi-
nition of head injury to include persons who have suffered a
cerebrovascular accident (CVA), also referred to as a
stroke. The study was an overview of selected literature of
the last 40 years related to rehabilitation of persons with
closed-head injuries, the function of the cerebral hemi-
spheres in music, and the function of music in speech and
motor development.

Rehabilitation planning for TBI and CVA patients needs
to be patient-specific. Following this rationale, the study
drew on the literature of head-injury rehabilitation to
recommend that current information be acquired in the

following functional areas in anticipation of establishing

21
treatment goals:

1. Speech and Language Deficits (dysphasia, dys-
arthria, or dyspraxia);

2. Visual Field or Auditory Defects

3. Hemi paresi s

4. Motor Incoordination/Restriction (affecting
balance, motor planning, range of motion, or

muscle strength and endurance)

5. Behavioral Disturbance (short attention span,
distractibility, affective lability)

6. Memory Deficits
7. Psychological Factors (depression, motivation,
self-image). (p. 34)

According to the literature on the neurological compo-
nents of music perception and performance, aspects of speech
and music function have been found in both cerebral hemi-
spheres. This, in part, addresses the questions concerning
brain function and site-specific anatomical function of the
hemispheres. Patients with aphasia were the subjects in
many of the studies cited. Remaining and/or damaged
cognitive language or motor functions were assessed, in
part, via the evaluation of the patients' music perception
and performance.

Of significance to the clinician using a music-based
rehabilitation program is the inclusion in Lucia's paper of
music therapy clinical examples. Using the Melodic
Intonation Therapy (discussed later in this chapter) which

is based on the principles of speech prosody and brain

22

plasticity, Lucia developed a Music Therapy Vocal Skills
Group for head trauma patients. Music therapy strategies
were designed to utilize preserved right brain functions for
singing, an automatic, non-propositional speech skill that
is thought to precede functional speech recovery. The tech-

niques involved a gradual withdrawal of melodic facilita-
tions toward rhythmic chanting and question-answer responses
with rhythmic and content structuring. Additional efforts
were made to promote rehabilitation of dysarthric and
dyspraxic elements, such as breath capacity and efficiency
of respiration-phonation patterns, articulation errors
caused by inappropriate rhythm or speed, and preparatory
motor planning for articulatory movements.

The music therapy assessment used by Lucia focused on
determining the preserved music skills in the patient as
well as on the degree of deficit in the above-described

areas. Items of the assessment were outlined as follows:

1. ability to match pitch

2. singing range

3. breath capacity while singing/chanting
4. attention to musical task

5. automatic recall of melody and words of
premorbidly learned songs/proverb chants

6. respiration-phonation patterns while singing!
chanting

7. syllabic production rate and rhythm during
singing/chanting

23

8. oral apraxic interferences while
singing/chanting. (p. 36)
Visual field deficits and alexic elements were assessed to
determine the value of visual cues such as large-print song
charts, regular—size print song sheets, or directives to
follow mouthing cues of the therapist.

The study did not indicate how many patients were in
the group. The patients met for music therapy one time per
week for a 40-minute session. All patients were involved
simultaneously in individual and/or group speech therapy at
least three times per week. Selected patients also received
individual music therapy sessions. Patients with hemiplegic
involvement also participated in a group occupational thera-
py upper-extremity exercise program during which singing of
familiar songs was part of the exercise routine in one of
five daily sessions per week. It was not indicated whether
any of the patients had sessions overlap in such a way that
they might have been in the Music Therapy Vocal Skills
Group, individual music therapy and the music-facilitated

occupational therapy group.

Transition Studies

Before discussing the brain studies and studies of
families with handicapped members, this author has chosen

four works that function as transition pieces between music

24

therapy on the one hand and medicine, neurology and family
therapy on the other. It is humbling to realize that the
most profound insights into what the music therapy profes-
sion can contribute to the rehabilitation of traumatically
brain-injured persons have not always come from within the
profession.

In 1945, Altshuler, a physician, musician, and director
of group music therapy at a psychiatric hospital, presented
the concept of identifying musically with the mood or tempo
of the mental patient. This concept was referred to as the
”iso-" principle. Once the therapist has equated the music
to the mood or tempo of the patient, it then becomes
possible to move the patient to the desired mood or tempo by
altering the music.

The process begins with music in which there is a
predominance of rhythm because of its strong appeal at the
instinctual primitive level. Rhythm, with its stress,
duration, and pause, exercises a specific physiological and
psychological effect different from that of melody. Melody
is apprehended as an entity and exercises an entirely
different effect from rhythm. Melody is followed by harmony
”which integrating effect can be linked with cerebellar
influences” (p.53).

The next music used is intended to capture the mood of
the patient and then, supported by music, help the patient
to shift into the emotional mood desired. Pictorial associ-

ative music is then played to stimulate imagery and

25

associations. Recall of past experiences is thus facilita-
ted. This can be of benefit for both the psychiatric
patient for whom this method was initially intended, as well
as for the traumatically brain-injured. While similar goals
may be achieved, the purposes vary. According to Altshuler,
”music leaves not only a 'memory' in the mind but in the
emotional sphere, movements and muscles" (p. 53). The
traces left by music are more easily recalled because it is
"more firmly implanted in his system. Calling up of past
experiences means bringing back into the mind . . . the
basic realities" (p. 53). If it is true that these bits of
realities "bridge the mental patient's mind with the outer
world" (p. 53), and that repetition of the appropriately
selected music clarifies that reality, then it is presumed
by this author that the same might hold true for the patient
who has suffered a traumatic brain injury.

Altshuler was careful to emphasize the importance of
tone color inherent in musical instruments and its effect on
patients. This author concurs that tone color as well as
musical preference and the patient's musical history all are
factors to be considered in determining the projected
benefits for a particular patient.

In 1973, Martin, Sparks and Helm presented a new form
of language therapy that has been used successfully with
aphasic patients who had severe, long-term, stable defects
and for whom other forms of therapy had failed. It is

termed Melodic Intonation Therapy (MIT) and it involves

26

embedding short phrases and sentences in a simple, non-
linguistically loaded melody pattern. Therapy progresses
through several levels. The first level of therapy involves
unison singing of the sentence by the patient and the
therapist, as in operatic recitative. The program then

progresses eventually to repetition of the sentence in
normal speech prosody. As the aphasic patient improves, the
melodic aspect of the program is gradually diminished, and
confrontation questions are introduced. If the patient has
difficulty at this stage, s/he is then directed to revert
temporarily to an intonational response.

Three case studies are presented of right-handed
patients for whom other therapeutic approachesghad failed.
All three patients had good language comprehension but
considerable expressive difficulty. After involvement with
Melodic Intonation Therapy, the expressive language ability
was significantly improved.

In an article solicited by the editor of the Journal of
Speech and Hearing Disorders to discuss Melodic Intonation
Therapy, Berlin (1976) described the physiological aspects
of the brain in relation to MIT. Based on the disconnection
syndromes and insights to date on the pathways from one
portion of the brain to other association areas (Geschwind,
1972), Berlin described a hypothetical patient with a lesion
in or around Broca's area (left hemisphere) who might be a
good candidate for MIT. If the right hemisphere is dominant

for interpretation of nonverbal acoustic processes like

27

music, then it is possible that MIT could activate the right
hemisphere in some way to control motor speech gestures.
Although primary auditory areas of the brain are not con-
nected transcallosally, Berlin points out that, once infor-
mation flows from the primary area outward, it reaches
auditory association areas; Wernicke's area projects to
Broca‘s area via the arcuate fasciculus. ”While the left
and right primary auditory areas do not interconnect the
corpus callosum, it is clear that association areas do
connect transcallosally. There is a presumed one-way
right-to-left transcallosal route for speech input to the
brain", according to Berlin (p.299). He hypothesized that,
in a patient with a lesion such as the one described above,
information from left auditory association areas necessary
to generate and monitor proper motor commands cannot reach
Broca's area through the arcuate fasciculus because the
supposed lesion disrupts posterior-anterior access. It is
possible, however, that posterior-anterior interaction might
occur by way of a remote route; that is,

transcallosal communication at Wernicke's area

with its homologue on the right side can permit

posterior-to-anterior connection via the intact

arcuate fasciculus on the right to the homologue

of Broca‘s area on the right side. From here,

information can either be routed back cross-

callosally to the pre-Rolandic areas, by-passing

the damaged Broca's area, or the right hemisphere

can itself attempt to control some of the motor

gestures being made. To activate left-to-right

hemisphere paths, one might be forced to translate

the task into a nonverbal acoustic or melodic
behavior. (p. 299)

28

Thus, Berlin concluded, good candidates for MIT have intact
left pre-Rolandic motor areas but lack input from a damaged
Broca's area.

The intact left motor strip might receive trans-

callosal command from an intact right Broca's

homologue, activated by MIT. A more remote possi-
bility is that motor areas of "good candidates for

MIT" have simply been disconnected from an intact

Broca's area on the left, but can still receive

input via a pathway from left Broca's area to the

right Broca's homologue, and then back to left

Rolandic areas transcallosally; this path may be

activated by exaggerated vocalic intonation.

(p. 299)

Clinicians often employ methods with clients without
fully understanding why. Berlin cautioned that proof for
such preliminary hypotheses should await pathological
material. This author feels that, by being aware of the
theories upon which research is based, productive observa-
tions can be made that can contribute to the knowledge which
will ultimately confirm or deny hypotheses. It was
suggested by Geschwind (1972) that it is possible to predict
the sites of brain lesions on the basis of the type of
language disorder. This points up the need for careful
observation and documentation, as well as open-minded
interaction among disciplines. Berlin affirmed this when he
concluded that ”these principles should remind us of the
importance of seeking alternate modalities or combinations
of access routes for our communication-handicapped patients”

(p. 300).

The efforts by Judd (1979), a neuromusicologist,

29

represent a comprehensive approach to the study of the rela-
tionship between brain damage and music, and provide an
appropriate transition from the literature on music with
head injuries to the scientific studies and neuropsychologi-
cal literature on head injuries. Judd offered a review of
Music and the Brain (by Critchley and Henson, 1977) and
discussed the potential benefits of studying music from a
biological perspective. The reader is then given an under-
standing of the alexias through a neurological description
of their known causes. There follows a discussion of the
conclusions drawn in the last one hundred years from the
literature on studies concerning the alexias. Judd pointed
out the difficulty researchers have had in attempting to
determine the nature of cerebral specialization. In more
recent years, researchers have made an effort to approach
the questions concerning cerebral specialization in less
problematic terms. Studies are likely to refer more to
stimulus properties and behavioral requirements than
previously. Shifting the perspective and weighing the new
information against what is already known increases the
likelihood of refining the knowledge of brain function.
Instead of talking about music centers in the right hemi-
sphere or word centers in the left hemisphere, investigators
are attempting to determine the stimulus and task demand
properties which typically engage the activity of different
parts of the brain. The efforts seem to be cyclical in that

research goes as far as it can in one direction, then must

30

seek verification from another direction. Ideally, enough
investigators will be involved from many perspectives so as
to make an ongoing synthesis of information possible. This
enables the theorist to approach application, and the
clinician to function with understanding.

Judd further referred to an area which has long been of
interest to this writer. That is, what happens to the
theories of hemispheric specialization when they are applied
to populations who possess reading skills different from
those skills which dominate the literature, such as in
Oriental cultures? Does the left-to-right orientation to
the written word in English affect the overall perceptions,
attitudes, and responses to life in general? Does the
presumption of left-hemisphere dominance prevail because of
a cultural bias toward a language made up of letters and
numbers which are read from left to right? The relative
preservation of number and symbol reading in some alexic
patients from a Western culture may reflect a relative
sparing, e.g., of the ideographic or semantic reading system
demonstrated in Japanese aphasics. This speculation awaits
confirmation in non-aphasic alexic Japanese patients, but it
is an intriguing hypothesis. What effect does an ideo-
graphic versus semantic reading system have on an approach
to problem-solving in terms of the hemisphere allowed to be
dominant in that context? Will musical or nonverbal
responses, that is, the use of the right hemisphere or the

integrative functions of both hemispheres, differ because of

31

a cultural (left-to-right or right-to-left) orientation to
the written word?

