|Woodcut by Petersham from The Poppy Seed Cakes, |
Doubleday Books (1930). [Click to enlarge]
Music and movement—frequently intertwined with each other—reach us via brain structures below the conscious level, that is, bypassing the prefrontal cortex (Levitin, 2006). For addicts, music or movement can both be part of the problem and part of the solution. The problem comes where certain music—sometimes along with movement done to it—has been embedded in the drug-using lifestyle. Such would be the case for ingesters of "ecstasy" (MDMA) who were given to hours of repetitive, oscillating dance movement to loud and impersonal Techno-style music. Another example would be those addicts who listened to rock music (often of the Heavy Metal genre) during their using days—strongly identifying with the anger and alienation expressed by the performers, and experiencing physiologically the strong beat and distorted guitars. Addicts such as either of these may find recovery nearly impossible without abstinence from their music in tandem with abstinence from chemical substances, as a return may easily trigger relapse (Horesh, 2010).
Music and movement become a solution when utilized therapeutically in addiction treatment. Depending on the activities devised, these performing arts have the potential to address bio-physical, psycho-emotional and psycho-spiritual issues that commonly accompany—either resulting from or being the original cause of—addiction and that hamper recovery (Borling, 2011). Beyond enhancing a treatment program, music and movement interventions offer clients new skills and forms of expression to be practiced in their restored lives—edifying them against relapse for the long run.
In examining research findings for MT or DMT interventions, one must bear in mind exactly what type of activity was involved—as the great variety of approaches and levels of engagement that fall under these categories can give generalizations limited value. It is also not always easy to draw the line between MT and DMT, as they frequently share many of the same techniques. But let us nonetheless begin with research summaries provided by the American Music Therapy Association. “Research indicates that music therapy is effective in reducing muscle tension and anxiety, and at promoting relaxation, verbalization, interpersonal relationships, and group cohesiveness. . . Group music therapy can facilitate self-expression and provide a channel for transforming frustration, anger, and aggression into the experience of creativity and self-mastery. . . Participants consistently rated music therapy as more effective than other programming in addressing specific psychiatric deficit areas” (American Music Therapy Association, 2010). Interventions classified as MT/DMT can be divided into sub-groups: 1] hands-on music-making, 2] moving to music, 3] listening to music and 4] discussing music or lyrics; many of these activities may, in current practice, be combined into one treatment program that may also include the dovetailing activities of creative writing or expressive movement without music.
One MT activity that makes a frequent appearance in the literature is group drumming. A study by Bittman, et al (2001) categorizes drumming with other “positive interventions that maintain robust cell-mediated responses, reduce perceived stress, and diminish heightened activation of the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system. . . sometimes described as ‘eustress paradigms,’ [which] include exercise, mirthful laughter, and nature's imagery combined with music and positive affirmations.” The study concludes, “Group drumming music therapy . . . that emphasizes camaraderie, group acceptance, light-hearted participation, and nonjudgmental performance, appears to attenuate and/or reverse specific neuroendocrine and neuroimmune patterns of modulation associated with the classic stress response.” He continued this work in a study performed at Yamaha Corporation—one of many research projects in support of Corporate Wellness programs (with the ulterior motive of promoting the sale of Yamaha drums?). Utilizing blood samples and questionnaires to document “changes in NK [natural killer] cell activity, coupled with gene expression changes”, the study suggests that group drumming (a.k.a. Recreational Music Making) strengthens the immune system and elicits “a reversal of stress responses.” (Wachi, et al, 2007).
