Ms. Nesbitt is music therapist and Ms. Tabatt-Haussmann is art therapist in the Pediatrics Department at New York University Langone Medical Center in New York City.
Disclosure: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.
Please direct all correspondence to: Kim Tabatt-Haussmann, MA, ATR-BC, Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders, 160 E 32nd St, Second Floor, New York, NY 10016; Tel: 212-263-9923; Fax: 212-263-8410; E-mail: email@example.com.
• The use of the creative arts therapies in pain management is a successful non-pharmacologic intervention.
• The presence of music and art therapy provide a context of normalization for a child in a medical environment.
The positive effects of art and music therapies for distraction during medical visits and procedures have been well studied. These interventions can reduce anxiety, promote relaxation, and minimize the perception of pain. This article describes combined art and music therapy interventions in the pediatric oncology/hematology environment and discusses various goals addressed during out-patient visits. Patient experiences are described as they relate to engagement in procedural accompaniments, creative arts therapy groups, individual therapy sessions, and group music therapy sessions. Interventions discussed include art making, active music listening, progressive muscle relaxation, music technology, active participation in music making, songwriting, and lyric analysis. The patients’ social, emotional, cognitive, and physical outcomes are discussed as they relate to treatment. In addition, the significance of the interventions for creative arts therapy practiced and researched is explored.
For over 50 years, creative arts therapists have been used in hospital environments to facilitate relaxation, decrease anxiety, and provide distraction. During this time, extensive research documented in medical journals has proven that non-pharmacologic interventions such as art and music therapy have a positive impact on the patient’s quality of life.1-5
The following description offers insight into the interventions provided by the art and music therapists at an outpatient pediatric hematology/oncology clinic at New York University Langone Medical Center. Both therapists worked individually with patients and families and exercised their specific skills to achieve various goals, including facilitating relaxation, providing social and peer interaction, decreasing anxiety, and providing an environment to normalize the patient within the medical environment. In the past year both disciplines collaborated so that patients and their families could have more opportunities to actively participate in the creative arts. The outcome was extremely positive.
The Creative Arts Defined
Music therapy is the art of using music to address a non-musical goal. In pediatric medical settings, the music therapist particularly focuses on decreasing a patient’s anxiety and normalizing the hospital or clinical environment through music activities.1-5 A variety of interventions can be used to bring about relaxation, promote normalization, and provide distraction, including progressive muscle relaxation with music, music and imagery, hypnosis, procedural accompaniment, songwriting, lyric analysis, and music and movement.1-5
In a medical environment, the music therapist works with patients, families, and medical staff in the treatment room. During various procedures, the therapist engages the patient in live music and introduces relaxation skills, including self-hypnosis, progressive muscle relaxation, and music-assisted imagery, to distract the patient from pain and decrease anxiety. Music therapy establishes a “therapeutic environment that enhances the effects of medication and involves patients in activities that direct attention away from the stresses of illness.”3 Once patients focus less on the stress and anxiety of an illness, their perception of pain often abates. West4 relates that relaxation, a goal in music-therapy interventions, decreases muscle tension and anxiety and results in a “positive influence on pain perception, nausea, and other symptoms.”
Art therapy, with the creative process of art making, improves and enhances the physical, mental, and emotional well being of individuals of all ages. It is based on the belief that clinical intervention with the act of art making can heal patients and enhance their quality of life while helping to reduce stress, increase self awareness, and cope with difficult experiences.6-11
Medical art therapy is a term applied to “the use of art expression and imagery with individuals who are physically ill, experiencing trauma to the body, or who are undergoing aggressive medical treatment such as surgery or chemotherapy.”7 A study of the innovative use of art therapy in relieving symptoms in cancer provides beginning evidence for the efficacy of art therapy in reducing a broad spectrum of symptoms in cancer patients.8
“When art therapy is partnered with medical treatment, children can meet the challenges of serious illness. For instance, when children create art in the medical setting, they have a sense of the familiar that produces pleasurable and positive associations. The child artist gains control by mastering art materials and developing personal imagery in a situation that is often out of his/her control.”9
A study of art therapy as a support for children during painful procedures was shown to be a useful intervention that can prevent permanent trauma and support children and parents during intrusive interventions.10
In medical settings, when children are not well enough or are unable to visit the playroom for an art therapy group, individual art therapy sessions can be provided in the treatment room so as to normalize their clinic environment and provide opportunities for socialization and expression.
