Nurturing Attentional Skills in Acute Pediatric Psychiatry Through Avant-Garde Musical Interventions

Nurturing Attentional Skills in Acute Pediatric Psychiatry Through Avant-Garde Musical Interventions Abstract This case report details how avant-garde musical interventions helped to nurture the attentional skills of eight pediatric patients admitted to a small 12-bed acute psychiatric unit. The music therapist encountered two major obstacles while working on the small psychiatric unit. First, hospital administration strongly recommended that all eight patients attended the music therapy groups together, regardless of a lack of space, and differences in ages, cultures, and diagnosis. Second, when music therapy interventions were centered on tonal harmonies, melodies, or counterpoint, including predictable rhythms or time signatures, the patients repeatedly lost focus, concentration, and attention, making it difficult to work on improving prerequisite skills, such as following directions and keeping safe boundaries, or to explore emotions and feeling-states. As an alternative to typical diatonic interventions, the music therapist created three novel sound-based interventions informed by the avant-garde composers Pauline Oliveros, John Cage, and Luigi Nono. The novel musical interventions not only helped the eight patients to improve attentional skills, but, unexpectedly, it helped to (a) build a strong therapist-patient bond built on trust, (b), allow the patients to struggle, explore, discover, and create within a safe therapeutic environment, (c), reveal unexpressed feeling-states nonverbally and (d) share their novel musical experiences with newly admitted patients. acute child psychiatry, experimental music, avant-garde music, attention As a music therapist working on an acute 12-bed pediatric psychiatric unit in a city hospital, I struggle with the fact that hospital administration strongly recommends that all patients attend music therapy groups together, despite the fact that the patients are of different ages, culturally diverse, and have a variety of unique problems and special needs. This administrative approach creates music therapy groups that are underproductive, chaotic, and overwhelming for the patients. Nevertheless, hospital administration tries their best to provide the finest care for their patients, despite a lack of space on the unit for simultaneous therapy groups to occur. This situation is challenging due to the fact that I will have to work with eight to twelve culturally diverse children, ages ranging from 4–12, and carrying different diagnoses, such as major depressive disorder (MDD), childhood-onset schizophrenia (COS), mood disorder not otherwise specified (MD-NOS), conduct disorder (CD), autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), body dysmorphic disorder (BDD), and oppositional defiant disorder (ODD), all in the same group together. Consequently, these music therapy groups create chaos and confusion for each of the patients, and, a feeling of frustration and incompetence within myself as a music therapist. In this city hospital, patients are referred to music therapy for a variety of reasons, such as to help improve communication, psychosocial, cognitive, emotional, and physical needs. After a short period of time running hectic music therapy groups on the unit, I realized that when music interventions were centered on tonal harmonies, melodies, or counterpoint, including predictable rhythms or time signatures, the patients repeatedly lost focus, making it nearly impossible to work on (1) prerequisite skills, such as staying seated, no cross talking, following 1-step directions, and keeping safe boundaries, and (2) exploring emotions and feeling-states. Within the diatonic harmonic climate, hyperactive group members would become over stimulated by the familiarity of the tonal chord changes and simple time signatures, shout over each other demanding that the music therapist play their favorite songs. At the same time, due to the chaotic outbursts, the quieter group members would become observably more detached and disconnected, shutting down emotionally. These behaviors were amplified when diatonicism was used as the foundation for different improvisational (Wigram, 2004; Gardstrom, 2007), songwriting (Baker & Wigram, 2005), and music and imagery (Grocke & Wigram, 2007) practices. As found in this present case report, novel sound-based practices, informed by the late avant-garde composers Pauline Oliveros, John Cage, and Luigi Nono, were more suitable than diatonicism for quickly engaging the patients’ attention without over stimulating their emotional states based upon musical tastes, likes, and dislikes (see Curreri, 2013). Therefore, via acts of discovery, the three avant-garde musical interventions presented in this case report centered on improving attentional skills first, and helping the patients to stay relaxed, curious, motivated, and challenged concurrently. Patients’ Background Setting The children described in this case report were inpatients, ages 6–12, on an acute care 12-bed pediatric psychiatric unit. The unit was part of a teaching hospital in a large, culturally and religiously diverse area in the eastern region of the United States. The unit was designed for the diagnosis and treatment of all pediatric psychiatric disorders, provided crisis stabilization, medication adjustment, and integrative-multicultural psychotherapeutic family and patient interventions. All interventions were focused on the resolution of acute symptoms and community reintegration for the patient. A patient typically remained on inpatient status for three to seven days, and was considered to be ready for discharge when he/she could receive safe and proper care in a less restrictive setting. The pediatric patients on the unit were scheduled to attend a variety of daily psychosocial and psychoeducational programming sessions, such as verbal psychotherapy, creative arts psychotherapy, medication education, community meetings, nursing groups, and activity/recreational groups. In addition, the patients had to attend the hospital inpatient elementary school, as well as work with volunteer tutors in the evenings. Following institutional guidelines, all patients and their guardians signed a letter of informed consent describing that session data could be used for a case report (non-research), wherein after completion of the report, all session data must be shredded and/or erased. The Pediatric Patients As part of their integrative psychosocial and psychoeducational programming, all of the patients described in this case report were expected to attend each music therapy group together despite differences in age, diagnosis, and cultural background. Each of the patients had a unique case with a unique set of problems and therapeutic needs. However, sadly, one common problem in each of the patients’ life was being bullied at school, undeniably playing a significant role in the patients’ admissions. See Table 1. Table 1 Patient Characteristics Pseudonym Age Ethnicity/Race Home Life Diagnosis Admitting Behaviors Unit Presentation Mary 7 Mexican Mary lived with her biological parents and four siblings. Her depression was an outcome of her father’s verbal and physical abuse at home, in addition to being bullied at school for “being Mexican”. Major depressive disorder (MDD) Self-injurious behaviors, such as cutting herself when feeling anxious Mary presented with a flat affect, preferred to have her hair cover her eyes, preferred to stay in her room alone, and did not initiate in conversation with staff or peers Glenda 12 Filipino Glenda lived with her biological parents and five siblings, including extended family. Although Glenda came from a loving family, her parents would not accept the fact that their daughter needed medical treatment, and equated her auditory hallucinations to “being possessed by demons”. At school, Glenda excelled in her studies, but had recently started to skip classes due to her current psychological condition, as well as verbally being bullied by her peers for “acting strangely” and being “a weirdo”. Childhood-onset schizophrenia (COS) Symptoms of auditory hallucinations, and abnormal behaviors, such as grinning while standing still on one leg for a long period of time Glenda presented with a restricted affect, was quiet, kept to herself, but was pleasant to staff and peers George 6 African American George lived with his biological mother, three biological siblings, and mother’s boyfriend. George never knew his biological father due to his father abandoning his family when George was a year old. George was in conflict with his mother’s boyfriend because he could not accept the boyfriend as a “fatherly figure”. In addition, George was constantly having verbal and physical altercations with his siblings. At school, George was bullied for “being black” by Caucasian and Latino students. Mood disorder not otherwise specified (MD-NOS) Conduct disorder (CD) Outbursts at home and at school Lack of focus in a standard classroom setting due to the conflicts at home and the bullying by his peers George presented with a labile affect and was confrontational with staff and peers, trying to kick and hit staff Mani 10 Caucasian Mani was living with her biological parents and three siblings. Mani exhibited repetitive patterns of behavior, such as occasionally rearranging books on a bookshelf, spending long periods of time lining up small objects, as well as sensory seeking (tactile) behaviors, as evidenced by craving physical contact and stimulation through deep pressure on her hands and feet. Mani was in special education classes at school and was an average student scholastically. She was being bullied at school for being “socially retarded”, causing her to lose interest in her studies and have constant emotional outbursts in her classes. Autism spectrum disorder (ASD) and Attention deficit hyperactivity disorder (ADHD) Aggressive behaviors Outbursts at home and at school Mani presented with a blunted affect, and stayed in her room most of the time Joe 8 Asian Indian Joe was living with his biological parents and six siblings. He was constantly comparing his body parts to others, and continually checked his appearance in mirrors. At school, Joe’s preoccupation with his appearance was interfering with his studies. He reported that one key component to his body dysmorphic disorder was due to being repeatedly bullied at school for having a “weird body without any muscle tone”. Body dysmorphic disorder (BDD) Eating disorder History of binge eating, such as eating large amounts of food Self-induced vomiting, accompanied by excessive exercise Joe was euthymic and was pleasant to staff and peers Anne 11 Caucasian Anne was an only child living with her biological mother due to Anne’s allegations of her father sexually abusing her at a young age. Attention deficit hyperactivity disorder (ADHD) Conduct disorder (CD) Aggressive behaviors Lack of focus in a standard classroom Anne presented with a labile affect and had constant verbal altercations with staff and her peers As an outcome of the sexual abuse, Anne’s biological parents had recently divorced. Anne found it difficult to focus at school due to her hyperactivity and constantly being bullied by students “for being white trash”. Paul 12 Mixed-race Latino Paul came from a loving a supportive family, living at home with his biological parents, three biological siblings, and extended family. However, at school, Paul was verbally and physically bullied and harassed for “being different” due to exhibiting a higher intelligence and creative abilities, and dressing in EMO clothing. Consequently, Paul had very few to no friends. Major depressive disorder (MDD) Self-injurious behaviors, such as deliberately harming his own body when feeling angry, anxious, or tense Paul was pleasant to staff and peers but presented with an inappropriate affect, such as smiling while talking about his depression and being bullied at school Lee 10 Mixed-race Latina Lee was given up for adoption by her biological mom, and never knew her biological father. She was currently living with a foster family, and reported that she was verbally and sexually abused repeatedly while living in past foster homes. In her present foster home, Lee was verbally abusive to her foster parents, stayed out late after curfew on school nights, and was believed to be in a local gang. At school, Lee skipped classes due to constantly being bullied and teased about her weight, causing her to get into physical altercations with her peers. Oppositional defiant disorder (ODD) Sexually inappropriate behavior Aggressive behaviors Self-injurious behaviors Lee presented with a labile affect, and was easily annoyed by staff and her peers Pseudonym Age Ethnicity/Race Home Life Diagnosis Admitting Behaviors Unit Presentation Mary 7 Mexican Mary lived with her biological parents and four siblings. Her depression was an outcome of her father’s verbal and physical abuse at home, in addition to being bullied at school for “being Mexican”. Major depressive disorder (MDD) Self-injurious behaviors, such as cutting herself when feeling anxious Mary presented with a flat affect, preferred to have her hair cover her eyes, preferred to stay in her room alone, and did not initiate in conversation with staff or peers Glenda 12 Filipino Glenda lived with her biological parents and five siblings, including extended family. Although Glenda came from a loving family, her parents would not accept the fact that their daughter needed medical treatment, and equated her auditory hallucinations to “being possessed by demons”. At school, Glenda excelled in her studies, but had recently started to skip classes due to her current psychological condition, as well as verbally being bullied by her peers for “acting strangely” and being “a weirdo”. Childhood-onset schizophrenia (COS) Symptoms of auditory hallucinations, and abnormal behaviors, such as grinning while standing still on one leg for a long period of time Glenda presented with a restricted affect, was quiet, kept to herself, but was pleasant to staff and peers George 6 African American George lived with his biological mother, three biological siblings, and mother’s boyfriend. George never knew his biological father due to his father abandoning his family when George was a year old. George was in conflict with his mother’s boyfriend because he could not accept the boyfriend as a “fatherly figure”. In addition, George was constantly having verbal and physical altercations with his siblings. At school, George was bullied for “being black” by Caucasian and Latino students. Mood disorder not otherwise specified (MD-NOS) Conduct disorder (CD) Outbursts at home and at school Lack of focus in a standard classroom setting due to the conflicts at home and the bullying by his peers George presented with a labile affect and was confrontational with staff and peers, trying to kick and hit staff Mani 10 Caucasian Mani was living with her biological parents and three siblings. Mani exhibited repetitive patterns of behavior, such as occasionally rearranging books on a bookshelf, spending long periods of time lining up small objects, as well as sensory seeking (tactile) behaviors, as evidenced by craving physical contact and stimulation through deep pressure on her hands and feet. Mani was in special education classes at school and was an average student scholastically. She was being bullied at school for being “socially retarded”, causing her to lose interest in her studies and have constant emotional outbursts in her classes. Autism spectrum disorder (ASD) and Attention deficit hyperactivity disorder (ADHD) Aggressive behaviors Outbursts at home and at school Mani presented with a blunted affect, and stayed in her room most of the time Joe 8 Asian Indian Joe was living with his biological parents and six siblings. He was constantly comparing his body parts to others, and continually checked his appearance in mirrors. At school, Joe’s preoccupation with his appearance was interfering with his studies. He reported that one key component to his body dysmorphic disorder was due to being repeatedly bullied at school for having a “weird body without any muscle tone”. Body dysmorphic disorder (BDD) Eating disorder History of binge eating, such as eating large amounts of food Self-induced vomiting, accompanied by excessive exercise Joe was euthymic and was pleasant to staff and peers Anne 11 Caucasian Anne was an only child living with her biological mother due to Anne’s allegations of her father sexually abusing her at a young age. Attention deficit hyperactivity disorder (ADHD) Conduct disorder (CD) Aggressive behaviors Lack of focus in a standard classroom Anne presented with a labile affect and had constant verbal altercations with staff and her peers As an outcome of the sexual abuse, Anne’s biological parents had recently divorced. Anne found it difficult to focus at school due to her hyperactivity and constantly being bullied by students “for being white trash”. Paul 12 Mixed-race Latino Paul came from a loving a supportive family, living at home with his biological parents, three biological siblings, and extended family. However, at school, Paul was verbally and physically bullied and harassed for “being different” due to exhibiting a higher intelligence and creative abilities, and dressing in EMO clothing. Consequently, Paul had very few to no friends. Major depressive disorder (MDD) Self-injurious behaviors, such as deliberately harming his own body when feeling angry, anxious, or tense Paul was pleasant to staff and peers but presented with an inappropriate affect, such as smiling while talking about his depression and being bullied at school Lee 10 Mixed-race Latina Lee was given up for adoption by her biological mom, and never knew her biological father. She was currently living with a foster family, and reported that she was verbally and sexually abused repeatedly while living in past foster homes. In her present foster home, Lee was verbally abusive to her foster parents, stayed out late after curfew on school nights, and was believed to be in a local gang. At school, Lee skipped classes due to constantly being bullied and teased about her weight, causing her to get into physical altercations with her peers. Oppositional defiant disorder (ODD) Sexually inappropriate behavior Aggressive behaviors Self-injurious behaviors Lee presented with a labile affect, and was easily annoyed by staff and her peers View Large Table 1 Patient Characteristics Pseudonym Age Ethnicity/Race Home Life Diagnosis Admitting Behaviors Unit Presentation Mary 7 Mexican Mary lived with her biological parents and four siblings. Her depression was an outcome of her father’s verbal and physical abuse at home, in addition to being bullied at school for “being Mexican”. Major depressive disorder (MDD) Self-injurious behaviors, such as cutting herself when feeling anxious Mary presented with a flat affect, preferred to have her hair cover her eyes, preferred to stay in her room alone, and did not initiate in conversation with staff or peers Glenda 12 Filipino Glenda lived with her biological parents and five siblings, including extended family. Although Glenda came from a loving family, her parents would not accept the fact that their daughter needed medical treatment, and equated her auditory hallucinations to “being possessed by demons”. At school, Glenda excelled in her studies, but had recently started to skip classes due to her current psychological condition, as well as verbally being bullied by her peers for “acting strangely” and being “a weirdo”. Childhood-onset schizophrenia (COS) Symptoms of auditory hallucinations, and abnormal behaviors, such as grinning while standing still on one leg for a long period of time Glenda presented with a restricted affect, was quiet, kept to herself, but was pleasant to staff and peers George 6 African American George lived with his biological mother, three biological siblings, and mother’s boyfriend. George never knew his biological father due to his father abandoning his family when George was a year old. George was in conflict with his mother’s boyfriend because he could not accept the boyfriend as a “fatherly figure”. In addition, George was constantly having verbal and physical altercations with his siblings. At school, George was bullied for “being black” by Caucasian and Latino students. Mood disorder not otherwise specified (MD-NOS) Conduct disorder (CD) Outbursts at home and at school Lack of focus in a standard classroom setting due to the conflicts at home and the bullying by his peers George presented with a labile affect and was confrontational with staff and peers, trying to kick and hit staff Mani 10 Caucasian Mani was living with her biological parents and three siblings. Mani exhibited repetitive patterns of behavior, such as occasionally rearranging books on a bookshelf, spending long periods of time lining up small objects, as well as sensory seeking (tactile) behaviors, as evidenced by craving physical contact and stimulation through deep pressure on her hands and feet. Mani was in special education classes at school and was an average student scholastically. She was being bullied at school for being “socially retarded”, causing her to lose interest in her studies and have constant emotional outbursts in her classes. Autism spectrum disorder (ASD) and Attention deficit hyperactivity disorder (ADHD) Aggressive behaviors Outbursts at home and at school Mani presented with a blunted affect, and stayed in her room most of the time Joe 8 Asian Indian Joe was living with his biological parents and six siblings. He was constantly comparing his body parts to others, and continually checked his appearance in mirrors. At school, Joe’s preoccupation with his appearance was interfering with his studies. He reported that one key component to his body dysmorphic disorder was due to being repeatedly bullied at school for having a “weird body without any muscle tone”. Body dysmorphic disorder (BDD) Eating disorder History of binge eating, such as eating large amounts of food Self-induced vomiting, accompanied by excessive exercise Joe was euthymic and was pleasant to staff and peers Anne 11 Caucasian Anne was an only child living with her biological mother due to Anne’s allegations of her father sexually abusing her at a young age. Attention deficit hyperactivity disorder (ADHD) Conduct disorder (CD) Aggressive behaviors Lack of focus in a standard classroom Anne presented with a labile affect and had constant verbal altercations with staff and her peers As an outcome of the sexual abuse, Anne’s biological parents had recently divorced. Anne found it difficult to focus at school due to her hyperactivity and constantly being bullied by students “for being white trash”. Paul 12 Mixed-race Latino Paul came from a loving a supportive family, living at home with his biological parents, three biological siblings, and extended family. However, at school, Paul was verbally and physically bullied and harassed for “being different” due to exhibiting a higher intelligence and creative abilities, and dressing in EMO clothing. Consequently, Paul had very few to no friends. Major depressive disorder (MDD) Self-injurious behaviors, such as deliberately harming his own body when feeling angry, anxious, or tense Paul was pleasant to staff and peers but presented with an inappropriate affect, such as smiling while talking about his depression and being bullied at school Lee 10 Mixed-race Latina Lee was given up for adoption by her biological mom, and never knew her biological father. She was currently living with a foster family, and reported that she was verbally and sexually abused repeatedly while living in past foster homes. In her present foster home, Lee was verbally abusive to her foster parents, stayed out late after curfew on school nights, and was believed to be in a local gang. At school, Lee skipped classes due to constantly being bullied and teased about her weight, causing her to get into physical altercations with her peers. Oppositional defiant disorder (ODD) Sexually inappropriate behavior Aggressive behaviors Self-injurious behaviors Lee presented with a labile affect, and was easily annoyed by staff and her peers Pseudonym Age Ethnicity/Race Home Life Diagnosis Admitting Behaviors Unit Presentation Mary 7 Mexican Mary lived with her biological parents and four siblings. Her depression was an outcome of her father’s verbal and physical abuse at home, in addition to being bullied at school for “being Mexican”. Major depressive disorder (MDD) Self-injurious behaviors, such as cutting herself when feeling anxious Mary presented with a flat affect, preferred to have her hair cover her eyes, preferred to stay in her room alone, and did not initiate in conversation with staff or peers Glenda 12 Filipino Glenda lived with her biological parents and five siblings, including extended family. Although Glenda came from a loving family, her parents would not accept the fact that their daughter needed medical treatment, and equated her auditory hallucinations to “being possessed by demons”. At school, Glenda excelled in her studies, but had recently started to skip classes due to her current psychological condition, as well as verbally being bullied by her peers for “acting strangely” and being “a weirdo”. Childhood-onset schizophrenia (COS) Symptoms of auditory hallucinations, and abnormal behaviors, such as grinning while standing still on one leg for a long period of time Glenda presented with a restricted affect, was quiet, kept to herself, but was pleasant to staff and peers George 6 African American George lived with his biological mother, three biological siblings, and mother’s boyfriend. George never knew his biological father due to his father abandoning his family when George was a year old. George was in conflict with his mother’s boyfriend because he could not accept the boyfriend as a “fatherly figure”. In addition, George was constantly having verbal and physical altercations with his siblings. At school, George was bullied for “being black” by Caucasian and Latino students. Mood disorder not otherwise specified (MD-NOS) Conduct disorder (CD) Outbursts at home and at school Lack of focus in a standard classroom setting due to the conflicts at home and the bullying by his peers George presented with a labile affect and was confrontational with staff and peers, trying to kick and hit staff Mani 10 Caucasian Mani was living with her biological parents and three siblings. Mani exhibited repetitive patterns of behavior, such as occasionally rearranging books on a bookshelf, spending long periods of time lining up small objects, as well as sensory seeking (tactile) behaviors, as evidenced by craving physical contact and stimulation through deep pressure on her hands and feet. Mani was in special education classes at school and was an average student scholastically. She was being bullied at school for being “socially retarded”, causing her to lose interest in her studies and have constant emotional outbursts in her classes. Autism spectrum disorder (ASD) and Attention deficit hyperactivity disorder (ADHD) Aggressive behaviors Outbursts at home and at school Mani presented with a blunted affect, and stayed in her room most of the time Joe 8 Asian Indian Joe was living with his biological parents and six siblings. He was constantly comparing his body parts to others, and continually checked his appearance in mirrors. At school, Joe’s preoccupation with his appearance was interfering with his studies. He reported that one key component to his body dysmorphic disorder was due to being repeatedly bullied at school for having a “weird body without any muscle tone”. Body dysmorphic disorder (BDD) Eating disorder History of binge eating, such as eating large amounts of food Self-induced vomiting, accompanied by excessive exercise Joe was euthymic and was pleasant to staff and peers Anne 11 Caucasian Anne was an only child living with her biological mother due to Anne’s allegations of her father sexually abusing her at a young age. Attention deficit hyperactivity disorder (ADHD) Conduct disorder (CD) Aggressive behaviors Lack of focus in a standard classroom Anne presented with a labile affect and had constant verbal altercations with staff and her peers As an outcome of the sexual abuse, Anne’s biological parents had recently divorced. Anne found it difficult to focus at school due to her hyperactivity and constantly being bullied by students “for being white trash”. Paul 12 Mixed-race Latino Paul came from a loving a supportive family, living at home with his biological parents, three biological siblings, and extended family. However, at school, Paul was verbally and physically bullied and harassed for “being different” due to exhibiting a higher intelligence and creative abilities, and dressing in EMO clothing. Consequently, Paul had very few to no friends. Major