Revista Música Hodie, Goiânia - V.15, 273p., n.2, 2015
Soothing relaxation journeys:
Amy Clements-Cortes (University of Toronto, Toronto, Canadá)
Abstract: This paper provides information on the creation of an original collection of music and imagery journeys based on the literature in oncology and palliative care. Background evidence is shared about music and relaxation, music relaxation in medical settings, and music and relaxation in oncology/hospice treatment. The development of the resource is illuminated with respect to principles that guided the design. The Journeys collection is a tool that can be used independently by persons experiencing a variety of issues including: anxiety, pain, stress, low self-esteem, and low mood, etcetera; as well as with groups when implemented by a healthcare professional. While the Journeys collection has been primarily developed for those receiving cancer care and palliative care, it has applications in a variety of settings for others in home, hospital, hospice, long-term care facilities and community centres; as well as for persons new to guided imagery and music.
Keywords: Relaxation; Imagery; Guided imagery and music; Pain, Palliative care; Oncology.
Revigorando jornadas relaxantes: desenvolvendo oportunidades de música e imagem baseadas em evidências
Resumo: Esse artigo traz informações sobre a criação de uma coletânea original de jornadas de música e imagem a partir da literatura em oncologia e cuidados paliativos. São compartilhadas evidências anteriores sobre música e re- laxamento, relaxamento musical em contextos de saúde, e música e relaxamento em tratamento oncológico / paliati- vo. O desenvolvimento desse recurso é elucidado de acordo com princípios que orientaram o design. A coletânea Jor- nadas é uma ferramenta que pode ser utilizada de maneira independente por pessoas que vivenciam uma variedade de questões, incluindo: ansiedade, dor, estresse, baixa autoestima e humor deprimido, etc., assim como com grupos conduzidos por um profissional de saúde. Embora a coletânea Jornadas tenha sido primeiramente desenvolvida para aqueles que fazem tratamento de câncer e de cuidados paliativos, ela tem aplicações em uma variedade de contextos para pessoas em domicílios, hospitais, cuidados paliativos, instituições de longa permanência e centros comunitá- rios, assim como para iniciantes em imagens guiadas e música.
Palavras-chave: Relaxamento; Imagens; Imagens guiadas e música; Dor; Cuidados paliativos; Oncologia.
Revigorando jornadas relajantes: construyendo oportunidades de música e imagen basadas en evidencias
Resumen: En este artículo se proporciona informaciones acerca de la creación de una colección original de jornadas de música e imagen a partir de la literatura en oncología y cuidados paliativos. Són compartidas evidencias anterio- res acerca de la música y la relajación, relajación musical en contextos de salud, música y relajación en tratamiento oncologico/paliativo. El desarrollo de esta función se aclara conforme a los principios que han guiado el diseño. La colección de las jornadas es una herramienta que se puede utilizar de forma independiente por las personas que ex- perimentan una variedad de temas, incluyendo: la ansiedad, el dolor, el estrés, la baja autoestima y depresión, etc., así como con grupos dirigidos por un profesional de la salud. Aunque la colección de las jornadas se ha desarrollado principalmente para aquellos que están pasando por el tratamiento del cáncer y de los cuidados paliativos, ella tie- ne aplicaciones en una variedad de contextos para las personas en domicilios, hospitales, cuidados paliativos, ins- tituiciones de atención a largo plazo y en los centros comunitarios, así como para principiantes en imágenes y mú- sica guiadas.
Palabras clave: Relajación; Imágenes; Imágenes guiadas y música; Dolor; Cuidados paliativos; Oncología.
“Soothing Relaxation Journeys”1 is a specifically designed relaxation and imagery music collection created to facilitate relaxation experiences, reduce anxiety and pain per- ception, improve mood and enhance comfort during treatments in oncology and palliative care. It is also developed as a tool for those new to the Guided Imagery and Music (GIM) process and imaging to music. There is a substantial body of research in the areas of mu- sic and relaxation, and music and relaxation in medical settings, and that research has in- formed the development of the Journeys collection. There are numerous relaxation and im-
Revista Música Hodie, Goiânia - V.15, 273p., n.2, 2015 Recebido em: 01/09/2015 - Aprovado em: 01/10/2015
agery recordings on the market but few have been developed upon evidence-based princi- ples, thus there was a need to create such a resource.