Judd applied a constructive skepticism, taking a
careful look at the assumptions that have sometimes been
made based on studies which lack clarification in their
design. He took the position that little is really known
about the relationships between music and the brain,
primarily because of the great complexity of each which is
often overlooked. Frequently the literature refers to a
"musical activity" performed by a patient without acknow-
ledging music's tremendous diversity. In Judd’s words,
"attempts to define music, or worse, assumptions that it has
been defined, probably limit attempts to study and propagate
it. It may be that it is music's diversity that accounts
for its existence and allows it to survive and flourish.“
This author feels that the same may be said for the brain.
Perhaps, if the brain were so simple that humans could
understand it, humans would be so simple that they could
not.

Observations by Luria (1947/1970) suggest that there
may be reason to pursue questions such as these. It was
determined that, in patients from a Western culture, the
critical region responsible for recognizing phonemes lies in
the secondary zones of the left temporal lobe, which are
intimately connected with other parts of the brain's speech
area. Patients with lesions in this region "cannot

distinguish b from p or t from d, and they may write 'pull'

32

instead of 'bull' or 'toae' instead of 'doae‘. Moreover,
they may make unsuccessful attempts to find the contents of
the sounds of words they try to write" (p. 71). What is
interesting about Luria's observations is that they do not

hold true for Chinese patients with severe injury to the

same acoustic region. They do not have similar difficulty,
presumably because their writing is based on ideographs
instead of on words that call for the coding of phonemes.
That suggests to this writer that communication difficulties
arising as a result of lesions in specific areas of the
brain are perhaps a function of the cultural context as much
as of the lesion itself. Considering this may offer new
insights into the functional outcome of the brain-injured
patient. It is functional outcome that partially defines
the success of rehabilitation for the TBI patient. And the
perception of the achievement of a particular quality of
life is also determined by the value placed on the
functional outcome achieved. Therefore, if quality of life
is defined in part as the level of one‘s ability to function
within society, and if the ability to function within socie-
ty is also in part determined by the ability to communicate,
then communication, and not only the recognition of

phonemes, becomes the goal.

33

r 'n u i h' t f

sic with rain- m d P ti nt

Botez & Wertheim (1959) studied expressive aphasia and
amusia in a right-handed patient with a right frontal
lesion. A complete examination of the musical functions was
performed one year post-injury. The patient was a 26-year
old farm band who had played the accordion since he was nine
years of age and played the accordion in a band prior to the
time of the injury. Before his illness he used to sing and
play dance music and folk songs. He had never attended a
music school and had had no musical training.

The clinical examination revealed intonational disturb-
ances, a pitch change in his voice, and the inability to
sing or to play the accordion. The prosodic quality of
human language gives to speech various shades of sense by
means of stress, pitch, and rhythm variations. The prosodic
quality of this patient's speech was such that stress (which
depends on the amplitude of vocal emission) was distributed
explosively, without any relation to the sense of the
sentence. The pitch (which depends on the frequency of the
sound) was of a remarkable monotony. The interval between
the higher and lower sound emitted by the patient while
speaking never exceeded a minor third. In normal speech
this interval should not be less than a fifth and at most an
octave (Grammont, 1947). Regarding rhythm, the patient

omitted the normal pauses between successive words,

34

prolonging the last syllable of a word and thus making a
transition to the following word. The dysphasic element of
speech was evident in the condensation of words.

The authors developed a battery of 45 tests designed to
investigate musical functions. The battery is based upon a
precise classification of human subjects according to their
musical aptitudes and training, an element which has been
lacking in the research literature. The critical attitude
of the patient to his own performance was considered impor-
tant; therefore, the battery was designed to distinguish the
receptive (gnosic) element from the productive (praxic) one.

This patient, however, was an "empiric" musician who
ignored musical notation and had no theoretical musical
knowledge. Consequently, there were a series of tests that
could not be applied: solfeggio, musical dictation, tran-
scription, nomination of the musical intervals, decomposi-
tion of chords, ”time-beating" movements, and more. The

battery was outlined as follows:

I. Receptive and Mnesic Components
A. Tonal, Melodic and Harmony Elements
8. Rhythmic Element
C. The Agogical and Dynamic Elements
II. Productive Component
A. Singing and Whistling Tests

8. Instrumental Tests

These elements were further defined in detail in the

35

battery.

Particular focus was given to the dysphasic troubles
and expressive amusia of this patient. An analysis of the
musical dysfunctions showed disturbances of the rhythmic
sense and praxic disturbances. Rhythaic dysfunction was
demonstrated by the fact that the patient lagged behind when
singing with accompaniment, and by the lack of definite
rhythm in spontaneous production. The authors considered
the possibility that this implied a dysgnosic phenomenon, as
suggested by the inability to reproduce the given rhythms.
They felt, however, that "rhythmic sense is a function of
superior integration, the limits of which are considerably
larger than the range of the musical functions" (Botez &
Wertheim, 1959, p. 197).

According to the authors, studies by Luria (1947/1970),
Kreindler & Fradis (1957), and Pavlov (1951) showed that the
correlation between the fundamental processes of higher
nervous activity, which are excitation and inhibition, are
determinants for the quality of rhythmic reproduction. It
is possible, however, that a rhythmic disturbance also has
an apraxic origin. This disturbance is evident when rhythms
are attempted without a melodic support. The same rhythm is
produced correctly when it is bound to a musical sound or
integrated into a melody. This is called the facilitation
phenomenon. There is a significant analogy relevant to the
field of music therapy between this phenomenon and another

which has been described in some dysphasic patients who can

36

pronounce complicated words and sentences distinctly and
correctly when they are sung. The major difficulty for this
patient was to abstract the rhythm, to dissociate it from
the melodic element of music.

Musical dyspraxic phenomena were evident in the case
study by Botez and Wertheim (1959). The spontaneous vocal
production and reproduction showed intonational and rhythmic
deficiencies. There was, however, no agnosic component and
no receptive disturbance.

Other observations made by these authors may prove to
be of some clinical value. As this patient tried to repro-
duce separate sounds, he made a systematic transposition to
the superior or inferior fourth. This never occurred when
facilitated by a melody. The authors called this vocal
transpositional apraxia, as the characteristic element is
the performed transposition. No explanation is yet
determined for this phenomenon.

Through many variations of testing musical function,
the patient's receptive skills appeared intact while
expressive skills did not. He was unable to perform
requested dynamic variations because of his inability to
control the strength (amplitude) of the emitted sound. He
was, however, able to perceive variations in the performance
of another. Response to agogical changes (tempo variations,
accelerando, ritardando) was similar.

The intonational deficiencies were more evident in

ascending passages of a melody than in descending ones.

37

This may not be of unusual significance to the head-injured
person as the same is typically true in vocalization
patterns within the normal population. The exaggeration of
the phenomenon in brain-injured persons, however, emphasizes
the difference and draws attention to the realistic
difficulties involved in rehabilitation. From the motor and
praxic point of view, the strain of the neuromuscular
apparatus of phonation increases in the ascending scale.

Praxic disturbances were evident in the difficulty
involved in bimanual activity. The patient was not able to
play the accordion with two hands at once and was not able
to accompany himself on the accordion while singing,
something he had previously been able to do. He was,
however, able to accomplish each of those tasks one hand at
a time. In addition, a totally chaotic "accompaniment” on
the accordion did not induce the slightest vocal tonal
deviation.

Much of the literature has implied a right hemisphere
dominance for musical function. Botez and Wertheim (1959)
cited several authors (Henschen, 1925; Henschen, 1926;
Nielsen, 1946; and Feuchtwanger, 1930) who indicated that
the center for vocal singing is the pars triangularis of the
third frontal convolution, a region which is left-sided in
right-handed people. This emphasizes the discussion
concerning the connection between the "minor" hemisphere and
the musical functions.

Bever and Chiarello (1974) further analyzed musical

38

function, not so much as a specific location in the brain,
but from the perspective of the nature of the musical task
to be performed. The perception of melodic contour, for
example, is a Gestalt phenomenon best undertaken by the
right hemisphere which processes information holistically.
The analysis of the structure of a tone sequence, on the
other hand, is undertaken best by the left hemisphere which
is dominant for analytic processing. Further, whether or
not a musical presentation is apprehended holistically or
analytically is largely determined by the level of musical
sophistication of the listener. Generally, according to
this study, the more musically sophisticated the listener,
the more analytical the response; the more musical‘y naive
the listener, the more Gestalt the response. Gates and
Bradshaw (1977) further confirmed the basis for accepting
the representation of musical functions in both hemispheres.
Studies by Wertheim (1963, 1969) clarified these functions
into receptive and expressive amusia in the brain-damaged
patients. He suggested that receptive amusia corresponds to
a lesion in the dominant hemisphere, while a lesion in the
minor hemisphere may cause expressive amusia.

Geschwind (1972) provided a summary of the classic
studies concerning speech disorders and the organization of
the human brain. According to this study, the obstruction
or rupture of blood vessels in the brain was the third
leading cause of death in the United States. Aphasia, which

is a disturbance of language resulting from damage to the

39

brain, is a common aftereffect for those who survive such
cerebral traumas.

A Frenchman, Broca, published the first of a series of
papers in 1861 on language and the brain, and was the first
to point out that damage to a specific area of the brain
results in disturbance of language output (Geschwind, 1972).
The portion he identified, lying in the third frontal gyrus
of the cerebral cortex, is now called Broca's area. This
area is adjacent to the portion of the motor cortex which
controls the muscles involved in speech production. Damage
to the motor cortex in one hemisphere does not cause
paralysis of these muscles because most of these muscles can
be controlled by either side of the brain.

In 1865, Broca made another contribution to the
knowledge of language and the brain. Drawing conclusions
from eight case studies, he reported that damage to specific
areas of the left hemisphere led to disorders of spoken
language. Destruction of corresponding areas in the right
side of the brain did not affect language abilities. Rarely
is there an exception. Unilateral control of certain
functions is called cerebral dominance.

Examining the hypothesis that aphasia might be the re-
sult of muscle paralysis, Geschwind negated this possibility
by noting that a person with aphasia of the Broca type, who
can utter at most only one or two slurred words, may be
”able to sing a melody rapidly, correctly and even with

elegance" (p. 76).

40

Wernicke was an unknown with no previous publications .
when, in 1874 at the age of 26, as a junior assistant in the
neurological service in Breslau, he published a paper on
aphasia (Geschwind, 1972). He described damage at a site in
the left hemisphere outside Broca's area that results in a
language disorder differing from Broca's aphasia. In
Broca's aphasia, speech is slow and labored. Articulation
is crude. Small grammatical words and the endings of nouns
and verbs are omitted, so that the speech has a telegraphic
style.

Wernicke's aphasia, however, is quite different. The
patient may speak very rapidly, preserving rhythm, grammar
and articulation. Speech may sound normal, but it is
abnormal in that it is devoid of content. The patient with
damage to Wernicke's area also suffers from a paraphasia,
which can be of two kinds: verbal paraphasia and literal or
phonemic paraphasia. Verbal paraphasia is the substitution
of one word or phrase for another, sometimes related in
meaning ("knife” for ”fork") and sometimes unrelated
("hammer" for "paper”). Literal or phonemic paraphasia is
the substitution of incorrect sounds in otherwise correct
words ("kench" for "wrench").