depressive disorder (MDD) Self-injurious behaviors, such as deliberately harming his own body when feeling angry, anxious, or tense Paul was pleasant to staff and peers but presented with an inappropriate affect, such as smiling while talking about his depression and being bullied at school Lee 10 Mixed-race Latina Lee was given up for adoption by her biological mom, and never knew her biological father. She was currently living with a foster family, and reported that she was verbally and sexually abused repeatedly while living in past foster homes. In her present foster home, Lee was verbally abusive to her foster parents, stayed out late after curfew on school nights, and was believed to be in a local gang. At school, Lee skipped classes due to constantly being bullied and teased about her weight, causing her to get into physical altercations with her peers. Oppositional defiant disorder (ODD) Sexually inappropriate behavior Aggressive behaviors Self-injurious behaviors Lee presented with a labile affect, and was easily annoyed by staff and her peers View Large Initial Music Therapy Sessions All of the music therapy group sessions on the pediatric unit took place in the afternoon and/or early evening timeslots, lasting between 30 to 65-min. Typically, the approach to therapy was integrated, utilizing interventions found in analytic music therapy (GAMT) (Ahonen-Eerikäinen, 2007), neurologic music therapy (NMT) (Thaut, 2005), sensory-motor music therapy (Schneck & Berger, 2006; Berger, 2002; 2016), and numerous music therapy songwriting (Baker & Wigram, 2005) and receptive methods (Grocke & Wigram, 2007). Moreover, the music therapy sessions had its foundation in music in psychotherapy (Bruscia, 1998), focusing on the patients’ therapeutic needs via creating and/or listening to music, with both the musical and the verbal experiences occurring alternately or simultaneously. As noted in each of the patients’ hospital charts, deficits in attentional skills hampered basic tasks of everyday living at home and at school, resulting in distractibility, poor concentration, hyperactivity, irritability, and impulsivity. In the initial music therapy sessions centered on various diatonic musical interventions, staff and the music therapist observed a range of inappropriate patient behaviors as a result of poor concentration, attentional, and listening skills. Staff reported to the music therapist that the inappropriate behaviors were amplified in the music therapy groups, and the disruptive behaviors continued outside of the music groups. Patients’ behaviors included: Verbal and/or shouting interruptions Verbal abuse or name-calling Constantly yawning and feeling fatigued An inability to participate in any of the various active and/or receptive musical tasks for over a 1-min. duration Requesting to end the musical tasks early to go to the bathroom Getting up from their seats to walk around the therapy room Play-hitting group members with various musical instruments Intolerance for environmental sounds (staff entering the therapy room, staff talking to each other, the sound of the air-conditioner, etc.) Patients walking out of the group multiple times without explanation Throwing printed copies of song lyrics at the music therapist and around the therapy room Purposely destroying musical instruments and/or mallets Throwing mallets or drum sticks across the therapy room during music improvisations Fighting and grabbing instruments A Spark of Interest in Sound Although the patients exhibited deficits in attentional skills, when participating in musical interventions centered on different tonalities they showed interest when various sustained tones were demonstrated to them on Tibetan singing bowls, as observable changes in the patients’ affect, eye gaze, and body language were documented in the music therapist’s written session notes. Their curiosity led to a brief discussion about different forms of experimental and avant-garde music, including demonstrations of some odd sounding timbres on various musical instruments using extended or irregular playing techniques informed by the composer Helmut Lachenmann (Griffiths, 1995). Consequently, the music therapist wanted to create avant-garde musical interventions that would quickly attract the patients’ attention, interest, and curiosity, helping the acute patients to improve their attentional skills. Musicological Review with Clinical Applications The music therapist conducted an extensive review of musical works by various 20th century avant-garde composers concerned with concentration, attention, and awareness. Composers that emphasized unique listening experiences within their compositions, or, as the major component of their compositions, were of special interest. For example, the composers Pauline Oliveros (Duckworth, 1995; Fuller, 1994; Oliveros, 1998, 2005; Smith & Walker Smith, 1995), John Cage (Kostelanetz, 1989, 1991; Peyser, 1971; Retallack, 1996; Revill, 1992), and Luigi Nono (Griffiths, 1995; McHard, 2001; Nielinger-Vakil, 2015) created compositions deeply concerned with attention and concentration for both performer and audience member alike. After further examination of various musical scores by Oliveros, Cage, and Nono, the music therapist felt their musical explorations would be an appropriate match for the patients’ collective need for improving attentional skills. Consequently, the music therapist created three novel clinical experiences, informed by Oliveros, Cage, and Nono, with the hope that the avant-garde interventions would be stimulating and motivating for the pediatric patients. Pauline Oliveros: Sonic Meditations In the early 1970s, the American composer and musician Pauline Oliveros (1932–2016) began to listen intently to a single sound for long periods of time, gradually developing a unique skill for deeply experiencing sounds (Duckworth, 1995; Fuller, 1994). This led Oliveros to create the composition of twenty-five prose instructions, Sonic Meditations (1971) (Oliveros, 1998, 2005), which became one of most important works of her career (Cope, 2001; Smith & Walker Smith, 1995). These probing texts focus on novel ways of inwardly listening to sound, not otherwise conceived, practiced, or considered by the participants (Struble, 1995). Oliveros Informed Intervention. The 1st novel intervention presented to the pediatric patients was inspired by Pauline Oliveros’ composition Sonic Meditations. Here, the intervention set out to improve attentional skills via the integration of walking-meditation and environmental-sound listening. Clinically, five receptive listening experiences, music relaxation, meditative, stimulative and perceptual listening, and projective movement to music (Bruscia, 2014), were integrated together with an adapted version of rhythmic auditory stimulation (RAS) (Thaut, 2005), focusing on helping the patients to listen to environmental sounds while silently walking with pronounced body movements, entraining to a slow and steady pulse. See Table 2 for instructions. Table 2 Pauline Oliveros Informed Intervention Group Goal: Sustained Attention: To develop the ability to focus on one task sufficiently for a continuous amount of time to enable participation in everyday tasks of longer duration. Group Objective: For the patients to sustain attention via auditory focus while slowly walking up to 5 minutes without interrupting verbally or attempting to disrupt the intervention. Intervention: The patients are to remove their shoes and socks and line up quietly in a single file. Once calm and quiet, the patients are asked to silently walk around the unit at a walking speed of 40 beats per minute (bpm), or slower, while focusing on all of the sounds around them as the sounds unfolded or materialized. A Tibetan singing bowl is used to lightly accent each beat, providing an audible and secure rhythmic structure for the patients to entrain or synchronize to while experiencing the environmental music. In addition, different colored and textured foot print markers are placed around the unit to outline the walking path, providing a multisensory experience for each of the patients. Clinical Strategies: Inform the patients that the group task is targeted towards improving their capacity for concentration by having them silently walk on the foot print markers while experiencing the environmental music on the unit for X minutes. After this task, they are to go into the therapy room and verbally process the sound-walking experience together. Furthermore, other staff members should be placed around the unit providing visual cues, such as facial expressions and gestures to encourage the patients to re-engage if they went off task. Explain to the patients that this is to be a full body experience, stimulating kinetic awareness because they are to be listening to sounds while slowly walking and moving to the tempo of the Tibetan singing bowl at 40 (bpm) or slower. Since the tempo is very slow, invite the patients to be creative and playful with their body movements and walking patterns. Encourage the patients to walk in slow motion, move with overly pronounced arm or leg gestures, walk backwards, or walk on their toes, just as long as one foot hits a foot print marker on the beat, while listening to the environmental sounds intently. Lastly, before beginning the sound-walking experience, gave this musical directive to the patients adapted from Pauline Oliveros’ Sonic Meditation V (Cope, 2001, p. 110): Lets walk around the unit together multiple times. Walk so silently that the bottoms of your feet becoame ears. Group Goal: Sustained Attention: To develop the ability to focus on one task sufficiently for a continuous amount of time to enable participation in everyday tasks of longer duration. Group Objective: For the patients to sustain attention via auditory focus while slowly walking up to 5 minutes without interrupting verbally or attempting to disrupt the intervention. Intervention: The patients are to remove their shoes and socks and line up quietly in a single file. Once calm and quiet, the patients are asked to silently walk around the unit at a walking speed of 40 beats per minute (bpm), or slower, while focusing on all of the sounds around them as the sounds unfolded or materialized. A Tibetan singing bowl is used to lightly accent each beat, providing an audible and secure rhythmic structure for the patients to entrain or synchronize to while experiencing the environmental music. In addition, different colored and textured foot print markers are placed around the unit to outline the walking path, providing a multisensory experience for each of the patients. Clinical Strategies: Inform the patients that the group task is targeted towards improving their capacity for concentration by having them silently walk on the foot print markers while experiencing the environmental music on the unit for X minutes. After this task, they are to go into the therapy room and verbally process the sound-walking experience together. Furthermore, other staff members should be placed around the unit providing visual cues, such as facial expressions and gestures to encourage the patients to re-engage if they went off task. Explain to the patients that this is to be a full body experience, stimulating kinetic awareness because they are to be listening to sounds while slowly walking and moving to the tempo of the Tibetan singing bowl at 40 (bpm) or slower. Since the tempo is very slow, invite the patients to be creative and playful with their body movements and walking patterns. Encourage the patients to walk in slow motion, move with overly pronounced arm or leg gestures, walk backwards, or walk on their toes, just as long as one foot hits a foot print marker on the beat, while listening to the environmental sounds intently. Lastly, before beginning the sound-walking experience, gave this musical directive to the patients adapted from Pauline Oliveros’ Sonic Meditation V (Cope, 2001, p. 110): Lets walk around the unit together multiple times. Walk so silently that the bottoms of your feet becoame ears. View Large Table 2 Pauline Oliveros Informed Intervention Group Goal: Sustained Attention: To develop the ability to focus on one task sufficiently for a continuous amount of time to enable participation in everyday tasks of longer duration. Group Objective: For the patients to sustain attention via auditory focus while slowly walking up to 5 minutes without interrupting verbally or attempting to disrupt the intervention. Intervention: The patients are to remove their shoes and socks and line up quietly in a single file. Once calm and quiet, the patients are asked to silently walk around the unit at a walking speed of 40 beats per minute (bpm), or slower, while focusing on all of the sounds around them as the sounds unfolded or materialized. A Tibetan singing bowl is used to lightly accent each beat, providing an audible and secure rhythmic structure for the patients to entrain or synchronize to while experiencing the environmental music. In addition, different colored and textured foot print markers are placed around the unit to outline the walking path, providing a multisensory experience for each of the patients. Clinical Strategies: Inform the patients that the group task is targeted towards improving their capacity for concentration by having them silently walk on the foot print markers while experiencing the environmental music on the unit for X minutes. After this task, they are to go into the therapy room and verbally process the sound-walking experience together. Furthermore, other staff members should be placed around the unit providing visual cues, such as facial expressions and gestures to encourage the patients to re-engage if they went off task. Explain to the patients that this is to be a full body experience, stimulating kinetic awareness because they are to be listening to sounds while slowly walking and moving to the tempo of the Tibetan singing bowl at 40 (bpm) or slower. Since the tempo is very slow, invite the patients to be creative and playful with their body movements and walking patterns. Encourage the patients to walk in slow motion, move with overly pronounced arm or leg gestures, walk backwards, or walk on their toes, just as long as one foot hits a foot print marker on the beat, while listening to the environmental sounds intently. Lastly, before beginning the sound-walking experience, gave this musical directive to the patients adapted from Pauline Oliveros’ Sonic Meditation V (Cope, 2001, p. 110): Lets walk around the unit together multiple times. Walk so silently that the bottoms of your feet becoame ears. Group Goal: Sustained Attention: To develop the ability to focus on one task sufficiently for a continuous amount of time to enable participation in everyday tasks of longer duration. Group Objective: For the patients to sustain attention via auditory focus while slowly walking up to 5 minutes without interrupting verbally or attempting to disrupt the intervention. Intervention: The patients are to remove their shoes and socks and line up quietly in a single file. Once calm and quiet, the patients are asked to silently walk around the unit at a walking speed of 40 beats per minute (bpm), or slower, while focusing on all of the sounds around them as the sounds unfolded or materialized. A Tibetan singing bowl is used to lightly accent each beat, providing an audible and secure rhythmic structure for the patients to entrain or synchronize to while experiencing the environmental music. In addition, different colored and textured foot print markers are placed around the unit to outline the walking path, providing a multisensory experience for each of the patients. Clinical Strategies: Inform the patients that the group task is targeted towards improving their capacity for concentration by having them silently walk on the foot print markers while experiencing the environmental music on the unit for X minutes. After this task, they are to go into the therapy room and verbally process the sound-walking experience together. Furthermore, other staff members should be placed around the unit providing visual cues, such as facial expressions and gestures to encourage the patients to re-engage if they went off task. Explain to the patients that this is to be a full body experience, stimulating kinetic awareness because they are to be listening to sounds while slowly walking and moving to the tempo of the Tibetan singing bowl at 40 (bpm) or slower. Since the tempo is very slow, invite the patients to be creative and playful with their body movements and walking patterns. Encourage the patients to walk in slow motion, move with overly pronounced arm or leg gestures, walk backwards, or walk on their toes, just as long as one foot hits a foot print marker on the beat, while listening to the environmental sounds intently. Lastly, before beginning the sound-walking experience, gave this musical directive to the patients adapted from Pauline Oliveros’ Sonic Meditation V (Cope, 2001, p. 110): Lets walk around the unit together multiple times. Walk so silently that the bottoms of your feet becoame ears. View Large Illustrative Vignette # 1. This session took place at 12:30 p.m., immediately after lunch, lasting only a half an hour. The dialogues, procedures, and the overall group process explained below, are based on music therapist’s written session notes taken before, during, and after the Oliveros intervention. Chaotic Prelude George: Do we have you? Mr. Enrico… what type of music group are we doing today? I want the drums! They are mine! Music Therapist: When everyone finishes lunch… I will let you know…it might be a bit strange. George ran back into the dining area to finish lunch and to tell his peers that there was going to be a strange music group today. After lunch, the patients were yelling, play fighting, walking around the unit, or sitting quietly in the dining area. Staff informed the patients that it was almost time for music therapy group, so they needed to go to their rooms and wash-up. Patient reactions to the room set up after they came out of their rooms and noticed the foot print markers on the floor included some who became overly excited, running and yelling around the unit, while other patients walked slowly and lethargically out of their rooms. The music therapist informed the patients that they only had a half an hour for group and that the commotion needed to settle down so the session could begin. Patient-Oliveros Introduction. The patients were informed that the purpose of the sound-walking task was to work on improving their attentional skills. The music therapist reminded the patients that the prior two music therapy groups were extremely disruptive and chaotic, making it difficult to express uncomfortable feeling-states and emotions within a safe therapeutic environment. Anne: I know Mr. Enrico…we are bad kids. MT: No…not at all…you guys are just not centered…or balanced…we can work on that today. Unexpectedly, the patients became more attentive after the music therapist used the words centered and balanced. Clearly, adults rarely spoke to the patients in this manner. It was quite remarkable how using the words centered or balanced could spark such attention in the patients when relating it to their inappropriate behaviors. In this moment of calm, the music therapist had a chance to explain and demonstrate the Oliveros task: MT: It is important that you move in tempo... or…in time with the sound of the Tibetan singing bowl…this will help improve your concentration. When the music therapist demonstrated slow motion walking, overly pronounced arm and leg gestures, and walking on his toes in the tempo of the singing bowl, the patients were excited to see that they could be as creative and playful with their body movements and walking patterns as they desired. Next, the music therapist read the group directive adapted from Pauline Oliveros’ Sonic Meditation V (Cope, 2001, p. 110). MT:Lets walk around the unit together multiple times. Walk so silently that the bottoms of your feet became ears. Patient-Oliveros Experience. The patients lined up in a single file. The music therapist stood in back of the line and began to play the Tibetan singing bowl in 4/4 time, at a tempo of 40 (bpm). The music therapist asked the patients to remain calm and still for a moment and to listen and feel the tempo of the singing bowl, and to begin walking when the first person in front of the line felt ready to walk. After one minute, the line started to move slowly in the tempo of the singing bowl. Some patients were walking with their hands in their pockets, looking down at the floor, and exhibiting blank expressionless gazes. Most of the patients seemed overly conscious about their walking, making sure that they were diligently stepping on the foot print markers in tempo. However, over time, their body movements became noticeably less tense, less unified, and more individualized. The music therapist noted the following: Mary: Slightly smiling, walking in slow motion, and at times, slowly punching the air. Glenda: Walking backwards. George: Smiling, slowing running in place. Mani: Holding her ears, while walking on her toes. Joe: Slowly and quietly stomping on the foot print markers in tempo. Anne: Smiling while alternating from forward and backward walking in tempo. Paul: Walking on his toes and heels. Lee: At times, pretending to jump in slow motion. In addition to the various body movements and gestures, the patients were listening to the environmental sounds on the unit, signaling to the music therapist when they heard something. The patients continued to walk for 5 minutes. After, the music therapist quietly guided the patients into the therapy room. Patients Process the Oliveros Experience. After the Oliveros experience, the patients sat in their chairs calmly, breathing softly, with serene facial expressions. Lee: Well…this was weird…but…cool…I feel a bit more chill. (Silence) Paul: I’m enjoying this silence. (Silence) MT: I’m enjoying this too…you guys really impressed me today…unfortunately…we have to end because we have run out of time and you need to go back to school. Mary: Oh… no…I want to stay here. MT: I understand…but…we need to end here… and… I will see you guys tomorrow for our next group adventure. The patients quietly got up from out of their seats and left the group to get ready for their afternoon school session. Some members of the nursing staff voiced how surprised they were to see the patients line up for school so calmly. Evaluating Effectiveness of the Oliveros Experience. The end of the noon music therapy group leads into the afternoon school session. It is crucial that each patient is able to sit calmly and focus on their afternoon coursework, making sure that no patient falls behind in their schoolwork while in the hospital. Here, the Oliveros experience was aimed to help the patients’ attentional skills, with the hope that improvement in attention and concentration would generalize outside of the music therapy room in everyday activities of daily living. Concerning the effectiveness of this Oliveros session, from the patients’ reaction and verbal responses towards the unfamiliar music therapy intervention, it was clear that the patients became calmer in the present moment, resting in the silence. Although there was not an abundance of verbal dialogue after the intervention, the patients’ relaxed and calm body language spoke volumes in comparison to the start of the group, as well as in the previous chaotic music therapy sessions. Moreover, while the music therapist walked the patients over to the school after the Oliveros session, some of patients mentioned that they appreciated that they were allowed to try out strange body movements as part of the intervention. It was revealed that because the patients had to match their body movements to the tempo of the Tibetan singing bowl, it not only helped them to stay focused on the various sounds around the unit, but was also an outlet for relieving stress due to making it easier to express their stress and tension in a fun way. Plausibly, the strange body movements facilitated an outlet for nonverbal expressivity, allowing the patients to tap into unexpressed emotions and feelings. Consequently, the teachers at the school hospital reported that most of the patients were calmer that day and more focused on their studies. John Cage: 4’33” On August 29, 1952, at a concert held in Woodstock, New York, the musical world was silenced due to the premier performance of the American composer John Cage’s (1912–1992) seminal composition, 4’33” (Kostelanetz, 1989). A musical composition scored in three-movements for any instrument or any combination of instruments, instructing the performer(s) not to play their instruments during the entire duration of the composition (Revill, 1992), encouraging the listener to experience and attend to all sounds as they materialize (Kostelanetz, 1991; Peyser, 1971). Cage Informed Intervention The 2nd novel intervention presented to the pediatric patients was inspired by John Cage’s experimental-composition 4’33”. Here, the intervention set out to improve attentional skills via sitting or standing meditation and environmental-sound listening. Clinically, an integration of a re-creative experience and four receptive listening experiences, meditative, stimulative, perceptual, and projective (Bruscia, 2014) were utilized to explore Cage’s silent piece. See Table 3 for instructions. Table 3 John Cage Informed Intervention Group Goal: Divided Attention: To develop the ability to focus on two or more simultaneous events or stimuli. Group Objective: For the patients to listen to a variety of unintentional sounds simultaneously as an aid to concentration. Intervention: Group performance or re-creative experience of John Cage’s “silent” composition, 4’33”, once or multiple times, followed by a group discussion of the experience. Color coordinated music stations are to be setup around the therapy room, with the option for the patient(s) to stand, to sit in a chair, or to sit on a floor mat. Depending on what materials are available to the music therapist, various “music stations” could be arranged in this fashion. See Online Supplement A for layout. 1) Standing-Music Stand Station (Red): Each red music stand is to have a red copy of Cage’s 4’33” score and a set of red desk bells placed on a small table with a red tablecloth. A variety of red drums are to be place around the small table, including a red electric bass. 2) Purple Floor Mat Station: Each purple floor mat is to have a purple copy of Cage’s 4’33” score and two purple desk bells placed in front of each floor mat. 3) Sitting-Music Stand Station (Blue Chairs): Each blue music stand is to have a blue copy of Cage’s 4’33” score with a set of blue maracas placed on each chair. A variety of small blue drums are to be placed around the chairs. 4) Green Floor Mat Station: Each green floor mat is to have a green copy of Cage’s 4’33” score and three small green drums placed in front of each floor mat. Clinical Strategies A) Ask the patients to find a music station that resonates with them, exploring which color, instrument(s), and seating/standing option catches their attention. B) After they have settled on a particular music station, inform the patients that the group task is targeted towards improving their capacity for concentration by having them perform John Cage’s composition, 4’33”, followed by a group discussion and processing of their experiences. C) Give a brief overview of Cage’s 4’33” composition, which, for those patients that are curious, will answer the question as to why the musical score doesn’t have any music written on it. D) Inform the patients that they are not to play their instruments for four minutes and thirty-three seconds, but instead, to silently listen to and explore all of the sounds around them as they materialized. E) Inform the patients that the music therapist will be the conductor of 4’33”, acting as support, keeping time on a cell phone timer or stopwatch, letting them know when to start and end the composition. Group Goal: Divided Attention: To develop the ability to focus on two or more simultaneous events or stimuli. Group Objective: For the patients to listen to a variety of unintentional sounds simultaneously as an aid to concentration. Intervention: Group performance or re-creative experience of John Cage’s “silent” composition, 4’33”, once or multiple times, followed by a group discussion of the experience. Color coordinated music stations are to be setup around the therapy room, with the option for the patient(s) to stand, to sit in a chair, or to sit on a floor mat. Depending on what materials are available to the music therapist, various “music stations” could be arranged in this fashion. See Online Supplement A for layout. 