Music Therapy

Effects of Music Therapy and Counselling: A Case of State Anxiety of a Ca - Hypo Pharynx Patient

Sundar, Sumathy

Abstract

This paper is about a single case study of a Squamous Cell Carcinoma - Hypopharynx patient, to find out if receptive music therapy could be combined with comprehensive counseling and also if health information coul be provided as a cognitive beahvioral intervention to address psychological distress and situational anxiety, which are common problems with cancer patients in a hospital environment. Baseline data was collected from the patient using Spielberger's State-Trait Anxiety Inventory. Assessments were done for situational anxiety before, during and after the music and counseling interventions. Pre- and Post-test composite anxiety scores were compared, which indicated the efficacy of the treatment. Though the primary endpoint of the study was state anxiety, the unique experiences of listening to music, which could be explained only by the patient listening to music and the self report made by the patient when analysed reflected the spiritual dimensions of the music therapy sessions

Keywords: Head & Neck Cancer, Carcinoma - Hypopharynx, music therapy, educative and informative counseling, health information on cancer, state anxiety, cognitive behavioral intervention

Background

The cultural and traditional context for music therapy in India

Music Therapy is just an emerging discipline in India that warrants more research in this area to make it evidence based. The existence of Music Therapy as a belief system and the integrated approach in treatment of diseases advocated by medical professionals in the clinical arena has made them turn favourably towards Music as a promising therapy. The potentials of the ancient healing roots of Indian Music like Nada Yoga, Vedic chanting and Ragachikitsa have been recognized by various medical professionals, psychologists and musicologists and music therapists, making them engage in more and more of experimental studies which might strengthen and vouch for the efficacy of Indian music and to make music therapy an evidence based practice (Sumathy & Sairam, 2005).

Indian music is predominantly melodic in nature and the unique Raga system, born of the various combinations and permutations of notes with the existence of microtones and different embellishments, produces sweet and soft impressions in the minds of listeners. They gratify the soul of the listeners and not just the senses. The Ragas create a consoling and transcending attitude of the mind, elevate the listener to an ethereal plane and purify the knots of the mind.

Since the ancient times, Indian music had a very clear differentiation in the different forms of music in use and had recognized the different aspects of music and the ways of expressing with the specific tone and rhythm to bring the desired equilibrium or desired emotions. The music of the peasants was different from that of the intellectuals. The music of the stage was different from that of the temple and the music for entertainment was different. This suits the therapeutic application of different kinds of music to cater to the preferences of the clients in the clinical settings (Sumathy & Sairam 2005).

Devotional music or Bhakti music is a vast repertoire in India which serves to convey traditional values and it pervades every part of the society, spreading devotion to God. It is an integral part of Hindu religion, culture and life. Traditionally, devotional music in South India has emerged out of religion, centered in and around the temple and with worship. Although social strata, in general are maintained within the society, listening to and singing devotional music and congregational worship is one area where persons from diverse social groups join together (Simon, R Leopold. 1984).

Context for music therapy in oncology settings

Cancer patients experience a wide range of stressors during the stages from diagnosis to treatment. Cancer not only presents physical challenges but also number of emotional and social needs during the illness, which necessitates integrated care addressing the psychological distress that the patients experience. With special reference to Head & Neck Cancer (HNC) patients, the disfigurement and dysfunction aspects account for the psychosocial consequences to this group. The treatments offered to HNC patients such as surgical resection, local radiotherapy or the presence of a specific device could also contribute to disturbances in the physical, social and psychological domains. Psychological problems as a consequence of the time taken for diagnosis and treatment due to involvement of various diagnostic procedures is common in HNC (Amir, Z. et al. 1999). Anxiety is a common symptom experienced by cancer patients which is mainly situational, in relation to stressful painful surgical procedures and treatments such as radio or chemo therapy (Chaturvedi, K Santosh & Chandra S. Prabha 1998).