Another difference between these aphasic patients and
those with Broca's aphasia was noted by Wernicke. A patient
with Broca's aphasia may have an essentially normal compre-
hension of language. A patient with a lesion in Wernicke's

area can suffer a severe loss of understanding, even though

41

hearing of nonverbal sounds and music may be fully normal.
Because of this, it is possible to predict the sites of
brain lesions on the basis of the type of language disorder.
Questions of hemispheric asymmetry and the implications
for rehabilitation are carefully considered. In the study
by Geschwind of 100 human brains it was noted that there
were striking asymmetries. The area studied was the upper
surface of the temporal lobe, which is not seen in the in—
tact brain because it lies within the depths of the Sylvian
fissure. The asymmetrical area was the planum temporale, an
extension of Wernicke's area. This region was larger on the
left side of the brain in 65 percent of cases, equal in 24
percent, and larger on the right side in 11 percent. Nada
(Geschwind, 1972) later confirmed those tests by studying a
series of brains from infants who had died shortly after
birth. The apparent genetic determination for the
asymmetries of the brain offers a new insight into the
search for an answer to the “nature or nurture“ question
concerning such things as handedness. It raises questions
regarding the plasticity of the brain and its implications
for therapy. For example, since the asymmetries of the
brain seem to imply a hemispheric dominance for particular
functions, how does one account for the apparent recovery of
language function in some cases? It seems that some capaci-
ty for speech function exists in the right hemisphere, for
although the left hemisphere is dominant for speech for most

left-handers, right-handers with a strong family history for

42

left-handedness show better speech recovery after injury
than people without left-handed inheritance. This kind of
information is valuable from the researcher/professional
point of view. In time it may prove to have very tangible
implications for rehabilitation potential for the traumati-
cally brain-injured person.

Ross (1988) called for clinicians to test brain-damaged
patients routinely for the ability to process affective
language. He proposed that language functions are lateral-
ized according to the behavior itself, e.g., affective
versus linguistic, and not according to the physical/acous-
tic carrier that expresses the behavior. Thus, he hypothe-
sized that the right hemisphere plays a privileged role in
the modulation of prosody at the sentence level (intonation,
fundamental frequency) in all speech production. This is in
contrast to the hypothesis that the right hemisphere plays a
role in imparting emotional-affective modulation of speech,
but is not critical to implementation of normal intonation
modulation in nonaffective contexts.

A point of interesting consideration to this author is
the acoustic consequence of right-brain lesions on the voice
of tone and monotone language speakers. It poses a differ-
ent possibility for brain organization if the manipulation
of fundamental frequency in tone languages, such as Handarin
Chinese and Taiwanese, is intimately tied in with word
meaning. In contrast, in nontone languages such as English,

only the intent of words, not their semantic representation,

43

can be altered by intonation. Music therapy might play a
quite different role with a head-injured patient depending
on the cultural context of the speaker and the learned
linguistic orientation. Ryalls (1988) would seem to suggest
that clinical observations must not only take into account
the presence or absence of coherent speech but also its
affective content. Clinical testing of Melodic Intonation
Therapy, for example, should document both neutral and
emotional contexts if the researcher is to refine his/her
diagnostic insights.

Studies concerning the precise location within the
cerebral hemispheres for musical tasks do not offer specific
conclusions for the functional application of music therapy
to the rehabilitation of the traumatically brain-injured
person. But what they do offer is an affirmation of musical
activity as a human process analogous to speech and cogni-
tion. Indeed, this author undertook this research with some
questions concerning the practical implications for thera-
peutic intervention with music for TBI patients. There are,
after all, persons who claim to be atonal or for whom music
has never held any significant place in everyday life.

Given the common tonal, harmonic, and rhythmic elements of
speech and music, and the potential for music to act as a
vehicle for the expression of affective thought, it seems
that music is as much a part of the human phenomenon as
talking and thinking. whether it is enjoyed or to what

depth it is pursued is dependent on the individual. And the

44

extent to which music can be used in the rehabilitation of
the traumatically brain-injured patient is most likely also
dependent on the neurological and aculturated receptivity of
the individual. But its role in the functional outcome of
rehabilitation appears to be more vital than previously

thought.

Family Studies

This section is divided into two subparts. In the
first subpart, there is a discussion of the history of the
development of the ecological approach in biology and
sociology. In this approach, the living organism and its
environment are viewed as an ecosystem. The perspective
which takes into consideration the interactions which occur
within the ecosystem is referred to as the ecological
framework. In the second subpart, a more specific focus is
placed on the environment, internal and external, of
families who have a handicapped member. By becoming
cognizant of the level and quality of support available to
the patient through the family, professionals can be more
sensitive to the implications of demands they place on the

family and patient for rehabilitation.

45

Ecglogical Framggggk

In 1868, Haekel, a German biologist, is credited with
coining the word Oekologie for a science he proposed to
study: life's relationship to the environment (Clarke,
1973). He did not pursue it but went on to develop other
life sciences. In 1892, Swallow, a New England chemist,
christened the term Oekology and used it to describe the
interdisciplinary environmental science she had worked to
develop.

The origin of the German word Oekologie can be traced
to the Greek word oikos which means house. Oek- stands for
every man’s house or environment, and -Iogie is derived from
the Greek logos, meaning science or word. According to
Swallow, Oekology was the “science of the house”. Histori-
cally, this concept has been used not only in the biological
sciences, but in sociology as well. The ecological approach
was introduced into sociology in the 19205 by Park and Bur-
gess. This concept has also been used in such disciplines
as geography, anthropology, psychology, and human ecology
(Goduka, 1987).

Hebster's New Morld Dictionary (1978) gives two defini-
tions of ecology. The first one has a biological base and
the second has a sociological base. The first definition
is: “the branch of biology that deals with the relations
between living organisms and their environment" (p. 442).

The second definition is: ”the study of the relationship and

46

adjustment of human groups to their geographical environ—
ment" (p. 442). In each there is an emphasis on the rela-
tionship of the living organisms or human groups to their
environment. In the second, also, the significance of the
definition lies in its inclusion of the idea of adjustment
as well as relationship. For families who need suddenly to
adjust to a handicapped member, as is the case when someone
suffers a traumatic brain injury, adaptation skills are both
critical and apparent.

Odum (1962) refined this definition in an effort to
make it more concrete. According to him, ecology is the
study of the structure and function of an ecosystem, that
is, the study of the structure and function of nature. By
structure is meant the composition of the biological
community, the quantity and distribution of the non-living
materials such as nutrients, and the physical matter. By
function is meant the rate of energy, matter and information
flow through the ecosystem.

Incorporating the concept of ecosystem into the defini-
tion of ecology, Odum brought it to a more tangible level.
It is easier to talk about relationships once they are seen
within the context of an ecosystem. This ecosystem could be
that of the patient, his/her family, or the medical institu-
tion, for example. The term ecosystem was formally proposed
by Tansley (1935) to describe "the whole system including
not only the organism—complex, but also the whole complex of

physical factors forming what we call the environment“

47

(p. 299). His definition encompasses all of the components
of an ecosystem, organic and inorganic, biomass or habitat.
All of these are regarded as interacting factors which, in a
mature ecosystem, are in appropriate equilibrium or homeo-
stasis. It is through this interaction that the system is
maintained.

As discussed by Tansley (1935), the term ecosystem
includes the whole idea of dynamic interaction, exchange, or
interdependence between an organism (D) and the environ-
ment (E). "Eco-", from which "ecology" is derived, means
environment. The concept of system comes from a general
systems model. It is conceptualized as a set of components
which act with and upon one another to bring about a state
of balance, interdependence or wholeness (Havelock, 1971).
Therefore, the term ecosystem is intended to imply an
interacting, interdependent complex of organisms which,
ideally, maintain an equilibrium among components of and
within a specific environment.

In the rehabilitation of the traumatically brain-
injured patient, for example, it is necessary to evaluate
the patient's physical, cognitive, and social-emotional
domains. These form a system of individual development.
These domains are interdependent and act with and upon one
another to help bring about the rehabilitation of the
patient. In addition, this personal ecosystem must inter-
face with the multiplicity of factors which make up the

environment or larger ecosystem which, in turn, influences

48

the responses of the patient. The totality of the environ-
ment in which a patient functions and which has some bearing
on his/her responses and decision-making process comprises
the ecosystem of the patient: for example, the socio-econom-
ic status of the patient or his/her family, the area of re-
sidence, the home environment and the type of family struc-
ture (e.g., closed or open). These factors all have some
effect on the availability of resources and the ability to
be receptive to these resources needed for rehabilitation.

Specifically, resources include personal, family and
environmental aspects. Personal resources or attributes
include interpersonal competence, intelligence, attractive-
ness, and coping skills (Nelson, 1980). The family as a
group provides a varying store of such resources as
stability, cohesiveness, and trust. Finally, the environ-
ment in which the family functions furnishes additional
resources and incurs additional costs.

The ecosystem view of the individual within the family
considers the family environment to be composed, not only of
family members with their reciprocal relationships, but also
family members within settings. Bronfenbrenner (1979)
contended that the study of human behavior as previously
conceived is really the study of development-out-of-context.
The model originally developed was for the observation of
sub-human species and was limited to the immediate, concrete
setting containing the living creature and focused on one

or, at most, two beings at a time in only one setting. The

49

understanding of human needs, however, requires the exami-
nation of multiperson systems of interaction that are not
limited to a single setting. It must take into account
aspects of the environment beyond the immediate setting
containing the person. For the patient, the environment
extends beyond the hospital and beyond the family, and may
indeed have some influence on his/her rehabilitation.

The ecological framework here presented is intended to
build context into the research model at the theoretical,
empirical, and clinical levels. In a proposed expansion and
subsequent convergence of the naturalistic and experimental
approaches, Bronfenbrenner offered several definitions of
substantive focus. Among these, this author has selected
four.

The first of these approaches is from the perspective
of the microsystem, defined as a ”pattern of activities,
roles, and interpersonal relations experienced by the
developing person in a given setting with particular
physical and material characteristics" (p. 22). This is the
immediate setting of the patient and includes the TBI
patient, then possibly the family, medical personnel, home,
and hospital, where the patient can readily engage in
face-to-face interaction.

The second definition is that of the mesosystem. This
comprises the ”interrelations among two or more settings in
which the developing person actively participates" (p. 25),

for example, home, hospital, church or work, and is

50

perceived to have a given role.

The third, the exosystem, refers to “one or more set-
tings that do not involve the developing person as an active
participant, but in which events must occur that affect, or
are affected by, what happens in the setting containing the
developing person” (p. 25). For the TBI patient, this might
be a spouse's or parent's place of employment. The rules
within that setting, for example, which govern the ability
to take time off to care for the handicapped member, have a
significant bearing on the decision-making process of the
family regarding the patient.

And the fourth perspective chosen for inclusion here is
that of the macrosystem. This includes ”consistencies, in
the form and content of lower-order systems (micro-, meso-,
and exo-) that exist, or could exist, at the level of the
subculture or the culture as a whole, along with any belief
systems or ideology underlying such consistencies” (p. 26).
At this level, realities such as the current political
ideology governing the country and the attitudes toward
legislation for the handicapped are likely to affect
choices. Though differing values may be evident between
systems at the microsystem level, there is generally an
overarching set of values at the macrosystem level which
affect the manner in which individuals function in their
microsystems.

The reason for analyzing these systems becomes more

apparent when looked at in terms of a simultaneous mutual

51

influence. Instead of an action and a reaction, it is more
accurately described as a transaction. Changes within any
of the systems will have an effect on other systems. “An
ecological transition occurs whenever a person's position in
the ecological environment is altered as the result of a
change in role, setting, or both” (Bronfenbrenner, p. 26).
Living systems are open or permeable, information-exchang-
ing, dynamic, and engage in a communication process by which

human systems and environments interconnect.

Families with Handica ed r

Overall, the literature on rehabilitation after an in-
jury has been client-centered as opposed to family-centered.
If the interactive ecological model is realistic, the rela-
tive success of rehabilitation is directly correlated to the
level and quality of support available to the patient
through the family. The family's ability to provide that
support is dependent on a variety of factors, such as
pre-trauma coping skills, open communication with the medi-
cal care system, support from extended family members, and
availability of resources such as time, energy, or money.

It is, therefore, the family's ability to adapt, to allow
the injured person's needs to alter and shape the perception
of what matters, that determines, positively or negatively,

what the outcome of the crisis will be.