1) Standing-Music Stand Station (Red): Each red music stand is to have a red copy of Cage’s 4’33” score and a set of red desk bells placed on a small table with a red tablecloth. A variety of red drums are to be place around the small table, including a red electric bass. 2) Purple Floor Mat Station: Each purple floor mat is to have a purple copy of Cage’s 4’33” score and two purple desk bells placed in front of each floor mat. 3) Sitting-Music Stand Station (Blue Chairs): Each blue music stand is to have a blue copy of Cage’s 4’33” score with a set of blue maracas placed on each chair. A variety of small blue drums are to be placed around the chairs. 4) Green Floor Mat Station: Each green floor mat is to have a green copy of Cage’s 4’33” score and three small green drums placed in front of each floor mat. Clinical Strategies A) Ask the patients to find a music station that resonates with them, exploring which color, instrument(s), and seating/standing option catches their attention. B) After they have settled on a particular music station, inform the patients that the group task is targeted towards improving their capacity for concentration by having them perform John Cage’s composition, 4’33”, followed by a group discussion and processing of their experiences. C) Give a brief overview of Cage’s 4’33” composition, which, for those patients that are curious, will answer the question as to why the musical score doesn’t have any music written on it. D) Inform the patients that they are not to play their instruments for four minutes and thirty-three seconds, but instead, to silently listen to and explore all of the sounds around them as they materialized. E) Inform the patients that the music therapist will be the conductor of 4’33”, acting as support, keeping time on a cell phone timer or stopwatch, letting them know when to start and end the composition. View Large Table 3 John Cage Informed Intervention Group Goal: Divided Attention: To develop the ability to focus on two or more simultaneous events or stimuli. Group Objective: For the patients to listen to a variety of unintentional sounds simultaneously as an aid to concentration. Intervention: Group performance or re-creative experience of John Cage’s “silent” composition, 4’33”, once or multiple times, followed by a group discussion of the experience. Color coordinated music stations are to be setup around the therapy room, with the option for the patient(s) to stand, to sit in a chair, or to sit on a floor mat. Depending on what materials are available to the music therapist, various “music stations” could be arranged in this fashion. See Online Supplement A for layout. 1) Standing-Music Stand Station (Red): Each red music stand is to have a red copy of Cage’s 4’33” score and a set of red desk bells placed on a small table with a red tablecloth. A variety of red drums are to be place around the small table, including a red electric bass. 2) Purple Floor Mat Station: Each purple floor mat is to have a purple copy of Cage’s 4’33” score and two purple desk bells placed in front of each floor mat. 3) Sitting-Music Stand Station (Blue Chairs): Each blue music stand is to have a blue copy of Cage’s 4’33” score with a set of blue maracas placed on each chair. A variety of small blue drums are to be placed around the chairs. 4) Green Floor Mat Station: Each green floor mat is to have a green copy of Cage’s 4’33” score and three small green drums placed in front of each floor mat. Clinical Strategies A) Ask the patients to find a music station that resonates with them, exploring which color, instrument(s), and seating/standing option catches their attention. B) After they have settled on a particular music station, inform the patients that the group task is targeted towards improving their capacity for concentration by having them perform John Cage’s composition, 4’33”, followed by a group discussion and processing of their experiences. C) Give a brief overview of Cage’s 4’33” composition, which, for those patients that are curious, will answer the question as to why the musical score doesn’t have any music written on it. D) Inform the patients that they are not to play their instruments for four minutes and thirty-three seconds, but instead, to silently listen to and explore all of the sounds around them as they materialized. E) Inform the patients that the music therapist will be the conductor of 4’33”, acting as support, keeping time on a cell phone timer or stopwatch, letting them know when to start and end the composition. Group Goal: Divided Attention: To develop the ability to focus on two or more simultaneous events or stimuli. Group Objective: For the patients to listen to a variety of unintentional sounds simultaneously as an aid to concentration. Intervention: Group performance or re-creative experience of John Cage’s “silent” composition, 4’33”, once or multiple times, followed by a group discussion of the experience. Color coordinated music stations are to be setup around the therapy room, with the option for the patient(s) to stand, to sit in a chair, or to sit on a floor mat. Depending on what materials are available to the music therapist, various “music stations” could be arranged in this fashion. See Online Supplement A for layout. 1) Standing-Music Stand Station (Red): Each red music stand is to have a red copy of Cage’s 4’33” score and a set of red desk bells placed on a small table with a red tablecloth. A variety of red drums are to be place around the small table, including a red electric bass. 2) Purple Floor Mat Station: Each purple floor mat is to have a purple copy of Cage’s 4’33” score and two purple desk bells placed in front of each floor mat. 3) Sitting-Music Stand Station (Blue Chairs): Each blue music stand is to have a blue copy of Cage’s 4’33” score with a set of blue maracas placed on each chair. A variety of small blue drums are to be placed around the chairs. 4) Green Floor Mat Station: Each green floor mat is to have a green copy of Cage’s 4’33” score and three small green drums placed in front of each floor mat. Clinical Strategies A) Ask the patients to find a music station that resonates with them, exploring which color, instrument(s), and seating/standing option catches their attention. B) After they have settled on a particular music station, inform the patients that the group task is targeted towards improving their capacity for concentration by having them perform John Cage’s composition, 4’33”, followed by a group discussion and processing of their experiences. C) Give a brief overview of Cage’s 4’33” composition, which, for those patients that are curious, will answer the question as to why the musical score doesn’t have any music written on it. D) Inform the patients that they are not to play their instruments for four minutes and thirty-three seconds, but instead, to silently listen to and explore all of the sounds around them as they materialized. E) Inform the patients that the music therapist will be the conductor of 4’33”, acting as support, keeping time on a cell phone timer or stopwatch, letting them know when to start and end the composition. View Large Illustrative Vignette # 2. This session took place at 3:45 p.m., lasting 45 minutes. A negative of running a music psychotherapy group at the 3:45 time slot was constant interruptions that caused the patients to lose focus and concentration within the therapeutic process. These interruptions occurred because (a) the patients needed to leave the group due to visiting hours, (b) the nursing staff administering medications, (c) a scheduled family meeting with the social worker, and/or (d) an individual session with the psychologist or psychology intern. However, in the spirit of John Cage, the positive side of running a process group at the 3:45 time slot was to embrace all of the above-mentioned disruptions and interruptions as they materialized, viewing all of the sounds created by the interruptions as part of the entire musical experience. The dialogues and the overall group process explained below, are based on the music therapist’s session notes taken during and after the Cage intervention. Patient-Cage Introduction. The patients exited a verbal psychotherapy group with the psychologist. Some of the patients hurried out of the room; some left calmly. Nursing staff guided the patients into a room where the music therapist had arranged a color coordinated chamber music ensemble. (See Online Supplement A for The 4’33” Ensemble Music Stations) MT: Hello everyone…please enter the therapy room calmly. Lee: Wow! What is this? Anne: You again? Looks cool in here! Mary: Didn’t we just have you? Mani: That was last night! Remember? Yesterday evening? MT: Right…last night…we walked in a circle in this room listening to sounds…just like we did yesterday afternoon around the unit…while listening to sounds on the unit. After the patients calmed down, the music therapist asked them to find a music station that resonated with them. Surprisingly, there was no fighting or bickering by the patients when choosing a music stations. Next, the music therapist gave a brief overview of Cage’s 4’33” composition, asking the patients to explore the Tacet score, instructing them not to play their instruments for four minutes and thirty-three seconds, but, to silently listen to all of the sounds around them as they materialized. Lee: What the fuck!! You expect me…us…not to do anything for four minutes?!! (Most of the group members are startled by Lee’s agitated response) MT: OK…your first reaction is an honest one. It sounds like this is going to be a new experience for you. Lee: Yes! This is not normal…but…I’ll do it…try it. MT:Great! Anne: Fuck this! You have some strange groups here Mr. Enrico! Glenda: Let’s just try this…I’m curious…let’s go. MT: Great…your reactions are honest…and I appreciate them…let’s focus and perform this Cage piece once and see what we hear…or…better… hear what we hear…and then we can talk about the experience. After a moment of silence, all of the patients agreed to try this strange musical task. The patients expressed that they felt more comfortable and less anxious when the music therapist informed the group that he was going to be the conductor of the ensemble, keeping time on his cell phone stopwatch, acting as support, letting them know when to start and stop the composition by using simple hand gestures. Patient-Cage Experience. The music therapist dropped his left arm indicating that the composition had begun. Some patients were looking around the room at each other, some were looking at the floor, and some were looking up at the ceiling. The ventilation system was quietly humming. The unit door buzzer rang. Nurses’ footsteps were sounding. Doors were opening and closing. Nurses were talking. A nurse came into the room to take a patient out of the group for a family visit. Whispers were heard. Another nurse entered the room to give a few of the patients their medication. The door closed. The quiet humming from the ventilation system took over, adding to the environmental musical soundscape. Nurses were heard laughing with the visitors. An unknown scrapping sound was heard in the distance underneath the floor. The music therapist dropped his right arm indicating that the composition had finished. MT: What did you notice? Mary: (Smiling) I heard the air conditioner…or this sound coming from the ceiling? Lee: Yes…that… and the door opening and closing…lots of disruptions. MT: Can you remember what you were feeling in your body when you heard the disruptions? Lee: I was pissed off…but…I kept watching you looking at your cellphone …keeping time. Paul: Yes…with you here…Mr. Enrico…I felt safe. MT: Safe? Paul: Yes... MT: (Silence) Safe? (Silence)…and…what else did we hear…what other music? Anne: Music? Was this music?!! MT: Well…yes…did anyone hear the sounds as an entire piece of music…or…view all of the sounds as musical? Anne: Mr. Enrico…can we do this again…now…and I’ll try to listen more closely. MT: OK…let’s do this again and we can try and listen more closely and carefully…hearing if the sounds themselves…as they develop…create a musical composition with a beginning and an end. The entire group agreed to perform Cage’s 4’33” three more times and to switch music stations for each re-creative experience. Interestingly, after each 4’33” experience, the group discussions centered on the how the first attempt at Cage’s composition was so difficult and hard for most of the patients to stay focused and pay attention to the environmental sounds without being distracted by boredom or thoughts. However, after each re-creation of 4’33”, it became easier for the patients to focus and pay attention to the environmental sounds as they surfaced. Consequently, to deepen their listening experience for future 4’33” sessions, the music therapist suggested to the patients that they could add structure, form, or a frame to the 4’33” experience, helping to foster attentional skills: MT: Think of the first sound that you hear as the opening theme…as the sounds move and progress…what are the patterns of rhythmic activity…what are the movements or motions of the sounds…do all of the sounds move in the same direction…do the sounds have any color…are there many silences…try to experience the sounds in this way. Evaluating Effectiveness of the Cage Experience. In addition to the color coordinated music stations catching the attention of all of the children, some other significant events took place within the therapeutic process: 1. Fear of the unknown. Lee and Anne became anxious and agitated when the music therapist explained the unfamiliar 4’33” group task. Their distress or anxieties were expressed by aggressive hand gesticulations and the use of strong language. 2. Acceptance of their fear. The music therapist’s acceptance and tolerance of the patients’ aggressive behaviors continued to develop the therapeutic relationship built on trust begun with the Oliveros intervention. 3. Support and encouragement. This trust was strengthened when the music therapist informed the group that he was going to be the conductor of 4’33”, acting as support, and as a guide throughout the unfamiliar listening experience. 4. Familiarity. By repeating Cage’s composition multiple times together, the patients became less anxious about the novel musical experience, letting go of their anxieties for a moment. 5. Organization and structure to help attentional skills. As the patients became more comfortable with the 4’33” experience, the music therapist was able to suggest different ways to enhance their focus and concentration by having them silently organize or shape the environmental sounds as they surfaced. Luigi Nono: Sound-Searching The Italian composer Luigi Nono’s (1924–1990) music from his last period in the 1980s reveals a uniquely personal musical voice that combined both precision and improvisation, creating unsettling sonic landscapes of subtlety and beauty (Curreri, 2015; McHard, 2001). As a socially committed composer, deeply concerned with how audience members would perceive and experience his music, these late compositions reflect Nono’s own commitment to collaborate with performers by shaping and molding various sound-textures together and observing what effect the space had on the prolonged silences, microtonal intervals, very subtle textures, and fluctuating timbres found in his compositions (Griffiths, 1995; Nielinger-Vakil, 2015). Consequently, the listener participates almost as much as the performers, by imagining his/her own dreamlike voyage, while navigating through the disintegrated sonic gestures, in search for another harmony (Griffiths, 1995). Nono Informed Intervention. The 3rd novel intervention presented to the pediatric patients was inspired by Nono’s very subtle textures and fluctuating timbres found in his late compositions, and the composer-performer collaborative experience of molding various sounds together and observing the results. Here, an integration of a free improvisatory sound-noise-exploration and receptive experiences, such as stimulative and perceptual listening (Bruscia, 2014) were utilized to help improve shared-attentional and interpersonal skills. See Table 4 for instructions. Table 4 Luigi Nono Informed Intervention Multimodal Group Goals a) Shared Awareness: To develop the ability of shared nonjudgmental focus on an object by two or more individuals. b) To develop tolerance for other’s ideas and concepts, perceptions, and contributions. c) Non-verbal form of creative exploration, discovery, and invention. Group Objective: For the patients to refrain from displaying socially inappropriate conduct towards their peers, such as verbal or shouting interruptions, physical abuse, or name-calling. Intervention: To construct delicate, linearly uniform, and almost inaudible fragmented group-sound-textures of uneven durations, to help improve (a) focused and concentrated listening; (b) shared attention/awareness; (c) interpersonal skills; and (d) creativity. A group discussion based on suggested focused questions listed below is to follow each sound-construction episode (a collection of 4–6 fragmented sound-textures) to verbally process the patients’ experiences. Clinical Strategies: Before the music therapy group begins, place chairs in a circle. Various instruments of definite and indefinite pitches should be neatly placed in the center of the circle. At the beginning of the group, the music therapist is to quietly welcome and greet the patients by gently playing a Tibetan singing bowl as they enter into the therapy room. Ask the patients to sit quietly in a circle, to relax, and to listen to the sustaining tones of the singing bowl. After the patients are relaxed and comfortable, the music therapist is to stop playing the singing bowl and inform the patients that the group task is centered on creating extremely quiet music in the style of Luigi Nono, with the intention of helping them improve concentration, listening skills, cooperation, and creativity. The music therapist is to speak briefly to the patients about the style of music Luigi Nono composed late in his life, demonstrating this style of concentrated composition by exploring extremely soft dynamics on various instruments, including prolonged silences, and extended techniques (unconventional or irregular playing techniques). Here, the music therapist is acting as a model, demonstrating different ways to investigate and explore the instruments creatively, avoiding any kind of specific form or structure. Next, invite each patient, one at a time, to investigate and experiment with any instrument that resonates with him or her. Explain to the patients that they are to remain quiet and refrain from any verbal remarks or outbursts while each peer is exploring their instrument of choice. After all of the members of the group find the musical instrument that they are comfortable playing and exploring, inform the members that they are going to participate in a group experimental-sound-exploration-composition conducted by the music therapist. Reiterate that the patients are to listen intently to each other during the creation of a unified or merged composition consisting of only extremely quiet dynamics, prolonged silences, and conventional and unconventional playing techniques. It is suggested that each sound-fragment follow this format: 1) The music therapist gives a conducting gesture or signal by dropping his/her right hand quickly to let the patients know when to begin the fragment. When the right hand has dropped, all of the members of the group are asked to play a unified attack on their instrument at the same time. 2) The attacks may be a fast (sharp) attack with or without sustain, or a slow attack with or without sustain. In both cases, the patients are invited to add effects of timbre (muted, pizzicato, col legno, or extended techniques) and/or various articulations (tenuto, marcato, staccato, or legato) to their note or sound. 3) During the collective sustaining sound-texture, the music therapist slowly and steadily moves his/her left hand horizontally from left to right, acting as a timekeeper, letting the patients know how long the fragment should last. 4) The music therapist will let the patient know when the fragment has ended by putting up his/her open right hand, acting as a stop sign. The entire group is to sit and listen to the sound-texture as it decays. 5) The group is to sit in a sustained silence, waiting for the music therapist to drop his/her right hand to begin another sound fragment, following the same format. Here, the idea is that the sound-texture fragment travels like one collective musical gesture, leading into a prolonged silence, and then into another fragment. After a completed episode, it is recommended to ask any of the following open-ended questions listed below to help the patients stay focused on the listening/shared awareness experience: a. Where there any moments in the group sound-creations where you felt connected to anyone or others in the group? b. Was there an overall motion to any of the fragments from beginning to end? c. Can you describe the movement of the sounds? d. What sounds fill in the detail of the motion? e. Did the sounds move in the same direction? f. Did you notice any of the sound-textures that you liked or disliked? g. Did any part of sound-textures that you created and heard today/tonight have any specific meaning for you? Multimodal Group Goals a) Shared Awareness: To develop the ability of shared nonjudgmental focus on an object by two or more individuals. b) To develop tolerance for other’s ideas and concepts, perceptions, and contributions. c) Non-verbal form of creative exploration, discovery, and invention. Group Objective: For the patients to refrain from displaying socially inappropriate conduct towards their peers, such as verbal or shouting interruptions, physical abuse, or name-calling. Intervention: To construct delicate, linearly uniform, and almost inaudible fragmented group-sound-textures of uneven durations, to help improve (a) focused and concentrated listening; (b) shared attention/awareness; (c) interpersonal skills; and (d) creativity. A group discussion based on suggested focused questions listed below is to follow each sound-construction episode (a collection of 4–6 fragmented sound-textures) to verbally process the patients’ experiences. Clinical Strategies: Before the music therapy group begins, place chairs in a circle. Various instruments of definite and indefinite pitches should be neatly placed in the center of the circle. At the beginning of the group, the music therapist is to quietly welcome and greet the patients by gently playing a Tibetan singing bowl as they enter into the therapy room. Ask the patients to sit quietly in a circle, to relax, and to listen to the sustaining tones of the singing bowl. After the patients are relaxed and comfortable, the music therapist is to stop playing the singing bowl and inform the patients that the group task is centered on creating extremely quiet music in the style of Luigi Nono, with the intention of helping them improve concentration, listening skills, cooperation, and creativity. The music therapist is to speak briefly to the patients about the style of music Luigi Nono composed late in his life, demonstrating this style of concentrated composition by exploring extremely soft dynamics on various instruments, including prolonged silences, and extended techniques (unconventional or irregular playing techniques). Here, the music therapist is acting as a model, demonstrating different ways to investigate and explore the instruments creatively, avoiding any kind of specific form or structure. Next, invite each patient, one at a time, to investigate and experiment with any instrument that resonates with him or her. Explain to the patients that they are to remain quiet and refrain from any verbal remarks or outbursts while each peer is exploring their instrument of choice. After all of the members of the group find the musical instrument that they are comfortable playing and exploring, inform the members that they are going to participate in a group experimental-sound-exploration-composition conducted by the music therapist. Reiterate that the patients are to listen intently to each other during the creation of a unified or merged composition consisting of only extremely quiet dynamics, prolonged silences, and conventional and unconventional playing techniques. It is suggested that each sound-fragment follow this format: 1) The music therapist gives a conducting gesture or signal by dropping his/her right hand quickly to let the patients know when to begin the fragment. When the right hand has dropped, all of the members of the group are asked to play a unified attack on their instrument at the same time. 2) The attacks may be a fast (sharp) attack with or without sustain, or a slow attack with or without sustain. In both cases, the patients are invited to add effects of timbre (muted, pizzicato, col legno, or extended techniques) and/or various articulations (tenuto, marcato, staccato, or legato) to their note or sound. 3) During the collective sustaining sound-texture, the music therapist slowly and steadily moves his/her left hand horizontally from left to right, acting as a timekeeper, letting the patients know how long the fragment should last. 4) The music therapist will let the patient know when the fragment has ended by putting up his/her open right hand, acting as a stop sign. The entire group is to sit and listen to the sound-texture as it decays. 5) The group is to sit in a sustained silence, waiting for the music therapist to drop his/her right hand to begin another sound fragment, following the same format. Here, the idea is that the sound-texture fragment travels like one collective musical gesture, leading into a prolonged silence, and then into another fragment. After a completed episode, it is recommended to ask any of the following open-ended questions listed below to help the patients stay focused on the listening/shared awareness experience: a. Where there any moments in the group sound-creations where you felt connected to anyone or others in the group? b. Was there an overall motion to any of the fragments from beginning to end? c. Can you describe the movement of the sounds? d. What sounds fill in the detail of the motion? e. Did the sounds move in the same direction? f. Did you notice any of the sound-textures that you liked or disliked? g. Did any part of sound-textures that you created and heard today/tonight have any specific meaning for you? View Large Table 4 Luigi Nono Informed Intervention Multimodal Group Goals a) Shared Awareness: To develop the ability of shared nonjudgmental focus on an object by two or more individuals. b) To develop tolerance for other’s ideas and concepts, perceptions, and contributions. c) Non-verbal form of creative exploration, discovery, and invention. Group Objective: For the patients to refrain from displaying socially inappropriate conduct towards their peers, such as verbal or shouting interruptions, physical abuse, or name-calling. Intervention: To construct delicate, linearly uniform, and almost inaudible fragmented group-sound-textures of uneven durations, to help improve (a) focused and concentrated listening; (b) shared attention/awareness; (c) interpersonal skills; and (d) creativity. A group discussion based on suggested focused questions listed below is to follow each sound-construction episode (a collection of 4–6 fragmented sound-textures) to verbally process the patients’ experiences. Clinical Strategies: Before the music therapy group begins, place chairs in a circle. Various instruments of definite and indefinite pitches should be neatly placed in the center of the circle. At the beginning of the group, the music therapist is to quietly welcome and greet the patients by gently playing a Tibetan singing bowl as they enter into the therapy room. Ask the patients to sit quietly in a circle, to relax, and to listen to the sustaining tones of the singing bowl. After the patients are relaxed and comfortable, the music therapist is to stop playing the singing bowl and inform the patients that the group task is centered on creating extremely quiet music in the style of Luigi Nono, with the intention of helping them improve concentration, listening skills, cooperation, and creativity. The music therapist is to speak briefly to the patients about the style of music Luigi Nono composed late in his life, demonstrating this style of concentrated composition by exploring extremely soft dynamics on various instruments, including prolonged silences, and extended techniques (unconventional or irregular playing techniques). Here, the music therapist is acting as a model, demonstrating different ways to investigate and explore the instruments creatively, avoiding any kind of specific form or structure. Next, invite each patient, one at a time, to investigate and experiment with any instrument that resonates with him or her. Explain to the patients that they are to remain quiet and refrain from any verbal remarks or outbursts while each peer is exploring their instrument of choice. After all of the members of the group find the musical instrument that they are comfortable playing and exploring, inform the members that they are going to participate in a group experimental-sound-exploration-composition conducted by the music therapist. Reiterate that the patients are to listen intently to each other during the creation of a unified or merged composition consisting of only extremely quiet dynamics, prolonged silences, and conventional and unconventional playing techniques. It is suggested that each sound-fragment follow this format: 1) The music therapist gives a conducting gesture or signal by dropping his/her right hand quickly to let the patients know when to begin the fragment. When the right hand has dropped, all of the members of the group are asked to play a unified attack on their instrument at the same time. 2) The attacks may be a fast (sharp) attack with or without sustain, or a slow attack with or without sustain. In both cases, the patients are invited to add effects of timbre (muted, pizzicato, col legno, or extended techniques) and/or various articulations (tenuto, marcato, staccato, or legato) to their note or sound. 