In this context, there is a growing body of literature regarding music therapy experiments that have been researched and documented in oncology settings in the West. A psycho immunology study identified significant changes in salivary immunoglobulin A for oncology patients as a function of music therapy (Lane 1991). Music therapy is used to promote relaxation, to reduce anxiety, to supplement other pain control methods and to enhance communication between patient and family (Bailey 1983; Bailey 1984). Bailey also discovered a significant improvement in mood when playing live music to cancer patients as opposed to playing taped music, which she attributes to the human element being involved. In addition to reducing pain, music as relaxation and distraction has been tried during chemotherapy to bring overall relief (Kerkvliet 1990) and listening to preferred music during a single chemotherapy treatment reduced nausea and vomiting (Frank 1985). Focus of attention to music can forestall or blunt the perception of pain (Standley 1986). From the initial diagnosis throughout the course of the disease, treatment and rehabilitation to the cure or end of life, music therapy is a service that addresses both the medical and psychosocial needs of the patient; It meets common psychological objectives in oncology like fear, anxiety, stress or grief and music therapists facilitate health objectives by reducing intensity or duration of pain, alleviating anxiety and decreasing the amount of analgesic medication needed (Standley & Hanser 1995). Pain and anxiety provoked by noxious medical procedures experienced frequently by cancer patients may be controlled by cognitive behavioral interventions such as music or distraction (Kwekkeboom 2003).

Music therapy and counseling

Also there are studies which have been documented that counseling techniques are often paired with music to achieve emotional objectives such as expression, adjustment, stability or locus of control; that music and assessment abilities could be combined with counseling, therapeutic and teaching skills to facilitate specific health or rehabilitative objectives (Standley & Hanser 1995). Use of music activities and counseling for 8 weeks reduced anxiety in adult and terminally ill patients (Gross & Schwartz 1992) Music therapy combined with social work techniques maximized counseling benefits with pediatric patients (Slivka & Magill 1986), psycho-behavioral interventions have shown to benefit meta static breast cancer patients and use of music therapy, a cognitive behavioral intervention using music strategies to cope with cancer related stressors basing on a transactional stress coping frame work with meta static breast cancer patients produced immediate benefits of enhanced relaxation and comfort (Hanser 2005) Music Therapy could be combined with psychological counseling to achieve desired therapeutic goals in clinical settings (Sairam & Sumathy, 2005).

Together, these studies demonstrate the author's initial understanding of the positive outcomes of combining music therapy and counseling techniques in a mixed group of patients with varying diagnoses, treatment regimens, and stages of disease. All provided some evidence to support that music therapy and counseling maximized benefits.

In this background, the author found out in her working experience in an oncology setting that almost all the patients who were not formally educated and who had a lower socio economic background, diagnosed with cancer did not have the knowledge about the complexities of the disease and its treatment. When suddenly exposed to the illness, they had great difficulty in coping with the stressful situation. The patient centered music therapy sessions encompassing trusting and caring relationship with the music therapist necessitated the author to clear all the apprehensions regarding the treatment side effects besides giving health information and comprehensive counseling regarding the disease, the procedures, the side effects, to cope with the side effects and also on the adherence to the treatment regimen. When the patients were adequately informed about the disease, their coping became easier and they were more receptive to music therapy sessions and the situational anxiety that was commonly expected with the patients was immediately alleviated. Also, the role of psychological counseling (educative and informative counseling) the patients became of paramount importance to the author to avoid misconceptions and irrational fear about the disease and providing emotional support to address the psychological needs, in addition to the music therapy techniques.

The author, in order to formalize these clinical stories, undertook to experimenting on this in a more objective manner by systematically documenting the findings and resorted to a case study design, which is a common feature of staying close to the practice of the clinician (Aldridge, 2002) to involve the patient in the process to make her also reflect what is going on (Aldridge, 2003).

The Case study

Patient data

The patient from the Cancer Institute in Chennai, India is a female, 36 years old, married, had studied up to Vth Division and was not employed, had a lower socio economic status and a rural background. In clinical examination, a squamous cell carcinoma (Hypo Pharynx), was diagnosed and was found in post Cricoid's region (Grade I-II; NG - Intermediate) and the tumor measured 4 x 2.5cm x 2.5cm. The goiter was involving both lobes. The following investigations (check the glossary below) were done when she entered the music therapy treatment: Hematology & Urine, Radiology Chest (PA) View, ECG, OGD Biopsy, Brushings from Cricopharynx, FNAC (L) Lobe of Thyroid, DLDP Esophagospy, Barium Swallow, CT Scan Neck, Rigidoscopy Biopsy, PFT.

Her former treatments included a jejunostomy, which is a surgery in which the jejunum is brought outside of the abdominal wall by creation of an opening between the jejunum and the anterior abdominal wall which will allow artificial feeding. She also received a laryngo pharyngo esophagectomy with gastric pull up along with post radiation treatment.

