FOOTNOTES:

[II.] “a discussion took place in 1913 on the physical significance of that mystic quality called “touch” by which a player attempts to vary the quality of the notes ... but it was concluded that the velocity of striking was all that could be varied by the player.”

Richardson, E. G.—Sound, p. 106

CHAPTER FOUR
PSYCHIATRY AND MUSIC

“His music mads me, let it sound no more,
For though it helps madmen to their wits,
To me it seems it will make wise men mad.”
Richard III, Shakespeare

Gaston[31] believes that

“The basic reason for the arts throughout the history of mankind has been the resultant mental hygiene benefits. The common creative urge, desire for diversion, and search for satisfactory expression exist in all people. Music—above all arts—guarantees the fulfillment of these elemental urges, and therein lies its greatest value.”

The suggestive power of music has given rise to a series of legends which go back to the very origin of civilization. But the methods of experimental physiology, so precise in the study of organic function, lead to no clear and easy picture in the presence of reactions as complex and subjective as those of esthetic emotion and artistic pleasures. The task of evaluating the effect of music on the mind is made increasingly difficult by the personal equation, and when to this is added the distortion of mental disease, great caution must be used in the approach, technique, and recommendations to be followed in the use of music as applied to psychiatry[27]. Altschuler[3] finds that music stimulates the libido, which he defines as

“the great amorphous power, the vital spark, out of which the will to pleasure, the longing for love or passion for procreation take their origin.”

He believes that music is the only “medicine” which helps to convert instinctual forces into socially acceptable forms.

“Stimulated by music, man can still offer his lowly instincts free expressions, camouflaged by jitter-bugging and boogie-woogieing.... Indeed there is therapeutic acumen to an agent which is capable of reconciling the instinctual with the social, and the sensual with the spiritual.”

The relationship between music and the mind is obvious, but the nature of the relationship which has led some musicians to facile claims of artistry remains for most psychiatrists a tempting but obscure field. Most of the writing on this subject has been done by musicians and so-called results obtained with music in mental patients have been evaluated without medical guidance or the use of scientific method. Physicians are hesitant to accept new ideas which are not founded on unquestionable evidence. Enthusiastic laymen might call this reactionary, and they would not be entirely wrong. It is the reaction to the too rapid spread of folklore, cults, and nostrums which physicians have had to combat to keep medicine on the highest possible plane. It is the only tool with which they can protect the sick from unscrupulous or even well-meaning people who, for personal gain or with ill-founded conviction, promise cures by the citation of accidental or falsified results. By custom, ethics, and state laws the treatment of disease is the province of the licensed physician.

The term “musical therapy” has been applied almost exclusively to the treatment of mental disease with music. The term “therapy” is derived from a Greek verb which means to cure. A cure can be practiced and determined only by a qualified physician, or under his direction. Claims can be made by anyone. To establish the curative value of any procedure, certain criteria must be observed. In the first place, the disease must be accurately classified so that the affliction of a series of patients can be scientifically grouped for study. Next, the therapeutic agent must possess qualities of constancy which permit controlled dosage. Last, the proper administration of the agent in the same disease condition must show a reasonably high percentage of results which can be proved to be of value in the control or elimination of symptoms or disease.

Until a relatively short time ago, the causes of most disease conditions were unknown and illnesses were named according to their superficial characteristics. Most newly named diseases are designated by the agents which cause them or by the variations from normal found in the tissues of the body they affect (pathology). In psychiatry, most diseases bear the names applied to their outward appearances.

A simplification of terms places mental disease into three general classes. Psychoses, Psychoneuroses, and Behavior Disorders. The subdivisions of these classes are not universally accepted and the musician who works in a mental hospital will soon become acquainted with the locally practiced terminology.

As a guide to vocabulary rather than an introduction to psychiatry, a brief review of some of the prominent symptoms of mental disease will be enumerated. The scientific material is based on Noyes’[62] excellent text.

The following list of the more common mental diseases is based upon the classification offered by the National Committee for Mental Hygiene.

