Voices: A World Forum for Music Therapy, Vol 12, No 3 (2012)

[Original Voices: Perspective on Practice]

Combining Functional and Psychoanalytic Techniques, Using

Rhythmic Auditory Stimulation (RAS) and Songwriting to Treat a Man
with a Traumatic Brain Injury
By Alex Street (United Kingdom)

Abstract
A common dilemma for music therapists, particularly when treating the symptoms of neurological damage, is deciding whether to employ
functional or psychotherapeutic treatment techniques. This paper discusses the process and outcomes of combining two different
techniques as a short-term treatment with a man with a traumatic brain injury (TBI) who is transitioning from post acute into the community
stage of rehabilitation. Beginning with a brief review of examples where other music therapists have used a combination of techniques in the
treatment of TBI patients, I will continue with a case study describing the referral, assessment and treatment plan for the client, including the
outcomes of the two main techniques and concluding with a discussion of the process, outcomes and some interpretation of the clients
responses within the six week period.
Working with Will, a 35-year-old man with a TBI, sessions began using several techniques in order to assess his condition, establish goals
and begin treatment. Following an initial four months of weekly music therapy we planned to employ two different techniques over a six
week period with two different aims: 1. RAS to improve gait parameters, 2. song writing to help sustain motivation for RAS and to address
adjustment, self-expression, identity and communication difficulties. This resulted in a highly motivating, holistic treatment plan that was
structured, with clear goals and timescales. Sessions lasted for 70 minutes, with 50 minutes of RAS and pregait exercises, followed by 20
minutes spent working on a song: "Life After a Bike Crash (that I cant remember having)." The RAS programme was set up conjointly with
a privately employed physiotherapist and also supported with a daily home programme of RAS and pregait exercises.
Keywords: Gait, pregait, rhythmic auditory stimulation (RAS), Neurologic music therapy (NMT).

Introduction
Combining music therapy techniques, as well as working conjointly with other health professionals, when treating specific symptoms in
adults with ABI, TBI and neurological disease can be seen in the work of other music therapists. Jochims (1990) combined receptive music
therapy using German lullaby melodies, well-known songs and improvisation in treating transitional psychosis and initial aggression with 15
female TBI patients. Barker and Brunk (1991) did not target specific clinical symptoms but combined song improvisation and arts and crafts
activities and worked alongside physiotherapists and other allied health professionals. Magee (1999) used group and then individual music
therapy followed by melodic intonation therapy with a 30 year old man with TBI who was previously a guitarist. Magee also worked
conjointly with a speech and language therapist in this work. Hazard (2008) combined techniques when working with Parkinsons patients in
a geriatric setting to "maintain and/or improve functionality" (Music Therapeutic Process, para 1) and to specifically improve gait measures,
mood and "motivation and willingness to face new tasks" (Introduction, para 4). For this he combined RAS with receptive and active
methods.
Baker (2005) highlights the challenges of engaging patients in rehabilitation following ABI, and documents her experience over 12 years of
employing various song writing techniques to effectively achieve this as well as help to address identity and adjustment issues that are
particularly difficult for patients to manage. Aldridge (2005) briefly discusses the challenge of deciding which therapy method is appropriate,
especially where the specific effects of techniques have not been fully established. Evidence is gathering for the effectiveness of both
songwriting and RAS, the former having widespread applications across patient groups, and the latter being a standardized technique,
supported with hard, scientific evidence gathered through randomized controlled clinical trials with adults and children with neurological
damage. In terms of music therapy practice, it has been noted (Baker, Wigram, Stott & McFerran, 2008) that in the UK and Europe
psychodynamic and psychoanalytic models of treatment predominate, compared with America and Australia, where song writing, vocal and
neurologic music therapy (NMT) techniques all contribute to a more eclectic toolbox for music therapists to access.