“One of the contributions of art therapy to cancer treatment is the possibility of helping young people emerge from their illness as emotionally whole and healthy as possible. Encouraging growth and development through art activities can help the ill child preserve many areas of normal functioning.”12
A Collaborative Approach: Art and Music Group at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders
Art therapy and music therapy used collaboratively in a group provides the children and families with an outlet for stress management. In such an environment, they can sustain social and peer interactions as well as normalization. In addition, they have an opportunity to develop effective coping skills. Furthermore, art and music “therapists can address the functional skills of individual patients and encourage improved social skills, while providing the emotional outlet that is necessary for patients and families involved” in treatment for cancer and blood disorders.5 The art and music group takes place 1–2 times a week during clinic hours. Patients are invited to the Wellness Room, which is a large, open, non-threatening space with ceiling tiles designed as night-time stars. A large sheet of blank mural paper lies in the center of the room, and plush pillows and blankets are placed around the art area for the patients’ comfort. Children, parents, and siblings are assisted into the room, and markers, crayons, colored pencils, foam cutouts, and a variety of other art mediums are available. The music therapist sitting on a bench near the art area begins the session by introducing a theme, such as a trip to the zoo, life under the sea, space exploration, future dreams, or the patient’s view of him- or herself. The music therapist chooses appropriate music for the theme, and the art therapist asks the patients to close their eyes or focus on the song lyrics. After the music therapist sings and plays the first verse of the song, the art therapist invites the children to draw, color, or paint what or how the music made them feel. As the group progresses, different songs related to the theme are introduced. This technique facilitates diverse imagery evident by the distinctive pictures that appear on the mural paper. At the conclusion of the group, patients are asked to draw a final image reflecting the creative arts group theme. The result is a beautiful, unique mural designed by the participants that reflects their self-concept and emotions.
Benefits of Combining Art and Music Therapy
Combining art and music therapy at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders (SDHCC) of New York University Langone Medical Center not only increases the participants’ creativity but also distracts them from the clinic environment. The interventions offered within the group “focus the attention away from the physical sensation of pain to other aspects of the person.”13 Pediatric-oncology patients are confronted with numerous challenging situations, as most of them have to undergo chemotherapy, radiation, and surgery. Because of their treatment, they are unable to experience a carefree childhood. Since patients often experience the side effects of treatment, including pain and nausea, non-pharmacologic treatments are extremely important in distracting them from the psychological aspects of pain. Music and art therapies actively involve patients in the creative process and, as a result, are able to draw attention “toward the art and music.”9 Therefore, “when an investment in the art or music occurs, an exchange of energy results, and energy is refocused [away] from the pain.”13 When music and art work together to enhance the creative process, the outcome is positive because it reveals decreased anxiety, distraction from pain, and increased relaxation response.
The music and art therapy group also provides children and families with an opportunity to develop a positive social support group. Not only do pediatric patients miss out on classroom activities with their teachers and peers when they are at a clinic, but they miss out on being with their friends and participating in community activities as well. However, with the combination of music and art in a social setting, children are able to socialize with peers in similar circumstances and not feel as isolated. In the creative arts group, patients have the opportunity to feel normal, make friends, work on art together, play and sing, learn, and, most importantly, have fun in a safe creative environment.