3) During the collective sustaining sound-texture, the music therapist slowly and steadily moves his/her left hand horizontally from left to right, acting as a timekeeper, letting the patients know how long the fragment should last. 4) The music therapist will let the patient know when the fragment has ended by putting up his/her open right hand, acting as a stop sign. The entire group is to sit and listen to the sound-texture as it decays. 5) The group is to sit in a sustained silence, waiting for the music therapist to drop his/her right hand to begin another sound fragment, following the same format. Here, the idea is that the sound-texture fragment travels like one collective musical gesture, leading into a prolonged silence, and then into another fragment. After a completed episode, it is recommended to ask any of the following open-ended questions listed below to help the patients stay focused on the listening/shared awareness experience: a. Where there any moments in the group sound-creations where you felt connected to anyone or others in the group? b. Was there an overall motion to any of the fragments from beginning to end? c. Can you describe the movement of the sounds? d. What sounds fill in the detail of the motion? e. Did the sounds move in the same direction? f. Did you notice any of the sound-textures that you liked or disliked? g. Did any part of sound-textures that you created and heard today/tonight have any specific meaning for you? Multimodal Group Goals a) Shared Awareness: To develop the ability of shared nonjudgmental focus on an object by two or more individuals. b) To develop tolerance for other’s ideas and concepts, perceptions, and contributions. c) Non-verbal form of creative exploration, discovery, and invention. Group Objective: For the patients to refrain from displaying socially inappropriate conduct towards their peers, such as verbal or shouting interruptions, physical abuse, or name-calling. Intervention: To construct delicate, linearly uniform, and almost inaudible fragmented group-sound-textures of uneven durations, to help improve (a) focused and concentrated listening; (b) shared attention/awareness; (c) interpersonal skills; and (d) creativity. A group discussion based on suggested focused questions listed below is to follow each sound-construction episode (a collection of 4–6 fragmented sound-textures) to verbally process the patients’ experiences. Clinical Strategies: Before the music therapy group begins, place chairs in a circle. Various instruments of definite and indefinite pitches should be neatly placed in the center of the circle. At the beginning of the group, the music therapist is to quietly welcome and greet the patients by gently playing a Tibetan singing bowl as they enter into the therapy room. Ask the patients to sit quietly in a circle, to relax, and to listen to the sustaining tones of the singing bowl. After the patients are relaxed and comfortable, the music therapist is to stop playing the singing bowl and inform the patients that the group task is centered on creating extremely quiet music in the style of Luigi Nono, with the intention of helping them improve concentration, listening skills, cooperation, and creativity. The music therapist is to speak briefly to the patients about the style of music Luigi Nono composed late in his life, demonstrating this style of concentrated composition by exploring extremely soft dynamics on various instruments, including prolonged silences, and extended techniques (unconventional or irregular playing techniques). Here, the music therapist is acting as a model, demonstrating different ways to investigate and explore the instruments creatively, avoiding any kind of specific form or structure. Next, invite each patient, one at a time, to investigate and experiment with any instrument that resonates with him or her. Explain to the patients that they are to remain quiet and refrain from any verbal remarks or outbursts while each peer is exploring their instrument of choice. After all of the members of the group find the musical instrument that they are comfortable playing and exploring, inform the members that they are going to participate in a group experimental-sound-exploration-composition conducted by the music therapist. Reiterate that the patients are to listen intently to each other during the creation of a unified or merged composition consisting of only extremely quiet dynamics, prolonged silences, and conventional and unconventional playing techniques. It is suggested that each sound-fragment follow this format: 1) The music therapist gives a conducting gesture or signal by dropping his/her right hand quickly to let the patients know when to begin the fragment. When the right hand has dropped, all of the members of the group are asked to play a unified attack on their instrument at the same time. 2) The attacks may be a fast (sharp) attack with or without sustain, or a slow attack with or without sustain. In both cases, the patients are invited to add effects of timbre (muted, pizzicato, col legno, or extended techniques) and/or various articulations (tenuto, marcato, staccato, or legato) to their note or sound. 3) During the collective sustaining sound-texture, the music therapist slowly and steadily moves his/her left hand horizontally from left to right, acting as a timekeeper, letting the patients know how long the fragment should last. 4) The music therapist will let the patient know when the fragment has ended by putting up his/her open right hand, acting as a stop sign. The entire group is to sit and listen to the sound-texture as it decays. 5) The group is to sit in a sustained silence, waiting for the music therapist to drop his/her right hand to begin another sound fragment, following the same format. Here, the idea is that the sound-texture fragment travels like one collective musical gesture, leading into a prolonged silence, and then into another fragment. After a completed episode, it is recommended to ask any of the following open-ended questions listed below to help the patients stay focused on the listening/shared awareness experience: a. Where there any moments in the group sound-creations where you felt connected to anyone or others in the group? b. Was there an overall motion to any of the fragments from beginning to end? c. Can you describe the movement of the sounds? d. What sounds fill in the detail of the motion? e. Did the sounds move in the same direction? f. Did you notice any of the sound-textures that you liked or disliked? g. Did any part of sound-textures that you created and heard today/tonight have any specific meaning for you? View Large Illustrative Vignette # 3. This session took place at 5:30 p.m., lasting sixty minutes. Typically, the evening music psychotherapy group would compete for space with the student tutors and the patients’ visitors. Fortunately, on this night, the tutors were off and visitors had not arrived. The dialogues, procedures, and the overall group process explained below, were based on the music therapist’s written group notes taken before, during, and after the Nono intervention, as well as audio recordings of each nonverbal musical exploration. “Crappy” Start. It was a surprisingly quiet evening on the unit. After dinner, the patients went to their rooms to relax. Nursing staff had informed the music therapist that the visiting hours earlier in the day were emotionally draining for some of the patients and that they had attended a difficult processing psychotherapy group that afternoon. With this in mind, the music therapist went and calmly knocked on the patients’ doors to let them know that music therapy group will begin in 5 minutes. One after another, the patients slowly came out of their rooms and found the music therapist greeting them in front of the therapy room, quietly playing a large Tibetan singing bowl. The patients found their seats and sat quietly, trying to listen to the singing bowl, but were observably internally anxious and restless. After the sound of the singing bowl stopped, everyone sat in silence for a few moments. MT: How are things going for all of you tonight on the unit? Mary: Crappy day…but…I liked the sounds you were playing. Joe: I agree about the music but…today…not good at all. MT: What happened today? (Silence) Lee: Don’t want to talk about it…is that OK? MT: Sure…but…what do you guys think about not talking…”about it”? All eight patients sat in silence for a few moments exhibiting worried facial expressions. Their breathing was a bit shallow. Observing their body language, they were in no mood to talk. Patient-Nono Introduction. The music therapist broke the silence to inform the patients the group task was going to be centered on creating extremely quiet music in the style of Luigi Nono with the intention of helping them improve attention and concentration via shared experimental-creativity. The music therapist demonstrated this style of focused composition by playing and exploring extremely soft dynamics on various instruments, including extended or irregular playing techniques. Glenda: (After hearing the music therapist demonstrate very quiet bow articulations on the muted strings of the psaltery) Wow! That’s cool…I really liked that…weird. The music therapist continued this type of exploration with other instruments and invited each patient, one at a time, to investigate and experiment with any instrument that resonated with them. The patients responded positively without interrupting each other. Observing their body language and facial expressions, the patients appeared to be calm and enjoying the sounds that they were producing; however, the sounds that they were creating were quiet, tense, and unnerving, an inappropriate match to their calm facial expressions and relaxed body language. Patient-Nono Experience. After the patients finished, the lingering sounds quietly decayed into the silence. Anne: Mr. Enrico…that was cool…I feel...calmer. MT: Cool and calmer? Anne: Yes…and…interested. Lee:Me too...What’s next? The music therapist informed the patients that they were going to participate in a group experimental-sound-exploration-composition together, with the intention of creating unified or merged sound fragments. MT: It is crucial that you listen intently to each other. It is extremely important that we create a unified sound-texture…together…to help improve attention or… shared attention…you must focus and listen. The following are two examples of the Nono informed sound fragments. Fragment # 1. The room was still. The patients were waiting for the music therapist to signal them to begin. The therapist dropped his right hand: MT: No…not together…remember... play an attack together… when my right hand drops…we need to sound and move like we are one person playing a group of notes at the same time...in one gesture. The therapist dropped his hand again. It was still not together. He dropped his hand 3 more times, no change. The group sat in silence for a moment. The therapist dropped his right hand again. They did it! The attack was very, very quiet. The sound-texture slowly developed as the therapist’s left hand gradually moved horizontally. Some notes were ringing out and some notes were sustained due to the patients trying out different articulations. The sounds decayed into the silence. The music therapist put up his open right hand to signal everyone to stop playing. There was a long silence with the sounds of the ventilation system and quiet conversation in the hallway. Fragment # 4 and Group Verbal Processing the Nono Experience. The therapist’s right hand dropped. Quiet sustaining tones were executed by various articulations. There was not much silence between each tone. Instead, there were many quiet sounds moving without pause. Tones were moving in different directions at different speeds. The tones created a sound-texture not fixed in space, but constantly moving. The sound-texture swirled into an unexpected halt, as the sustained sounds decayed into a short silence with sounds of talking in the hallway. MT: Did you notice any of the sound-textures or fragments that you liked or disliked? George: Well…it sounds like from what you told us to do…it was to listen carefully to the sounds that we created and to each other…right? MT: Yes. George: OK…when I did that…I noticed that I liked everything because I was creating it…and the other guys in the group were trying to create music too…that I liked. MT: So…it sounds like you enjoyed the music making…creating? The other group members became rather excited and expressed that they agreed with George about enjoying the creative process. MT: OK…great! Now… focus on our shared attention during the creative process… for a moment. Mary: I think it was difficult for me…at the beginning…to really listen and…play together. Mani: Yes… playing at the same time…but we started to listen to each other. Joe: We played together and listened to each other… more naturally near the end of this exercise. As the discussion continued, most of the patients disclosed that they had problems with paying attention and listening in everyday life outside of the hospital, as echoed by Anne: Anne: To listen to what other people want to say…well…I have trouble with this…bad trouble…and it sounds like most of us here have problems with this…it is hard for me to stop and listen…it takes time. Evaluating Effectiveness of the Nono Experience. The music therapist’s written session notes and audio recordings reveal some interesting findings about the group Nono experience. 1) Nonverbal expression. Although the patients did not want to talk about their day, the sound-exploration warm-up was an appropriate therapeutic tool to help the patients express themselves nonverbally. The sound-explorations sonically revealed the patients’ collective depressed mood that evening, acting as a nonverbal outlet for unexpressed feeling-states. This was made evident when the patients verbally reported feeling calmer after the warm-up. 2) Collective nonverbal interaction. Unpredictably, the patients were able to match or improvise around each other’s musical explorations during the sound-based Fragments, creating interesting nonverbal interactions based on the characteristics or the quality of the sounds. 3) Verbal insight into attentional needs. When verbally processing the Nono experience, the patients revealed that while it was fun and weird to create the sound-textures, it was rather a demanding task. The patients commented that the difficulties they experienced with attention, listening, and staying focused during the Nono intervention, were the same difficulties that they experienced in everyday life at home and at school. Discussion Familiar Musical Form As demonstrated in the initial music therapy sessions with the pediatric patients described in this case report, when diatonic music was presented in a large group format, the patients quickly lost focus and attention, disrupting any efforts made to complete the group goals identified at the beginning of the session. Receptive listening experiences using popular songs, improvisational experiences using clear binary, ternary, or rondo forms, a group sing-along using children songs, or music and imagery intervention using familiar classical or film music, created simultaneous uncontrollable outbursts where the patients were unable to regulate their emotions. However, in the midst of the shouting and the chaos, the music therapist was able to catch a glimpse of happy memories of family barbeques, cooking together, parties, sleepovers with friends, cutting school, or playing video games, frantically recalled by the patients. Sadly, the music therapist was unable to explore or process any of these past experiences because of poorly modulated emotional responses within a tonal harmonic climate. Consequently, it was clear to the music therapist that presenting familiar tonal music to acute pediatric patients in a large group setting was unsuccessful and not productive. Group participants became frantic and unmanageable, frozen in past experiences, which were stimulated by the diatonic music. However, it is important to note that the music therapist experienced the above-mentioned problems with diatonic music only in a large group setting. Individual therapy sessions, or a dyad or triad sessions focusing on tonal or diatonic music, were manageable and productive, where the patients were able to process emotions and feeling-states. Altering Musical Form Despite the fact that diatonic music quickly caught the attention of the acute pediatric patients, it was also the cause for over-stimulating the patients in a large group setting, making it difficult for the group to function productively due poorly managed emotional responses. Therefore, the music therapist needed to produce musical interventions that would not over-stimulate the acute patients. Specifically, it was important to find music that was not intended to produce emotional-states-of-being but instead, nurture attentional-states-of-awareness, moving away from familiar musical forms by altering musical conventions. Here, sound-based interventions informed by the three avant-garde composers Pauline Oliveros, John Cage, and Luigi Nono, were centered on improving attentional skills without trying to stimulate emotional states. Clinicians may find musical interventions that are not intended to produce an emotional response a bit curious. However, music therapists should be aware of the emotional power that diatonic music possesses within an acute pediatric psychiatric setting, especially if the music is causing a group of pediatric patients to become uncontrollably over-stimulated. In fact, while the attentional needs of the pediatric patients described in this case report were addressed through the three avant-garde interventions, these interventions did not stimulate feeling-states or emotional responses. As with most challenging contemporary classical music, the listener needs to become familiar with a new musical language before finding pleasure in novel organized sounds (Rosen, 1994), making the three avant-garde interventions described in this case report a useful tool for catching the acute pediatric patients’ attention without stimulating an emotional response. Further Developments with the Patients Presented in this Case Report In the last music therapy sessions together, the patients described in the case report helped the music therapist to create a condensed 5 to 7 minute warm-up exercise based on the Oliveros, Cage, and Nono interventions, without the need for the colored foot print markers or the color coordinated 4’33” ensemble. When constructing the warm-up, the patients wanted to use themselves as the standard for all children with mental problems because they felt that they were the best models with the worst attention problems. By examining their own attentional needs, including what would be fun for kids our age, the patients constructed the warm-up in this fashion: (a) Oliveros intervention. Patients’ rationale: “It calmed our bodies down and helped us to relax after very active events.” Transition into: (b) Cage intervention. Patients’ rationale: “It helped us to sit and focus on the sounds around the room without grabbing for instruments.” Transition into: (c) Nono intervention. Patients’ rationale: “It helped us to pick instruments calmly and explore them, and to play united group-sounds together.” The patients decided to title the finalized warm-up as the Group Strange-Listening Warm-up. The creation of the Group Strange-Listening Warm-up was important because it became the “contact music” between the music therapist and the patients presented in this case report. Specifically, the warm-up was used to begin the music therapy sessions, helping the patients to stay calm and attentive. The warm-up led into different diatonic music improvisational experiences that focused on the patients’ nonverbal feeling-states, where the patients were comfortable having the music therapist work with them to try to find meaning in their improvisations. The group felt safe if they verbally processed different feeling-states and emotions together as a unit or a squad, proving that a strong therapeutic bond developed between the music therapist and the patients, as well as with each other during the avant-garde sound-based explorations. In addition, in later music therapy sessions, the remaining patients from the original eight described in this report, helped the music therapist by co-leading the music therapy groups, explaining and demonstrating to the new patients how to implement the warm-up constructively. Age-Appropriate Warm-up While what impact their ages had on the Oliveros, Cage, or Nono experiences was not discussed with the pediatric patients described in this case report, the music therapist was curious to find out if age was a pivotal factor, introducing the Group-Strange Listening Warm-up on the acute adolescent and adult psychiatric units in the hospital. Interestingly, both the adolescent and adult patients reported feeling embarrassed, uncomfortable, and awkward having to produce overly pronounced body movements while walking around the unit at the beginning of the warm-up, eventually giving up and leaving the group session. In addition, during the Nono informed section, the adolescent patients felt lost and confused about having to play so quietly, opting not to play at all, even after encouragement by the music therapist. The adult patients echoed the adolescents’ reaction about the Nono section. However, there was some interest in the Cage informed section. Many of the adult patients were trying to practice meditation daily, so 4’33” was a way for the adults to incorporate listening into their meditation practice. Similarly, due to the unit psychologist introducing the adolescent patients to mindfulness-based coping skills exercises, the adolescents were interested in the Cage section, revealing that it was a different way of practicing mindfulness. Consequently, some of these were more enticing and suitable for children. Clinical Implications for Music Therapy Practice It is strongly recommended that before a music therapist leads a group using any of the musical interventions presented in this paper, they must be a practitioner and consumer of avant-garde music, which is a specialized musical language that needs to be studied and practiced in order to understand how to utilize it clinically (Lee, 2003). The music therapist (author) presenting this case report is a practitioner of avant-garde and experimental music. My expertise in avant-garde, new, and unusual music played a significant role in understanding how to develop efficient novel musical experiences for the pediatric patients. Nevertheless, I recommend that future clinicians try exploring the Group Strange-Listening Warm-up when facilitating a group of hyperactive, agitated, and disruptive acute pediatric patients, due to its ability to stimulate curiosity and attention. After the group participants are more relaxed, the group could progress from the novel sound-based warm-up into a variety of diatonic-based musical experiences focusing on the pediatric patients’ feeling-states and emotional responses. Conclusion This case report explored how avant-garde sound-based interventions helped pediatric patients improve attentional skills while admitted on a small acute psychiatric unit. Various problems with attention hampered the patients’ basic tasks of everyday living at home and at school, resulting in distractibility, poor concentration, hyperactivity, irritability, and impulsivity. Signs of the patients’ dysfunctional attentional skills were observed during initial music therapy group sessions focusing on diatonic-based interventions utilizing tonal harmonic languages, including predictable rhythms or time signatures. Within the diatonic harmonic climate, the patient presented in this case report became over stimulated by the familiarity of the tonal chord changes and simple time signatures, repeatedly loosing focus, concentration, and attention, making it difficult to work on (1) prerequisite skills, such as staying seated, no cross talking, following 1-step directions, and keeping safe boundaries, and (2) exploring emotions and feeling-states. When three avant-garde musical interventions, informed by the late composers Pauline Oliveros, John Cage, and Luigi Nono were introduced to the patients, the novel sound experiences were more suitable than diatonicism for quickly engaging the patients’ attention without over stimulating their emotional states bent on musical tastes, likes, and dislikes. The patients were able to build a strong therapeutic alliance with the music therapist while engaging in the novel musical interventions. This alliance led the patients to create their own condensed warm-up version of the three avant-garde interventions in which they helped to teach to newly admitted patients with similar attentional needs. Future clinicians are encouraged to explore the warm-up or any of the avant-garde sound-based group interventions presented in this case report with acute pediatric patients struggling with deficits in attention, concentration, and focus. Supplementary Materials Supplementary data is available at Music Therapy Perspectives online. Enrico Curreri is a creative arts psychotherapist working on both child and adolescent acute psychiatric units at Elmhurst Hospital Center. His clinical interests focus on the patient’s own encounters with various active or receptive unconventional musical experiences, as well as experimental creative arts. References Ahonen-Eerikäinen , H . ( 2007 ). Group analytic music therapy . Gilsum, NH : Barcelona Publishers . Baker , F. , & Wigram , T . (Eds.). ( 2005 ). Songwriting: Methods, techniques and clinical applications for music therapy clinicians, educators and students . London, England : Jessica Kingsley Publishers . Berger , D. S . ( 2002 ). Music therapy, sensory integration and the autistic child . London, England : Jessica Kingsley Publishers . Berger , D. S . ( 2016 ). Eurhythmics for autism and other neurophysiologic diagnoses: A sensorimotor music-based treatment approach . London, England : Jessica Kingsley Publishers . Bruscia , K . ( 1998 ). An introduction to music psychotherapy . In K.E. Bruscia (Ed.), The dynamics of music psychotherapy (pp. 1 – 15 ). Gilsum, NH : Barcelona Publishers . Bruscia , K . ( 2014 ). Defining music therapy ( 3rd ed .). University Park, IL : Barcelona Publishers . Cope , D . ( 2001 ). New directions in music ( 7th ed .). Long Grove, IL : Waveland, Press, Inc . Curreri , E . ( 2013 ). Aesthetic perturbation: Using a chance/ aleatoric music therapy intervention to reduce rigidity in adult patients with psychiatric disorders . Music Therapy Perspectives , 31 ( 2 ), 105 – 111 . https://doi.org/10.1093/mtp/31.2.105 Google Scholar CrossRef Search ADS Curreri , E . ( 2015 ). An unguided music therapy listening experience of Luigi Nono’s Fragmente-Stille, an Diotima: A case report . Music Therapy Perspectives , 33 ( 1 ), 63 – 70 . https://doi.org/10.1093/mtp/miu047 Google Scholar CrossRef Search ADS Duckworth , W . ( 1995 ). Talking music: Conversations with John Cage, Philip Glass, Laurie Anderson, and five generations of American experimental composers . New York, NY : Schirmer Books . Fuller , S . ( 1994 ). The Pandora guide to women composers: Britain and the united states: 1629-present . Hammersmith, London : Pandora . Gardstrom , S. C . ( 2007 ). Music therapy improvisation for groups: Essential leadership competencies . Gilsum, NH : Barcelona Publishers . Griffiths , P . ( 1995 ). Modern music and after: Directions since 1945 . New York, NY : Oxford University Press, Inc . Grocke , D. , & Wigram , T . ( 2007 ). Receptive methods in music therapy: Techniques and clinical applications for music therapy clinicians, educators and students . London, England : Jessica Kingsley Publishers . Kostelanetz , R . (Ed.). ( 1989 ). Conversing with cage . New York, NY : Limelight Editions . Kostelanetz , R . ( 1991 ). John cage: An anthology . New York, NY : Da Capo Press, Inc . Lee , C. A . ( 2003 ). The architecture of aesthetic music therapy . Gilsum, NH : Barcelona Publishers . McHard , J . ( 2001 ). The future of modern music: A vibrant new modernism in music for the future: Modernism redefined and reassessed in a philosophical examination of music’s potential for the future . Salt Lake City, UT : American University & Colleges Press . Nielinger-Vakil , C . ( 2015 ). Luigi nono: A composer in context . Cambridge, United Kingdom : Cambridge University Press . Google Scholar CrossRef Search ADS Oliveros , P . ( 1998 ). The roots of the moment: Collected writings 1980–1996 . New York, NY : Drogue Press . Oliveros , P . ( 2005 ). Deep listening: A composer’s sound practice . Lincoln, NE : iUniverse, Inc . Peyser , J . ( 1971 ). The new music: The sense behind the sound . New York, NY : Delacorte Press . Retallack , J . ( 1996 ). Musicage: Cage muses on words, art, music: John Cage in conversation with Joan Retallack . Hanover, NH : Wesleyan University Press . Revill , D . ( 1992 ). The roaring silence: John cage: A life . New York, NY : Arcade Publishing . Rosen , C . ( 1994 ). The frontiers of meaning: Three informal lectures on music . New York, NY : Hill and Wang . Schneck , D. J. , & Berger , D. S . ( 2006 ). The music effect: Music physiology and clinical applications . London, England : Jessica Kingsley Publishers . Smith , G. , & Walker Smith , N . ( 1995 ). New voices: American composers talk about their music . Portland, OR : Amadeus Press . Struble , J. W . ( 1995 ). The history of American classical music: Macdowell through minimalism . New York, NY : Facts On File, Inc . Thaut , M. H . ( 2005 ). Rhythm, music, and the brain: Scientific foundations and clinical applications . New York, NY : Routledge . Wigram , T . ( 2004 ). Improvisation: Methods and techniques for music therapy clinicians, educators and students . London, England : Jessica Kingsley Publishers . © American Music Therapy Association 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Music Therapy Perspectives Oxford University Press