Psychoses

Detailed descriptions are confusing to the layman because within one disease subclass, the variations possible as a result of duration, time of onset, mental background, etc. are very great. Only generalizations will be mentioned.

The two major divisions of mental disease—psychosis and psychoneurosis—are not always readily differentiated. In the psychotic, the personality is usually distorted, whereas in the psychoneurotic the personality remains normal in relation to the realities of the world and social life. The psychotic is the more obviously deranged, the psychoneurotic usually passes for almost normal.

General Paresis is a late result of syphilis. The patient becomes increasingly forgetful and disinterested in his surroundings and social relations. There is a gradual loss of judgment and other mental faculties. The facial expression becomes empty and the speech slurred. This is the disease in which the knee reflex disappears, an indication popularly associated with “crazy people”. It is a progressive disease which becomes more difficult to treat as it progresses. The treatment at this writing consists of the use of drugs containing arsenic and the production of fever in the patient. The results are not remarkable, ordinarily. Return to normal is unusual. Music for such patients could in no manner be conceived as curative or even helpful.

Alcoholic Psychosis results from continued excesses of drinking. The patient usually resents criticism because he is convinced that his reverses have driven him to drink. The prolonged use of alcohol relaxes inhibitions, produces anti-social actions, and results in more sorrows to drown in more alcohol. Alcoholic psychosis usually begins suddenly with mental confusion, muscle twitches known as tremors, and vivid, visual imaginary thought known as hallucinations. The treatment for such patients includes withdrawal of alcohol and the use of sedative measures. One of these measures is a prolonged bath in a tub of water just below body temperature. Once the patient has recuperated to the convalescent stage, music may be employed. Some alcoholics like to join in group singing, especially if the group is made up exclusively of fellow inebriates. Any encouragement to join non-alcoholics in group singing, or any use of music which may stimulate a permanent interest in a new instrument or diversion would be valuable. These patients lack self-imposed discipline. If music can be used as a discipline, it might lead to decreased drinking.

Arteriosclerotic Psychosis. As its name implies this is a condition of the aged and is probably related to hardening of the brain arteries. The symptoms may include emotional instability, mental fatigue, disinterestedness, and some loss of memory. The patient begins to look and act old. The treatment consists of custodial care, physical rest, and mental occupation. Music is well suited to this combination. Oldtime favorites played softly for several periods daily is indicated. Obviously, where specific musical numbers are requested they should be played.

There is another disease which resembles this called senile psychosis. Usually it can be handled in the home, and is.

Involutional Melancholia occurs at an age when certain important biologic functions of the body begin to regress or involute. For women this age is usually forty-five, but for men it can be ten or more years later. The condition is seen especially in those who did not lead an average life previously. A study of the personality of such patients usually shows them to have been uninterested and uninteresting people, with few close friends. An unfavorable experience may bring on worry and unrest. They become saddened and exaggerate the minor sins of their past. They develop false beliefs known as delusions about their surroundings or themselves. At least half of them never recover completely.

There is little that can be done for them, except to encourage healthful diets and hygienic regimes to keep them physically well. Some physicians might encourage the use of music for such patients to distract their attention from themselves. Familiar melodies are recommended, because of the age group, old time favorites will be the most suitable.

Manic-Depressive psychosis is a relatively common condition in most large mental hospitals. It is so called because the same patient may have periods of excitement or depression separated by phases of apparent well-being. The stage of excitement begins with arrogance, assurance, exuberance and energy, and may superficially resemble the pleasantly boisterous drunk seen at a national convention. The patient talks rapidly, histrionically, and with a play on words called “flight of ideas” because each new phrase suggests new ideas on which the patient will embark, leaving the main thought-stream. This excitement may continue to the point where the fatigueless drive is remarkably great. This may or may not be followed by an opposite reaction.

In the depressive phase patients may feel gloomy, speak slowly, and look worried. A feeling of inadequacy may lead to self-punishment and suicidal intent. The symptoms may progress to the complete inactivity known as stupor.

The first manifestation of this disease is usually manic with the first depressive state years later. Attacks last about six months or longer and although they usually recur at a future date, may not. In the time between attacks the patient may appear quite normal and return to his previous activities.