Studies that focus on music and relaxation highlight the biological and neurolog- ical effects that music has on the body and the brain. Fried (1990) discussed decreasing heart and respiratory rates initiated by changes in the autonomic nervous system activity when relaxing music is played; and changes that occurred in paradoxical arousal patterns that were contrary to those in cognitive function and anxiety, which is a positive result showing how music was used to create physical relaxation symptoms that are opposite of physical symptoms experiences during anxiety.
Significant decreases in state anxiety were found in college students when listen- ing to preferred, relaxing music (DAVIS & THAUT, 1989). In a broader study, Robb (2000) found music relaxation and progressive muscle relaxation were the most effective in elic- iting changes in anxiety and perceived relaxation when listening to music and participat- ing in various relaxation techniques, but that state and trait anxiety did not differ among treatments. A meta-analysis of 22 studies focusing on using music to decrease physiolog- ical arousal due to stress found that music and music-assisted relaxation significantly decreased arousal due to stress, and the amount of stress that was reduced was depen- dent on the client’s age, type of stress, musical preferences, and the type of music utilized (PELLETIER, 2004).
There are multiple studies on music used in medical settings to alleviate pain or improve treatment procedures. Below a few examples are shared.
Surgery
Research with music and relaxation in post-operative pain shows that relaxation
and music were effective in reducing affective and observed pain in the majority of stud- ies, and that music and relaxation treatments were effective for pain across ambulation over several days (GOOD, et al., 2001). Studies in gynecologic surgery show that pain was significantly reduced when music was used post-surgery, and music and relaxation helped relieve anxiety and lower pain scores (GOOD, CRANSTON, STANTON-HICKS, GRASS, & MAKII, 2002; DAVIS, 1992). For burn victims, music has been used to decrease pain and initiate relaxation before and after surgery resulting in decreases in state trait anxiety and assisting in pain and anxiety management after surgery or treatment (ROBB, et al., 1995; PRENSNER, YOWLER, SMITH, STEELE, & FRATIANNE, 2001). When relaxation and mu-
sic was used with postoperative pain after major abdominal surgery, results showed that the relaxation and music groups scored significantly less on all pain, sensation, and dis- tress tests, except after ambulation (GOOD, et al., 1999).
Medical Treatments
Research in music and relaxation in pediatric care shows that when undergoing bone marrow aspirations, pediatric patients showed a significant reduction in anticipa- tory fear, experienced fear, and experienced pain when participating in music-assisted relaxation during the procedure (PFAFF, SMITH & GOWAN, 1989). A study by Wolfe, O’Connell & Waldon (2002) focused on determining the kinds of musical selections/CDs that could be used in a music listening/relaxation program for parents of children in a pe- diatrics hospital.
Research on specific procedures established that music and relaxation during la- bour helped relieve pain during contractions (HANSER, LARSON, & O’CONNELL, 1983). In a study with patients diagnosed with presumptive acute myocardial infarction in a coro- nary care unit, the group who received music and relaxation had a lower incidence of car- diac complications, and that physical relaxation such as lowered heart rates and raising peripheral temperature was also achieved (GUZZETTA, 1989). Chlan (1998) found that pa- tients who received music and relaxation reported significantly less anxiety than those sub- jects in the control group, and heart rate and respiratory rate decreased over time for those subjects in the music group as compared with the control group subjects with patients re- ceiving ventilator assistance. Patients undergoing MRI treatments who received live music therapy had significantly better perception of the MRI procedure and asked for less breaks during the scan. It also took subjects receiving the live music protocol less time to complete the scans (WALWORTH, 2010).
The literature on the use of music therapy in the treatment of patients diagnosed with cancer or long-term illnesses in medical settings is rich. Krout (2001) found that sin- gle-session music therapy interventions were effective in increasing participant perceived pain control, physical comfort, and relaxation in hospice patients. Similarly, Curtis (1986) found that patients with terminal malignant diseases who received music therapy had an increase in contentment; Burns, et al. (2001) found: increased well-being and relaxation and less tension during music listening experiences; and increased well-being and energy with reduced tension during music improvisation with adult cancer patients; and, live and re- corded music listening resulted in statistically significant reductions in pain perception in palliative care patients (CLEMENTS-CORTES, 2011). In a study with patients in palliative care, music creativity and music therapy significantly alleviated pain (O’CALLAGHAN, 1996). When the Bonny Method of Guided Imagery and Music (BMGIM) was used to im- prove the mood and quality of life in cancer patients, the study found that patients who participated in BMGIM sessions scored better on mood scores and quality of life scores, and that mood and quality of life continued to improve in the experimental group even af- ter sessions were complete. Sabo & Michael (1996) found that when a personal message was played with music during chemotherapy treatments, state anxiety significantly decreased from pre-test to post-test with cancer patients.