Nurturing Attentional Skills in Acute Pediatric Psychiatry Through Avant-Garde Musical Interventions

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Abstract

Abstract This case report details how avant-garde musical interventions helped to nurture the attentional skills of eight pediatric patients admitted to a small 12-bed acute psychiatric unit. The music therapist encountered two major obstacles while working on the small psychiatric unit. First, hospital administration strongly recommended that all eight patients attended the music therapy groups together, regardless of a lack of space, and differences in ages, cultures, and diagnosis. Second, when music therapy interventions were centered on tonal harmonies, melodies, or counterpoint, including predictable rhythms or time signatures, the patients repeatedly lost focus, concentration, and attention, making it difficult to work on improving prerequisite skills, such as following directions and keeping safe boundaries, or to explore emotions and feeling-states. As an alternative to typical diatonic interventions, the music therapist created three novel sound-based interventions informed by the avant-garde composers Pauline Oliveros, John Cage, and Luigi Nono. The novel musical interventions not only helped the eight patients to improve attentional skills, but, unexpectedly, it helped to (a) build a strong therapist-patient bond built on trust, (b), allow the patients to struggle, explore, discover, and create within a safe therapeutic environment, (c), reveal unexpressed feeling-states nonverbally and (d) share their novel musical experiences with newly admitted patients. acute child psychiatry, experimental music, avant-garde music, attention As a music therapist working on an acute 12-bed pediatric psychiatric unit in a city hospital, I struggle with the fact that hospital administration strongly recommends that all patients attend music therapy groups together, despite the fact that the patients are of different ages, culturally diverse, and have a variety of unique problems and special needs. This administrative approach creates music therapy groups that are underproductive, chaotic, and overwhelming for the patients. Nevertheless, hospital administration tries their best to provide the finest care for their patients, despite a lack of space on the unit for simultaneous therapy groups to occur. This situation is challenging due to the fact that I will have to work with eight to twelve culturally diverse children, ages ranging from 4–12, and carrying different diagnoses, such as major depressive disorder (MDD), childhood-onset schizophrenia (COS), mood disorder not otherwise specified (MD-NOS), conduct disorder (CD), autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), body dysmorphic disorder (BDD), and oppositional defiant disorder (ODD), all in the same group together. Consequently, these music therapy groups create chaos and confusion for each of the patients, and, a feeling of frustration and incompetence within myself as a music therapist. In this city hospital, patients are referred to music therapy for a variety of reasons, such as to help improve communication, psychosocial, cognitive, emotional, and physical needs. After a short period of time running hectic music therapy groups on the unit, I realized that when music interventions were centered on tonal harmonies, melodies, or counterpoint, including predictable rhythms or time signatures, the patients repeatedly lost focus, making it nearly impossible to work on (1) prerequisite skills, such as staying seated, no cross talking, following 1-step directions, and keeping safe boundaries, and (2) exploring emotions and feeling-states. Within the diatonic harmonic climate, hyperactive group members would become over stimulated by the familiarity of the tonal chord changes and simple time signatures, shout over each other demanding that the music therapist play their favorite songs. At the same time, due to the chaotic outbursts, the quieter group members would become observably more detached and disconnected, shutting down emotionally. These behaviors were amplified when diatonicism was used as the foundation for different improvisational (Wigram, 2004; Gardstrom, 2007), songwriting (Baker & Wigram, 2005), and music and imagery (Grocke & Wigram, 2007) practices. As found in this present case report, novel sound-based practices, informed by the late avant-garde composers Pauline Oliveros, John Cage, and Luigi Nono, were more suitable than diatonicism for quickly engaging the patients’ attention without over stimulating their emotional states based upon musical tastes, likes, and dislikes (see Curreri, 2013). Therefore, via acts of discovery, the three avant-garde musical interventions presented in this case report centered on improving attentional skills first, and helping the patients to stay relaxed, curious, motivated, and challenged concurrently. Patients’ Background Setting The children described in this case report were inpatients, ages 6–12, on an acute care 12-bed pediatric psychiatric unit. The unit was part of a teaching hospital in a large, culturally and religiously diverse area in the eastern region of the United States. The unit was designed for the diagnosis and treatment of all pediatric psychiatric disorders, provided crisis stabilization, medication adjustment, and integrative-multicultural psychotherapeutic family and patient interventions. All interventions were focused on the resolution of acute symptoms and community reintegration for the patient. A patient typically remained on inpatient status for three to seven days, and was considered to be ready for discharge when he/she could receive safe and proper care in a less restrictive setting. The pediatric patients on the unit were scheduled to attend a variety of daily psychosocial and psychoeducational programming sessions, such as verbal psychotherapy, creative arts psychotherapy, medication education, community meetings, nursing groups, and activity/recreational groups. In addition, the patients had to attend the hospital inpatient elementary school, as well as work with volunteer tutors in the evenings. Following institutional guidelines, all patients and their guardians signed a letter of informed consent describing that session data could be used for a case report (non-research), wherein after completion of the report, all session data must be shredded and/or erased. The Pediatric Patients As part of their integrative psychosocial and psychoeducational programming, all of the patients described in this case report were expected to attend each music therapy group together despite differences in age, diagnosis, and cultural background. Each of the patients had a unique case with a unique set of problems and therapeutic needs. However, sadly, one common problem in each of the patients’ life was being bullied at school, undeniably playing a significant role in the patients’ admissions. See Table 1. Table 1 Patient Characteristics Pseudonym Age Ethnicity/Race Home Life Diagnosis Admitting Behaviors Unit Presentation Mary 7 Mexican Mary lived with her biological parents and four siblings. Her depression was an outcome of her father’s verbal and physical abuse at home, in addition to being bullied at school for “being Mexican”. Major depressive disorder (MDD) Self-injurious behaviors, such as cutting herself when feeling anxious Mary presented with a flat affect, preferred to have her hair cover her eyes, preferred to stay in her room alone, and did not initiate in conversation with staff or peers Glenda 12 Filipino Glenda lived with her biological parents and five siblings, including extended family. Although Glenda came from a loving family, her parents would not accept the fact that their daughter needed medical treatment, and equated her auditory hallucinations to “being possessed by demons”. At school, Glenda excelled in her studies, but had recently started to skip classes due to her current psychological condition, as well as verbally being bullied by her peers for “acting strangely” and being “a weirdo”. Childhood-onset schizophrenia (COS) Symptoms of auditory hallucinations, and abnormal behaviors, such as grinning while standing still on one leg for a long period of time Glenda presented with a restricted affect, was quiet, kept to herself, but was pleasant to staff and peers George 6 African American George lived with his biological mother, three biological siblings, and mother’s boyfriend. George never knew his biological father due to his father abandoning his family when George was a year old. George was in conflict with his mother’s boyfriend because he could not accept the boyfriend as a “fatherly figure”. In addition, George was constantly having verbal and physical altercations with his siblings. At school, George was bullied for “being black” by Caucasian and Latino students. Mood disorder not otherwise specified (MD-NOS) Conduct disorder (CD) Outbursts at home and at school Lack of focus in a standard classroom setting due to the conflicts at home and the bullying by his peers George presented with a labile affect and was confrontational with staff and peers, trying to kick and hit staff Mani 10 Caucasian Mani was living with her biological parents and three siblings. Mani exhibited repetitive patterns of behavior, such as occasionally rearranging books on a bookshelf, spending long periods of time lining up small objects, as well as sensory seeking (tactile) behaviors, as evidenced by craving physical contact and stimulation through deep pressure on her hands and feet. Mani was in special education classes at school and was an average student scholastically. She was being bullied at school for being “socially retarded”, causing her to lose interest in her studies and have constant emotional outbursts in her classes. Autism spectrum disorder (ASD) and Attention deficit hyperactivity disorder (ADHD) Aggressive behaviors Outbursts at home and at school Mani presented with a blunted affect, and stayed in her room most of the time Joe 8 Asian Indian Joe was living with his biological parents and six siblings. He was constantly comparing his body parts to others, and continually checked his appearance in mirrors. At school, Joe’s preoccupation with his appearance was interfering with his studies. He reported that one key component to his body dysmorphic disorder was due to being repeatedly bullied at school for having a “weird body without any muscle tone”. Body dysmorphic disorder (BDD) Eating disorder History of binge eating, such as eating large amounts of food Self-induced vomiting, accompanied by excessive exercise Joe was euthymic and was pleasant to staff and peers Anne 11 Caucasian Anne was an only child living with her biological mother due to Anne’s allegations of her father sexually abusing her at a young age. Attention deficit hyperactivity disorder (ADHD) Conduct disorder (CD) Aggressive behaviors Lack of focus in a standard classroom Anne presented with a labile affect and had constant verbal altercations with staff and her peers As an outcome of the sexual abuse, Anne’s biological parents had recently divorced. Anne found it difficult to focus at school due to her hyperactivity and constantly being bullied by students “for being white trash”. Paul 12 Mixed-race Latino Paul came from a loving a supportive family, living at home with his biological parents, three biological siblings, and extended family. However, at school, Paul was verbally and physically bullied and harassed for “being different” due to exhibiting a higher intelligence and creative abilities, and dressing in EMO clothing. Consequently, Paul had very few to no friends. Major depressive disorder (MDD) Self-injurious behaviors, such as deliberately harming his own body when feeling angry, anxious, or tense Paul was pleasant to staff and peers but presented with an inappropriate affect, such as smiling while talking about his depression and being bullied at school Lee 10 Mixed-race Latina Lee was given up for adoption by her biological mom, and never knew her biological father. She was currently living with a foster family, and reported that she was verbally and sexually abused repeatedly while living in past foster homes. In her present foster home, Lee was verbally abusive to her foster parents, stayed out late after curfew on school nights, and was believed to be in a local gang. At school, Lee skipped classes due to constantly being bullied and teased about her weight, causing her to get into physical altercations with her peers. Oppositional defiant disorder (ODD) Sexually inappropriate behavior Aggressive behaviors Self-injurious behaviors Lee presented with a labile affect, and was easily annoyed by staff and her peers Pseudonym Age Ethnicity/Race Home Life Diagnosis Admitting Behaviors Unit Presentation Mary 7 Mexican Mary lived with her biological parents and four siblings. Her depression was an outcome of her father’s verbal and physical abuse at home, in addition to being bullied at school for “being Mexican”. Major depressive disorder (MDD) Self-injurious behaviors, such as cutting herself when feeling anxious Mary presented with a flat affect, preferred to have her hair cover her eyes, preferred to stay in her room alone, and did not initiate in conversation with staff or peers Glenda 12 Filipino Glenda lived with her biological parents and five siblings, including extended family. Although Glenda came from a loving family, her parents would not accept the fact that their daughter needed medical treatment, and equated her auditory hallucinations to “being possessed by demons”. At school, Glenda excelled in her studies, but had recently started to skip classes due to her current psychological condition, as well as verbally being bullied by her peers for “acting strangely” and being “a weirdo”. Childhood-onset schizophrenia (COS) Symptoms of auditory hallucinations, and abnormal behaviors, such as grinning while standing still on one leg for a long period of time Glenda presented with a restricted affect, was quiet, kept to herself, but was pleasant to staff and peers George 6 African American George lived with his biological mother, three biological siblings, and mother’s boyfriend. George never knew his biological father due to his father abandoning his family when George was a year old. George was in conflict with his mother’s boyfriend because he could not accept the boyfriend as a “fatherly figure”. In addition, George was constantly having verbal and physical altercations with his siblings. At school, George was bullied for “being black” by Caucasian and Latino students. Mood disorder not otherwise specified (MD-NOS) Conduct disorder (CD) Outbursts at home and at school Lack of focus in a standard classroom setting due to the conflicts at home and the bullying by his peers George presented with a labile affect and was confrontational with staff and peers, trying to kick and hit staff Mani 10 Caucasian Mani was living with her biological parents and three siblings. Mani exhibited repetitive patterns of behavior, such as occasionally rearranging books on a bookshelf, spending long periods of time lining up small objects, as well as sensory seeking (tactile) behaviors, as evidenced by craving physical contact and stimulation through deep pressure on her hands and feet. Mani was in special education classes at school and was an average student scholastically. She was being bullied at school for being “socially retarded”, causing her to lose interest in her studies and have constant emotional outbursts in her classes. Autism spectrum disorder (ASD) and Attention deficit hyperactivity disorder (ADHD) Aggressive behaviors Outbursts at home and at school Mani presented with a blunted affect, and stayed in her room most of the time Joe 8 Asian Indian Joe was living with his biological parents and six siblings. He was constantly comparing his body parts to others, and continually checked his appearance in mirrors. At school, Joe’s preoccupation with his appearance was interfering with his studies. He reported that one key component to his body dysmorphic disorder was due to being repeatedly bullied at school for having a “weird body without any muscle tone”. Body dysmorphic disorder (BDD) Eating disorder History of binge eating, such as eating large amounts of food Self-induced vomiting, accompanied by excessive exercise Joe was euthymic and was pleasant to staff and peers Anne 11 Caucasian Anne was an only child living with her biological mother due to Anne’s allegations of her father sexually abusing her at a young age. Attention deficit hyperactivity disorder (ADHD) Conduct disorder (CD) Aggressive behaviors Lack of focus in a standard classroom Anne presented with a labile affect and had constant verbal altercations with staff and her peers As an outcome of the sexual abuse, Anne’s biological parents had recently divorced. Anne found it difficult to focus at school due to her hyperactivity and constantly being bullied by students “for being white trash”. Paul 12 Mixed-race Latino Paul came from a loving a supportive family, living at home with his biological parents, three biological siblings, and extended family. However, at school, Paul was verbally and physically bullied and harassed for “being different” due to exhibiting a higher intelligence and creative abilities, and dressing in EMO clothing. Consequently, Paul had very few to no friends. Major depressive disorder (MDD) Self-injurious behaviors, such as deliberately harming his own body when feeling angry, anxious, or tense Paul was pleasant to staff and peers but presented with an inappropriate affect, such as smiling while talking about his depression and being bullied at school Lee 10 Mixed-race Latina Lee was given up for adoption by her biological mom, and never knew her biological father. She was currently living with a foster family, and reported that she was verbally and sexually abused repeatedly while living in past foster homes. In her present foster home, Lee was verbally abusive to her foster parents, stayed out late after curfew on school nights, and was believed to be in a local gang. At school, Lee skipped classes due to constantly being bullied and teased about her weight, causing her to get into physical altercations with her peers. Oppositional defiant disorder (ODD) Sexually inappropriate behavior Aggressive behaviors Self-injurious behaviors Lee presented with a labile affect, and was easily annoyed by staff and her peers View Large Table 1 Patient Characteristics Pseudonym Age Ethnicity/Race Home Life Diagnosis Admitting Behaviors Unit Presentation Mary 7 Mexican Mary lived with her biological parents and four siblings. Her depression was an outcome of her father’s verbal and physical abuse at home, in addition to being bullied at school for “being Mexican”. Major depressive disorder (MDD) Self-injurious behaviors, such as cutting herself when feeling anxious Mary presented with a flat affect, preferred to have her hair cover her eyes, preferred to stay in her room alone, and did not initiate in conversation with staff or peers Glenda 12 Filipino Glenda lived with her biological parents and five siblings, including extended family. Although Glenda came from a loving family, her parents would not accept the fact that their daughter needed medical treatment, and equated her auditory hallucinations to “being possessed by demons”. At school, Glenda excelled in her studies, but had recently started to skip classes due to her current psychological condition, as well as verbally being bullied by her peers for “acting strangely” and being “a weirdo”. Childhood-onset schizophrenia (COS) Symptoms of auditory hallucinations, and abnormal behaviors, such as grinning while standing still on one leg for a long period of time Glenda presented with a restricted affect, was quiet, kept to herself, but was pleasant to staff and peers George 6 African American George lived with his biological mother, three biological siblings, and mother’s boyfriend. George never knew his biological father due to his father abandoning his family when George was a year old. George was in conflict with his mother’s boyfriend because he could not accept the boyfriend as a “fatherly figure”. In addition, George was constantly having verbal and physical altercations with his siblings. At school, George was bullied for “being black” by Caucasian and Latino students. Mood disorder not otherwise specified (MD-NOS) Conduct disorder (CD) Outbursts at home and at school Lack of focus in a standard classroom setting due to the conflicts at home and the bullying by his peers George presented with a labile affect and was confrontational with staff and peers, trying to kick and hit staff Mani 10 Caucasian Mani was living with her biological parents and three siblings. Mani exhibited repetitive patterns of behavior, such as occasionally rearranging books on a bookshelf, spending long periods of time lining up small objects, as well as sensory seeking (tactile) behaviors, as evidenced by craving physical contact and stimulation through deep pressure on her hands and feet. Mani was in special education classes at school and was an average student scholastically. She was being bullied at school for being “socially retarded”, causing her to lose interest in her studies and have constant emotional outbursts in her classes. Autism spectrum disorder (ASD) and Attention deficit hyperactivity disorder (ADHD) Aggressive behaviors Outbursts at home and at school Mani presented with a blunted affect, and stayed in her room most of the time Joe 8 Asian Indian Joe was living with his biological parents and six siblings. He was constantly comparing his body parts to others, and continually checked his appearance in mirrors. At school, Joe’s preoccupation with his appearance was interfering with his studies. He reported that one key component to his body dysmorphic disorder was due to being repeatedly bullied at school for having a “weird body without any muscle tone”. Body dysmorphic disorder (BDD) Eating disorder History of binge eating, such as eating large amounts of food Self-induced vomiting, accompanied by excessive exercise Joe was euthymic and was pleasant to staff and peers Anne 11 Caucasian Anne was an only child living with her biological mother due to Anne’s allegations of her father sexually abusing her at a young age. Attention deficit hyperactivity disorder (ADHD) Conduct disorder (CD) Aggressive behaviors Lack of focus in a standard classroom Anne presented with a labile affect and had constant verbal altercations with staff and her peers As an outcome of the sexual abuse, Anne’s biological parents had recently divorced. Anne found it difficult to focus at school due to her hyperactivity and constantly being bullied by students “for being white trash”. Paul 12 Mixed-race Latino Paul came from a loving a supportive family, living at home with his biological parents, three biological siblings, and extended family. However, at school, Paul was verbally and physically bullied and harassed for “being different” due to exhibiting a higher intelligence and creative abilities, and dressing in EMO clothing. Consequently, Paul had very few to no friends. Major depressive disorder (MDD) Self-injurious behaviors, such as deliberately harming his own body when feeling angry, anxious, or tense Paul was pleasant to staff and peers but presented with an inappropriate affect, such as smiling while talking about his depression and being bullied at school Lee 10 Mixed-race Latina Lee was given up for adoption by her biological mom, and never knew her biological father. She was currently living with a foster family, and reported that she was verbally and sexually abused repeatedly while living in past foster homes. In her present foster home, Lee was verbally abusive to her foster parents, stayed out late after curfew on school nights, and was believed to be in a local gang. At school, Lee skipped classes due to constantly being bullied and teased about her weight, causing her to get into physical altercations with her peers. Oppositional defiant disorder (ODD) Sexually inappropriate behavior Aggressive behaviors Self-injurious behaviors Lee presented with a labile affect, and was easily annoyed by staff and her peers Pseudonym Age Ethnicity/Race Home Life Diagnosis Admitting Behaviors Unit Presentation Mary 7 Mexican Mary lived with her biological parents and four siblings. Her depression was an outcome of her father’s verbal and physical abuse at home, in addition to being bullied at school for “being Mexican”. Major depressive disorder (MDD) Self-injurious behaviors, such as cutting herself when feeling anxious Mary presented with a flat affect, preferred to have her hair cover her eyes, preferred to stay in her room alone, and did not initiate in conversation with staff or peers Glenda 12 Filipino Glenda lived with her biological parents and five siblings, including extended family. Although Glenda came from a loving family, her parents would not accept the fact that their daughter needed medical treatment, and equated her auditory hallucinations to “being possessed by demons”. At school, Glenda excelled in her studies, but had recently started to skip classes due to her current psychological condition, as well as verbally being bullied by her peers for “acting strangely” and being “a weirdo”. Childhood-onset schizophrenia (COS) Symptoms of auditory hallucinations, and abnormal behaviors, such as grinning while standing still on one leg for a long period of time Glenda presented with a restricted affect, was quiet, kept to herself, but was pleasant to staff and peers George 6 African American George lived with his biological mother, three biological siblings, and mother’s boyfriend. George never knew his biological father due to his father abandoning his family when George was a year old. George was in conflict with his mother’s boyfriend because he could not accept the boyfriend as a “fatherly figure”. In addition, George was constantly having verbal and physical altercations with his siblings. At school, George was bullied for “being black” by Caucasian and Latino students. Mood disorder not otherwise specified (MD-NOS) Conduct disorder (CD) Outbursts at home and at school Lack of focus in a standard classroom setting due to the conflicts at home and the bullying by his peers George presented with a labile affect and was confrontational with staff and peers, trying to kick and hit staff Mani 10 Caucasian Mani was living with her biological parents and three siblings. Mani exhibited