Physical symptoms were reported as difficulty in swallowing, progressive dysphagia, she had an edema in the neck, weight loss was reported, as well as choking sensation on taking food, severe pain on swallowing and pain radiating to the ear. Behavioral symptoms included crying spells, poor sleep patterns, a craving for normal oral feed and restlessness. Affective symptoms were reported as excessive fear, the client reported feelings of anxiousness, isolation, worthlessness and described herself as being hopeless. She had worrying thoughts about dying, reported difficulty when trying to concentrate, had intrusive thoughts and was catastrophising about her state of illness. In her interpersonal relations she felt totally withdrawn from others and felt socially inferior.

Aims

Aims and objectives of our music therapy treatment therefore was focusing on the following aspects:

• To bring down the level of state anxiety of the client by eliciting relaxation responses by music sessions as a behavioral intervention
• To help the client to have a better personal control of the disease and its treatment by counseling
• To educate the client on the disease and the treatment she had to undergo by giving health information.
• To give emotional support to the patient

Treatment schedule, psychometric measures and therapeutic interventions

The author recorded the patient variables including age, gender, ethnic heritage, education, income, type of cancer, the symptoms, and the procedures to be performed and previous procedures. A listening pattern schedule developed by the author consisted of instructions and 20 questions on the following factors: musical training, musical preferences, duration of listening to music, time of listening to music, pattern of listening, preferred mood to music and general responses to preferred music. The musical selections made for use in the intervention were based on the patient's musical preferences, treatment goals and approach (Sumathy, 2006).

Spielberger State Trait Anxiety Inventory (STAI)

Anxiety was assessed at the base line with the STAI (Spielberger, 1999). The STAI was completed immediately after the diagnosis, during surgical procedures, before surgery, after surgery, before radiation treatment, during radiation treatment and after the radiation treatment. The STAI state portion measures feelings of apprehension, tension, nervousness and worry. Scores increase in response to physical danger and psychological stress. The scale consists of 20 statements that evaluate how the patients feel "right now" with scores ranging from 20 to 80 rated on a 1 (not at all to) 4 (very much). The scale has been documented to be reliable and valid and has been extensively used with cancer patients and music therapy studies. Self-Report by the patient was also recorded every day of how the patient felt after the music therapy and counseling sessions.

The Tamil language version of the listening pattern schedule and the STAI were read out loud to the patient and the responses recorded by the author.

Self-reports and diary

The patient's husband wrote the daily self-report by the patient and kept a diary. The assessments were made during each stage before the music therapy and counseling sessions so as to know the effects of the previous sessions to rule out the possibility of temporary positive outcome immediately due to music and counseling sessions.

Counseling sessions

The entire history of the patient from the case record - the diagnosis, the stage of the disease, the treatment planning of the doctors, the nature of the treatment that had been planned, the surgical procedures that she had to undergo before the surgery were comprehensively collected. The patient was very quick in developing a working relationship with the author and she was encouraged Catharsis for emotional ventilation at the outset.

The subsequent session was to know the cognitive structure of the client, gathering information about her fears, the social support she has, her family background, the reason for her excessive fear and anxiety by informal interview.

The musicality and listening pattern of the patient to choose the right type of music for daily sessions to elicit relaxation responses were assessed.

During treatment planning, the author realized the need to provide information support about the disease, the diagnosis, the symptoms relating to her disease, about the further investigations that she had to undergo before the treatment, the time taken for the extensive investigations she had to undergo and the need for such investigations before the surgery etc. We discussed her faulty assumptions and negative thoughts about the disease, the treatment and the music and counseling intervention was to focus on changing the cognition to produce desired change in the behavior and cognition. The sessions were also designed to make her understand and accept reality about her losing her voice, significance of the surgery and to help her to cope with the treatment and to provide emotional support.

The counseling sessions also targeted to alleviate anxiety level, to change the cognitive map of the patient before and after treatment, to help the client understand the reality of the situation and to help the client to gain confidence to face the future after the surgery Laryngo Pharyngo esophagectomy by counseling.