The Music and Art Group Defined
Patients visit the outpatient clinic with parents/guardians, siblings, grandparents, other relatives and friends. Because cancer affects the child’s family and network of support, the therapists encourage and invite caregivers to actively participate in the creative arts group. Focusing on family-centered care, the group aims to reduce anxiety and educate participants on effective coping skills and relaxation tools to increase understanding and support. For each caregiver present, the group work reinforces the idea that the child’s creativity, imagination, development, and spirit are maintained and validated throughout their treatment.
The Music and Art Group is a 45-minute session that takes place in a controlled and comfortable space with minimal design and distraction. The Wellness Room is separate from the playroom and waiting room, which helps participants focus on the music and art. Mural paper is placed in the middle of the floor as well as markers, crayons, foam shapes, and colored pencils. Pillows surround the paper, posing as comfortable seats for the participants.
The therapists decide on a theme for the group (eg, animals, beach activities, rainbows, water and outer space) that has vivid imagery related to it. After the music therapist collects appropriate song material, both therapists gather the patients to begin the group. The art therapist provides various materials and co-facilitates guiding participants in imagery before the art creating begins.
The group is encouraged to sit comfortably and participate in active listening, a music therapy intervention. As the music therapist performs the song, participants are asked to listen to the music, close their eyes, and imagine the pictures that come to mind from the song lyrics. Songs performed in the past to elicit vivid imagery include “Going to the Zoo,” “Under the Sea,” “Rocketship Run,” and “Puff the Magic Dragon” (Figures 1–4).
While the music therapist continues to perform a variety of theme-related songs, the patients and families, who often sing along, are encouraged by the art therapist to begin drawing images on the mural paper. While they are listening and singing, the art therapist helps the participants think about the song and images that come to mind. Working on one piece of mural paper, which is a metaphor for the group working together, encourages therapeutic play through image making. One initial image inspires another and gradually transforms the mural into storytelling through music and art.
While the group is creating images and listening to the music, individuals often talk about their drawings, and others sing and dance to the music. As they observe the dynamics of the group, the leaders reinforce the idea that there is no right or wrong method.
As the session ends, the therapists review the journey and discuss the images created on the mural paper, naming the particular songs that guided the patients’ imagination. Participants are encouraged to first discuss the images and music then choose a title for the group mural. All participants sign their names on the artwork, an act which increases their self-esteem, produces self-actualization, and provides positive reinforcement for their creative abilities. The group mural is then displayed in the playroom for the SDHCC’s staff, patients, and families. The participants take pride in their finished product, and as a result, more patients are encouraged to participate in the next creative arts group.
Art and music therapy used together is extremely effective, especially with pediatric oncology/hematology patients, because it helps them address the physical issues of pain as well as the emotional issues in a non-pharmacologic and non-threatening way. The dynamics of sound and its impact on physical symptoms should be understood. For example, when sound travels through the “reticular activating system of the brain stem [and] coordinates sensory input, it alerts the cortex to incoming information.”1 Therefore, when the brain is activated, the sound “competes for cognitive awareness” and causes pain and nausea to be ignored.1
Music therapy and its effect on anxiety and relaxation have been well documented in research and case studies over the years.2,5,13,14 Hanser2 reports decreased scores on the A-State Anxiety Inventory in the presence of induced anxiety when music is playing, whereas Trauger-Querry relates that music has a way to “engage, activate and alter affective, cognitive and sensory processes through distraction, alteration of mood, improved sense of control, the use of prior skills and relaxation.”2,13 Exercising these skills and establishing a normal environment where pediatric patients can play and have fun without thinking about their illness is of paramount importance.
Imagery, facilitated by the art and music therapist, is another layer that can be added to musical stimuli in diverting pain perception. A study in which progressive muscle relaxation and guided imagery was used to delay or prevent “chemotherapy-induced nausea and vomiting” with HIV patients was conducted, and the findings demonstrated that 24 hours after chemotherapy, the experimental group, having used guided imagery techniques, had decreased levels of nausea for up to 60 hours after treatment.15 As patients focus positively and reach new levels of awareness through music and art, their tension and anxiety decrease. PP
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