Studies that look at drumming in addiction treatment tend to be qualitative, crediting drumming with “enhanced sensorimotor coordination and integration, increased bodily awareness and attention span, anxiety reduction, enhanced nonverbal and verbal communication skills, greater group participation and leadership skills and relationship building, and self-skills for self-conscious development and social and emotional learning.” (Winkelman, 2003). Another music therapist, Fricken (2010), used drumming to reinforce recovery by having clients base a drum improvisation on the rhythmic pattern of a 12-step slogan. Similar improvisation exercises have been developed using pitched percussion instruments. These instruments having been developed by Carl Orff (German 20th century composer) to be accessible to children makes them ideal for use by clients with limited music-making background and/or cognitive impairments related to addiction. A study by Hedigan (2010) found—through phenomenological analysis of open-ended interviews—that “improvisation was a exposing experience that brought down defenses and revealed the participants to one another”. An important component in this therapeutic process—and others like it described in the literature—is verbal processing by clients with one another following the musical activity, where clients hearing of others' discomfort “made it easier to be honest” (Hedigan, 2010).
Another common MT activity in addiction treatment is songwriting and/or lyric analysis. This can go from a single-session “rockumentary” intervention—lyric analysis of select popular songs coupled with a detailed history of the band and their substance abuse—performed at a detox facility (Silverman, 2011) to a sequence of activities spread out over multiple sessions that culminate in clients composing an entire song—or at least the complete lyrics to a known tune (Freed, 1987). An approach used by Gallant, et. al. (1997) is centered in the client-therapist relationship—as no mention is made of group work—resulting in the creation of a song in which the client has written the words that the therapist sets to music.
Less mentioned in addiction treatment studies is group singing—which is most often mentioned as the last stage of a songwriting activity as opposed to being a true chorus. Outside of the addiction field, Kreutz, et. al. (2003) found that “amateur group singing may lead to significant increases in the production of salivary immunoglobulin A (sIgA), a protein considered as the first line of defense against respiratory infections, as well as increases of positive affect.” One leader of a women’s prison choir credited increased sensitivity, listening, eye contact, self-esteem, and anger management resulting—or surfacing to be dealt with—out of the standard choir routines of warm-up, rehearsal and performance. She wrote of personal conflicts being ironed out through the “give and take, of a soloist accompanied by the warm and powerful tones of the other choir members singing in harmony, creat[ing] a sense of acceptance, openness and support” (Silber, 2005).
Also considered as Music Therapy are relaxation/meditation interventions, where the therapist may provide a narration of guided imagery over a background of (usually) recorded music. Such activities have been found to raise natural morphine levels in the blood, lower blood pressure, decrease self-perceived stress and increase attention span (Dijkstra, et. al., 2010).
Dance/Movement Therapy, when used in addiction treatment, often seeks to rectify the patient’s “lack of, or fear of, embodiment” (Plevin, 1999). It has been used effectively in combination with Role Theory and Group Development Theory where, as in music improvisations, dance improvisations expose rigidly defined roles in a group. The therapist seeks to transform the group into a healthy model “where people play a wide variety of roles and perform them in their own unique styles” (Shmais, 1998).
Ficken (2010) calls for an eclectic approach to MT tailored to the mission, vision and values of the treatment facility program. He has designed a table with relapse prevention behavioral goals on the x-axis and possible music interventions on the y-axis. Resulting activities include “Drumming to enforce participation in recovery program. . . Exercising to music to practice physical self-care. . . songwriting to reinforce 12-step concepts.” The most comprehensive music program for drug treatment I came across (Cevasco, et. al., 2005) outlines the following goals: building concentration, movement for physical exercise and enhancement of coordination and perceptual motor skills, socialization through teamwork and interacting with peers as equals, play, relaxation, communication, and creativity. This program came close to covering all the areas that would be found in an elementary school music curriculum: seated movements, locomotor movements (steps common to folk dance traditions), rhythm instruments/activities, call-response songs, learning to read music through Kodaly (solfege), resonator bells, Orff rondos, auditory/visual short-term recall, group singing, competitive games involving discrimination of rhythms within songs, “name that tune”, playing notated rhythms, and finding “hidden reasons”—cognitive flaws justifying actions—within lyrics of songs (Cevasco, et. al., 2005).
As rich and varied as the music/movement interventions brought to light by the literature may be (and current space limitations makes this summary less than comprehensive), this author’s understanding and experience of music, movement, and education—coupled with the implications of current research in music and addiction affects—suggest further exploration in a number of exciting directions.