Receptive music therapy intervention

The subsequent sessions targeted to give music listening sessions, the songs chosen by the author. It was light devotional music of half hour duration, for five days a week during the entire period of her stay (about 2 months) in the hospital. The patient was administered with light devotional music recordings of the author through CD Walkman. The songs chosen were simple south Indian devotional songs of the modern times with easy-to-understand lyric and religious theme, devoid of any technical virtuosity, in medium tempo, having both melodic and literary beauty. Here is one example:

The song is in Raga Dwijavanthi, a hexatonic raga with frequent usage of special oscillations (Mudrita, Ullasita, Kampita).

• Kampita is a type of oscillation or a shake. The manipulation of the note is such that there is not even the remotest suggestion of the adjacent notes (Sambamurthy, P 1998).
• Ullasita is a kind of a glide of notes, which is of two kinds. Upward glide and downward glide. This oscillation is obtained by starting on a note and reaching a higher or lower note as the case may be, by gliding over the intermediate notes without at the same time giving the impression of the individuality of these intermediate notes (Sambamurthy, P 1998).
• Mudrita is a kind of oscillation produced by closing the mouth and singing (Sambamurthy, P 1998).

The ascending notes in the raga are: s r m g m p d s

The descending notes are s n d p m g r g r s

The MP3 excerpt in Dwijavanthi is a popular melody, a simple light devotional song in medium tempo with meaningful lyrics in Tamil language administered to the patient frequently on her request.

---Download an MP3 excerpt Dwijavanthi.mp3 (2,9 MB) ---

Translation of the song (by the author):

One cannot get peace of mind

Even by doing penance.

But being in your sanctum sanctorum

Brings comfort and tranquility.

The light of the month karthigai

And the beauty of the cymbals

In your sanctum sanctorum

Where, the primordial sound `OM' resonates

all bring solace and peace of mind.

Your cymbals, the dancing peacock

And the flag of the cock at the sanctum sanctorum, where all

Your devotees visit everyday to pray to you

Bring comfort and peace of mind

Results and discussion

The primary goal of the treatment was to bring down the state anxiety of the patient by music sessions and counseling.

State and Trait Anxiety Inventory (STAI)

For analysis, the composite score in the STAI was taken to compare the levels of anxiety during different stages of assessments. During base line assessment, the patient's' level of trait anxiety was low (30), but her level of state anxiety was the highest (65) immediately after the diagnosis. At this stage, the cause of anxiety in the patient was multidimensional - Diagnosis of cancer in Hypo Pharynx, the treatment by way of surgery by which she would lose her voice, the fear of the major surgery, the fact that she could not eat normally, various minor procedures she had to undertake before the surgery - etc.

After the music therapy and counseling sessions, the findings show that the anxiety level of the client had come down considerably (34) during the pre surgical procedural stage (see figure 1).

FIGURE 1. STAI levels of anxiety in different stages

The time line of the interventions as tabled below show that the actual positive effect of music and counseling happened after surgery, which is reflected by the recording of the anxiety level. The anxiety level is reduced to a great extent in a stable manner, after the surgery, prior, during and after the radiation treatment sessions.

The patient was informed on the causes of the long time taken between the diagnosis and the treatment, combination of treatments like surgery and radiation, the ignorance and faulty beliefs about the disease alleviated anxiety. The scores just before the surgery was high (65), as she would lose her voice after the surgery and the anxiety levels arose in spite of the earlier music therapy and counseling sessions. Immediately after the surgery, the pain and the fact that she had lost her voice made her feel anxious to face the future.

The music sessions were welcoming relaxing sessions and the counseling sessions provided the patient with information and emotional support, trained for relaxation, brought about cognitive restructure by changing faulty beliefs and the irrational fear by educating the client with relevant information about the disease, the investigation procedures, the treatment modalities and the side effects of the treatment etc. Emotional crying spells and expressions of fear of death were absolutely controlled (see figure 2).

FIGURE 2. Levels of emotional outbursts and fear of death

Self-report

The self-report of the patient recorded by the author after the music therapy sessions revealed that the spiritual undercurrent of the songs gave strength and morale boost to her sore heart when her inner strength was failing. The songs elevated her spirits and brought solace and peace of mind after a prayer to God in the form of listening to the songs and that she believed that God would do good things to her. She would continue to listen to these songs every day.

FIGURE 3. Self report after the music sessions as recorded by the author and translated.