52

Kflbler-Ross (1983) spoke of the confusion, guilt,
absence of information, fear of irritating those medical
personnel whom the families will need for help, anger and
helplessness that families experience when confronted with a
child or a spouse suffering a head injury. It is as though
the health care providers' only goal for the patient is to
keep him/her breathing at all costs. Family members are
often kept uninformed. Yet they are the ones who, ultimate-
ly, must live with the outcome of those initial post-trauma
hours. Medical advancements have created serious ethical
dilemmas. The answer to these dilemmas is not simple, it is
not final, and it is not solely the domain of the physician
or medical staff.

Future research needs to discuss quality of life, but
not as an absolute. The comatose patient's life is not pre-
dictably of less value because s/he does not respond. With-
out in any way attempting to diminish the pain, the anger,
and the tragedy of "losing" someone to a head injury, the
potential for growth and cohesiveness within the patient's
family as a result of the crisis should not be overlooked.

Kflbler-Ross (1983) alluded to the more gentle side of
tragedy in a saying:

Should you shield the canyons from the windstorms,

You would never see the beauty of their carvings.

(p. xix)

Brown and McCormick (1988) did a study on family coping

strategies following traumatic head injury. Often, they

53

felt, the family was presumed not to have the ability to
.'understand." For this reason, family members were not
informed or consulted frequently enough to elicit their
participation in decision-making. Lack of understanding for
the grieving and adaptation process the family needed to go
through tended to magnify their difficulties and interpret
them as weaknesses. Brown and McCormick suggested that, by
addressing the needs of family members in this situation, it
is possible to nurture their strengths. Research with ten
families having a head-injured member identified areas of
need. To each of these needs, the authors addressed a
specific recommendation. They paraphrased HcCubbin and
Patterson (1982) when they said that it is essential, if
there be a serious commitment to families with a head-
injured member, to adopt the perspective that families are
an integral part of the rehabilitation team. Hilz (1985)
said researchers and clinicians are wise to pay attention to
the families who have been liVing with a brain-injured
member. In most cases, they have made it their life's
business to learn everything there is to know about head
injuries. Professionals often view the patient from one
perspective, but the families interface with many
perspectives every day. They live the experience and they
have much to teach professionals.

Fortier and Hanlass (1984) proposed a five-faceted
model of a family crisis. Each facet is described in terms

of its effects upon the modalities of behavior, affect,

54

sensation, interpersonal relations, and cognition. On a
behavioral level, the family may need to provide immediate
care for the handicapped person, arrange transportation to
treatment, alter previous methods of scheduling time, and
meet new financial needs. On the affective level, the
family members begin working through feelings of grief,
anger, guilt, helplessness and isolation. On a physical or
sensory level, somatic symptoms may arise as a result of the
stress of the crisis experience. On an interpersonal level,
the family may have to deal with labeling or stereotyping, a
sense of isolation from others, handling ”helpfulness" and
advice from friends, and providing support for other family
members. On a cognitive level, the family is called upon to
assimilate technical information about the disability and to
deal with the impact of the diagnosis on established values
and expectations.

By understanding how family members work through the
stages of crisis resolution, the reasons and places for
therapeutic intervention become clearer. The therapist is
better able to recognize important symptoms and accept
certain "abnormal" behavior as normal in the context of the
crisis. With such knowledge, the therapist is more prepared
to implement appropriate intervention methods. Crisis reso-
lution involves reconciling the ”loss” of the family member
with the inclusion into the family of a new, now-handicapped
member. Kflbler-Ross (1969) proposed six stages of grief:

(a) denial and isolation, (b) anger, (c) bargaining,

55

(d) depression, (e) acceptance, and (f) hope. Closely
paralleling these, Bristor (1984) outlined a holistic model
for grieving when confronted with the inclusion of a
handicapped member into the family. The model detailed four

important factors that affect an individual's reaction to

loss: (a) degree of attachment, (b) the change the loss
causes in the day-to-day routine, (c) the manner in which
stress is usually handled and the individual's ability to
cope, and (d) the individual's support system and whether or
not family and friends give the individual permission to
grieve.

When Altshuler (1945) first applied the ”iso-” princi-
ple to the mental patient, he intended it to bring the
patient from what was presumed to be a distorted view of
reality into the reality which actually existed around
him/her via the use of music. Use of the ”iso-” principle
concept with head-injured patients and their families has
its value not in moving them away from the reality they
perceive, as is sometimes necessary with mental patients,
but in helping them to accept the reality they perceive.
Another value lies in helping them to recognize the
implications of their reactions to the loss, to understand
the cause of their feelings, and ultimately to accept the
reality as it is. To this end, Bristor (1984) suggested
that there are eight areas which the family needs to
explore: (a) initial awareness of the loss and its

immediate meaning; (b) acceptance of a range of emotions as

56

normal: (c) freedom to express feelings and to cry, and to
encourage this for men as well as women and children:

(d) inclusion of children in the grieving process:

(e) importance of friendships; (f) value of support groups:
(9) need for time for oneself; and (h) benefits of
counseling.

While a focus is rightfully on the gains to be made
through rehabilitation of the patient, the professionals
need also to be aware of the loss to the family incurred by
the injury. Demands for support of the patient‘s rehabili-
tative needs must interface with the family's need to
grieve.

Even while the grieving and rehabilitative process is
going on, new methods of coping are most likely needed. For
most, the experience of having suddenly to adjust to a
handicap is one they have never had before, and for which
there is little way to prepare. Schilling, Gilchrist and
Schinke (1984) refer to a definition of caping as problem-
solving efforts made by an individual when the demands of a
given situation tax adaptive resources. The authors sepa-
rate these efforts into personal coping and social support.
The first deals directly with coping mechanisms which can
help family members with the daily demands of caring for the
handicapped person. The second enables families to maintain
a sense of "normalcy" by continuing to interact with other
persons in addition to the handicapped member.

The magnitude of the needs of the brain-injured person

57

requires that family members often must act as therapists.
Harris (1984) pointed out that it is important for the
professional to go beyond teaching family members behavioral
skills and recognize that such training occurs within a
family context. Unless there is sensitivity to the impact
of behavioral interventions upon family functioning, such
training may prove disruptive rather than helpful to the
family as a whole. Healia (1976) raised concerns that some
behavioral approaches to clinical problems required a narrow
scope of treatment and felt that this failure to be aware of
the broad impact of one's interventions could lead to a
deterioration in the family unit. Recognizing this, Harris
(1984) thought-it best to approach families with handicapped
members from a family systems viewpoint instead of from the
viewpoint of only one member or from the viewpoint of the
handicapped person. From this perspective, it is important
to stress that the environment is not viewed as the cause of
the problem. Rather, family issues are seen as likely to
arise from, or be intensified by, the unusual stress of
unexpectedly having to incorporate a handicapped person into
the family.

There are only a few conceptual frameworks designed to
help clinicians differentiate families in disequilibrium
from those families who are stressed but coping well. Longo
and Bond (1984) did a review of the research literature to
identify measures of successful family functioning along

with models of practice to promote healthy family

58

adaptation. Two issues were addressed: (a) potential
dysfunction, and (b) potential adaptation. Does the stress
of having a handicapped family member necessarily result in
dysfunction of the family and/or family members? And are
there alternative ways of conceptualizing this clinical
problem without using models for intervention based on
impairment as an expected outcome? The implications are
predictable. If the assumption is that dysfunction is a
normative pattern in families with handicapped members, it
is conceivable that some clinicians may expect to find
problems in these families where none exist. For example, a
normal denial stage may be inaccurately assessed and
clinical interVention strategies may be non-productive and
even dangerous, rather than realistically supportive and
reassuring.

Kazak and Marvin (1984) discussed the differences,
difficulties, and adaptation styles in families with handi-
capped members. One of the unexpected findings in the
analysis of families where there was mother-child "overin-
volvement”, with the father peripheral to the day-to-day
parenting subsystem, was the lack of marital dissatisfac-
tion. Rather than reflecting a family structure in which
the father was peripheral to the family as a whole, this
experience could reflect a structure in which the father is
very central to the spouse subsystem, and peripheral only to
the day-to-day parenting subsystem. It was pointed out that

the importance of such a distinction can be seen when

59

viewing families within a family system model.

Sherman and Cocozza (1984) gave yet another perspective
on the kinds of decisions requiring the use and evaluation
of coping and adaptive skills within families. The decision
to seek out-of-home placement for the handicapped member is
affected by a number of factors: client characteristics as
well as other situational factors such as family character-
istics, stress on families, and social supports and
community services. While it is often true that the more
disabled a person is, the more likely the family is to seek
out-of-home placement, it is not always true. Because of
the difficulties encountered during the period of crisis
around the diagnosis, families frequently turn to persons
outside the family for advice and support, and are sometimes
greatly influenced by these advisers. The decision to
institutionalize may be a direct result of professional or
medical advice and not a function of client disability,
family stress, or inability to cope. Professionals need to
be cognizant of the potential role they play, not only in
the physical rehabilitation of the client but also in the
nurturing of the appropriate support system for the client.

Evolving out of the discussion of these issues, which
represent a portion of the kinds of issues families with
handicapped members must address, is an appropriate concern
for the implications for policy-making and clinical
practice. Bubolz and Hhiren (1984) discussed the linkages

between values, resources, and decisions in the various

60

parts of the total family ecosystem. While the focus is on
the varying systems (micro-, meso-, exo-, and macro-) of the
patient and his/her family, the clinician also needs to look
at the differing levels of influence s/he exercises within
the rehabilitative schema. The authors proposed an ecolo-
gical systems model as an appropriate vantage point from
which to look at the family as a microunit of society and as
an environment and source of resources for all its members
including a handicapped person. The expectation is that
clinicians make a consistent effort to keep it all in
perspective. While the handicapped person is at times an
all-consuming focus of attention, s/he is not, or might not
be, the only point of focus.

The ecological systems model, or ecosystems model, is
based on a systems perspective, a unifying holistic model
which focuses on the interrelationships and feedback
processes between components of a system (Buckley, 1967). A
basic tenet of this approach is that a change in any part of
the system, such as the loss of a family member or the
addition of a handicapped member to the family, affects the
system as a whole and its other subparts. This creates the
need for a system-adaptation rather than simply attending to
a single part of the system. Based on the general systems
concept of ”wholeness“, it is presumed that as segments of
the family system or the environment change, the state of
equilibrium of the ecosystem will be disrupted necessitating

counterbalancing or elaborating changes.

61

According to Bubolz and Whiren (1984), in an ecosystem
model of the family the following assumptions are made:
1. Any alteration in the flow of energy,

matter, information, and other resources
through the family system requires adaptive

change.
2. Supplies of human energy -- physical and
psychic —- are limited.

3. Behavior of individual family members creates
stress, which requires additional energy inputs
by other family members or from external
supports, as well as energy input for obtaining
these supports.

4. Undue energy demands create "energy sinks“ -

where adaptive, creative behavior may no longer
be possible —- resulting in still greater
stresses on the family. (pp. 7-8)

The microunit of the family cannot operate indefinitely
with extremely high energy expenditures. It can do so
repeatedly for brief periods if the resource base and
capital goods (savings, knowledge, kinship, and friendship
support) are adequate. However, as was shown in Chapter I
of this thesis, persons with traumatic brain injury may, on
the average, live another 40 or so years beyond the time of
the injury. The ongoing demands on material and psychic
energy, as well as other resources of the family, can
exhaust the resources. Again, difficult moral/ethical
judgments and decision-making dilemmas must be confronted by
families and other societal units. If family resources are

depleted in caring for the handicapped members, other family

members may be deprived. Society as a whole is then

62

affected. But society is also affected if families strive
to develop the nurturant and caring capacities of the
non-handicapped, which in turn asks of society that it
develop a way of supporting the families in that effort.
Following are some of the implications for policy and
practice quoted and adapted from Bubolz and Whiren (1984).
These stem from, and are more accessible because of, the use

of an ecological model.

1. The total family unit must be considered in the
development of a plan and program for a handicapped member
so that decisions are made which are most likely to produce
the greatest benefits or least costs to all members of the
family.

2. “Appropriate support and services must be provided
to the total family unit. Healthy children whose lives are
inextricably altered by the presence of a handicapped family
member may inadvertently be placed at developmental risk in
the family's attempts to cope with a crisis producing
member" (p. 11).