Neurologic Music Therapy Techniques for Sensory Motor Rehabilitation

NMT is given five basic definitions (Thaut, 2005), which can be summarized as: the therapeutic application of music to cognitive, sensory
and motor dysfunction due to neurological disease of the human nervous system. All techniques are evidence based and are applied based
on growing evidence for music supporting neuroplasticity. NMT follows a transformational design model whereby formal assessment leads
to the setting of non-musical, functional goals, music is applied to facilitate these goals using the appropriate NMT technique and then,
when achieved, the music is gradually faded. NMTs are trained in neuroanatomy, physiology, rehabilitation of cognitive, motor and speech
and language functions and medical terminology.
RAS uses "the physiological effects of auditory rhythm on the motor system to improve the control of movement" (Thaut, 2005, p. 139),
specifically gait as this is the only movement that is intrinsically rhythmic. This is the only music therapy technique that can be identified as
effective in improving gait in patients with neurological damage or disease, with good emerging scientific and clinical evidence (Thaut,
2005), (Kwak, 2007), (Thaut, McIntosh & Rise, 1993; 1996), (Hurt et al, 1998), (Bradt, Magee, Dileo, Wheeler & McGilloway, 2010).

Other NMT techniques used in sensory motor treatment are Patterned Sensory Enhancement (PSE), which uses harmony and melody as
well as rhythm in order to facilitate sensorimotor goals and Therapeutic Instrumental Music Performance (TIMP), where musical parameters
as well as the selection and positioning of specific instruments facilitate improved movement trajectories, range of movement, improved
stamina and increased muscle strength.
In my work with Will before beginning RAS, I had used both PSE and TIMP to improve his upper limb motor planning and range of
movement and he had shown very good attunement to rhythm with clearly improved movement trajectories and carry over observed in his
baseline performance of exercises each week. This helped to establish that a programme of RAS would be appropriate and could be
supported by PSE and TIMP being used for the pregait exercises.

Case Study
Will sustained a severe head injury following a motorcycle accident. When referred to me he was just finishing his post acute rehabilitation
at a center where he had been receiving two sessions per month of occupational and speech and language therapy. Each Saturday
morning Will began attending music therapy sessions in his wheelchair at a private clinic that I had just set up. His new home was in the
process of being fitted with rails in order that he could walk around more independently. His wife and mother-in-law, with whom he lived and
who brought him each week, explained that he had been falling quite regularly and that on some occasions this had caused him minor
injuries. I wondered whether RAS would be an effective treatment for him and I began gathering information regarding his muscular and
skeletal condition that was not included in the initial referral form. He was recovering from myositis ossifican, a condition occurring in some
TBI patients where the bone "over-repairs" causing a protrusion of bone to rub on surrounding tissue and cause inflammation - this was
being treated with a course of steroids.
Before his injury Will had loved to play the guitar and had been quite proficient. He listed some favourite bands and songs in assessment
they were also noted on his referral form. His right side had more physical damage due to bone breaks and muscle damage and his overall
coordination was impaired with a degree of dyspraxia. Wills speech was dysarthric and his articulation and breath control made
communication challenging and frustrating for him. Behaviour in the form of aggressive outbursts and a sensitivity to sudden noise was also
reported on his referral form. Added to this Will had sleep apnoea and this resulted in him suffering quite badly at times from fatigue.

Referral, Assessment and Planning Treatment at the Community Stage of

Rehabilitation
Will was referred for music therapy by his mother-in-law due to behavioural problems, particularly some aggression and anger towards his
wife. Other reasons concerned his depression and the feeling that he would engage well with music therapy as he had played the guitar and
he loved music.
At the beginning of Wills referral we used the Measure Yourself Medical Outcome Profile (MYMOP) (Ruta & Garratt, 1996) scale as an
added guide to establishing an appropriate treatment programme. He highlighted communication and walking as his priority problems. He
was able to describe how his speech affected his confidence and self-esteem, as well as isolating him as he could not contact friends by
phone any more due to the difficulty he found in making himself understood and how this was impacting on his confidence and feelings of
embarrassment.
We agreed to think about RAS as a later option due to his myositis ossifican, the need for an up-to-date physiotherapy assessment and to
contact the consultant at the hospital who had carried out all of the surgery on his limbs. I also felt there was a need to build Wills
confidence using his love for music and to take time to explore what skills may have been preserved, including guitar skills. This approach
seemed a safe and effective way to begin working towards functional goals whilst also building a therapeutic relationship for emotional and
psychological support.
Will was still coming to terms with his loss of abilities and edging towards adjustment. This would correspond with Holbrooks (1982) third
and fourth stages of recovery, with the third stage frequently leading to depression and feelings of despair and frustration, as was the case
with Will. This, as well as Will reaching the end of his post acute rehabilitation, suggested that his emotional and psychological state and his
self constructs would need more attention.
In music therapy assessment Will showed:
Low confidence and self-esteem
a good level of sustained attention
good sensory and working memory
excellent motivation to engage in structured exercises using music
immediate improvement in upper limb motor control when supported by rhythm using a metronome and strongly pulsed music (PSE)
initiation when discussing song title and lyric ideas
initiation, awareness and self-expression when improvising with me at the piano