This literature provided a rationale and the support to create an original Journeys collection of music and imagery experiences.
Jung’s (1983), “Integration, Wholeness and the Self ”, speaks of learning to integrate all aspects of one’s life for balance and wellness. This reading was inspiration in the de- velopment of Soothing Relaxation Journeys. The Journeys were created by the author for her clients to use independently in order to help them achieve a sense of wholeness and wellness. Learning to quiet the mind, and to relax are essential to one experiencing op- portunities for repose, reflection and integration of the self. In BMGIM sessions clients are guided to a deep inner space in order to work on unconscious issues that are prominent in their lives, but that clients may or may not be aware of readily. This Journeys collec- tion can be used by clients as a way to learn to relax, trust oneself and prepare for poten- tial BMGIM sessions.
Lewis (1998/1999) speaks of the importance of the BMGIM in guiding the therapeu- tic process for clients towards transpersonal experiences by:
Quieting the mind, therefore allowing a more expanded state of consciousness,
Loosening attachments to thoughts, emotions and beliefs,
Facilitating growth and development, and
Allowing clients to be connected with God or spirituality and nature.
In order to do this a client must be in a frame of mind and a space that will allow and permit this accomplishment. Being able to relax and trust the experiences of GIM are key to achieving success. Soothing Relaxation Journeys may help clients learn about trust- ing the relaxation and induction process while also engaging in the potential of imagery. The scripts and music in the collection have been developed to provide prepared journeys where clients can learn: how they image, to be open to the imaging process, and how they can trust and work with a GIM guide in future BMGIM sessions.
Bonny (2001) inspired the development of the original music in this collection. She states that in GIM the music she selected for the programs was done purposefully; the musicians must be stellar and the musical structure is an integral part of the GIM experi- ence. As a researcher the author became excited by the opportunities to design studies that look at what brain waves and/or parts of the brain are engaged when listening to the dif- ferent programs. Soothing Relaxation Journeys was developed to target a resting brain wave and for the client to be entrained to that external pulse in order to open their mind to im- aging in a semi-relaxed state. The author developed the music with much consideration of the images she was trying to invoke via the scripts. Together the author worked in collabo- ration with the pianist to create original music of the highest quality in order to elicit the described images. With respect to the balance between voice and piano, the pair worked with the sound engineer to provide the voice in the forefront and the music to serve as the true accompaniment to the guided scripts.
The discussion below provides insight into the choices and rationale for the script and music preparation in the Journeys collection.
Indications, Goals
If a client discusses experiences of anxiety, pain, difficulty sleeping or tension, mu- sic for relaxation is indicated (BAILEY, 1986). A number of goals are aligned with music for relaxation for persons receiving palliative care. These include: enhancing physical com- fort; decreasing anxiety, agitation and/or restlessness, and shortness of breath; and facilitat- ing muscle relaxation (GALLAGHER, et al., 2006). According to Grocke and Wigram (2007) music and relaxation may also be effectively used to: reduce tension and stress as well as anxiety prior to medical procedures, lessen pain and its intensity, and regulate breath- ing. Journeys was created to provide images that would assist with and/or are associated with: freedom, release, comfort and relaxation to maximize obtaining relative goals for this population.
Contraindications
When a client desires or is struggling to remain conscious, music for relaxation is contraindicated. Further, if a client wishes to remain alert and awake and is receiving med- ications which cause drowsiness or are fatigued due to their illness, music for relaxation is not advisable. For other clients wishing to actively participate in a music making interven- tion or discussion, introducing music for relaxation may cause anxiety and restlessness. Additional contraindications for music and relaxation are shared by Grocke and Wigram (2007) and include clients: who may have trouble with abstract thought or confusion with scripts that require embodied experiences, difficulties engaging in deep breathing, feel- ing vulnerable by being observed or uncomfortable focusing on their bodies in the pres- ence of the therapist. Formal assessment of the client will uncover these potential contra- indications. The Journeys collection is not for all clients, and was designed for clients who are able to understand images and abstract thought and is contraindicated for persons with cognitive impairments including Alzheimer’s disease.