repetitive patterns of behavior, such as occasionally rearranging books on a bookshelf, spending long periods of time lining up small objects, as well as sensory seeking (tactile) behaviors, as evidenced by craving physical contact and stimulation through deep pressure on her hands and feet. Mani was in special education classes at school and was an average student scholastically. She was being bullied at school for being “socially retarded”, causing her to lose interest in her studies and have constant emotional outbursts in her classes. Autism spectrum disorder (ASD) and Attention deficit hyperactivity disorder (ADHD) Aggressive behaviors Outbursts at home and at school Mani presented with a blunted affect, and stayed in her room most of the time Joe 8 Asian Indian Joe was living with his biological parents and six siblings. He was constantly comparing his body parts to others, and continually checked his appearance in mirrors. At school, Joe’s preoccupation with his appearance was interfering with his studies. He reported that one key component to his body dysmorphic disorder was due to being repeatedly bullied at school for having a “weird body without any muscle tone”. Body dysmorphic disorder (BDD) Eating disorder History of binge eating, such as eating large amounts of food Self-induced vomiting, accompanied by excessive exercise Joe was euthymic and was pleasant to staff and peers Anne 11 Caucasian Anne was an only child living with her biological mother due to Anne’s allegations of her father sexually abusing her at a young age. Attention deficit hyperactivity disorder (ADHD) Conduct disorder (CD) Aggressive behaviors Lack of focus in a standard classroom Anne presented with a labile affect and had constant verbal altercations with staff and her peers As an outcome of the sexual abuse, Anne’s biological parents had recently divorced. Anne found it difficult to focus at school due to her hyperactivity and constantly being bullied by students “for being white trash”. Paul 12 Mixed-race Latino Paul came from a loving a supportive family, living at home with his biological parents, three biological siblings, and extended family. However, at school, Paul was verbally and physically bullied and harassed for “being different” due to exhibiting a higher intelligence and creative abilities, and dressing in EMO clothing. Consequently, Paul had very few to no friends. Major depressive disorder (MDD) Self-injurious behaviors, such as deliberately harming his own body when feeling angry, anxious, or tense Paul was pleasant to staff and peers but presented with an inappropriate affect, such as smiling while talking about his depression and being bullied at school Lee 10 Mixed-race Latina Lee was given up for adoption by her biological mom, and never knew her biological father. She was currently living with a foster family, and reported that she was verbally and sexually abused repeatedly while living in past foster homes. In her present foster home, Lee was verbally abusive to her foster parents, stayed out late after curfew on school nights, and was believed to be in a local gang. At school, Lee skipped classes due to constantly being bullied and teased about her weight, causing her to get into physical altercations with her peers. Oppositional defiant disorder (ODD) Sexually inappropriate behavior Aggressive behaviors Self-injurious behaviors Lee presented with a labile affect, and was easily annoyed by staff and her peers View Large Initial Music Therapy Sessions All of the music therapy group sessions on the pediatric unit took place in the afternoon and/or early evening timeslots, lasting between 30 to 65-min. Typically, the approach to therapy was integrated, utilizing interventions found in analytic music therapy (GAMT) (Ahonen-Eerikäinen, 2007), neurologic music therapy (NMT) (Thaut, 2005), sensory-motor music therapy (Schneck & Berger, 2006; Berger, 2002; 2016), and numerous music therapy songwriting (Baker & Wigram, 2005) and receptive methods (Grocke & Wigram, 2007). Moreover, the music therapy sessions had its foundation in music in psychotherapy (Bruscia, 1998), focusing on the patients’ therapeutic needs via creating and/or listening to music, with both the musical and the verbal experiences occurring alternately or simultaneously. As noted in each of the patients’ hospital charts, deficits in attentional skills hampered basic tasks of everyday living at home and at school, resulting in distractibility, poor concentration, hyperactivity, irritability, and impulsivity. In the initial music therapy sessions centered on various diatonic musical interventions, staff and the music therapist observed a range of inappropriate patient behaviors as a result of poor concentration, attentional, and listening skills. Staff reported to the music therapist that the inappropriate behaviors were amplified in the music therapy groups, and the disruptive behaviors continued outside of the music groups. Patients’ behaviors included: Verbal and/or shouting interruptions Verbal abuse or name-calling Constantly yawning and feeling fatigued An inability to participate in any of the various active and/or receptive musical tasks for over a 1-min. duration Requesting to end the musical tasks early to go to the bathroom Getting up from their seats to walk around the therapy room Play-hitting group members with various musical instruments Intolerance for environmental sounds (staff entering the therapy room, staff talking to each other, the sound of the air-conditioner, etc.) Patients walking out of the group multiple times without explanation Throwing printed copies of song lyrics at the music therapist and around the therapy room Purposely destroying musical instruments and/or mallets Throwing mallets or drum sticks across the therapy room during music improvisations Fighting and grabbing instruments A Spark of Interest in Sound Although the patients exhibited deficits in attentional skills, when participating in musical interventions centered on different tonalities they showed interest when various sustained tones were demonstrated to them on Tibetan singing bowls, as observable changes in the patients’ affect, eye gaze, and body language were documented in the music therapist’s written session notes. Their curiosity led to a brief discussion about different forms of experimental and avant-garde music, including demonstrations of some odd sounding timbres on various musical instruments using extended or irregular playing techniques informed by the composer Helmut Lachenmann (Griffiths, 1995). Consequently, the music therapist wanted to create avant-garde musical interventions that would quickly attract the patients’ attention, interest, and curiosity, helping the acute patients to improve their attentional skills. Musicological Review with Clinical Applications The music therapist conducted an extensive review of musical works by various 20th century avant-garde composers concerned with concentration, attention, and awareness. Composers that emphasized unique listening experiences within their compositions, or, as the major component of their compositions, were of special interest. For example, the composers Pauline Oliveros (Duckworth, 1995; Fuller, 1994; Oliveros, 1998, 2005; Smith & Walker Smith, 1995), John Cage (Kostelanetz, 1989, 1991; Peyser, 1971; Retallack, 1996; Revill, 1992), and Luigi Nono (Griffiths, 1995; McHard, 2001; Nielinger-Vakil, 2015) created compositions deeply concerned with attention and concentration for both performer and audience member alike. After further examination of various musical scores by Oliveros, Cage, and Nono, the music therapist felt their musical explorations would be an appropriate match for the patients’ collective need for improving attentional skills. Consequently, the music therapist created three novel clinical experiences, informed by Oliveros, Cage, and Nono, with the hope that the avant-garde interventions would be stimulating and motivating for the pediatric patients. Pauline Oliveros: Sonic Meditations In the early 1970s, the American composer and musician Pauline Oliveros (1932–2016) began to listen intently to a single sound for long periods of time, gradually developing a unique skill for deeply experiencing sounds (Duckworth, 1995; Fuller, 1994). This led Oliveros to create the composition of twenty-five prose instructions, Sonic Meditations (1971) (Oliveros, 1998, 2005), which became one of most important works of her career (Cope, 2001; Smith & Walker Smith, 1995). These probing texts focus on novel ways of inwardly listening to sound, not otherwise conceived, practiced, or considered by the participants (Struble, 1995). Oliveros Informed Intervention. The 1st novel intervention presented to the pediatric patients was inspired by Pauline Oliveros’ composition Sonic Meditations. Here, the intervention set out to improve attentional skills via the integration of walking-meditation and environmental-sound listening. Clinically, five receptive listening experiences, music relaxation, meditative, stimulative and perceptual listening, and projective movement to music (Bruscia, 2014), were integrated together with an adapted version of rhythmic auditory stimulation (RAS) (Thaut, 2005), focusing on helping the patients to listen to environmental sounds while silently walking with pronounced body movements, entraining to a slow and steady pulse. See Table 2 for instructions. Table 2 Pauline Oliveros Informed Intervention Group Goal: Sustained Attention: To develop the ability to focus on one task sufficiently for a continuous amount of time to enable participation in everyday tasks of longer duration. Group Objective: For the patients to sustain attention via auditory focus while slowly walking up to 5 minutes without interrupting verbally or attempting to disrupt the intervention. Intervention: The patients are to remove their shoes and socks and line up quietly in a single file. Once calm and quiet, the patients are asked to silently walk around the unit at a walking speed of 40 beats per minute (bpm), or slower, while focusing on all of the sounds around them as the sounds unfolded or materialized. A Tibetan singing bowl is used to lightly accent each beat, providing an audible and secure rhythmic structure for the patients to entrain or synchronize to while experiencing the environmental music. In addition, different colored and textured foot print markers are placed around the unit to outline the walking path, providing a multisensory experience for each of the patients. Clinical Strategies: Inform the patients that the group task is targeted towards improving their capacity for concentration by having them silently walk on the foot print markers while experiencing the environmental music on the unit for X minutes. After this task, they are to go into the therapy room and verbally process the sound-walking experience together. Furthermore, other staff members should be placed around the unit providing visual cues, such as facial expressions and gestures to encourage the patients to re-engage if they went off task. Explain to the patients that this is to be a full body experience, stimulating kinetic awareness because they are to be listening to sounds while slowly walking and moving to the tempo of the Tibetan singing bowl at 40 (bpm) or slower. Since the tempo is very slow, invite the patients to be creative and playful with their body movements and walking patterns. Encourage the patients to walk in slow motion, move with overly pronounced arm or leg gestures, walk backwards, or walk on their toes, just as long as one foot hits a foot print marker on the beat, while listening to the environmental sounds intently. Lastly, before beginning the sound-walking experience, gave this musical directive to the patients adapted from Pauline Oliveros’ Sonic Meditation V (Cope, 2001, p. 110): Lets walk around the unit together multiple times. Walk so silently that the bottoms of your feet becoame ears. Group Goal: Sustained Attention: To develop the ability to focus on one task sufficiently for a continuous amount of time to enable participation in everyday tasks of longer duration. Group Objective: For the patients to sustain attention via auditory focus while slowly walking up to 5 minutes without interrupting verbally or attempting to disrupt the intervention. Intervention: The patients are to remove their shoes and socks and line up quietly in a single file. Once calm and quiet, the patients are asked to silently walk around the unit at a walking speed of 40 beats per minute (bpm), or slower, while focusing on all of the sounds around them as the sounds unfolded or materialized. A Tibetan singing bowl is used to lightly accent each beat, providing an audible and secure rhythmic structure for the patients to entrain or synchronize to while experiencing the environmental music. In addition, different colored and textured foot print markers are placed around the unit to outline the walking path, providing a multisensory experience for each of the patients. Clinical Strategies: Inform the patients that the group task is targeted towards improving their capacity for concentration by having them silently walk on the foot print markers while experiencing the environmental music on the unit for X minutes. After this task, they are to go into the therapy room and verbally process the sound-walking experience together. Furthermore, other staff members should be placed around the unit providing visual cues, such as facial expressions and gestures to encourage the patients to re-engage if they went off task. Explain to the patients that this is to be a full body experience, stimulating kinetic awareness because they are to be listening to sounds while slowly walking and moving to the tempo of the Tibetan singing bowl at 40 (bpm) or slower. Since the tempo is very slow, invite the patients to be creative and playful with their body movements and walking patterns. Encourage the patients to walk in slow motion, move with overly pronounced arm or leg gestures, walk backwards, or walk on their toes, just as long as one foot hits a foot print marker on the beat, while listening to the environmental sounds intently. Lastly, before beginning the sound-walking experience, gave this musical directive to the patients adapted from Pauline Oliveros’ Sonic Meditation V (Cope, 2001, p. 110): Lets walk around the unit together multiple times. Walk so silently that the bottoms of your feet becoame ears. View Large Table 2 Pauline Oliveros Informed Intervention Group Goal: Sustained Attention: To develop the ability to focus on one task sufficiently for a continuous amount of time to enable participation in everyday tasks of longer duration. Group Objective: For the patients to sustain attention via auditory focus while slowly walking up to 5 minutes without interrupting verbally or attempting to disrupt the intervention. Intervention: The patients are to remove their shoes and socks and line up quietly in a single file. Once calm and quiet, the patients are asked to silently walk around the unit at a walking speed of 40 beats per minute (bpm), or slower, while focusing on all of the sounds around them as the sounds unfolded or materialized. A Tibetan singing bowl is used to lightly accent each beat, providing an audible and secure rhythmic structure for the patients to entrain or synchronize to while experiencing the environmental music. In addition, different colored and textured foot print markers are placed around the unit to outline the walking path, providing a multisensory experience for each of the patients. Clinical Strategies: Inform the patients that the group task is targeted towards improving their capacity for concentration by having them silently walk on the foot print markers while experiencing the environmental music on the unit for X minutes. After this task, they are to go into the therapy room and verbally process the sound-walking experience together. Furthermore, other staff members should be placed around the unit providing visual cues, such as facial expressions and gestures to encourage the patients to re-engage if they went off task. Explain to the patients that this is to be a full body experience, stimulating kinetic awareness because they are to be listening to sounds while slowly walking and moving to the tempo of the Tibetan singing bowl at 40 (bpm) or slower. Since the tempo is very slow, invite the patients to be creative and playful with their body movements and walking patterns. Encourage the patients to walk in slow motion, move with overly pronounced arm or leg gestures, walk backwards, or walk on their toes, just as long as one foot hits a foot print marker on the beat, while listening to the environmental sounds intently. Lastly, before beginning the sound-walking experience, gave this musical directive to the patients adapted from Pauline Oliveros’ Sonic Meditation V (Cope, 2001, p. 110): Lets walk around the unit together multiple times. Walk so silently that the bottoms of your feet becoame ears. Group Goal: Sustained Attention: To develop the ability to focus on one task sufficiently for a continuous amount of time to enable participation in everyday tasks of longer duration. Group Objective: For the patients to sustain attention via auditory focus while slowly walking up to 5 minutes without interrupting verbally or attempting to disrupt the intervention. Intervention: The patients are to remove their shoes and socks and line up quietly in a single file. Once calm and quiet, the patients are asked to silently walk around the unit at a walking speed of 40 beats per minute (bpm), or slower, while focusing on all of the sounds around them as the sounds unfolded or materialized. A Tibetan singing bowl is used to lightly accent each beat, providing an audible and secure rhythmic structure for the patients to entrain or synchronize to while experiencing the environmental music. In addition, different colored and textured foot print markers are placed around the unit to outline the walking path, providing a multisensory experience for each of the patients. Clinical Strategies: Inform the patients that the group task is targeted towards improving their capacity for concentration by having them silently walk on the foot print markers while experiencing the environmental music on the unit for X minutes. After this task, they are to go into the therapy room and verbally process the sound-walking experience together. Furthermore, other staff members should be placed around the unit providing visual cues, such as facial expressions and gestures to encourage the patients to re-engage if they went off task. Explain to the patients that this is to be a full body experience, stimulating kinetic awareness because they are to be listening to sounds while slowly walking and moving to the tempo of the Tibetan singing bowl at 40 (bpm) or slower. Since the tempo is very slow, invite the patients to be creative and playful with their body movements and walking patterns. Encourage the patients to walk in slow motion, move with overly pronounced arm or leg gestures, walk backwards, or walk on their toes, just as long as one foot hits a foot print marker on the beat, while listening to the environmental sounds intently. Lastly, before beginning the sound-walking experience, gave this musical directive to the patients adapted from Pauline Oliveros’ Sonic Meditation V (Cope, 2001, p. 110): Lets walk around the unit together multiple times. Walk so silently that the bottoms of your feet becoame ears. View Large Illustrative Vignette # 1. This session took place at 12:30 p.m., immediately after lunch, lasting only a half an hour. The dialogues, procedures, and the overall group process explained below, are based on music therapist’s written session notes taken before, during, and after the Oliveros intervention. Chaotic Prelude George: Do we have you? Mr. Enrico… what type of music group are we doing today? I want the drums! They are mine! Music Therapist: When everyone finishes lunch… I will let you know…it might be a bit strange. George ran back into the dining area to finish lunch and to tell his peers that there was going to be a strange music group today. After lunch, the patients were yelling, play fighting, walking around the unit, or sitting quietly in the dining area. Staff informed the patients that it was almost time for music therapy group, so they needed to go to their rooms and wash-up. Patient reactions to the room set up after they came out of their rooms and noticed the foot print markers on the floor included some who became overly excited, running and yelling around the unit, while other patients walked slowly and lethargically out of their rooms. The music therapist informed the patients that they only had a half an hour for group and that the commotion needed to settle down so the session could begin. Patient-Oliveros Introduction. The patients were informed that the purpose of the sound-walking task was to work on improving their attentional skills. The music therapist reminded the patients that the prior two music therapy groups were extremely disruptive and chaotic, making it difficult to express uncomfortable feeling-states and emotions within a safe therapeutic environment. Anne: I know Mr. Enrico…we are bad kids. MT: No…not at all…you guys are just not centered…or balanced…we can work on that today. Unexpectedly, the patients became more attentive after the music therapist used the words centered and balanced. Clearly, adults rarely spoke to the patients in this manner. It was quite remarkable how using the words centered or balanced could spark such attention in the patients when relating it to their inappropriate behaviors. In this moment of calm, the music therapist had a chance to explain and demonstrate the Oliveros task: MT: It is important that you move in tempo... or…in time with the sound of the Tibetan singing bowl…this will help improve your concentration. When the music therapist demonstrated slow motion walking, overly pronounced arm and leg gestures, and walking on his toes in the tempo of the singing bowl, the patients were excited to see that they could be as creative and playful with their body movements and walking patterns as they desired. Next, the music therapist read the group directive adapted from Pauline Oliveros’ Sonic Meditation V (Cope, 2001, p. 110). MT:Lets walk around the unit together multiple times. Walk so silently that the bottoms of your feet became ears. Patient-Oliveros Experience. The patients lined up in a single file. The music therapist stood in back of the line and began to play the Tibetan singing bowl in 4/4 time, at a tempo of 40 (bpm). The music therapist asked the patients to remain calm and still for a moment and to listen and feel the tempo of the singing bowl, and to begin walking when the first person in front of the line felt ready to walk. After one minute, the line started to move slowly in the tempo of the singing bowl. Some patients were walking with their hands in their pockets, looking down at the floor, and exhibiting blank expressionless gazes. Most of the patients seemed overly conscious about their walking, making sure that they were diligently stepping on the foot print markers in tempo. However, over time, their body movements became noticeably less tense, less unified, and more individualized. The music therapist noted the following: Mary: Slightly smiling, walking in slow motion, and at times, slowly punching the air. Glenda: Walking backwards. George: Smiling, slowing running in place. Mani: Holding her ears, while walking on her toes. Joe: Slowly and quietly stomping on the foot print markers in tempo. Anne: Smiling while alternating from forward and backward walking in tempo. Paul: Walking on his toes and heels. Lee: At times, pretending to jump in slow motion. In addition to the various body movements and gestures, the patients were listening to the environmental sounds on the unit, signaling to the music therapist when they heard something. The patients continued to walk for 5 minutes. After, the music therapist quietly guided the patients into the therapy room. Patients Process the Oliveros Experience. After the Oliveros experience, the patients sat in their chairs calmly, breathing softly, with serene facial expressions. Lee: Well…this was weird…but…cool…I feel a bit more chill. (Silence) Paul: I’m enjoying this silence. (Silence) MT: I’m enjoying this too…you guys really impressed me today…unfortunately…we have to end because we have run out of time and you need to go back to school. Mary: Oh… no…I want to stay here. MT: I understand…but…we need to end here… and… I will see you guys tomorrow for our next group adventure. The patients quietly got up from out of their seats and left the group to get ready for their afternoon school session. Some members of the nursing staff voiced how surprised they were to see the patients line up for school so calmly. Evaluating Effectiveness of the Oliveros Experience. The end of the noon music therapy group leads into the afternoon school session. It is crucial that each patient is able to sit calmly and focus on their afternoon coursework, making sure that no patient falls behind in their schoolwork while in the hospital. Here, the Oliveros experience was aimed to help the patients’ attentional skills, with the hope that improvement in attention and concentration would generalize outside of the music therapy room in everyday activities of daily living. Concerning the effectiveness of this Oliveros session, from the patients’ reaction and verbal responses towards the unfamiliar music therapy intervention, it was clear that the patients became calmer in the present moment, resting in the silence. Although there was not an abundance of verbal dialogue after the intervention, the patients’ relaxed and calm body language spoke volumes in comparison to the start of the group, as well as in the previous chaotic music therapy sessions. Moreover, while the music therapist walked the patients over to the school after the Oliveros session, some of patients mentioned that they appreciated that they were allowed to try out strange body movements as part of the intervention. It was revealed that because the patients had to match their body movements to the tempo of the Tibetan singing bowl, it not only helped them to stay focused on the various sounds around the unit, but was also an outlet for relieving stress due to making it easier to express their stress and tension in a fun way. Plausibly, the strange body movements facilitated an outlet for nonverbal expressivity, allowing the patients to tap into unexpressed emotions and feelings. Consequently, the teachers at the school hospital reported that most of the patients were calmer that day and more focused on their studies. John Cage: 4’33” On August 29, 1952, at a concert held in Woodstock, New York, the musical world was silenced due to the premier performance of the American composer John Cage’s (1912–1992) seminal composition, 4’33” (Kostelanetz, 1989). A musical composition scored in three-movements for any instrument or any combination of instruments, instructing the performer(s) not to play their instruments during the entire duration of the composition (Revill, 1992), encouraging the listener to experience and attend to all sounds as they materialize (Kostelanetz, 1991; Peyser, 1971). Cage Informed Intervention The 2nd novel intervention presented to the pediatric patients was inspired by John Cage’s experimental-composition 4’33”. Here, the intervention set out to improve attentional skills via sitting or standing meditation and environmental-sound listening. Clinically, an integration of a re-creative experience and four receptive listening experiences, meditative, stimulative, perceptual, and projective (Bruscia, 2014) were utilized to explore Cage’s silent piece. See Table 3 for instructions. Table 3 John Cage Informed Intervention Group Goal: Divided Attention: To develop the ability to focus on two or more simultaneous events or stimuli. Group Objective: For the patients to listen to a variety of unintentional sounds simultaneously as an aid to concentration. Intervention: Group performance or re-creative experience of John Cage’s “silent” composition, 4’33”, once or multiple times, followed by a group discussion of the experience. Color coordinated music stations are to be setup around the therapy room, with the option for the patient(s) to stand, to sit in a chair, or to sit on a floor mat. Depending on what materials are available to the music therapist, various “music stations” could be arranged in this fashion. See Online Supplement A for layout. 1) Standing-Music Stand Station (Red): Each red music stand is to have a red copy of Cage’s 4’33” score and a set of red desk bells placed on a small table with a red tablecloth. A variety of red drums are to be place around the small table, including a red electric bass. 2) Purple Floor Mat Station: Each purple floor mat is to have a purple copy of Cage’s 4’33” score and two purple desk bells placed in front of each floor mat. 3) Sitting-Music Stand Station (Blue Chairs): Each blue music stand is to have a blue copy of Cage’s 4’33” score with a set of blue maracas placed on each chair. A variety of small blue drums are to be placed around the chairs. 