Functional Approach: RAS Treatment

As we worked through the fourth month of weekly music therapy we discussed RAS and began planning the treatment. During this period
Will maintained a high level of motivation as we worked towards other functional goals such as improving breath control and upper limb
motor control using rhythm based NMT techniques. Throughout this period Will occasionally referred to the song and lyric ideas we had
explored in assessment and we would sing through what we had so far, perhaps at the end of a session. Clearly this song was very much
alive in his mind.

RAS Planning
I contacted Wills consultant at the hospital in order to determine if the RAS treatment would lead to any aggravation where the myositis

ossifican had occurred. I received a copy of the most recent physiotherapy report from Wills family, which was now quite out of date, and
contacted a private physiotherapist from a private practice specialising in neurorehabilitation, that I had discovered through the hospital.
Following a home visit I made to Wills house in order to assess for home programme feasibility, his family agreed to fund a physiotherapy
reassessment and for the physiotherapist to come to one or two music therapy sessions with me to do this.
The physiotherapist came to the music therapy session and assessed Will, and we had our first RAS session. Following this Will, his family
and the solicitor agreed to five further RAS sessions, making 6 in total. Sessions would take place in the music therapy room and in a
corridor in the same building, just outside the door. Music for the RAS was provided using an autoharp, played to a metronome beat that
was set to Wills existing walking frequency and gradually reduced in frequency once his walking pattern was observed to be stable. A
reduction in this baseline frequency, from 122bpm to 116bpm, was necessary in order to achieve the goals outlined below. The
physiotherapist attended the following music therapy session and a further session, she also made some home visits to support and update
an existing exercise programme for muscle strengthening, as well as support some of the pre-gait exercises and other goals around
improving independent mobility at home.

RAS Assessment outcomes

The goals for walking, in consultation with the physiotherapist and based on our assessments, were set as:
Improve balance
Increase stride length
Improve symmetry
Increase confidence in walking
Build muscle strength and stamina

RAS Program and Results

Week 1
No. of
steps

Week
2

Week
3

Week
4

Week
5

Week
6

Range

Average

18

16

15

15

15

16

15.38

Duration

8.80secs

8.16

8.19

7.14

7.44

7.55

7.88

Distance

10m

10m

10m

10m

10m

10m

Cadence

122
step/min

117

109

126

120

127

120

Velocity

68m/min

73

73

84

80

79

+11m/min

76m/min

1.11m

1.24m

1.33m

1.33m

1.33m

1.24m

+13cm

1.26m

corridor

corridor

corridor

corridor

corridor

corridor

Stride
length
Walking
conditions

Table 1. The results from the 6 baseline walks over 10 meters showing changes in duration, cadence, velocity and stride length. The
number of steps can be seen to decrease whilst stride length and velocity increase by 13cm and 11meters per minute, indicating
improved balance.

Descriptive Data
Initiating, stopping and turning visibly improved each week

The Process
As part of the programme each week Will transferred from his wheelchair into a chair in the music therapy room and he did this with
increasing confidence. In the final three sessions of the RAS treatment he began to walk from the car to the music room, to the corridor and
back again at the end of each 70 minute session. He showed great satisfaction and pride in this.
Will commented that he felt more confident and had a beat in his head when walking, indicating that he was internalising the beat. Early on
in the treatment he also stopped holding onto the wall at the end of the 10 meter walk in order to steady himself. A rhythmic stop, balance,
turn verbal prompting sequence had to be built into the music for each walk in order to give him time to plan this sequence of movements,
maintaining his balance and building his confidence. When he was seen to be managing this sequence of movements with increased
control the verbal prompts were faded.
Will frequently commented on his lost abilities. For example he would say: I used to be able to finger pick (on the guitar), I should be able
to do this by now. Comparing his responses in the first two assessments where he huffed in disappointment with himself repeatedly, to later
sessions where he would make remarks such as I did it better that time, I had a beat in my head and I corrected myself, it is clear that
Wills confidence improved and that he was actively monitoring his performance and communicating with me about it.