Preparation of Session, Music and Environment
There are four essential aspects to providing an environment that fosters music for relaxation including: light and dark, a comfortable position for the patient, continual space, and ensuring the music equipment is properly placed and prepared (GROCKE & WIGRAM, 2007). It is important to consider the client’s preferences when selecting music and the therapist should individualize the selections as music and relaxation is optimally received when the music selections are chosen or catered to the client’s preferences (SAPERSTON, 1999). When selecting music for relaxation, a number of factors are important to consider such as: steady and predictable melodies, consistent tempos with only minor changes in dynamics, repetition, and tonal and consonant melodies and harmonies. When listening to classical music Kemper and Danhauer (2005) maintain clients demonstrate decreased ten- sion, and when listening to music created for well-being participants reported increased mental clarity, relaxation, and compassion as well as decreased feelings of sadness, fatigue and tension. Again these principles were considered in creating the Journeys collection. For example, the inductions begin by inviting a person to get into a more comfortable posi- tion, and predictable melodies and harmonies, steady tempi and continual space are includ- ed. There are times in each of the Journeys where there is no speaking, allowing the client to process the images just presented and transition to the next images.
Observation and Assessment
Both objective and subjective measures can be used to assess clients in music and relaxation sessions. Questionnaires that the client reports upon are implemented to allow the client to convey changes they experience as a result of the music for relaxation session. A number of tools could be used including: Spielberger’s State-Trait Anxiety Invento- ry (STAI), the Short-Form McGill Pain Questionnaire (SFMPQ), the Linear Analog Self- Assessment Scale (LASA), and visual analogue scales (CALOVINI, 1993, LONGFIELD, 1995). Objective observation methods offer the potential to assess the client’s breathing, if tension is released, and also attend to the client’s level of consciousness. It is important for therapists to assess the musical selections and to tailor future sessions based on the client’s response. Informally the author piloted the Journeys collection with clients and asked them to rate themselves on anxiety, pain, mood and energy using visual analogue scales. Infor- mal reporting from these clients suggests that persons found pain and anxiety reduced by an average of 2 points (i.e. from 5 pre- session to 3 post- session) and mood and energy were increased by an average of 2 points from pre- to post- session. A formal study to assess the self-reporting of clients is need and is being planned.
Inductions and Recorded Music
The inductions and start to each of the Journeys was guided by the BMGIM ses- sion structure which includes: Preparation, the induction, music, return to alert state, and verbal processing (GROCKE & WIGRAM, 2007). Further the various types of inductions as discussed by Grocke & Wigram (2007) were instrumental in helping guide the begin- ning of the scripts. These include: structured/count-down induction, autogenic-type in- duction, colour induction, light inductions, and progressive muscle relaxation (GROCKE & WIGRAM, 2007).
As opposed to a typical BMGIM, the music on the Journeys collections begins with the induction. While Journeys may easily be used independently by persons, it also has ap- plications for use by healthcare professionals. For example a music therapist might chose to use a track from the Journeys collection while having a session with a client. A therapist might find it challenging to play live music in a continuous manner while also describing imagery and facilitating the relaxation techniques and therefore recorded journeys may be more practical in some settings.
Adaptations
Shorter music for relaxation sessions may be indicated if a person has trouble fo- cusing. Inductions might also require adaptations depending on the cognitive abilities of the client and their understanding of abstract concepts. Delirium and confusion can be side effects of pain medication, and scripts that require considerable abstract thought could cause frustration and further confusion. These factors need to be considered when a health- care professional considers recommending products such as the Journeys collection as they are not for everyone. Journeys could also be done in group settings or with the client and their family members to offer a unique experience and in these situations should be facili- tated by a healthcare professional.
Indications, Goals
There are a number of goals that can be accomplished with the use of GIM in- cluding: reducing anxiety, improving mood while decreasing depressive symptoms or sad- ness, enhancing quality of life, decreasing symptoms such as pain, nausea, and emotional stress while also facilitating emotional outlets, and avenues for expressing grief and hope (LOGAN, 1998; BURNS, 2001). GIM can be used to help clients who are experiencing psy- chological pain to address these issues and emotions while facilitating emotional relief. Short (2002) explains that reducing psychological distress is an important goal of GIM as psychological distress can reduce a person’s immune function, and GIM has positive effects on immune and endocrine function for persons experiencing a chronic illness. In medical settings Clark (2000) acknowledges there are four ways to use guided imagery with clients: to decrease negative feelings, promote healing, improve problem solving, and prepare for upcoming situations. In a study with chemotherapy patients, Troesch et Ales (1993) found patients who received guided imagery had delayed symptoms compared to those in the con- trol group. These persons also reported feeling relaxed, more prepared and in control prior to their chemotherapy treatments.