4) Green Floor Mat Station: Each green floor mat is to have a green copy of Cage’s 4’33” score and three small green drums placed in front of each floor mat. Clinical Strategies A) Ask the patients to find a music station that resonates with them, exploring which color, instrument(s), and seating/standing option catches their attention. B) After they have settled on a particular music station, inform the patients that the group task is targeted towards improving their capacity for concentration by having them perform John Cage’s composition, 4’33”, followed by a group discussion and processing of their experiences. C) Give a brief overview of Cage’s 4’33” composition, which, for those patients that are curious, will answer the question as to why the musical score doesn’t have any music written on it. D) Inform the patients that they are not to play their instruments for four minutes and thirty-three seconds, but instead, to silently listen to and explore all of the sounds around them as they materialized. E) Inform the patients that the music therapist will be the conductor of 4’33”, acting as support, keeping time on a cell phone timer or stopwatch, letting them know when to start and end the composition. Group Goal: Divided Attention: To develop the ability to focus on two or more simultaneous events or stimuli. Group Objective: For the patients to listen to a variety of unintentional sounds simultaneously as an aid to concentration. Intervention: Group performance or re-creative experience of John Cage’s “silent” composition, 4’33”, once or multiple times, followed by a group discussion of the experience. Color coordinated music stations are to be setup around the therapy room, with the option for the patient(s) to stand, to sit in a chair, or to sit on a floor mat. Depending on what materials are available to the music therapist, various “music stations” could be arranged in this fashion. See Online Supplement A for layout. 1) Standing-Music Stand Station (Red): Each red music stand is to have a red copy of Cage’s 4’33” score and a set of red desk bells placed on a small table with a red tablecloth. A variety of red drums are to be place around the small table, including a red electric bass. 2) Purple Floor Mat Station: Each purple floor mat is to have a purple copy of Cage’s 4’33” score and two purple desk bells placed in front of each floor mat. 3) Sitting-Music Stand Station (Blue Chairs): Each blue music stand is to have a blue copy of Cage’s 4’33” score with a set of blue maracas placed on each chair. A variety of small blue drums are to be placed around the chairs. 4) Green Floor Mat Station: Each green floor mat is to have a green copy of Cage’s 4’33” score and three small green drums placed in front of each floor mat. Clinical Strategies A) Ask the patients to find a music station that resonates with them, exploring which color, instrument(s), and seating/standing option catches their attention. B) After they have settled on a particular music station, inform the patients that the group task is targeted towards improving their capacity for concentration by having them perform John Cage’s composition, 4’33”, followed by a group discussion and processing of their experiences. C) Give a brief overview of Cage’s 4’33” composition, which, for those patients that are curious, will answer the question as to why the musical score doesn’t have any music written on it. D) Inform the patients that they are not to play their instruments for four minutes and thirty-three seconds, but instead, to silently listen to and explore all of the sounds around them as they materialized. E) Inform the patients that the music therapist will be the conductor of 4’33”, acting as support, keeping time on a cell phone timer or stopwatch, letting them know when to start and end the composition. View Large Table 3 John Cage Informed Intervention Group Goal: Divided Attention: To develop the ability to focus on two or more simultaneous events or stimuli. Group Objective: For the patients to listen to a variety of unintentional sounds simultaneously as an aid to concentration. Intervention: Group performance or re-creative experience of John Cage’s “silent” composition, 4’33”, once or multiple times, followed by a group discussion of the experience. Color coordinated music stations are to be setup around the therapy room, with the option for the patient(s) to stand, to sit in a chair, or to sit on a floor mat. Depending on what materials are available to the music therapist, various “music stations” could be arranged in this fashion. See Online Supplement A for layout. 1) Standing-Music Stand Station (Red): Each red music stand is to have a red copy of Cage’s 4’33” score and a set of red desk bells placed on a small table with a red tablecloth. A variety of red drums are to be place around the small table, including a red electric bass. 2) Purple Floor Mat Station: Each purple floor mat is to have a purple copy of Cage’s 4’33” score and two purple desk bells placed in front of each floor mat. 3) Sitting-Music Stand Station (Blue Chairs): Each blue music stand is to have a blue copy of Cage’s 4’33” score with a set of blue maracas placed on each chair. A variety of small blue drums are to be placed around the chairs. 4) Green Floor Mat Station: Each green floor mat is to have a green copy of Cage’s 4’33” score and three small green drums placed in front of each floor mat. Clinical Strategies A) Ask the patients to find a music station that resonates with them, exploring which color, instrument(s), and seating/standing option catches their attention. B) After they have settled on a particular music station, inform the patients that the group task is targeted towards improving their capacity for concentration by having them perform John Cage’s composition, 4’33”, followed by a group discussion and processing of their experiences. C) Give a brief overview of Cage’s 4’33” composition, which, for those patients that are curious, will answer the question as to why the musical score doesn’t have any music written on it. D) Inform the patients that they are not to play their instruments for four minutes and thirty-three seconds, but instead, to silently listen to and explore all of the sounds around them as they materialized. E) Inform the patients that the music therapist will be the conductor of 4’33”, acting as support, keeping time on a cell phone timer or stopwatch, letting them know when to start and end the composition. Group Goal: Divided Attention: To develop the ability to focus on two or more simultaneous events or stimuli. Group Objective: For the patients to listen to a variety of unintentional sounds simultaneously as an aid to concentration. Intervention: Group performance or re-creative experience of John Cage’s “silent” composition, 4’33”, once or multiple times, followed by a group discussion of the experience. Color coordinated music stations are to be setup around the therapy room, with the option for the patient(s) to stand, to sit in a chair, or to sit on a floor mat. Depending on what materials are available to the music therapist, various “music stations” could be arranged in this fashion. See Online Supplement A for layout. 1) Standing-Music Stand Station (Red): Each red music stand is to have a red copy of Cage’s 4’33” score and a set of red desk bells placed on a small table with a red tablecloth. A variety of red drums are to be place around the small table, including a red electric bass. 2) Purple Floor Mat Station: Each purple floor mat is to have a purple copy of Cage’s 4’33” score and two purple desk bells placed in front of each floor mat. 3) Sitting-Music Stand Station (Blue Chairs): Each blue music stand is to have a blue copy of Cage’s 4’33” score with a set of blue maracas placed on each chair. A variety of small blue drums are to be placed around the chairs. 4) Green Floor Mat Station: Each green floor mat is to have a green copy of Cage’s 4’33” score and three small green drums placed in front of each floor mat. Clinical Strategies A) Ask the patients to find a music station that resonates with them, exploring which color, instrument(s), and seating/standing option catches their attention. B) After they have settled on a particular music station, inform the patients that the group task is targeted towards improving their capacity for concentration by having them perform John Cage’s composition, 4’33”, followed by a group discussion and processing of their experiences. C) Give a brief overview of Cage’s 4’33” composition, which, for those patients that are curious, will answer the question as to why the musical score doesn’t have any music written on it. D) Inform the patients that they are not to play their instruments for four minutes and thirty-three seconds, but instead, to silently listen to and explore all of the sounds around them as they materialized. E) Inform the patients that the music therapist will be the conductor of 4’33”, acting as support, keeping time on a cell phone timer or stopwatch, letting them know when to start and end the composition. View Large Illustrative Vignette # 2. This session took place at 3:45 p.m., lasting 45 minutes. A negative of running a music psychotherapy group at the 3:45 time slot was constant interruptions that caused the patients to lose focus and concentration within the therapeutic process. These interruptions occurred because (a) the patients needed to leave the group due to visiting hours, (b) the nursing staff administering medications, (c) a scheduled family meeting with the social worker, and/or (d) an individual session with the psychologist or psychology intern. However, in the spirit of John Cage, the positive side of running a process group at the 3:45 time slot was to embrace all of the above-mentioned disruptions and interruptions as they materialized, viewing all of the sounds created by the interruptions as part of the entire musical experience. The dialogues and the overall group process explained below, are based on the music therapist’s session notes taken during and after the Cage intervention. Patient-Cage Introduction. The patients exited a verbal psychotherapy group with the psychologist. Some of the patients hurried out of the room; some left calmly. Nursing staff guided the patients into a room where the music therapist had arranged a color coordinated chamber music ensemble. (See Online Supplement A for The 4’33” Ensemble Music Stations) MT: Hello everyone…please enter the therapy room calmly. Lee: Wow! What is this? Anne: You again? Looks cool in here! Mary: Didn’t we just have you? Mani: That was last night! Remember? Yesterday evening? MT: Right…last night…we walked in a circle in this room listening to sounds…just like we did yesterday afternoon around the unit…while listening to sounds on the unit. After the patients calmed down, the music therapist asked them to find a music station that resonated with them. Surprisingly, there was no fighting or bickering by the patients when choosing a music stations. Next, the music therapist gave a brief overview of Cage’s 4’33” composition, asking the patients to explore the Tacet score, instructing them not to play their instruments for four minutes and thirty-three seconds, but, to silently listen to all of the sounds around them as they materialized. Lee: What the fuck!! You expect me…us…not to do anything for four minutes?!! (Most of the group members are startled by Lee’s agitated response) MT: OK…your first reaction is an honest one. It sounds like this is going to be a new experience for you. Lee: Yes! This is not normal…but…I’ll do it…try it. MT:Great! Anne: Fuck this! You have some strange groups here Mr. Enrico! Glenda: Let’s just try this…I’m curious…let’s go. MT: Great…your reactions are honest…and I appreciate them…let’s focus and perform this Cage piece once and see what we hear…or…better… hear what we hear…and then we can talk about the experience. After a moment of silence, all of the patients agreed to try this strange musical task. The patients expressed that they felt more comfortable and less anxious when the music therapist informed the group that he was going to be the conductor of the ensemble, keeping time on his cell phone stopwatch, acting as support, letting them know when to start and stop the composition by using simple hand gestures. Patient-Cage Experience. The music therapist dropped his left arm indicating that the composition had begun. Some patients were looking around the room at each other, some were looking at the floor, and some were looking up at the ceiling. The ventilation system was quietly humming. The unit door buzzer rang. Nurses’ footsteps were sounding. Doors were opening and closing. Nurses were talking. A nurse came into the room to take a patient out of the group for a family visit. Whispers were heard. Another nurse entered the room to give a few of the patients their medication. The door closed. The quiet humming from the ventilation system took over, adding to the environmental musical soundscape. Nurses were heard laughing with the visitors. An unknown scrapping sound was heard in the distance underneath the floor. The music therapist dropped his right arm indicating that the composition had finished. MT: What did you notice? Mary: (Smiling) I heard the air conditioner…or this sound coming from the ceiling? Lee: Yes…that… and the door opening and closing…lots of disruptions. MT: Can you remember what you were feeling in your body when you heard the disruptions? Lee: I was pissed off…but…I kept watching you looking at your cellphone …keeping time. Paul: Yes…with you here…Mr. Enrico…I felt safe. MT: Safe? Paul: Yes... MT: (Silence) Safe? (Silence)…and…what else did we hear…what other music? Anne: Music? Was this music?!! MT: Well…yes…did anyone hear the sounds as an entire piece of music…or…view all of the sounds as musical? Anne: Mr. Enrico…can we do this again…now…and I’ll try to listen more closely. MT: OK…let’s do this again and we can try and listen more closely and carefully…hearing if the sounds themselves…as they develop…create a musical composition with a beginning and an end. The entire group agreed to perform Cage’s 4’33” three more times and to switch music stations for each re-creative experience. Interestingly, after each 4’33” experience, the group discussions centered on the how the first attempt at Cage’s composition was so difficult and hard for most of the patients to stay focused and pay attention to the environmental sounds without being distracted by boredom or thoughts. However, after each re-creation of 4’33”, it became easier for the patients to focus and pay attention to the environmental sounds as they surfaced. Consequently, to deepen their listening experience for future 4’33” sessions, the music therapist suggested to the patients that they could add structure, form, or a frame to the 4’33” experience, helping to foster attentional skills: MT: Think of the first sound that you hear as the opening theme…as the sounds move and progress…what are the patterns of rhythmic activity…what are the movements or motions of the sounds…do all of the sounds move in the same direction…do the sounds have any color…are there many silences…try to experience the sounds in this way. Evaluating Effectiveness of the Cage Experience. In addition to the color coordinated music stations catching the attention of all of the children, some other significant events took place within the therapeutic process: 1. Fear of the unknown. Lee and Anne became anxious and agitated when the music therapist explained the unfamiliar 4’33” group task. Their distress or anxieties were expressed by aggressive hand gesticulations and the use of strong language. 2. Acceptance of their fear. The music therapist’s acceptance and tolerance of the patients’ aggressive behaviors continued to develop the therapeutic relationship built on trust begun with the Oliveros intervention. 3. Support and encouragement. This trust was strengthened when the music therapist informed the group that he was going to be the conductor of 4’33”, acting as support, and as a guide throughout the unfamiliar listening experience. 4. Familiarity. By repeating Cage’s composition multiple times together, the patients became less anxious about the novel musical experience, letting go of their anxieties for a moment. 5. Organization and structure to help attentional skills. As the patients became more comfortable with the 4’33” experience, the music therapist was able to suggest different ways to enhance their focus and concentration by having them silently organize or shape the environmental sounds as they surfaced. Luigi Nono: Sound-Searching The Italian composer Luigi Nono’s (1924–1990) music from his last period in the 1980s reveals a uniquely personal musical voice that combined both precision and improvisation, creating unsettling sonic landscapes of subtlety and beauty (Curreri, 2015; McHard, 2001). As a socially committed composer, deeply concerned with how audience members would perceive and experience his music, these late compositions reflect Nono’s own commitment to collaborate with performers by shaping and molding various sound-textures together and observing what effect the space had on the prolonged silences, microtonal intervals, very subtle textures, and fluctuating timbres found in his compositions (Griffiths, 1995; Nielinger-Vakil, 2015). Consequently, the listener participates almost as much as the performers, by imagining his/her own dreamlike voyage, while navigating through the disintegrated sonic gestures, in search for another harmony (Griffiths, 1995). Nono Informed Intervention. The 3rd novel intervention presented to the pediatric patients was inspired by Nono’s very subtle textures and fluctuating timbres found in his late compositions, and the composer-performer collaborative experience of molding various sounds together and observing the results. Here, an integration of a free improvisatory sound-noise-exploration and receptive experiences, such as stimulative and perceptual listening (Bruscia, 2014) were utilized to help improve shared-attentional and interpersonal skills. See Table 4 for instructions. Table 4 Luigi Nono Informed Intervention Multimodal Group Goals a) Shared Awareness: To develop the ability of shared nonjudgmental focus on an object by two or more individuals. b) To develop tolerance for other’s ideas and concepts, perceptions, and contributions. c) Non-verbal form of creative exploration, discovery, and invention. Group Objective: For the patients to refrain from displaying socially inappropriate conduct towards their peers, such as verbal or shouting interruptions, physical abuse, or name-calling. Intervention: To construct delicate, linearly uniform, and almost inaudible fragmented group-sound-textures of uneven durations, to help improve (a) focused and concentrated listening; (b) shared attention/awareness; (c) interpersonal skills; and (d) creativity. A group discussion based on suggested focused questions listed below is to follow each sound-construction episode (a collection of 4–6 fragmented sound-textures) to verbally process the patients’ experiences. Clinical Strategies: Before the music therapy group begins, place chairs in a circle. Various instruments of definite and indefinite pitches should be neatly placed in the center of the circle. At the beginning of the group, the music therapist is to quietly welcome and greet the patients by gently playing a Tibetan singing bowl as they enter into the therapy room. Ask the patients to sit quietly in a circle, to relax, and to listen to the sustaining tones of the singing bowl. After the patients are relaxed and comfortable, the music therapist is to stop playing the singing bowl and inform the patients that the group task is centered on creating extremely quiet music in the style of Luigi Nono, with the intention of helping them improve concentration, listening skills, cooperation, and creativity. The music therapist is to speak briefly to the patients about the style of music Luigi Nono composed late in his life, demonstrating this style of concentrated composition by exploring extremely soft dynamics on various instruments, including prolonged silences, and extended techniques (unconventional or irregular playing techniques). Here, the music therapist is acting as a model, demonstrating different ways to investigate and explore the instruments creatively, avoiding any kind of specific form or structure. Next, invite each patient, one at a time, to investigate and experiment with any instrument that resonates with him or her. Explain to the patients that they are to remain quiet and refrain from any verbal remarks or outbursts while each peer is exploring their instrument of choice. After all of the members of the group find the musical instrument that they are comfortable playing and exploring, inform the members that they are going to participate in a group experimental-sound-exploration-composition conducted by the music therapist. Reiterate that the patients are to listen intently to each other during the creation of a unified or merged composition consisting of only extremely quiet dynamics, prolonged silences, and conventional and unconventional playing techniques. It is suggested that each sound-fragment follow this format: 1) The music therapist gives a conducting gesture or signal by dropping his/her right hand quickly to let the patients know when to begin the fragment. When the right hand has dropped, all of the members of the group are asked to play a unified attack on their instrument at the same time. 2) The attacks may be a fast (sharp) attack with or without sustain, or a slow attack with or without sustain. In both cases, the patients are invited to add effects of timbre (muted, pizzicato, col legno, or extended techniques) and/or various articulations (tenuto, marcato, staccato, or legato) to their note or sound. 3) During the collective sustaining sound-texture, the music therapist slowly and steadily moves his/her left hand horizontally from left to right, acting as a timekeeper, letting the patients know how long the fragment should last. 4) The music therapist will let the patient know when the fragment has ended by putting up his/her open right hand, acting as a stop sign. The entire group is to sit and listen to the sound-texture as it decays. 5) The group is to sit in a sustained silence, waiting for the music therapist to drop his/her right hand to begin another sound fragment, following the same format. Here, the idea is that the sound-texture fragment travels like one collective musical gesture, leading into a prolonged silence, and then into another fragment. After a completed episode, it is recommended to ask any of the following open-ended questions listed below to help the patients stay focused on the listening/shared awareness experience: a. Where there any moments in the group sound-creations where you felt connected to anyone or others in the group? b. Was there an overall motion to any of the fragments from beginning to end? c. Can you describe the movement of the sounds? d. What sounds fill in the detail of the motion? e. Did the sounds move in the same direction? f. Did you notice any of the sound-textures that you liked or disliked? g. Did any part of sound-textures that you created and heard today/tonight have any specific meaning for you? Multimodal Group Goals a) Shared Awareness: To develop the ability of shared nonjudgmental focus on an object by two or more individuals. b) To develop tolerance for other’s ideas and concepts, perceptions, and contributions. c) Non-verbal form of creative exploration, discovery, and invention. Group Objective: For the patients to refrain from displaying socially inappropriate conduct towards their peers, such as verbal or shouting interruptions, physical abuse, or name-calling. Intervention: To construct delicate, linearly uniform, and almost inaudible fragmented group-sound-textures of uneven durations, to help improve (a) focused and concentrated listening; (b) shared attention/awareness; (c) interpersonal skills; and (d) creativity. A group discussion based on suggested focused questions listed below is to follow each sound-construction episode (a collection of 4–6 fragmented sound-textures) to verbally process the patients’ experiences. Clinical Strategies: Before the music therapy group begins, place chairs in a circle. Various instruments of definite and indefinite pitches should be neatly placed in the center of the circle. At the beginning of the group, the music therapist is to quietly welcome and greet the patients by gently playing a Tibetan singing bowl as they enter into the therapy room. Ask the patients to sit quietly in a circle, to relax, and to listen to the sustaining tones of the singing bowl. After the patients are relaxed and comfortable, the music therapist is to stop playing the singing bowl and inform the patients that the group task is centered on creating extremely quiet music in the style of Luigi Nono, with the intention of helping them improve concentration, listening skills, cooperation, and creativity. The music therapist is to speak briefly to the patients about the style of music Luigi Nono composed late in his life, demonstrating this style of concentrated composition by exploring extremely soft dynamics on various instruments, including prolonged silences, and extended techniques (unconventional or irregular playing techniques). Here, the music therapist is acting as a model, demonstrating different ways to investigate and explore the instruments creatively, avoiding any kind of specific form or structure. Next, invite each patient, one at a time, to investigate and experiment with any instrument that resonates with him or her. Explain to the patients that they are to remain quiet and refrain from any verbal remarks or outbursts while each peer is exploring their instrument of choice. After all of the members of the group find the musical instrument that they are comfortable playing and exploring, inform the members that they are going to participate in a group experimental-sound-exploration-composition conducted by the music therapist. Reiterate that the patients are to listen intently to each other during the creation of a unified or merged composition consisting of only extremely quiet dynamics, prolonged silences, and conventional and unconventional playing techniques. It is suggested that each sound-fragment follow this format: 1) The music therapist gives a conducting gesture or signal by dropping his/her right hand quickly to let the patients know when to begin the fragment. When the right hand has dropped, all of the members of the group are asked to play a unified attack on their instrument at the same time. 2) The attacks may be a fast (sharp) attack with or without sustain, or a slow attack with or without sustain. In both cases, the patients are invited to add effects of timbre (muted, pizzicato, col legno, or extended techniques) and/or various articulations (tenuto, marcato, staccato, or legato) to their note or sound. 3) During the collective sustaining sound-texture, the music therapist slowly and steadily moves his/her left hand horizontally from left to right, acting as a timekeeper, letting the patients know how long the fragment should last. 4) The music therapist will let the patient know when the fragment has ended by putting up his/her open right hand, acting as a stop sign. The entire group is to sit and listen to the sound-texture as it decays. 