Psychoanalytic Approach: Songwriting

Baker (2005) writes that patients rarely begin songwriting in the first session, possibly because this idea may seem direct or confronting
and because firstly rapport needs to develop between client and therapist. This probably being a much later stage in rehabilitation to that

which Baker is referring to, Will was clearly motivated by the idea of song writing from the first two assessments and always showed a high
level of enthusiasm to continue with the ideas we had begun whilst also maintaining his commitment to the functional exercises in sessions
and with his home programme. One week he commented: I dont want to forget about it [the song], its really important to me. As Will, his
wife and mother-in-law discussed with me the planning of 6 RAS sessions, it was further emphasised by them that he was extremely
enthusiastic about the song and that continuing with it might help him to persevere with the RAS and home programme each week.
Asking what style of accompaniment he would prefer for the song, we went through a number of artists that Will listened to. He chose
Nirvana as the musical style for the song and so I played a harmonic progression in that style which he expressed a strong liking for. The
song is transcribed below.

Started on the Sight as a Goffer

Big cheese looking like a loafer
Go for this go for that
I felt like a prat
Lurch was a useless prick
Before he got sacked, for being so bloody thick
Now he works in wholesale selling electrical gumpf
Its suits him for being such a chump

Chorus
My speech is knackered ..
Failed my bike test first time
Wanker pulled out so I gave him the sign
Second time round I was on good behaviour
Didnt have to kiss arse either
Riding my Yamaha FZ6
Mary on the back burning up the slower pricks
Jimmy is a warehouse bum
Off wed go on the Hunstanton run

Chorus
My speech is knackered ..
Fig. 2. The finished song, showing notation for the chorus and first verse and with the rest of the lyrics written out below the score. Indications for the guitar are loud or distorted in the chorus and pizzicato, clean
sound with a chugging rhythm as soon as the chorus ends on the word "tattered." This emulates the sudden changes in dynamic and intensity led by the guitar that is characteristic of the grunge sound and found in
many Nirvana songs. The word "knackered" in the chorus is a colloquial word meaning broken or not functioning properly.

Discussion
Psychoanalytic: The Song and the Singing
Here I will not be discussing the functional aspects that emerged through the songwriting process such as the benefits to memory and
cognitive function, but the psychological; the rational for song writing with this client and some interpretation of lyrics and chosen musical
style for the song.
Baker and Tamplin (2005) write about songwriting to explore identity change and sense-of-self concept following TBI and state that the
second stage of vulnerability to adjustment occurs 6 to 12 months after discharge. They emphasize the importance of timing the introduction
of songwriting and that this second phase is an important time in which to introduce it. Will began attending the music therapy clinic much
later post discharge, approximately two years, and three-and-a-half years post injury, just as he was coming to the end of his post acute
rehabilitation. Perhaps this should have been seen as a clear indicator that adjustment, in the sense of identity and self-construct, should

have been the priority. Even with all medical, background and assessment information considered for the RAS treatment, the question
remains: should we have focused purely on the emotional and psychosocial adjustment needs? Wills response when I told him the results
of the six week RAS programme and demonstrated the increase in stride length using a measure, was a downbeat: sorry if I dont jump for
joy. Will was very aware of how he functioned before his injuries, both physically and cognitively and I wonder if this response may have
communicated something of how he saw his potential to improve his walking and overall movement and coordination at this stage after his
injury.
Wills responses to RAS outcomes contrast strongly with those regarding writing a song with me. Whenever we wrote a new verse he
wanted his wife and mother-in-law to come into the room and hear it immediately. Wills wife, in the early months of our music therapy
sessions, before RAS, once said to me: I wish youd been there when he was in the hospital, we couldnt get him to do anything. Whilst
this remark reflects the high level of engagement that his wife had observed as Will was attending music therapy with me and the struggle
he had to engage in his acute rehab programme, he was now transitioning into the community stage of rehabilitation and had an emerging
agenda of his own regarding what was important to him, which was gradually helping him to recognize his motivations and strengths.