Part I of this study summarized available literature on Music Therapy (MT) and Dance/Movement Therapy (DMT) as applies to addiction treatment. The author grouped these interventions into the following categories: 1] hands-on music-making, 2] moving to music, 3] listening to music and 4] discussing music or lyrics. Before proposing a series of—yet to be documented in publications known to this author—group activities for utilization in the treatment setting, I will examine in greater depth the human experience of music.
A recent article in the New York Times describes musical moments in classical (specifically, Romantic and 20th-century) works that “really get” the listener—as in, “I still get shivers every time I hear it or play it” (Tommasini, 2012). The writer invited readers to write in (these days, a more-or-less instantaneous process) with their own favorite “moments”; the response included more of the same physiologically-based imagery inspired by works in these genres. Many of us, clearly, have a deeply personal relationship with music—whatever level of music education we may have reached—and it makes us feel less alone to share and acknowledge this individualized experience with one another. That my own involvement with music was the catalyst in ending my experimentation with drugs—at age 15—causes me to now explore untapped ways that its multi-leveled healing effects might be recruited to assist addicts with recovery.
In This is Your Brain on Music, Daniel Levitin summarizes the brain’s response to music:
The story of your brain on music is the story of an exquisite orchestration of brain regions, involving the oldest and newest parts of the human brain, and regions as far apart as the cerebellum in the back of the heard and the frontal lobes just behind your eyes. It involves a precision choreography of neurochemical release and uptake between logical prediction systems and emotional reward systems. We love a piece of music, it reminds us of other music we have heard, and it activates memory traces of emotional times in our lives (Levitin, 2006).He cites research attributing the “thrills and chills” resulting from music listening to the Reward Reinforcement Pathway—including a study showing that “the pleasure of music listening could be blocked by administering the drug naloxone, believed to interfere with dopamine in the nucleus accumbens” (Levitin, 2006). Of his own quantitative study—using Functional and Effective Connectivity Analysis—he says,
We found exactly what we had hoped. Listening to music caused a cascade of brain regions to become activated in a particular order: first, auditory cortex for initial processing of the components of the sound. Then the frontal regions . . . that we had previously identified as being involved in processing musical structure and expectations. Finally, a network of regions—the mesolimbic system—involved in arousal, pleasure, and the transmission of opioids and the production of dopamine, culminating in activation in the nucleus accumbens. And the cerebellum and basal ganglia were active throughout, presumably supporting the procession of rhythm and meter. The rewarding and reinforcing aspects of listening to music seem, then, to be mediated by increasing dopamine levels in the nucleus accumbens, and by the cerebellum's contribution to regulating emotion through its connections to the frontal lobe and the limbic system (Levitin, 2006).This, then, speaks to an engaged (“foreground” as opposed to background) music listening experience. How does this process change when the person is engaged in the activity of making music?
It has been shown through neuro-cognitive tests how addiction negatively affects learning, memory, abstraction, verbal problem-solving, perceptual-motor speed, speed of information processing, and efficiency (Lesiuk, 2010). Some interventions designed to address these deficits are Music Attention Control Training (MCAT)—structured music listening for improvement of sustained attention—and Music-based Executive Function Training (MEFT)—which includes improvisation and composition exercises (Lesiuk, 2010). MT, through these and other approaches, has offered a continuum of interventions from passive—relaxation enhancement—to active—playing instruments, singing, dance/movement. A second continuum—that we may think of running along a perpendicular axis—would span from cognitive to emotional/spiritual. Let us first look at some interventions that address cognitive deficiencies listed above, many bearing close resemblance to those found in a grade-school General Music curriculum.