3. The issues of longevity of the seriously handicapped
need careful examination in the development of policies and
programs for care of the handicapped. What responsibility
do siblings have in this regard?

4. "The total energy needs of the family must be consi-
dered in establishing external systems of support. . . .

Additional energy flow into the family in goods, money, or

63

labor should be at least equal to the energy sink generated
by the presence of a handicapped member.

[Therefore], . . . the inputs and the energy sink would be
higher than normal but the outputs from the family would
remain normal in quality and quantity” (p 11).

5. ‘Easily accessible information retrieval systems and
advocacy systems need to be established,” such as the
National Head Injury Foundation and state and local
chapters, so that patients and families “can receive the
kinds of information and service inputs they need for caring
for the handicapped member" (p. 11).

6. ”An ecological model should be used in the design
and implementation of delivery systems for community
programs for the handicapped” (p. 11). The focus of
assistance should be on the holistic nature of the needs of
the handicapped person and his/her family.

7. Placement of the handicapped person needs to be
carefully evaluated, whether that placement be with the
handicapped person's family or with a community agency. Are
these persons going into microunits in which there may not
be sufficient energy or resource base for the maintenance of
the group and appropriate outputs into the community by
other family members?

8. Adoption of handicapped children, as far as this
author knows, has not been discussed for the traumatically
brain-injured person. It may be, however, a sensitive,

though difficult option based on the value system and energy

64

needs of the family of the handicapped person. Variations
of this possibility are already in use such as foster care
and respite care.

9. Education of the public into an awareness of the
psychological, physical, ethical and economic dimensions of
the family systems of the handicapped needs to be

emphasized.

CHAPTER III

PROPOSED INTERFACE OF BRAIN INJURY AND
MUSIC THERAPY WITHIN AN ECOLOGICAL FRAMEWORK

Through various therapeutic modalities over the years,
many treatment possibilities have been explored with differ-
ent populations. Verbal and non-verbal approaches have been
utilized. Treatment has focused on the individual patient
as well as on the environment in which the patient is
receiving treatment. In some instances, the families have
also been included in treatment. These and other avenues
have served to create a background from which to gain
insights into what has proven to be beneficial with specific
populations and what has not. During earlier years, treat-
ment efforts focused on developmental and psychological dis-
orders. In more recent years, medical science has added the
traumatically brain-injured patient to its list of those who
can potentially be helped. Without discounting past experi-
ences in therapy, but recognizing the ever-evolving insights
and technical capabilities available to clinicians today,
the music therapist needs to assess and choose carefully
those forms and aspects of therapeutic intervention which

are likely to be most beneficial in treating this

65

66

population.

The new health paradigm has been gradually shifting
away from the concept of institutionalizing those who need
the assistance of the medical profession. The insurance
system, while it has not resolved the issues of recuperation
and rehabilitation, has forced health care professionals to
grapple with cost-effectiveness and alternative means of
support. As a result, there is added impetus to make use of
whatever human resources may be available to the patient.
One way to determine the type and level of available
resources is through the use of an ecological model. This
can be expressed as a visual tool which is easily accessible

to both the client and the therapist.

Ratignale for Use 2f an Ecolggical Approach

The traumatically brain-injured patient is generally in
need of multiple interventions by a variety of treatment
professionals. These can include physicians, surgeons,
psychiatrists, neuropsychologists, speech therapists,
physical therapists, occupational therapists, and recreation
therapists. They also include social workers, nurses,
laboratory personnel, technicians and educators. Most will
interact directly with the patient at some time. Family
members and significant others provide the emotional and

financial support which determine in varying degrees the

67

potential for, and actual outcome of, rehabilitation for the
patient. The music therapist will not likely be the sole
nor the primary therapist for the typical TBI patient, and
therefore must be able to interface effectively with other
professionals, personnel and family members. Those involved
with the TBI patient will be called on to absorb and inter-
pret essential and relevant information from multiple sour-
ces, each often with its own brand of technical language.

In Chapter I, it was noted that, in a careful search of
the literature concerning the use of music therapy in the
rehabilitation of persons with closed-head injuries, no
clearly elaborated framework or model which takes in the
multiplicity of factors concerning the patient had been
developed. A single-discipline model draws on the theory,
principles and practice of music therapy, identifies a need,
and attempts to provide a beneficial and therapeutic inter-
vention to the head-injured victim. The relationship is
direct between the therapist and the client, and the focus
is on the specific goals attainable through the medium of
music therapy. However, if the single-discipline approach
ignores or affords only limited communication with other
health care personnel or family of the patient, it would not
likely be efficient or effective. The extensive time period
involved in rehabilitating a TBI patient requires that there
be a built-in means of communication that can span time as
well as numbers of systems involved.

Considerable improvement in communication supportive to

68

the therapeutic process is possible with an interdiscipli-
nary approach, wherein the various care providers act as a
team, having a greater or lesser degree of structure. In
this model, each treatment professional shares information,
treatment goals, and progress notes with all the others.
There must be some effective means for joint decision-making
in terms of treatment priorities, coordination and continu-
ity of care, and conflict resolution when indicated. The
purpose of such an interdisciplinary structure is to ensure
that the care is not unduly fragmented and that the patient
derives optimum benefit. Often, however, there is a
dominant discipline within the agency or within some other
support system which imposes aspects of its own theoretical
and practical structure on the other disciplines. For
example, the interdisciplinary approach frequently begins
and ends within the hospital setting. Treatment takes place
within the hospital and with a necessarily narrow focus.
Schedules revolve around hospital staff, and the support
system for rehabilitation comes from within the medical
facility. It is an appropriately concentrated effort at
certain levels of recovery.

Each contributor in the interdisciplinary approach
maintains a vantage point unique to a particular discipline,
yet the boundaries of separate theoretical frameworks are
expanded to include concepts borrowed from other disci-
plines. One difficulty is that only those concepts which

pose no serious challenge to the others or which involve no

69

major language difficulties can be received or welcomed.
Further, and of most significance to this thesis, in the
interdisciplinary approach, the interfaces between concep-
tual frameworks of different disciplines are sometimes
ignored, and, as a result, the interfaces between the
systems represented by the various disciplines are ignored
(Auerswald, 1968).

Building upon the recognized strengths of the interdis-
ciplinary approach, the ecological framework can offer addi-
tional advantages. It is a contextual approach which takes
into account the total environment in which the patient
actually lives and functions, including the resources, the
stressors, and all of the subsystems. It is to be
distinguished from the concept of an artificially created
therapeutic environment3 which is designed to maximize the
positive influences on the patient long enough to enhance
his/her ability to become stabilized at a level receptive to
the development of appropriate coping mechanisms. A
possible difficulty with this approach is that the coping
mechanisms are generally directed toward adaptation to the
artificially created environment, thus, in effect, teaching
the client to be a good patient. The ecological model

considers the real environment of the patient as it is,

 

3 As in the technique known as milieu therapy.

70

recognizing that emotional and financial resources, both
positive and negative, will come from the internal and
external environment as it exists for that patient.

In the ecological model, coping skills and programs for
rehabilitation are developed which take into account what
resources are available or possibly available for that
particular patient. Knowing this increases awareness of the
consequences of the decisions made on behalf of the patient.
The ecological framework is used to structure the gathering,
processing, and utilization of information relating to the
patient, the patient's family, and the various therapies and
professional disciplines. The framework would thus enable
and foster information exchange among all members of the
system, and would encourage thoughtful and comprehensive
goal setting with appropriate input, not only from the
professionals, but also from the family of the patient and,
when possible, from the patient as well.

For these reasons, the ecological model enhances the
potential for consistency and continuity of care, as the
various care providers are familiar with, supportive of, and
reinforcing of one another's efforts. According to Howard
(1986), there are seven factors which must be present
throughout treatment in order to facilitate the best
possible response from the TBI patient. Treatment must be
(a) structured, (b) consistent, (c) repetitious, (d) speci-

fic, (e) practical, (f) reinforced, and (g) meaningful to

71

the patient. If the communication is open and consistent
among team members, that, as well as these seven factors,
becomes a valuable resource for the patient involved in
rehabilitation.

A major contribution of the ecological approach is that
it changes the vantage point of all participants. Instead
of each viewing the patient from the narrow perspective of
one discipline, the starting point becomes the system as a
whole. The model focuses on the interrelationships and
feedback processes among components of a system (Buckley,
1967), that is to say, on the holistic nature of the problem
of the individual or family needing attention.

The following is a proposed model of an ecological
framework for the use of music therapy with the traumati-
cally brain-injured patient. Its purpose is to demonstrate
the interface and energy flow between the patient and each
”system" and among the systems themselves. More specifi-
cally, its purpose is to illustrate how interventions of a
music therapist may be purposefully integrated into the

rehabilitative process.

Proggsal for an Ecological MQge;

The utilization of an ecological model to assess the
head-injured patient requires a focus on the complex ecolo-

gical system which includes the TBI patient, his/her family,

72

their total environment, and the transactional relationships
within that environment. Specifically, the ecological sys-
tem of the patient, as the source of nurturance, stimula-
tion, and support that must be available for the successful
rehabilitation of the patient and the survival of the family
unit, becomes the point of focus.

In order better to visualize these resources which are
embedded in a complex mass of interrelated data, a model has
been devised. It is intended for use by the professional as
an interviewing and assessment tool with the TBI patient and
his/her family. Its use helps the family of the head-
injured patient, the health care personnel, and perhaps
eventually the patient to assess the quality of the life
space of that patient and family. Stress and conflict are
recognized as part of the environment of any living system,
but it is also recognized within the ecological view that a
balance must be achieved between stress and support, between
demands and resources, when considering the potential for
success in the rehabilitation of the TBI patient. This model
assists the therapist to assess the implications of the
rehabilitative demands on the patient and the family and to
gauge whether they have an excess of resources, whether they
are already stressed, or if they are without support. In
addition, this kind of analysis helps the family think
through the implications of having a head-injured member and
what impact a TBI patient with all his or her needs,

demands, and requirements may have on the balance currently

73

being maintained in the family's ecological system.

The focus of an ecological model is on the life space,
that is, the ecological system, of the patient and family.
Within this format the family members can feel comfortable
and non-defensive and at the same time begin to see them-
selves as part of a system capable of supplying a support
base.

In developing an ecological model for use with the TBI
patient, the EcoMap, which is an interviewing and assessment
tool, is used in order to provide a gross evaluation of the
life space of the patient (Hartman, 1981). The EcoMap may
be sketched on a plain piece of paper or may be constructed
by filling in a blank EcoMap as pictured in Figure 1. It
was decided by this author that for the family under stress
and unlikely to have had experience with the EcoMapping
process, the simple, structured model would be used first
because the process may be easier to learn by following the
structured map.

The circles represent the systems involved with the
family and patient and thus begin to introduce them to the
systems approach to problem solving. Most circles are
initially the same size to allow those participating in the
process to place their own value on them; however, the size
and placement can vary. Value can be implied by the size of
the circle, the distance from the smaller circles to the
central circle of significance, or the variations in the

lines drawn between them. This type of assessment tool is

74

 

Date

 

a
a O a

Figure 1. EcoMap I

This is a blank map which is intended to provide

an introduction to the systems approach.

75

flexible and family members should be encouraged to make
their own evaluations.

Figure 2 suggests possible ways to vary the size and
distance of the circles and to fill them in. The tool is a
flexible one and is intended to be specific to the parti-
cular family and patient in question. Therefore, it will
probably be helpful for the therapist applying the tool to
make suggestions. People are often unaware of themselves as
part of a system. As such, they are also unaware of the
interactions taking place between systems or the control
they themselves might be able to exercise over the influ-
ences in their lives. Persons in crisis may tend to look
for support from inappropriate sources and not recognize the
resources which may now appropriately provide support. When
one considers the number of words it would take to discuss
and explain this network, the usefulness of pictures becomes
more evident.

Figure 3 deepens the understanding of the effect of the
TBI patient's injury on the family. Members of the house-
hold are depicted as follows: a woman is indicated by a

circle; a man by a square; a married couple as follows:

 

Tom

44

 

 

 

76

 

Dete

 

extended
feeily

rehabilita-
tion can-
eultent

heed injured
patient

Figure 2. EcoMap II

 

Fill in connections where they exist.