Lyrics, Identity and Musical Style

For me, the therapist, lyric interpretation was helpful as part of my inner processing and monitoring of how our relationship was developing
and how I monitored Wills capacity to express himself and communicate. This was based on both his perceived psychological state and his
self-reported pain and fatigue levels each session. This process for me would then influence my responses, for example the timing and
phrasing of any questions I may formulate to help the song writing process. The parallels are clear between this process and those found in
psychotherapy, except that here the client understands a framework within which to place words (the song) and there is a clear aim
(completing the song). For a man with cognitive and emotional impairments resulting from traumatic brain injury, which impair his capacity to
attend, remember and perform operations calling on executive skills, such clear structure and purpose are necessary in order for him to
benefit psychotherapeutically.
"Life After A Bike Crash I Cant Remember Having" is a song title that bluntly and clearly communicates that the song is about a past event
and present state of mind and being. The chorus lyrics, which were the first we wrote together, describe Wills speech and his hip as being
knackered, matching his answers in the MYMOP questionnaire in our first session and also communicating very bluntly his raw feelings
about his present condition and difficulties in terms of body image and function and communication and self-expression. The line "I lie
tattered" evokes an image of him lying in the road at the scene of the accident. These words could refer to Wills present feelings of being in
tatters or to an imagined image or unconscious memory of himself at the crash scene. Perhaps the most important information to be taken
from these specific examples and the stage at which they were formulated in the process are: 1. Will communicated these raw thoughts and
feelings as soon as we began songwriting, showing that Will is immediately engaged in a process of reflection and self-discovery; 2. They
indicate significant points on his lifeline: past, extreme trauma and me now.
In this process Will immediately began unraveling his feelings about himself now and his self-image before injury as part of his process of
recognizing the good bits that are intact and the bad bits that have been damaged and need to be reintegrated into his newly formed and
accepted self. This self image must be formed and he must be assisted in finding it by someone with whom he is in a relationship akin to an
early relationship in the sense described by Stern (1977).
Because the music is in a style that Will identifies with, that was taken from his listening repertoire pre-injury and that is recognisable to
others and therefore has some integrity as a style it feels safe and a part of him; his history; his world. The sentiments of the song are
communicated not through spoken confession or admission, but carried in the song and therefore encoded with a safe, recognisable,
coherent, expressive voice, by which I mean the lyrics, music, genre, voice and arrangement all-together. Even the Nirvana-like chord
sequence and vocal line carry clearly identifiable meaning for Will and many other people who he played it to. The lead singer, Kurt Cobain,
is widely recognised as someone who struggled to express himself and be understood, ultimately taking his own life as a result of his
struggles. The bands musical style expresses angst, as do the singing style and lyrics that are difficult to decipher in terms of literal
meaning. Will has used Nirvanas style as a vehicle to communicate to others the rawness of his emotions in relation to what he has lost
and what he feels he has lost his old life and ways of being he has used words that describe clearly his life and traumatic events and
how he sees himself, but, as already discussed, some of the lyrics are open to interpretation in the context of what he has been through. In
this sense, Will has been highly creative and used songwriting with great freedom of self-expression. Perhaps then, given the stage of
rehabilitation he was in, songwriting was the perfect technique to address his emotional and identity difficulties, and served well as a
supporting and motivating intervention to improve his access to and outcomes from RAS.
Using song and lyric formation allowed Will to encapsulate his thoughts and feelings and this experience, to listen to the words when we
sang them or from the recording we made, and share them with family, friends and relatives. Perhaps listening to and performing the song
also brought a sense of safety through seeing that he was removed from the trauma; that he had survived it and was able to look back
safely on it and begin a process of reintegration of who he is now; the preserved and the transformed or altered body, voice, brain.