“The brain's time-event processing of music has therapeutic value for cognitive rehabilitation of drug addiction” (Lesiuk, 2010). This may begin simply in “identification of the moods and feelings conveyed” by a listening exercise (James, 1989)—in other words, abstraction. The next level could be structured listening—where clients answer questions about such things as how many times a melody and/or rhythm was heard (memory). “When individuals make comparisons between tonal-rhythmic events, they exercise sustained attention, working memory, and repeated decision-making” (Cevasco, 2005). Learning may be plied through lessons in notation, musical form or other concepts. Folk traditions such as square/contra and ethnic dancing (which I have not seen utilized in the literature) would address Perceptual-motor as well as information processing speed challenges—as a series of generic movement patterns (“balance”, “swing”, “promenade”, “right-hand star”, et. al.) are individually taught prior to being “called” in the sequence required for a given traditional dance; these are also known as locomotor movements. In common with the elementary music curriculum—and also addressing the aforementioned cognitive challenges—is the non-locomotor (feet stationary) movement involved in solfege (“do-re-mi”) hand signs or other hand motions synchronized to the singing of a song. Speaking of singing, developing and exercising a sense of pitch may also aid the brain in recovery—as it would appear to engrave neural pathways in the primary cortex, along with the other regions (hippocampus for memory, cerebellum/basal ganglia for rhythm) involved in accurate echoing of sung phrases (Levitin, 2006). The last of the tested-for challenges listed above, cognitive efficiency, would likely be addressed in the playing of instruments; for example, executing an ostinato on an Orff xylophone using alternating left and right mallets rather than one alone. The last two interventions have routinely been part of a treatment program for females in substance abuse rehabilitation (Cevasco, 2005).
As compelling as the above interventions may be for cognitive rehabilitation, they—along with many additional MT and DMT activities—also have the power to address the emotional and spiritual outcomes desired for successful addiction treatment. Prior to entering into treatment, many drug users sought chemical means to euphoric states. Once their body chemistry has had time to stabilize, they will ideally develop the ability to attain similar states by natural means—through movement, for example. “The relaxation response is the behavioral and physiological opposite of the fight-or-flight response . . . Vigorous dancing induces the release of endorphins thought to produce analgesia and euphoria. Unlike simple exercise, dance/movement activity adds the benefit of emotional expression, ostensibly tied to the emotion or perceived threat that triggered the fight-flight response to begin with” (Goodill, 2005). A warm-up exercise I have used many times in elementary music class comes to mind: The class stands in a semi-circle and follows my movements to Carl Orff’s O Fortuna (the dramatic opening to his choral/orchestral work Carmina Burana), where a long crescendo unfolds over a meter of six—the intensity increasing with each four-measure phrase. Subtle arm motions build into leaps, leaving students breathless and satisfied by the time the final chord sounds less than three minutes later. Knowing the form, students may take turns leading the group in a movement style comfortable to them. The exercise engages them cognitively in the counting and negotiation of the crescendo; it builds group unity through simultaneous actions; and it encourages leadership and expression. It could have the same effect on addicts in the appropriate stage of recovery.
Expression itself contributes to recovery in a variety of ways. As discussed earlier, addicts must face and feel the isolation and inauthenticity that marked their using days (Hedigan, 2010). Owing to the brain structures affected by music, it ‘gets in through the back door’—as it were—allowing a client to “share inner or unconscious parts . . .that might otherwise remain hidden” and to “access feelings, an outcome which in turn has been shown to increase self-confidence and self-esteem” (Hedigan, 2010). Dancing a crescendo can also serve as a movement metaphor for overcoming the pull to return to the old self, old thought patterns and drug use. Metaphor has been shown to be a safe way for clients to bring their struggles to the surface, whether it be in the writing of poetry/song lyrics (Freed, 1987) or in expressive movement (Plevin, 1999) (Shmais, 1998). When a group meets regularly over a period of time, interactions—either in the performing of an activity or in verbal processing afterwards—reveal much about a client’s coping mechanisms (Dijkstra, 2010); “One might say that the multi-vocal ensemble is a metaphor for relationship,” observed one women’s prison choir director (Silber, 2005).