5) The group is to sit in a sustained silence, waiting for the music therapist to drop his/her right hand to begin another sound fragment, following the same format. Here, the idea is that the sound-texture fragment travels like one collective musical gesture, leading into a prolonged silence, and then into another fragment. After a completed episode, it is recommended to ask any of the following open-ended questions listed below to help the patients stay focused on the listening/shared awareness experience: a. Where there any moments in the group sound-creations where you felt connected to anyone or others in the group? b. Was there an overall motion to any of the fragments from beginning to end? c. Can you describe the movement of the sounds? d. What sounds fill in the detail of the motion? e. Did the sounds move in the same direction? f. Did you notice any of the sound-textures that you liked or disliked? g. Did any part of sound-textures that you created and heard today/tonight have any specific meaning for you? View Large Table 4 Luigi Nono Informed Intervention Multimodal Group Goals a) Shared Awareness: To develop the ability of shared nonjudgmental focus on an object by two or more individuals. b) To develop tolerance for other’s ideas and concepts, perceptions, and contributions. c) Non-verbal form of creative exploration, discovery, and invention. Group Objective: For the patients to refrain from displaying socially inappropriate conduct towards their peers, such as verbal or shouting interruptions, physical abuse, or name-calling. Intervention: To construct delicate, linearly uniform, and almost inaudible fragmented group-sound-textures of uneven durations, to help improve (a) focused and concentrated listening; (b) shared attention/awareness; (c) interpersonal skills; and (d) creativity. A group discussion based on suggested focused questions listed below is to follow each sound-construction episode (a collection of 4–6 fragmented sound-textures) to verbally process the patients’ experiences. Clinical Strategies: Before the music therapy group begins, place chairs in a circle. Various instruments of definite and indefinite pitches should be neatly placed in the center of the circle. At the beginning of the group, the music therapist is to quietly welcome and greet the patients by gently playing a Tibetan singing bowl as they enter into the therapy room. Ask the patients to sit quietly in a circle, to relax, and to listen to the sustaining tones of the singing bowl. After the patients are relaxed and comfortable, the music therapist is to stop playing the singing bowl and inform the patients that the group task is centered on creating extremely quiet music in the style of Luigi Nono, with the intention of helping them improve concentration, listening skills, cooperation, and creativity. The music therapist is to speak briefly to the patients about the style of music Luigi Nono composed late in his life, demonstrating this style of concentrated composition by exploring extremely soft dynamics on various instruments, including prolonged silences, and extended techniques (unconventional or irregular playing techniques). Here, the music therapist is acting as a model, demonstrating different ways to investigate and explore the instruments creatively, avoiding any kind of specific form or structure. Next, invite each patient, one at a time, to investigate and experiment with any instrument that resonates with him or her. Explain to the patients that they are to remain quiet and refrain from any verbal remarks or outbursts while each peer is exploring their instrument of choice. After all of the members of the group find the musical instrument that they are comfortable playing and exploring, inform the members that they are going to participate in a group experimental-sound-exploration-composition conducted by the music therapist. Reiterate that the patients are to listen intently to each other during the creation of a unified or merged composition consisting of only extremely quiet dynamics, prolonged silences, and conventional and unconventional playing techniques. It is suggested that each sound-fragment follow this format: 1) The music therapist gives a conducting gesture or signal by dropping his/her right hand quickly to let the patients know when to begin the fragment. When the right hand has dropped, all of the members of the group are asked to play a unified attack on their instrument at the same time. 2) The attacks may be a fast (sharp) attack with or without sustain, or a slow attack with or without sustain. In both cases, the patients are invited to add effects of timbre (muted, pizzicato, col legno, or extended techniques) and/or various articulations (tenuto, marcato, staccato, or legato) to their note or sound. 3) During the collective sustaining sound-texture, the music therapist slowly and steadily moves his/her left hand horizontally from left to right, acting as a timekeeper, letting the patients know how long the fragment should last. 4) The music therapist will let the patient know when the fragment has ended by putting up his/her open right hand, acting as a stop sign. The entire group is to sit and listen to the sound-texture as it decays. 5) The group is to sit in a sustained silence, waiting for the music therapist to drop his/her right hand to begin another sound fragment, following the same format. Here, the idea is that the sound-texture fragment travels like one collective musical gesture, leading into a prolonged silence, and then into another fragment. After a completed episode, it is recommended to ask any of the following open-ended questions listed below to help the patients stay focused on the listening/shared awareness experience: a. Where there any moments in the group sound-creations where you felt connected to anyone or others in the group? b. Was there an overall motion to any of the fragments from beginning to end? c. Can you describe the movement of the sounds? d. What sounds fill in the detail of the motion? e. Did the sounds move in the same direction? f. Did you notice any of the sound-textures that you liked or disliked? g. Did any part of sound-textures that you created and heard today/tonight have any specific meaning for you? Multimodal Group Goals a) Shared Awareness: To develop the ability of shared nonjudgmental focus on an object by two or more individuals. b) To develop tolerance for other’s ideas and concepts, perceptions, and contributions. c) Non-verbal form of creative exploration, discovery, and invention. Group Objective: For the patients to refrain from displaying socially inappropriate conduct towards their peers, such as verbal or shouting interruptions, physical abuse, or name-calling. Intervention: To construct delicate, linearly uniform, and almost inaudible fragmented group-sound-textures of uneven durations, to help improve (a) focused and concentrated listening; (b) shared attention/awareness; (c) interpersonal skills; and (d) creativity. A group discussion based on suggested focused questions listed below is to follow each sound-construction episode (a collection of 4–6 fragmented sound-textures) to verbally process the patients’ experiences. Clinical Strategies: Before the music therapy group begins, place chairs in a circle. Various instruments of definite and indefinite pitches should be neatly placed in the center of the circle. At the beginning of the group, the music therapist is to quietly welcome and greet the patients by gently playing a Tibetan singing bowl as they enter into the therapy room. Ask the patients to sit quietly in a circle, to relax, and to listen to the sustaining tones of the singing bowl. After the patients are relaxed and comfortable, the music therapist is to stop playing the singing bowl and inform the patients that the group task is centered on creating extremely quiet music in the style of Luigi Nono, with the intention of helping them improve concentration, listening skills, cooperation, and creativity. The music therapist is to speak briefly to the patients about the style of music Luigi Nono composed late in his life, demonstrating this style of concentrated composition by exploring extremely soft dynamics on various instruments, including prolonged silences, and extended techniques (unconventional or irregular playing techniques). Here, the music therapist is acting as a model, demonstrating different ways to investigate and explore the instruments creatively, avoiding any kind of specific form or structure. Next, invite each patient, one at a time, to investigate and experiment with any instrument that resonates with him or her. Explain to the patients that they are to remain quiet and refrain from any verbal remarks or outbursts while each peer is exploring their instrument of choice. After all of the members of the group find the musical instrument that they are comfortable playing and exploring, inform the members that they are going to participate in a group experimental-sound-exploration-composition conducted by the music therapist. Reiterate that the patients are to listen intently to each other during the creation of a unified or merged composition consisting of only extremely quiet dynamics, prolonged silences, and conventional and unconventional playing techniques. It is suggested that each sound-fragment follow this format: 1) The music therapist gives a conducting gesture or signal by dropping his/her right hand quickly to let the patients know when to begin the fragment. When the right hand has dropped, all of the members of the group are asked to play a unified attack on their instrument at the same time. 2) The attacks may be a fast (sharp) attack with or without sustain, or a slow attack with or without sustain. In both cases, the patients are invited to add effects of timbre (muted, pizzicato, col legno, or extended techniques) and/or various articulations (tenuto, marcato, staccato, or legato) to their note or sound. 3) During the collective sustaining sound-texture, the music therapist slowly and steadily moves his/her left hand horizontally from left to right, acting as a timekeeper, letting the patients know how long the fragment should last. 4) The music therapist will let the patient know when the fragment has ended by putting up his/her open right hand, acting as a stop sign. The entire group is to sit and listen to the sound-texture as it decays. 5) The group is to sit in a sustained silence, waiting for the music therapist to drop his/her right hand to begin another sound fragment, following the same format. Here, the idea is that the sound-texture fragment travels like one collective musical gesture, leading into a prolonged silence, and then into another fragment. After a completed episode, it is recommended to ask any of the following open-ended questions listed below to help the patients stay focused on the listening/shared awareness experience: a. Where there any moments in the group sound-creations where you felt connected to anyone or others in the group? b. Was there an overall motion to any of the fragments from beginning to end? c. Can you describe the movement of the sounds? d. What sounds fill in the detail of the motion? e. Did the sounds move in the same direction? f. Did you notice any of the sound-textures that you liked or disliked? g. Did any part of sound-textures that you created and heard today/tonight have any specific meaning for you? View Large Illustrative Vignette # 3. This session took place at 5:30 p.m., lasting sixty minutes. Typically, the evening music psychotherapy group would compete for space with the student tutors and the patients’ visitors. Fortunately, on this night, the tutors were off and visitors had not arrived. The dialogues, procedures, and the overall group process explained below, were based on the music therapist’s written group notes taken before, during, and after the Nono intervention, as well as audio recordings of each nonverbal musical exploration. “Crappy” Start. It was a surprisingly quiet evening on the unit. After dinner, the patients went to their rooms to relax. Nursing staff had informed the music therapist that the visiting hours earlier in the day were emotionally draining for some of the patients and that they had attended a difficult processing psychotherapy group that afternoon. With this in mind, the music therapist went and calmly knocked on the patients’ doors to let them know that music therapy group will begin in 5 minutes. One after another, the patients slowly came out of their rooms and found the music therapist greeting them in front of the therapy room, quietly playing a large Tibetan singing bowl. The patients found their seats and sat quietly, trying to listen to the singing bowl, but were observably internally anxious and restless. After the sound of the singing bowl stopped, everyone sat in silence for a few moments. MT: How are things going for all of you tonight on the unit? Mary: Crappy day…but…I liked the sounds you were playing. Joe: I agree about the music but…today…not good at all. MT: What happened today? (Silence) Lee: Don’t want to talk about it…is that OK? MT: Sure…but…what do you guys think about not talking…”about it”? All eight patients sat in silence for a few moments exhibiting worried facial expressions. Their breathing was a bit shallow. Observing their body language, they were in no mood to talk. Patient-Nono Introduction. The music therapist broke the silence to inform the patients the group task was going to be centered on creating extremely quiet music in the style of Luigi Nono with the intention of helping them improve attention and concentration via shared experimental-creativity. The music therapist demonstrated this style of focused composition by playing and exploring extremely soft dynamics on various instruments, including extended or irregular playing techniques. Glenda: (After hearing the music therapist demonstrate very quiet bow articulations on the muted strings of the psaltery) Wow! That’s cool…I really liked that…weird. The music therapist continued this type of exploration with other instruments and invited each patient, one at a time, to investigate and experiment with any instrument that resonated with them. The patients responded positively without interrupting each other. Observing their body language and facial expressions, the patients appeared to be calm and enjoying the sounds that they were producing; however, the sounds that they were creating were quiet, tense, and unnerving, an inappropriate match to their calm facial expressions and relaxed body language. Patient-Nono Experience. After the patients finished, the lingering sounds quietly decayed into the silence. Anne: Mr. Enrico…that was cool…I feel...calmer. MT: Cool and calmer? Anne: Yes…and…interested. Lee:Me too...What’s next? The music therapist informed the patients that they were going to participate in a group experimental-sound-exploration-composition together, with the intention of creating unified or merged sound fragments. MT: It is crucial that you listen intently to each other. It is extremely important that we create a unified sound-texture…together…to help improve attention or… shared attention…you must focus and listen. The following are two examples of the Nono informed sound fragments. Fragment # 1. The room was still. The patients were waiting for the music therapist to signal them to begin. The therapist dropped his right hand: MT: No…not together…remember... play an attack together… when my right hand drops…we need to sound and move like we are one person playing a group of notes at the same time...in one gesture. The therapist dropped his hand again. It was still not together. He dropped his hand 3 more times, no change. The group sat in silence for a moment. The therapist dropped his right hand again. They did it! The attack was very, very quiet. The sound-texture slowly developed as the therapist’s left hand gradually moved horizontally. Some notes were ringing out and some notes were sustained due to the patients trying out different articulations. The sounds decayed into the silence. The music therapist put up his open right hand to signal everyone to stop playing. There was a long silence with the sounds of the ventilation system and quiet conversation in the hallway. Fragment # 4 and Group Verbal Processing the Nono Experience. The therapist’s right hand dropped. Quiet sustaining tones were executed by various articulations. There was not much silence between each tone. Instead, there were many quiet sounds moving without pause. Tones were moving in different directions at different speeds. The tones created a sound-texture not fixed in space, but constantly moving. The sound-texture swirled into an unexpected halt, as the sustained sounds decayed into a short silence with sounds of talking in the hallway. MT: Did you notice any of the sound-textures or fragments that you liked or disliked? George: Well…it sounds like from what you told us to do…it was to listen carefully to the sounds that we created and to each other…right? MT: Yes. George: OK…when I did that…I noticed that I liked everything because I was creating it…and the other guys in the group were trying to create music too…that I liked. MT: So…it sounds like you enjoyed the music making…creating? The other group members became rather excited and expressed that they agreed with George about enjoying the creative process. MT: OK…great! Now… focus on our shared attention during the creative process… for a moment. Mary: I think it was difficult for me…at the beginning…to really listen and…play together. Mani: Yes… playing at the same time…but we started to listen to each other. Joe: We played together and listened to each other… more naturally near the end of this exercise. As the discussion continued, most of the patients disclosed that they had problems with paying attention and listening in everyday life outside of the hospital, as echoed by Anne: Anne: To listen to what other people want to say…well…I have trouble with this…bad trouble…and it sounds like most of us here have problems with this…it is hard for me to stop and listen…it takes time. Evaluating Effectiveness of the Nono Experience. The music therapist’s written session notes and audio recordings reveal some interesting findings about the group Nono experience. 1) Nonverbal expression. Although the patients did not want to talk about their day, the sound-exploration warm-up was an appropriate therapeutic tool to help the patients express themselves nonverbally. The sound-explorations sonically revealed the patients’ collective depressed mood that evening, acting as a nonverbal outlet for unexpressed feeling-states. This was made evident when the patients verbally reported feeling calmer after the warm-up. 2) Collective nonverbal interaction. Unpredictably, the patients were able to match or improvise around each other’s musical explorations during the sound-based Fragments, creating interesting nonverbal interactions based on the characteristics or the quality of the sounds. 3) Verbal insight into attentional needs. When verbally processing the Nono experience, the patients revealed that while it was fun and weird to create the sound-textures, it was rather a demanding task. The patients commented that the difficulties they experienced with attention, listening, and staying focused during the Nono intervention, were the same difficulties that they experienced in everyday life at home and at school. Discussion Familiar Musical Form As demonstrated in the initial music therapy sessions with the pediatric patients described in this case report, when diatonic music was presented in a large group format, the patients quickly lost focus and attention, disrupting any efforts made to complete the group goals identified at the beginning of the session. Receptive listening experiences using popular songs, improvisational experiences using clear binary, ternary, or rondo forms, a group sing-along using children songs, or music and imagery intervention using familiar classical or film music, created simultaneous uncontrollable outbursts where the patients were unable to regulate their emotions. However, in the midst of the shouting and the chaos, the music therapist was able to catch a glimpse of happy memories of family barbeques, cooking together, parties, sleepovers with friends, cutting school, or playing video games, frantically recalled by the patients. Sadly, the music therapist was unable to explore or process any of these past experiences because of poorly modulated emotional responses within a tonal harmonic climate. Consequently, it was clear to the music therapist that presenting familiar tonal music to acute pediatric patients in a large group setting was unsuccessful and not productive. Group participants became frantic and unmanageable, frozen in past experiences, which were stimulated by the diatonic music. However, it is important to note that the music therapist experienced the above-mentioned problems with diatonic music only in a large group setting. Individual therapy sessions, or a dyad or triad sessions focusing on tonal or diatonic music, were manageable and productive, where the patients were able to process emotions and feeling-states. Altering Musical Form Despite the fact that diatonic music quickly caught the attention of the acute pediatric patients, it was also the cause for over-stimulating the patients in a large group setting, making it difficult for the group to function productively due poorly managed emotional responses. Therefore, the music therapist needed to produce musical interventions that would not over-stimulate the acute patients. Specifically, it was important to find music that was not intended to produce emotional-states-of-being but instead, nurture attentional-states-of-awareness, moving away from familiar musical forms by altering musical conventions. Here, sound-based interventions informed by the three avant-garde composers Pauline Oliveros, John Cage, and Luigi Nono, were centered on improving attentional skills without trying to stimulate emotional states. Clinicians may find musical interventions that are not intended to produce an emotional response a bit curious. However, music therapists should be aware of the emotional power that diatonic music possesses within an acute pediatric psychiatric setting, especially if the music is causing a group of pediatric patients to become uncontrollably over-stimulated. In fact, while the attentional needs of the pediatric patients described in this case report were addressed through the three avant-garde interventions, these interventions did not stimulate feeling-states or emotional responses. As with most challenging contemporary classical music, the listener needs to become familiar with a new musical language before finding pleasure in novel organized sounds (Rosen, 1994), making the three avant-garde interventions described in this case report a useful tool for catching the acute pediatric patients’ attention without stimulating an emotional response. Further Developments with the Patients Presented in this Case Report In the last music therapy sessions together, the patients described in the case report helped the music therapist to create a condensed 5 to 7 minute warm-up exercise based on the Oliveros, Cage, and Nono interventions, without the need for the colored foot print markers or the color coordinated 4’33” ensemble. When constructing the warm-up, the patients wanted to use themselves as the standard for all children with mental problems because they felt that they were the best models with the worst attention problems. By examining their own attentional needs, including what would be fun for kids our age, the patients constructed the warm-up in this fashion: (a) Oliveros intervention. Patients’ rationale: “It calmed our bodies down and helped us to relax after very active events.” Transition into: (b) Cage intervention. Patients’ rationale: “It helped us to sit and focus on the sounds around the room without grabbing for instruments.” Transition into: (c) Nono intervention. Patients’ rationale: “It helped us to pick instruments calmly and explore them, and to play united group-sounds together.” The patients decided to title the finalized warm-up as the Group Strange-Listening Warm-up. The creation of the Group Strange-Listening Warm-up was important because it became the “contact music” between the music therapist and the patients presented in this case report. Specifically, the warm-up was used to begin the music therapy sessions, helping the patients to stay calm and attentive. The warm-up led into different diatonic music improvisational experiences that focused on the patients’ nonverbal feeling-states, where the patients were comfortable having the music therapist work with them to try to find meaning in their improvisations. The group felt safe if they verbally processed different feeling-states and emotions together as a unit or a squad, proving that a strong therapeutic bond developed between the music therapist and the patients, as well as with each other during the avant-garde sound-based explorations. In addition, in later music therapy sessions, the remaining patients from the original eight described in this report, helped the music therapist by co-leading the music therapy groups, explaining and demonstrating to the new patients how to implement the warm-up constructively. Age-Appropriate Warm-up While what impact their ages had on the Oliveros, Cage, or Nono experiences was not discussed with the pediatric patients described in this case report, the music therapist was curious to find out if age was a pivotal factor, introducing the Group-Strange Listening Warm-up on the acute adolescent and adult psychiatric units in the hospital. Interestingly, both the adolescent and adult patients reported feeling embarrassed, uncomfortable, and awkward having to produce overly pronounced body movements while walking around the unit at the beginning of the warm-up, eventually giving up and leaving the group session. In addition, during the Nono informed section, the adolescent patients felt lost and confused about having to play so quietly, opting not to play at all, even after encouragement by the music therapist. The adult patients echoed the adolescents’ reaction about the Nono section. However, there was some interest in the Cage informed section. Many of the adult patients were trying to practice meditation daily, so 4’33” was a way for the adults to incorporate listening into their meditation practice. Similarly, due to the unit psychologist introducing the adolescent patients to mindfulness-based coping skills exercises, the adolescents were interested in the Cage section, revealing that it was a different way of practicing mindfulness. Consequently, some of these were more enticing and suitable for children. Clinical Implications for Music Therapy Practice It is strongly recommended that before a music therapist leads a group using any of the musical interventions presented in this paper, they must be a practitioner and consumer of avant-garde music, which is a specialized musical language that needs to be studied and practiced in order to understand how to utilize it clinically (Lee, 2003). The music therapist (author) presenting this case report is a practitioner of avant-garde and experimental music. My expertise in avant-garde, new, and unusual music played a significant role in understanding how to develop efficient novel musical experiences for the pediatric patients. Nevertheless, I recommend that future clinicians try exploring the Group Strange-Listening Warm-up when facilitating a group of hyperactive, agitated, and disruptive acute pediatric patients, due to its ability to stimulate curiosity and attention. After the group participants are more relaxed, the group could progress from the novel sound-based warm-up into a variety of diatonic-based musical experiences focusing on the pediatric patients’ feeling-states and emotional responses. Conclusion This case report explored how avant-garde sound-based interventions helped pediatric patients improve attentional skills while admitted on a small acute psychiatric unit. Various problems with attention hampered the patients’ basic tasks of everyday living at home and at school, resulting in distractibility, poor concentration, hyperactivity, irritability, and impulsivity. Signs of the patients’ dysfunctional attentional skills were observed during initial music therapy group sessions focusing on diatonic-based interventions utilizing tonal harmonic languages, including predictable rhythms or time signatures. Within the diatonic harmonic climate, the patient presented in this case report became over stimulated by the familiarity of the tonal chord changes and simple time signatures, repeatedly loosing focus, concentration, and attention, making it difficult to work on (1) prerequisite skills, such as staying seated, no cross talking, following 1-step directions, and keeping safe boundaries, and (2) exploring emotions and feeling-states. When three avant-garde musical interventions, informed by the late composers Pauline Oliveros, John Cage, and Luigi Nono were introduced to the patients, the novel sound experiences were more suitable than diatonicism for quickly engaging the patients’ attention without over stimulating their emotional states bent on musical tastes, likes, and dislikes. The patients were able to build a strong therapeutic alliance with the music therapist while engaging in the novel musical interventions. This alliance led the patients to create their own condensed warm-up version of the three avant-garde interventions in which they helped to teach to newly admitted patients with similar attentional needs. Future clinicians are encouraged to explore the warm-up or any of the avant-garde sound-based group interventions presented in this case report with acute pediatric patients struggling with deficits in attention, concentration, and focus. 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Music Therapy PerspectivesOxford University Press

Published: Feb 1, 2018

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