Humour and Anger

An enduring and extremely important quality that this process brought out in Will was his sense of humour. He found it highly amusing that
he could come up with humorous perspectives on himself and other people he had known and put them into such a creative, identifiable
and communicative format that could be and has since been shared with those important people in his life, some of whom he has had
much less contact with since his injury. Will would make comments such as I love it, its spot on as we performed this song together
through open and supressed laughter. He told me how happy he was with the song.
The humour also contained expressions of anger, frustration, fear and anxiety and Will could indirectly express and contain these feelings.
The song allowed this to happen within our therapeutic alliance, but in a way that was safely removed from the now the real and present
life context through Wills eyes and it served as a step towards recognising this process and our relationship as a place where difficult
emotions and feelings that Will did not like or want to own could be identified, looked at, accepted and integrated to form a much healthier
self-construct.

Considering transference
The transference in the context of my therapeutic roles emerged as phenomena requiring extra attention and was a central and ongoing
process that became tangled at times, as I had to play two different roles: 1. The instructor/trainer, who encouraged performance and
measured results in RAS, 2. The listener, collaborator and companion on the songwriting journey. The combination of techniques brought
with it a combination of roles and this had an effect on how the therapeutic relationship developed and how Will came to trust me and each

process. Was I going to comment on his performance quality in the songwriting process, or was this very clearly only the case when he was
walking (during RAS)? Just as Will was in transition between post acute and community rehabilitation, I was having to transition each week
from instructor/trainer to psychotherapist; functional to psychoanalytic thinking. Using two different spaces helped with this potential conflict
in my roles as the RAS took place in the corridor outside the music therapy room. The pregait exercises were performed in the music
therapy room, but Wills wife and mother-in-law attended and assisted or observed Will in this part of the session. When we had finished the
pregait exercises we did the RAS in the corridor, then when we returned to the music room where it was just Will and I. This too helped to
provide clear enough markers to indicate our journey each week from the physical to the cognitive, emotional and sense of self.

Functional Discussion: RAS

The Cochrane review into music therapy with acquired brain injury (Bradt, Magee, Dileo, Wheeler & McGilloway, 2010) reports that some of
the fourteen RAS trials included showed significantly greater improvements in patients stride length than the standard, physiotherapy only
treatment groups. Wills results indicate a clear response in terms of functional gains, in particular stride length. The structure of sessions
and the clear protocol for RAS were easily accessible for him and he understood the way in which internalizing the beat was enabling him to
improve the overall quality of his walking pattern.
Other benefits from the RAS programme for Will were in carry over and confidence, where he began to walk in and out of the clinic, to the
music room, the corridor, back to the room and back out to the car after each session.
Fatigue and mood influenced Wills performance in the RAS at the clinic, as well as in the home programme where his family also had to
find the mental and physical strength to maintain the daily exercises with him.

End Comment
It comes as no surprise that I find myself thinking about and writing about the psychoanalytic approach the therapeutic relationship, the
song and the process of writing the song more than the functional approach. Even considering the process alone of RAS it is clear that
there will be six weeks over which we will do the same exercise with the aim of increasing stride length and improving balance and stability.
With RAS each week we would be able to observe the quality of walking as it is an external, physical action. Compare this to the process of
writing a song and immediately we can see that the effort is more cognitive, emotional and psychological and involves externalizing an
internal thought process through communication and the development of a relationship based on complete trust.
The psychotherapeutic and functional needs for Will at this stage of transition needed to be viewed and addressed together. The RAS
results were positive and encouraging in terms of potentially planning for and securing funding for further sessions and the clinical
reasoning for using this technique is justified from a practical perspective. The songwriting not only served as a motivating factor in Wills
RAS engagement each week at the clinic, it served as an immediately accessible and effective means of self-expression, communication
and identity integration. The composition of the lyrics and music and our performance of the song in the recording gave Will an opportunity
to display his well preserved sense of humor, exercise his competent problem solving, organising and decision making skills and to follow a
new, creative process which he could feel increasingly in control of. The whole process of treatment facilitated the identification and
reintegration of both preserved and altered self, thus working towards a more cohesive and accepted internal representation of self.
Will and I sang the song together. Our voices blended together and conveyed the literal and underlying meaning and emotional tone of what
he wanted to say. With the formation of a therapeutic relationship at the core, the process of collaboration, song writing and singing
facilitated a process of self-discovery for Will that was empowering in many ways for him.

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