• I look forward to the music sessions
• By listening to these songs, I can feel a compassion for the sore heart and succour when inner strength is failing.
• The spiritual undercurrent is a strength and a morale boost
• I strongly feel that God will resolve my issues.
• It elevates my spirits to face my challenges everyday.
• The lyric of the song gives a great solace to me.
• The beat of the music lifts the heart
• The songs bring solace and peace of mind in a distressing mood
• It is like a prayer to me
• My mood is improved
• I am able to forget my worries.
• I will sleep well today
• I feel good and relaxed. My mind is clear
• I don't feel the pain
• I am happy to be away from the ward for these sessions and listen to soothing music, as the moaning sounds of the other patients disturb me.
• I want to listen to these songs regularly to elevate my spirits whenever I am low.

The end of the intervention report given by the patient translated.

"Listening to music was a great solace and comfort to me when I was suffering. The informative and the educative sessions about the disease, the treatment sessions and the after effects of the treatment helped me to get rid of my fear and also gave me strength to face the life bravely and to accept things as they come. The songs lifted my heart and I believe that God will save me and will take care of me. Good things will happen to me and I have faith in him. He will never turn me down."

Conclusion

This single case study of combining music therapy and educative and informative counseling techniques suggest maximum benefits in alleviating situational anxiety with cancer patients and would pave the way for more and more work to be undertaken in oncology settings to strengthen these formalized recordings. It is also an attempt to emphasize that the caring and social dimensions warranted in the health care delivery system could be met with and be reinforced by Music Therapists when they combine counseling techniques in their therapeutic sessions. The more cultural and traditional Eastern music has a spiritual influence, which expresses one's devotional feelings and may bring comfort, hopes and peace of mind to the listeners.

Glossary

Medical terms used in the paper.

Barium Swallow: It is an x-ray test to examine the upper digestive tract (oesophagus, stomach and small intestine.

Carcinoma: Cancer of the epithelium, the tissue that lines the skin and internal organs of the body.

Catharsis: Clients are encouraged to let their emotions out freely during counseling process, so that their feelings are ventilated.

DLDP ESOPHAGOSPY: Examination of esophagus by a tube inserted into the mouth

Dysphagia: A condition in which swallowing becomes difficult

Edema: Swelling

FNAC: Fine needle aspiration cytology in which a thin needle is used to withdraw fluid or cells from the tissue and examined for the presence of cysts or tumour

HNC: Head and neck cancer

Hypo Pharynx: Bottom portion of the throat

Jejunum: Part of the small intestine between the duodenum and the ileum

Jejunostomy: A surgery in which the jejunum is brought outside of the abdominal wall by creation of an opening between the jejunum and the anterior abdominal wall which will allow artificial feeding

Larynx: Voice Box or the organ responsible for the production of vocal sounds. It is also an air passage conveying air from the pharynx to the lungs.

Laryngo Pharyngo Esophagestomy with gastric pull: Surgery done in the treatment of extensive carcinoma of the hypo pharynx, larynx and cervical oesophagus.

Pulmonary function tests: Tests in assessing the functional status of the lungs as a part of pre operative evaluation

OGD Biopsy: is a procedure that enables a gastro entrologist to visualize the esophagus, stomach and duodenum using a thin flexible tube that can be looked through or seen on a TV monitor and biopsy performed on the tumour

Radiation treatment: This treatment uses large doses of high-energy beams or particles to destroy cancer cells in a specifically targeted area. (www.mdanderson.org)

Radiology: The branch of medicine concerned with the use of radiation including X-rays

State anxiety: Transitory emotional state of a person characterized by subjective consciously perceived feelings of tension and apprehension and heightened autonomic nervous system.

Trait anxiety: Denotes relatively stable individual differences in anxiety proneness and refers to a general tendency to respond with anxiety to perceived threats in the environment.

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Author information

Sumathy Sundar

MA (Indian Music), MA (Applied Psychology), Dip. In Counselling Psychology.

Ph.D. research scholar with University of Madras in Music Therapy.

President, Nada Centre for Music Therapy, Chennai, India

Address

Nada Centre for Music Therapy,

Plot No.11/25 Jothi Ramalingam Street,

Madipakkam,

Chennai 600 091, India

http://www.nada.in

This article can be cited as:

Sundar, S. (2006) Effects of Music Therapy and Counselling: A Case of State Anxiety of a Ca - Hypo Pharynx Patient. Music Therapy Today (online) Vol. VII (1) 8-29. available at http://www.MusicTherapyWorld.net

Peer reviewed article - Received 22. May 2005 ; accepted in revised form 14. February 2006