In the manic phase, sedatives are frequently administered. Stimulating music would only tend to increase the disturbance. If the physician prescribes music it should be of the restful type, preferably a selection which will attract the patient’s attention by its familiarity.

In the depressive phase, patients should not hear cheerful and gay music. Entertainment often deepens the depressive state because of the contrast, and the awareness of their own problem, which prevents enjoyment.

Schizophrenia literally means splitting of the mind. It is a group of conditions in which the usual harmonious blending of emotions, intellect, and drive are disorganized into a seeming inactivity and resultant apathy. In the simple type the patient becomes uninterested in his environment and responsibilities. This result is seen in the vagrant and the delinquent.

In the type known as catatonic there are phases of excitement or stupor. In the stuporous state the attitude of the patient resembles that of an automaton. In this state it is difficult to make any contact with the patient who refuses to co-operate or even move. Catatonic excitement sometimes follows the stupor and is evidenced by the same purposeless absence of emotion, but may include unexpected acts of destructiveness.

There is another type called paranoid in which the patient develops false beliefs of persecution, and a hebephrenic type in which the patient becomes even more inaccessible and inattentive.

Schizophrenia, once thought incurable, is now considered amenable to treatment and about one fourth of the stricken recover completely after the first attack.

In treating these patients an attempt is often made to promote an interest in real things and social consciousness. It is necessary to stimulate attention and redirect it to things outside the patient. Music has a more important place in this disease than in any other mental condition, and this disease may account for more than half the population of many mental hospitals.

Altshuler and Shebesta[4] tried music in the treatment of four excited female schizophrenics in conjunction with hydrotherapy. To have some basis for evaluation of effect, the amount of vocal productions and head movements were recorded for thirty minute periods. This combination is referred to as “output”. Observations were made for a six week period, five days a week for two to three hours a day. Two patients were given continuous baths and two were given cold wet sheet packs during the observation periods. A violinist played behind a screen for the first thirty minutes. During the first ten to twenty minutes of playing no changes were noted, and the patients seemed more or less inattentive to the music. Soon it was found that familiar tunes were most effective in centering and keeping their attention. Thus, very noisy and upset patients might begin to sing a familiar song with the violin, keeping their output of energy at the same level but changing from irrelevant purposeless activity to the directed activity of singing or humming a tune. It was also noted that the effect of familiar tunes extended far beyond the termination of the music, as manifested by continued singing after the music stopped. Familiar waltzes were found to be the best type of music to use in quieting the patients, but these were more effective when preceded by more lively tunes which secured their attention.

As a control, patients were placed in dry sheets and after twenty to thirty minutes of music the output diminished in the same degree (50%) that was observed with patients in wet packs. This showed that possibly the music alone may have been responsible for the quieting effect.

These authors conclude that musical accompaniment tends to prevent the feeling that hydriatic measures are punitive and that the return of real memories is a natural substitute for states of phantasy and excitement.

Julia Eby[29] feels that

“If in the development of a person’s talent for music, stress is laid upon the enjoyment it will give further listeners, he is being made conscious of the social significance of his own accomplishments and this helps the development of the personality as a contributing member of the community.

“Music contributes emotional energy needed to turn dissatisfaction into mental reconstruction. The playing of music arouses associations which stimulate the intellect and if this is sufficient it gives satisfaction and enhances self respect.” But “We must be careful to excite only those activities that will be followed by a feeling of success”.

“The intellectual stimuli of music bring the expenditure of emotional energy from unconscious levels to conscious and intellectually controlled levels ... a concentration on environment stimuli instead of intrapsychic impulses, a perseverance in effort to adjust one’s own conduct to group standards.”

Altshuler[2] points out that the seat of all sensation, emotion, and esthetic feeling (the thalamus) is not involved in mental illness, and is directly attacked by music. The musical stimulation of the thalamus automatically transfers from this “below awareness” level to the brain cortex.

“Little constructive therapy is possible as long as the patient is acutely disturbed; therefore anything which may lessen disturbance and bring about association familiar to the patient and which will revive thoughts to a real level will be desirable.”