Indicate the nature of connections with a
descriptive word or by drawing different kinds of
lines: for strong, ------ - for tenuous,
======== for stressful.

Draw arrows along lines to signify flow of energy,
resources, etc. --9 --> --9.

Identify significant people and fill in empty
circles as needed.

77

       
 

Naee
Date
Rehabilitation
resources '
4
v
‘9.
\ ¢>
a \ 4
c ‘\ ‘
p’ \
‘\ m“
e “‘
pirents , Faaily of
I .
to "run "Pine

I'll ‘lllj s'-wtw
s$“"“ ‘ m m a
s tort um“

head-injured patient
‘1 .g:

s
\

Extended

~ fanly
(not sure about
(Aunt very

 

close to

tiee off for
731 patient)

father)

Figure 3. EcoMap III

This type of model gives family, patient, or
professional the opportunity to describe systems
they see as significant, as well as strength of
connection between and among the systems.

78

Children and siblings are connected to the diagram of the

parent like this:

 

Steve John

 

 

Ages are written in, giving the reader a better sense of the
patient‘s possible role within the family. Additional
information on genograms can be found in Hartman, 1981.

Connections in the following figure are intended to
portray the total family group's relationship with various
systems in the environment. Three kinds of lines for
strong, tenuous, and conflicted relationships are an
effective shorthand for a quick, objective assessment of
relationships. For a more thorough evaluation, however, it
would be useful to have the family or patient offer a word
most descriptive of their interpretation of the type of line
chosen (Figure 3).

Finally, the last model presented (see Figure 4) is
designed to show the complexity of the interfaces between
and among the micro-meso-exo-macrosystems of the patient and
family. Connections are drawn from the family as a whole as

well as from the individual family members. Not all

T71?

 

 

  
 

 

 

 

 

 

 

 

 

 
      
 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

laee
Date
Eeergency Rauro- tare
rum «mum tiff/f
Ieighbors
IEOIORL Church!
HOSPITAL Cultural
friends
Iori
Extended
faeily
ll 4 42
Econoeic
institu- Education
tion 20 IS 12 Friends
/'
head-iniur
aeeoer
CORRORITY School
RESOURCES Voca-
Rehabili- tional reha-
tation bilitation
consultant
Social REHABILITATION
Service SERVICES

 

 

 

 

Aes/ “that”
A’/ mm m

 

 

 

 

Speech Recreation
Therapy Therapy

Figure 4. EcoMap IV

80

possible lines have been drawn, but only enough to suggest
possible interfaces which affect the TBI patient. Larger,
overarching systems are depicted by squares, while smaller
circles indicate the multiple systems with which the patient
and family are required to interact more directly. It
should be possible for the professional or other individual
to find him/herself in the diagram and identify lines of
communication that will most likely enhance the rehabilita-
tion of the patient. Such a model helps the professionals
to realize that the patient and the family must interface
with many people each day where the rehabilitation of the
patient is concerned. Hopefully, this will highlight areas
of support as well as areas of weakness.

Figure 4 was developed for the purpose of showing that
many systems interface with the system of the patient and
family. Varying lines were not used only because of the
great variety of possibilities. It is important to note
that connections can be strong or weak, strenuous or nurtur-
ing. Agencies that exist in theory as support systems can
at times add to the stress, e.g., insurance companies or
political institutions. And other systems which play a
minor role for one patient may be a tremendous source of
support for another such as extended family or church
affiliations.

Use of an ecological model requires that we

realize that policies, programs, and services for

the handicapped and their families are directly
related to the value we hold about equality of

81

opportunity and access to resources, respect for

life and human dignity, work, health and well-

being, development of human potential, indepen-

dence and justice. The model does not make it any

easier to resolve and manage the complex decisions

and problems related to caring for the handicapped

and their familiies, but it can increase the

awareness of consequences that may follow from the

decisions we make. (Bubolz & Whiren, 1984)

The music therapist might begin using the model by
drawing an EcoMap and placing him/herself in the appropriate
relationship to the patient. The ecological model then
becomes a way of thinking about a patient and accounting for
significant components of his/her ecosystem. It is not in—
tended to be mechanistically applied through a single tool.

The EcoMap was selected as one clear means of expressing the

ecological concept.

CHAPTER IV

SUMMARY AND RECOMMENDATIONS FOR RESEARCH

In this paper, an effort was made to develop a resource
base which can facilitate research on the use of music
therapy with the traumatically brain-injured patient.
Several types of literature were reviewed in order to
identify what forms of music intervention have been utilized
with the head-injured population, to attempt a theoretical
explanation for the efficacy of this intervention, and to
describe an ecological framework. Suggestions for further

research will be discussed.

Summary and Discussion

This study has brought together the available
theoretical and empirical foundation which supports the
usefulness of music therapy with TBI patients. Sufficient
evidence exists to suggest that music therapy is a valid
intervention with this kind of patient, and that further
research in this area is critically needed.

In addition, the study has described the value of

82

83

employing, as an overarching framework, the ecological or
contextual approach within which information exchange is
more readily facilitated. It is suggested that the ecologi-
cal model will contribute to the beneficial integration of
factors affecting the brain-injured client.

This thesis has, moreover, brought an abundance of
useful information within ready grasp of the music therapist
who is considering work with brain-injured patients. The
study reviewed all of the known literature regarding the use
of music therapy with persons who have experienced brain
injuries. As noted, these are not carefully constructed
studies and do not of themselves form a sound basis for
generalizable conclusions. They do, however, suggest that
an important beginning has been made. While these papers
were mostly published in media readily available to the
practicing music therapist, they are few in number and may
be easily overlooked.

The study has also reviewed a representative portion of
the literature on brain research insofar as it appears to
provide a rationale for the possible beneficial use of music
in rehabilitation of persons with closed-head injuries. In
these cases, however, the articles are generally published
in books or journals not typically within reach of the prac-
ticing music therapist nor are these materials, for the most
part, familiar to those in the music therapy profession.

Finally, this study has described some of the litera-

ture in family ecology which may be helpful to the music

84

therapist in this highly complex area. Once again, this
body of literature is not usually found in the library of a
music therapy practitioner or of a university music therapy
department.

Besides making available this review of relevant
literature, a number of other resources are also provided.
The terminology and technical vocabulary relating to
neuropsychological, medical, and ecological disciplines can
be confusing. To aid in managing the language specific to
these professions, and to facilitate communication with
other professionals, a glossary of terms is supplied in this
study.

Appendix A gives a brief listing of informational and
supportive resources for the traumatically brain-injured
patient or for the family or therapist of a TBI patient.

For a music therapist newly entering this field, this mate-
rial may be of considerable assistance. The professional
listings of Appendix B can be similarly useful.

Appendix C contains the principal components of the
Rancho Los Amigos Hospital scale for rating levels of cog-
nitive functioning. These levels range from fully comatose
patients (no response) to those evincing purposeful and
appropriate responses. This scale is highly useful and will
be indispensable for the therapist-researcher in this area.

Finally, in addition to the index of published materi-
als which were cited in the text of this paper, an extensive

listing of related literature can be found in the general

85

reference section of the bibliography.

§gggestions for Further Research

As a consequence of the literature review and the

development of the model presented in this paper, a number

of questions for continuing research have been generated.

Among these are the following:

1.

How can music therapy be of benefit to the traumati-
cally brain injured client?

What functional outcomes can be expected as a result
of music therapy intervention?

Is music therapy best employed in isolation or in
conjunction with another discipline, e.g., speech
therapy?

To what extent can music therapy be useful as a
means of integration among various therapeutic
interventions, supporting and reinforcing what other
therapists do, and ensuring that human needs of the
patient are not overlooked, affording, where

appropriate, necessary relaxation and comfort?

In addition, the ecological model needs to be thorough-

ly field tested with professionals and families involved

with TBI patients to assess its utility and applicability in

this arena. Moreover field testing should be employed to

86

determine how best to adapt the ecological concepts to the

needs of the music therapist.

Experimental Rgsearch

The utility of music therapy with traumatic brain
injuries should be carefully studied, since little more than
anecdotal and conjectural information is presently avail-
able, although the theoretical basis for its efficacy
appears to be in evidence in neurological and physiological
research. Future studies with TBI patients should differen-
tiate the diagnosis, precise location and type of lesion,
nature and extent of functional deficit, pre-existing
cultural characteristics and premorbid tastes, preferences,
habits and skills. It may be that music therapy offers
potential benefit to certain distinguishable types of TBI
patients rather than to others. It may also be that use of
specific music therapy tools and methods are more effective
than others with this clientele. The presence or absence of
previous or concomitant interventions by other therapeutic
disciplines may be very relevant. To identify the separate
and interactive influence of each of these factors,
multivariate analysis of data will be required. Well-
controlled studies can be designed with patients randomly
assigned to experimental and control groups, following the

appropriate protocols for conducting research on human

87

subjects.

An essential prerequisite for any serious studies of
this type is the development of a comprehensive assessment
instrument to use in gathering information on all parameters
relevant to music therapy, including neurological, physiolo-
gical, social, emotional, educational, familial, musical,
and environmental data. The preparation and field testing
of such an instrument will represent another opportunity for
research. The assessment tool should prove helpful, not

only to researchers, but to practicing therapists as well.

Case Studies -- ngily and Individual

This paper has described an ecological framework for
the use of music therapy with TBI patients. Whether this
approach is better under all or certain circumstances than
such alternatives as the single-discipline approach or the
interdisciplinary approach can be evaluated using the
case-study method.

Use of an ethnographic research approach which allows
for careful and thorough observation of a wide variety of
characteristics of the individual, family, and environment
of TBI patients can help to discover and assess the relative
advantages of these approaches and can ascribe a plausible
rationale. Case study methodology is particularly useful

for explanatory, descriptive and exploratory purposes (Yin,

1984). It frequently can supply details which aid in

understanding the phenomena under scrutiny.

Practical and Clinic 1 li ations

From the literature which has been reviewed (Chap-
ter II), it is expected that music therapy will be found
particularly useful with speech and motor impairments, in
teaching relaxation skills, and in enhancing higher levels
of cognitive and affective rehabilitation. There is no a
priori reason to conclude that music therapy will not be of
benefit in most remediable deficits of persons who have
suffered closed-head injuries. Again, only through detailed
patient classification and careful empirical research can
one point with greater certainty to the relative utility of
this discipline for these clients.

The patient will be the beneficiary if the therapists
make effective use of the ecological model to enhance
information exchange and to ensure that important processes
are not overlooked. This approach, too, can and should be
tested and refined.

Finally, it is contended by this writer that music
therapy, properly applied, is integrative and can serve to
help avert fragmentation and discontinuity of patient care.
The basis for this assertion is that (a) music itself is

integrative, (b) the involvement of left and right hemi-

89

spheres of the brain in the production and reception of
music is an integrative process, and (c) the recommended
ecological framework for the use of music therapy with TBI

patients is essentially an integrative concept.

GLOSSARY OF TERMS

GLOSSARY OF TERMS“

A. Neuropsychological Terms

ACALCULIA: inability to perform mathematical operations,
recognize numbers, or count.

ACQITY: keenness of sensation.

AGNOSIA: loss of ability to recognize familiar people,
places, and objects.

AGRAPHIA: loss of ability to express thoughts in writing.
fiLEXIA: inability to read or recognize words.
ALEXIAS: disorders of reading ability:

Alexia with agraphia: characterized by marked disa-
bility in reading and writing at all levels, includ-
ing reading aloud and silently, matching words to
pictures, identifying letters, and writing spontane-
ously and to dictation.

Alexia without agraphia: characterized by marked
impairment in reading ability with relatively well-
preserved writing ability. Letter recognition and
naming, although slow, are typically fairly well-
preserved. Words are only poorly and slowly recog-
nized, usually by spelling and sounding them aloud.
Letter recognition is often facilitated by tracing
the letter with the finger, or even with head or eye
movements. Writing is well-preserved. However, pa-
tients often cannot recognize what they have written
a few moments after they have written it.