While there are many further MT/DMT activities in my imagining, I have space only for one more. Maslow (1968) wrote influentially of “a biologically-based drive toward spiritual self-actualization” and of “peak experiences”:
There are signals from inside; there are voices that yell out, “By gosh this is good, don't ever doubt it!” We use these signals as a path to teach the discovery of the self and self-actualization. The discovery of identity comes via the impulse voices, via the ability to listen to your own guts and what is going on inside of you (Maslow, 1971).I have found my own peak musical experiences in nearly every genre—“moments” (referring back to p. 6) that have nurtured me since childhood. They likely have qualities in common with drug users’ first high: the euphoria, sense of my place in the Grand Scheme, the Dark (pessimism) and the Light (optimism) all at once, and the co-existing senses of vulnerability and omnipotence. As a musician they are available to me as a performer or a listener. It feels like I am channeling the angst of the composer, in some cases, or, in others, bathed in God’s peace. I believe similar experiences can be fostered in clients at the appropriate level of recovery, using the genres they are familiar with as a starting point—as previous familiarity (i.e. involvement of the hippocampus) appears to deepen the experience. Unfamiliar material can “grow on” one through repeated listening, however, and can be chosen by the therapist to strengthen recovery goals. When the time seemed ripe, I would use the uplifting recording “To the Ends of the Earth” (by the Christian Rock group Hillsong United) and assign clients to choreograph their own dance. Most clients would probably feel more comfortable working on this in small groups, which combines socialization with the other treatment goals referred to above. Individually choreographed dances would give a group the opportunity to discuss what became apparent about that particular client in his/her solo—as we all have a unique story to tell and the witnessing by others helps us process that story. [Click to see whole table].
Cevasco, A. M., Kennedy, R., & Generally, N. R. (2005). Comparison of movement-to-music, rhythm activities, and competitive games on depression, stress, anxiety, and anger of females in substance abuse rehabilitation. Journal of Music Therapy, 42(1), 64-80.
Dijkstra, I. T. F. & Hakvoort, L. G. (2010), 'How to Deal Music'? Music Therapy with Clients Suffering from Addiction Problems: Enhancing Coping Strategies. In Aldridge, D. & Fachner, J. (Eds.), Music Therapy and Addictions (pp 88-102). London: Jessica Kingsley Publishers.
Ficken, T. (2010), Music Therapy with Chemically Dependent Clients: A Relapse Prevention Model. In Aldridge, D. & Fachner, J. (Eds.), Music Therapy and Addictions (pp 103-122). London: Jessica Kingsley Publishers.
Freed, B. S. (1987). Songwriting with the Chemically Dependent. Music Therapy Perspectives, 4; 13-18.
Gallant, W., Holosko, M. & Siegel, S. (1997). The Use of Music in Counseling Addictive Clients. Journal of Alcohol & Drug Education, 42, 2; 42-53.
Hedigan, J. (2010), Authenticity and Intimacy: The Experience of Group Music Therapy for Substance Dependent Adults Living in a Therapeutic Community. In Aldridge, D. & Fachner, J. (Eds.), Music Therapy and Addictions (pp 35-56). London: Jessica Kingsley Publishers.
James, M. R. & Freed, B. S. (1989). A Sequential Model for Developing Group Cohesion in Music Therapy. Music Therapy Perspectives, 7; 28-34.
Lesiuk, Teresa L. (2010). A Rationale for Music-Based Cognitive Rehabilitation Toward Prevention of Relapse in Drug Addiction. Music Therapy Perspectives, 28, 2; 124-130.
Levitin, D. (2006). This Is Your Brain on Music: The Science of a Human Obsession. New York: Dutton (Penguin Group)
Shmais, C. (1998). Understanding the Dance/Movement Therapy Group. American Journal of Dance Therapy, 20, 1; 23-35.
Silber, L. (2005). Bars behind bars: the impact of a women's choir on social harmony. Music Education Research, 7, 2; 251-271.
Siverman, M. (2011). Effects of Music Therapy on Change Readiness and Craving in Patients on a Detoxification Unit. Journal of Music Therapy, 48, 4; 509-531.
Winkelman, M. (2003). Complementary therapy for addiction: "drumming out drugs". American Journal of Public Health, 93(4), 647-51.