Psychoneurosis differs from psychosis in that the patient recognizes that he is ill and wants to get well, although his more powerful subconscious desire does not. Several types are recognized.

Hysteria is an unconscious reaction on the part of an individual to solve a personal problem by the acquisition of some symptom or symptoms. If this is done consciously it is called malingering. Any and every physical or mental symptom is possible. Examples of physical involvement are blindness, paralysis, aches and pains. Mental manifestations may include loss of memory, delirium, etc. Hysteria permits the patient to achieve his purpose and maintain his self-respect. It is an escape mechanism to evade responsibility, excuse failure, or gain attention.

Many forms of treatment have been used and each physician uses his own approach. The more commonly accepted methods include psychotherapy, persuasion, suggestion, and psycho-analysis. Psychotherapy encourages the patient to talk about his condition and with the guidance of the psychiatrist discover the basis of his difficulties. Logical persuasion is used but is not considered effective by most. Suggestion under hypnosis is used by some who are expert in hypnotism. Psychoanalysis attempts to discover the subconscious thoughts and experiences which have caused the disturbance.

Music may be of some value for this group. Levine[56] believes that

“Many individuals achieve a feeling of self-confidence if they develop hobbies such as music. Learning to play musical instruments may compensate a feeling of inferiority, especially when the individual has ability which he underestimates.”

Listening to music may stimulate the patient to talk about his condition or about things that trouble him. Altshuler[3] feels that where large groups of patients must be treated with limited personnel, such as exists in hospitals which handle cases of war neuroses, group treatment is the only solution, and that when there is group psychotherapy music is indispensable, for it not only can “turn any aggregation of people into an ‘organic’ group. It is one of the mightiest socializing agents.”

Harrington[43] believes that music has an important place in the mental hospital although he regards technical instruction for heterogeneous groups unworthy of the effort. He is convinced that, “Mass singing has therapeutic value, and that subdued instrumental music during mealtimes is desirable.”

According to Kraines[54]

“Recreation and hobbies are also extremely important energy release techniques. The apparently passive listening to music may accomplish release of energy. The passivity is only seeming. The person following the music tends by identification to swing muscularly with the music, nodding his head, tapping his feet; and even when there is no manifest movement, there is often a non-observable but yet definite movement. In many forms of music such rhythmic movements can be performed only by relaxed muscles; and tense persons who are influenced by harmonious music are perforce relaxed. Some sanatariums very effectively utilize dancing to music as a means of relaxing patients. Moreover in this general relaxation and harmonious appeal to the senses, the person “feels” that peace and harmony do exist outside himself and will continue to exist despite his own troubles; and by such general “feeling tone”, the person puts aside his conflicts for the while. On the other hand some types of music will stimulate persons into increased activity (e.g. martial music, dance music) by reason of the tendency to make rapid and staccato rhythmic movement in time with the music. The rhythmic muscle movement can, under the influence of a skillful composer, increase to such a pitch as to make the person excited, exhilarated, etc. Outlets for energy release should be selected which will give enjoyment to the patient.”

In chronic mental institutions the patient band has been found most valuable. Pierce[66] believes that

“Music can be a co-operative effort for a wholesome discipline. It tends to break down the sense of isolation so common to mental disease. It assists in adaptation to the mental state.

“First, playing must be made a pleasure to the members. This means there must be no severity of discipline and great tact must be exercised in correcting errors—preferably privately so as not to be humiliating to the patient.

“Second, have some easy numbers: otherwise the results may discourage the patients.

“Public appearances away from the hospital have the advantages of enhancing self respect and pride.

“Admit a small number of hospital personnel to the band—but not those of great ability. The more varied the instrumentation, the more gratifying the result to the participants.”

Mental deficiency means the incomplete development of the mind which makes independent living impossible for the victims. The degrees of deficiency are classified according to the results obtained in intelligence tests: 1. Idiot—mental age of less than three years. 2. Imbecile—age of three to seven. 3. Moron—above the age of eight, but deficient. The treatment for these groups consists of custodial and hygienic care plus any education which can be attained, and of course music will play its part in this in a purely academic manner.