 

‘ Adapted from: Baker, 1988: Bannister, 1985: Campbell,
1981; Carpenter, 1978: Fincher, 1981; Freedman and Kaplan,
1967; Geschwind, 1972: Miller, Keane, & Saunders, 1978:
NAMT, 1985; NHIF, 1986: Posner, 1978: Ross, 1981; Rowe,
1970; Swiercinsky, Price & Leaf, 1987.

90

91

Anterior alexia: accompanies Broca's or motor
aphasia and is characterized by an incomplete
disability in reading and writing. Letter naming,
identification, and writing to dictation are poor,
while word recognition, word-picture matching and
word writing is better. Concrete words, especially
nouns, are handled better than abstract and gramma-
tical words.

AMUSIA: impairment of premorbid musical ability following
brain damage, whether for perception or (re-)produc-
tion of vocal or instrumental sounds.

ANOMIA: inability to name objects or recall individual
names.

ANTEROGRADE eflNESI : loss of memory for events and periods
of time following an injury or traumatic event.

APHASIA: impairment, due to brain damage, in the ability to
understand and produce language.

APRAXIA: loss of ability to carry out a purposive movement,
the nature of which the patient understands, in the
absence of severe motor paralysis, sensory loss, and
ataxia.

APROSODIA: the various combinations of affective language
disturbances, encompassing both production and/or
comprehension of gestures and the affective compo-
nents of prosody, caused by focal right-brain
lesions.

ARCUATE FASCICULUS: a bundle of interconnecting fibers in
the left hemisphere which serves as the nerve
pathway from Wernicke's area to Broca‘s area. An
utterance arises in Wernicke's area. It is then
transferred through the arcuate fasciculus to
Broca's area, where it evokes a detailed and coordi-
nated program for vocalization. The program is
passed on to the adjacent face area of the motor
cortex, which activates the appropriate muscles of
the mouth, the lips, the tongue, and the larynx.

ASTEREOGNOSIS: inability to recognize objects or shapes by
feeling them.

ASYMMETRY: discrepancy in function or appearance between
sides of organs.

ATAXIA: failure of muscular coordination; irregularity of
muscular action.

92

ATHETQID: affected with athetosis.

ATHETQSIS: slow, repeated, involuntary, purposeless, muscu-
lar distortion involving part of a limb, toes and
fingers or almost the entire body.

ATTENTION: ability for sustaining focus on task for a period
of time to allow for coding and storing of informa-
tion in memory.

TTENTIONAL DEFICITS: behavior problems common after a head
injury, and/or difficulty in concentrating.

AUTOAGNOSIA: disorientation to body parts.

QOGNITION: the process of thinking, understanding, and
reasoning.

COMA: those states in which cognitive functions are
diminished and the patient is unresponsive to all
outside stimuli.

CONDUCTION APHASIA: speech impairment caused by a lesion
which disconnects Wernicke's area (adjacent to the
cortical region that receives auditory stimuli) from
Broca's area (adjacent to the cortical regions of
the brain that control the muscles of speech). If
the two areas are disconnected but intact, speech
will be fluent but abnormal, and comprehension
should be intact. Repetition of spoken language
would be grossly impaired.

CONTRA-COUP DAMAGE: damage to the brain opposite the side of
the head which was hit.

COUP DAMAGE: damage to the brain at the point of impact.

DISASSOCIATION: inability to conceptualize; concern with
details rather than with the whole.

DISINHIBITION: loss of restraint or decrease in ability to
stop oneself from saying or doing something that is
typically undesirable.

DISORIENTATIUN: disturbance in recognition of person, place,
and/or time and day.

QISSOCIATION: separation of an idea or desire from the main
stream of consciousness and making it coconscious:
the splitting of the personality into disunited
parts.

93

DISTBAQTIQILIT : the reaction to all stimuli available at
one time, being unable to eliminate all but the
essential stimuli.

DYSARTHRIA: imperfect articulation of speech due to
disturbances of muscular control resulting from
central or peripheral nervous system damage.

DYSGNOSIC: any anomaly of intellect.

DYSPHASIA: a disorder of the symbolic function of speech
involved in the comprehension and expression of
meanings by means of words.

DYSPRAXIA: difficulty or pain in performing any function.

EMOTIQNAL LABILIIX: intense fluctuation of emotions in
response to experiences.

GLOBAL APHASIA: total aphasia, which results from massive
destruction of the frontotemporal region of the left
hemisphere.

GNOSIA: the perceptive faculty of recognizing persons and
things.

GYRUS: a convolution of the cerebral hemisphere of the
brain. Gyri are separated by shallow grooves
(sulci) or deeper grooves (fissures).

 

HEMIPARESIS: muscle weakness of one side of the body.
HEMIPLEGIA: paralysis of one side of the body.

IMPULSIVITY: a behavioral trait, common following head
injury, in which the individual acts or speaks
without first considering the consequences.

INFLEXIBILIT : rigidity in thinking; overreliance on
stereotypes: difficulty in recognizing alternative
possibilities.

ORIENTATION: awareness of time (current day, month, and
year), place (where s/he is), and person (who s/he
is).

PERSEVERATION: the prolonged after-effect of stimuli, as
distinguished from the purely psychological
mechanism of perseveration due to anxiety, fear of
proceeding to new experiences or other emoional
factors. It is the overreliance on or repetition of
a specific response or behavior to different tasks.

94

PHONEME: a family of closely related speech sounds regarded
as a single sound and represented in phonetic
transcription by the same symbol. There are 46
phonemes in the English language.

ELANTAR RESPONSE: contraction of toes upon irritation of the
sole.

POST-TRAUMATIC AMNESI : loss in memory for events related to
a traumatic event and the period immediately follow-
ing the trauma. (Same as ANTEROGRADE AMNESIA)

PRQSOD : the science or art of versification (including the
study of metrical structure or rhyme); a system of
versification.

RETROGRADE AMNESIA: loss of memory for events and periods of
time before an injury or accident.

REVERSAL FIELD TENDENCIES: a condition in which figure and
ground relationships become confused. Background
appears more prominent than foreground.

RIGIDITY: tenseness; immovability; stiffness; inability to
bend or be bent.

ROLANDO'S AREA: motor area in the cerebral cortex.
Rolando's fissure lies between the parietal and
frontal lobes.

TONE: the normal degree of vigor and tension: in muscle, the
resistance to passive elongation or stretch.

Hypertonia: abnormally increased tonicity or
strength.

Hypotonia: abnormally decreased tonicity or
strength.

Spasticity: continuous resistance to stretching by a
muscle due to abnormally increased tension, with
heightened dystendon reflexes.

TRAUMATIC BRAIN INJURY: an insult to the brain, not of a
degenerative or congenital nature, but caused by an
external physical force, that may produce a
diminished or altered state of consciousness, which
results in impairment of cognitive abilities or
physical functioning. It can also result in the
disturbance of behavioral or emotional functioning.
These impairments may be either temporary or
permanent and cause partial or total functional
disability or psychosocial maladjustment.

95

[RgflOR: shaking or trembling: an involuntary movement of a
part or parts of the body resulting from alternate
contractions of opposing muscles.

UNILATERAL NEGLEQT: unawareness or inattention to one side
of the body or the space or events occurring on one
side of the body.

VISUAL ANOMIA: inability to name objects presented visually.

WADA PROCEDURE: a test to determine cerebral dominance for
brain function. It is performed by administering
fast-acting sodium amytal into one or the other of
the carotid arteries.

WERNICKE'S APHASIA: a condition resulting in loss of content
in speech although fluency may remain; caused by
damage to Wernicke's area in the left temporal lobe.

96

8. Hospital Equipment

eRTEEIAE LINE: a catheter placed in an artery, used to
monitor blood pressure in the arteries and to allow
for access to arterial blood for laboratory studies.

CATHETER: a hollow tube placed into a part of the body for
the removal of fluids or to allow fluids to be
introduced into the body.

CENTRAL VENOUS PRESSURE (CVP) LINE: a catheter that is
threaded into the right atrium of the heart. The
CVP reading directly reflects the right ventricular
filling and diastolic pressure in the right atrium
of the heart.

CHEST TUBES: tubes placed into the chest to drain fluid from
the body.

ENDOTRACHIAL TUBE: a tube inserted into the trachea through
either the mouth or nose to ensure an open airway.

FOLEY CATHETER: a catheter that has a small inflatable bal-
loon on the end, usually inserted into the bladder.
The balloon is inflated to keep the catheter in the
bladder so that urine can be continuously drained
into an external bag.

HALO: a metal ring used with patients who have spinal cord
injuries to preserve proper alignment of the neck
and spinal columns during healing.

INTRACRANIAL PRESSURE MONITOR: a monitor, inserted through
the skull, that measures pressure of the fluid
inside the brain and skull.

INTEAVENOUS (IV) LINE: a small catheter placed into a vein.
It can be used to give a patient fluids, drugs, or
blood, and can also be used to monitor venous blood
pressure.

INTRAVENOUS BOARD: a board that is used to hold an extremity
immobile so as not to dislodge an IV line.

NASOGASTRIC TUBE: a tube inserted through the nose into the
stomach, through which to feed a patient or give me-
dications. It is used if a patient is unconscious,
has a severe jaw injury, or is unable to swallow.

97

BESPIRATOR/VENTIEQTOR: machines that either assist a patient
with breathing or actually breathe for the patient
by forcing oxygen into the lungs.

SPACE BOOTS: large, soft protective shoes used to support
muscles and tendons during coma.

SWAN-EANZ QATHETER: a catheter that is threaded into the
heart and wedged in a pulmonary arteriole. It is
used to measure pulmonary artery pressure and
pulmonary capillary wedge pressure, both good
indicators of left ventricular function.

TRACTION: application of a pulling force to reduce, align,
and immobilize fractures: to lessen, prevent, or
correct deformity asociated with bone injury and
muscle disease; and to reduce muscle spasms in
fracture of a long bone or in back injury.

TRANSDUCER: a device that changes input energy of one form
into output energy of another. For example, physio-
logical energy of the heart beating is changed from
beats to lines on a strip of paper that can be read.

VENTRICULOSTOMY: anmoperation that is performed to drain
fluid from a ventricle of the brain to treat hydro-
cephalus.

98

C. Medications

QQQTRIM: relieves muscle spasms, cramping, and tightness of
muscles.

QECADRON: a corticosteroid used to reduce inflammation and
improve brain functioning through reduction of brain
swelling.

QILANTIN: used to control or prevent seizures and convulsive
disorders.

HALDOL: used to calm agitated, combative, anxious, or tense
patients, usually during the relatively early stages
of post-acute treatment.

LASIX: used to reduce excess water from the body and help
reduce intracranial pressure, water in the lungs, or
sluggish kidneys.

 

MANNITOL: used to decrease intracranial pressure by removing
water from the brain.

MORPHINE SULFATE: used to reduce pain and to reduce bodily
reflexes through sedation.

MYSOLINE: an antiseizure medication, often used if other
similar-acting drugs fail to work.

NEMBUTAL: used to reduce intracranial pressure and reduce
pain.

PAVULON: used to relax skeletal muscles to help keep the
patient from struggling, usually while on a
respirator.

PHENOBARBITAL: used to control or prevent seizures and
convulsive disorders.

SLEEPING MEDIQATIQNE: a category of drugs used to assist in
maintaining regular sleep/wake cycles: examples are
Dalmane, Halcion, Restoril.

STEROIDS: a category of drugs used to reduce brain swelling.

TAGAMET: used to help prevent stomach ulcers to which
hospitalized patients are prone.

TEGRETQE: an antiseizure medication that also affects
impulsive behaviors.

99
VALIUM: used to reduce anxiety, tension, and muscle
activity.

XANEX: an antianxiety medication to help reduce tension and
muscle activity.

 

100

D. Neurological Tests and Procedures

( A N LECTRICAL CT VITY PPI ): a computerized
analysis of background EEG activity, much more
sensitive than conventional EEG, which is especially
helpful in identifying abnormalities of early
dementia or suspected brain damage from head injury.