Contraindications
Contraindications for GIM include: emotionally unstable clients, persons with re- ality problems and intellectual impairments (WIGRAM, PEDERSON, & BONDE, 2002) as well as persons suffering from suicidal ideations, hallucinations and personality disorders. For persons having acute pain, it may be helpful for sessions to occur after medical treat- ments as pain can make the imagery process more challenging (Burns, 2002). Patients who have difficulty focusing due to their illness might not have the ability or energy to partici- pate in a longer imagery journey. Cohen (2002) states particular populations should not re- ceive guided imagery to music, which includes clients who are: mentally unstable, acutely psychotic, in acute phases of substance withdrawal, or those lacking cognitive skills to in- terpret the abstract material from their unconscious. Again these factors should be consid- ered when any type of GIM experience is being recommended to clients.
Music and Imagery Selections
The music created for Journeys was influenced by Burns and Woolrich (2008), who recognize that the choice of music is important as it provides the structure for the imagery experience. Music selection provides a focus for sessions (BUSH, 1995) and Bush describes how music can be categorized into 6 groups based on aesthetic differences including: earth music, fire music, air music, water music, descent music and ascent music. These properties were considered when creating the original music for the scripts in the Journeys collection.
Clinical Observation
If a therapist is providing one of the Journey’s recordings during sessions there are a number of areas to observe and also facilitate discussion upon with the client post jour- ney. These areas are informed by Grocke (2002) who prepared a list of typical experiences that clients have in BMGIM as: body sensations or movements, somatic sensations, altered auditory perceptions, associations and transference to the music, spiritual experiences, et- cetera. Further directives are provided by Grocke and Wigram (2007) who state four essen-
tial items that a therapist should observe includind if the client can: listen to the relaxation induction and follow instructions, concentrate on the therapist’s voice when giving visu- alization, return from the relaxed state, and discuss and gain benefit from the experience.
Types of Guided Imagery and Music Experiences
The various music and imagery methods are described by Grocke and Wigram (2007) as: directed music imaging which includes an imagery script; unguided music imag- ery which is when a client produces imagery in response to the music he/she hears; group music and imagery where individual responses are generated by each group member; and guided music imaging where the client and therapist dialogue and the client describes the imagery while the therapist asks clarifying questions and augments material to discuss. The Journeys collection was designed as a directed music imagery experience.
Clark (2000) provides images to suggest in guided imaging taking place in medical settings. These include: picturing radiant light, blood flow inside the body, giving cancer an image and voice, inner advisors, or images of health and wellness. These images were considered in the Journeys creation and implemented.
Adaptations
The addition of physical objects or visual images could be useful to help clients who are challenged to have clear images (CLARK, 2000). This is certainly something a ther- apist could do if they are using the Journeys collection with individuals or groups. Depend- ing on the client’s level of functioning and psychological need, music and imagery could be combined with other forms of therapy, including gestalt dream work therapy, Jung’s analytical psychology, psychodynamic approaches, and incorporating spiritual growth (WARD, 2002).
The research and literature support the efficacy of using music for relaxation and music and imagery in medical settings with persons experiencing a variety of issues. The Journeys collection is one tool that has been created based on the evidence, and this paper discussed the rationale for selections in the collection as well as the background in- formation and literature. The Journeys collection can be used independently by persons or by healthcare professionals in a variety of settings including palliative and oncology care. Music and imagery experiences are not for all clients and a number of contraindications are also discussed alongside the potential goals. It is hoped that by describing and discussing the importance of such relaxation tools that more will be created as resources for individu- als as well as healthcare professionals and their effectiveness will be assessed in future re- search studies.
1 Soothing Relaxation Journeys was created by Amy Clements-Cortes; vocals are provided by Amy Clements- Cortes, and piano accompaniment is provided by Sincere Tung. The Cd is available at http://www.notesbyamy. com/store.html
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Amy Clements-Cortes - Assistant Professor, Music and Health Research Collaboratory, University of Toronto; Se- nior Music Therapist/Practice Advisor, Baycrest; Instructor and Supervisor, Wilfrid Laurier University; and Reg- istered Psychotherapist. Amy has extensive clinical experience working with clients across the lifespan with a specialty in work with older adults and end-of-life care. She has given over 90 conference and/or invited academic presentations, and is published in peer reviewed journals and books. She is the President of the World Federation of Music Therapy (WFMT), and a former President of the Canadian Association for Music Therapy (CAMT). Amy is the Managing Editor of the Music and Medicine journal and serves on the editorial review board of the Journal of Music Therapy, Music Therapy Perspectives and Voices.