CEREBRAL ANGIOGRAPHY: an injection of dye into an artery so
that the vascular system of the brain can be studied
through an x-ray. This procedure can detect
aneurysms, tumors, or circulation problems.

CT SCAN (COMPUTERIZED TOMQBRAPHY : a computerized x-ray

taken at different levels of the brain to yield a
three-dimensional representation of the physical
shape of the brain.

ELECTROCARDIOGRAM (ECG or EKG): an electrical measure of
heart activity and heartbeat that is produced on a
chart recording.

ELECTROENCEPHALOGRAM (EEG): an evaluation of electrical
activity of the brain. Detects epilepsy, coma, and
death.

MRI SCAN (MAGNETIC RESONANCE IMAGING): an instrument that
develops images from biochemical operations of the
brain, using a magnetic field.

MYELOGRAPHY: an injection of dye into the spinal sub-
arachnoid space so that an x-ray of the spine can be
taken. Can detect spinal cord tumors and disc
problems.

NEUROLOGICAL EXAMINATION: an assessment of gross nerve
functioning via reflexes and reactions, performed by
a neurologist or neurosurgeon.

PET SCAN (POSITRON EMISSION TOMOGRAPHY): an instrument that
records chemical activity in specific regions of the
brain.

APPENDIX A

Informational and Supportive Head Injury Resources

APPENDIX A

INFORMATIONAL AND SUPPORTIVE HEAD INJURY RESOURCES

National Head Injury Foundation (NHIF)
Local or state associations of the NHIF

State Department of Vocational Rehabilitation (or private
agencies)

Special programs for head-injured or learning-disabled
persons offered through adult education or community
colleges

Local family support groups

Rehabilitation agencies and hospitals for outpatient support
programs and/or therapies

Local parks and recreational agencies that have programs for
special groups

Local volunteer placement and clearinghouse agencies
Agencies and organizations providing day care programs
Schools and community colleges

University medical centers

University and clinical center libraries

Transitional living centers

Long-term residential centers

Traumatic Brain Injury Rehabilitation Services

101

APPENDIX B

Professional Listings

APPENDIX B

PROFESSIONAL LISTINGSa

COGNITIVE THERAPIST: one who practices cognitive behavior
therapy, i.e., an active, structured, time-limited,
and directive form of therapy, based on the belief
that the way a person perceives and structures the
world determines his/her feelings and behavior.

 

MUSIC THERAPIST: uses music to assist the patient in the
restoration, maintenance, and improvement of speech
and motor functions, as well as in mental, physical
and emotional well-being.

NEUROLOGIST: a physician whose functions include evaluation
of neurological status and medical management of
brain disorder, after the emergency is past. The
neurologist frequently follows the patient beyond
the hospitalization period, especially for seizure
control.

NEUROPSYCHOLOGIST: a psychologist who specializes in
clinical evaluation of brain functions as reflected
in behavior and emotions. The neuropsychologist may
consult with other therapists and the family, and
may conduct a variety of therapies to aid both the
patient and the family with the psychological
adjustment to trauma.

NEUROSURGEQN: the physician who performs brain surgery and
who coordinates the emergency trauma treatment of a
brain-injured patient.

 

P Adapted from: Swiercinsky, Price, & Leaf, 1987.

102

103

QCQUPATLQQQE THERAPIST: assists the patient to use the body
to accomplish the familiar activities of daily
living. Responsibilities include evaluation and
treatment for regaining the use of fingers and
hands, eye-hand coordination, self-care skills,
eating, bathing, and learning numerous other
functional skills, and requires knowledge and
application of how the brain directs the body to
carry out practical tasks.

PHYSIATRIST: a physician specializing in physical medicine
and rehabilitation who often takes over primary care
when the patient moves into a rehabilitation facili-
ty, but may be called in to consult very early, par-
ticularly when other physical injuries are apparent.
This physician usually directs and coordinates
rehabilitation services in hospitals and is a
specialist in the physical retraining of the body.

PHYSICAL THERAPIST: focuses on restoring purely physical use
of the body to as high a level as possible. Teaches
walking, posture, balance, endurance, strength, and
coordination through a complex program of skillfully
designed exercises consistent with the physical and
neurological potentials of the patient.

PSYCHIATRIST: a physician specializing in mental health who
is often called upon to evaluate problem behaviors
and adjustment, particularly when psychotropic
medications can be of benefit.

RECREATION THERAPIST: teaches the patient to make the most
of leisure time, to enjoy relaxation, and to gain
the necessary self-confidence for balancing work and
play. The recreation therapist attempts to teach
self-motivating skills so the patient can identify
and use time satisfactorily.

REHABILITATION NURE : a nurse who cares for the patient on a
moment-by—moment basis and coordinates routine daily
activities, including carrying out the doctor's
medical management orders, attending to the
patient's needs, and monitoring his or her physical
and neurological health. This specialist is often
the coordinator of several health and social
services for the patient and family.

REHABILITATION PSYCHOLOGIST: a psychologist who specializes
in evaluation of and counseling for adjustment to

the physical and mental changes brought about by
head injury.

104

REEFIRATQEY THERAPIST: assists patients experiencing
breathing problems, particularly those on
respirators, in adapting to such equipment to
achieve proper oxygenation of the blood.

EOCIQE QQEKER: often the link between the patient/family and
virtually all of the other care providers, as well
as with the "outside world." The social worker may

help resolve financial concerns, obtain
rehabilitation equipment needed at home, provide
emotional support for the family, and link the
movement of the patient from facility to facility
and eventually to home. The social worker is often
the ”case manager."

SPEECH AND LANGUAGE PATHQEQEIS : a specialist in restoring

language and thinking or intellectual skills.
Motor-speech, reading, hearing, and talking are
retrained by involvement in graded programs, to
strengthen conversational and other communication
skills and to develop higher level cognitive skills.
These goals are geared toward reintegration of the
patient into the family and community.

APPENDIX C

Rancho los Amigos Scale

APPENDIX C

Rancho Los Amigos Scale‘

LEVELS OF COGNITIVE FUNCTIONING

I. NO RESPONSE

Patient appears to be in a deep sleep and is com-
pletely unresponsive to any stimuli presented to him.

II. GENERALIZED RESPONSE

Patient reacts inconsistently and non-purposefully to
stimuli in a non-specific manner. Responses are lim-
ited in nature and are often the same regardless of
stimulus presented. Responses may be physiological
changes, gross body movements and/or vocalization.
Often the earliest response is to deep pain. Respon-
ses are likely to be delayed.

III. LOCALIZED RESPONSE

Patient reacts specifically but inconsistently to sti-
muli. Responses are directly related to the type of
stimulus presented as in turning head toward a sound,
focusing on an object presented. The patient may with-
draw an extremity and/or vocalize when presented with a
painful stimulus. He may follow simple commands in an
inconsistent, delayed manner, such as closing his eyes,
squeezing or extending an extremity. Once external
stimuli are removed, he may lie quietly. He may also
show a vague awareness of self and body by responding
to discomfort by pulling at nasogastric tube or cathe-
ter or resisting restraints. He may show a bias toward

 

‘ Prepared by: C. Hagen, D. Malkmus, P. Durham, and K.
Bowman, of Rancho los Amigos Hospital, Adult Head Trauma
Service.

105

IVm

106

responding to some persons (especially family, friends)
but not to others.

CONFUSED-AGITATED

Patient is in a heightened state of activity with
severely decreased ability to process information. He
is detached from the present and reponds primarily to
his own internal confusion. Behavior is frequently
bizarre and non-purposeful relative to his immediate
environment. He may cry out or scream out of propor-
tion to stimuli even after removal, may show aggressive
behavior, attempt to remove restraints or tubes or
crawl out of bed in a purposeful manner. He does not,
however, discriminate among persons or objects and is
unable to cooperate directly with treatment efforts.
Verbalization is frequently incoherent and/or inappro-
priate to the environment. Confabulation may be pre-
sent; he may be euphoric or hostile. Thus gross atten-
tion to environment is very short and selective atten-
tion is often nonexistent. Being unaware of present
events, patient lacks short-term recall and may be
reacting to past events. He is unable to perform self-
care (feeding, dressing) without maximum assistance.

If not disabled physically, he may perform motor
activities as sitting, reaching and ambulating, but as
part of his agitated state and not as a purposeful act
or on request necessarily.

CONFUSED, INAPPROPRIATE, NON-AGITATED

Patient appears alert and is able to respond to simple
commands fairly consistently. However, with increased
complexity of commands or lack of any external struc-
ture, responses are non-purposeful, random, or at best,
fragmented toward any desired goal. He may show
agitated bahavior, but not on an internal basis (as in
Level IV), but rather as a result of external stimuli,
and usually out of porportion to the stimulus. He has
gross attention to the environment, but is highly
distractible and lacks ability to focus attention to a
specific task without frequent redirection back to it.
With structure, he may be able to converse on a social-
automatic level for short periods of time. Verbaliza-
tion is often inappropriate; confabulation may be trig-
gered by present events. His memory is severely
impaired, with confusion of past and present in his
reaction to ongoing activity. Patient lacks initiation
of functional tasks and often shows inappropriate use
of objects without external direction. He may be able

VI.

VII.

107

to perform previously learned tasks when structured for
him, but is unable to learn new information. He
responds best to self, body, comfort and often family
members. The patient can usually perform self-care
activities with assistance and may accomplish feeding
with maximum supervision. Management on the ward is
often a problem if the patient is physically mobile, as
he may wander off either randomly or with vague inten-
tion of "going home."

CONFUSED-APPROPRIATE

Patient shows goal-directed behavior, but is dependent
on external input for direction. Response to discom-
fort is appropriate and he is able to tolerate unpleas-
ant stimuli (as NG tube) when need is explained. He
follows simple directions consistently and shows
carry-over for tasks he has relearned (as self-care).
He is at least supervised with old learning; [and is]
unable to [function or must be] maximally assisted for
new learning with little or no carry-over. Responses
may be incorrect due to memory problems, but they are
appropriate to the situation. They may be delayed to
immediate [responses] and he shows decreased ability to
process information with little or no anticipation or
prediction of events. Past memories show more depth
and detail than recent memory. The patient may show
beginning immediate awareness of situation by realizing
he does not know an answer. He no longer wanders and
is inconsistently oriented to time and place. Selective
attention to tasks may be impaired, especially with
difficult tasks and in unstructured settings, but is
now functional for common daily activities (30 min.
with structure). He may show a vague recognition of
some staff, has increased awareness of self, family and
basic needs (as food), again in an appropriate manner
as in contrast to Level V.

AUTOMATIC-APPROPRIATE

Patient appears appropriate and oriented within hospi—
tal and home settings, goes through daily routine auto-
matically, but frequently robot-like, with minimal to
absent confusion, but has shallow recall of what he has
been doing. He shows increased awareness of self,
body, family, foods, people and interaction in the
environment. He has superficial awareness of, but lacks
insight into his condition, decreased judgment and
problem-solving and lacks realistic planning for his
future. He shows carryover for new learning, but at a

108

decreased rate. He requires at least minimal super-
vision for learning and for safety purposes. He is
independent in self-care activities and supervised in
home and community skills for safety. With structure
he is able to initiate tasks as social or recreational
activities in which he now has interest. His judgment
remains impaired: such that he is unable to drive a
car. Pre-vocational or avocational evaluation and
counseling may be indicated.

VIII. PURPOSEFUL AND APPROPRIATE

Patient is alert and oriented, is able to recall and
integrate past and recent events and is aware of and
responsive to his culture. He shows carryover for new
learning if acceptable to him and his life role, and
needs no supervision once activities are learned.
Within his physical capabilities, he is independent in
home and community skills, including driving.
Vocational rehabilitation, to determine ability to
return as a contributor to society (perhaps in a new
capacity), is indicated. He may continue to show a
decreased ability, relative to premorbid abilities, in
abstract reasoning, tolerance for stress, judgment in
emergencies or unusual circumstances. His social,
emotional and intellectual capacities may continue to
be at a decreased level for him, but functional in
society.

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