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C R E A T I V I T Y A N D
C O N S C I O U S N E S S :
M U S I C T H E R A P Y I N
I N T E N S I V E C A R E
David Aldridge
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. . . h o w e v e r g r e a t t h e o r g a n i c
d a m a g e . . . t h e r e r e m a i n s t h e
u n d i m i n i s h e d p o s s i b i l i t y o f r e -
i n t e g r a t i o n b y a r t , b y
c o m m u n i o n , b y u n l o c k i n g t h e
h u m a n s p i r i t ; a n d t h i s c a n b e
p r e s e n t e d i n w h a t a t f i r s t s e e m s
a t f i r s t a h o p e l e s s s t a t e o f
n e u r o l o g i c a l d e v a s t a t i o n p 3 7
( S a c k s , 1 9 8 6 ) .
he neurologist Oliver Sacks reminds us of
the necessary balance we must bring to
our work with patients in the field of
medicine. All too often we are concerned with
testing the patient for deficits, for measuring
and for assessing problem-solving capacities. As
a balance he urges us too consider the
narrative and symbolic organisation of the
patient, such that we consider their possibilities
and abilities. In this way what seems to be
damaged, ill organised and chaotic becomes
composed and fluent. This is the function of the
creative arts; through art and play we realise
other selves elusive to measurement and
fugitive to assessment. Furthermore there is a
quality of time which is apparent in arts
activities which is intentional and involves the
will of the patient where their spirit is set free.
When we consider the situation of intensive
care, where patients are often damaged,
disorganised, intubated, machine - regulated,
often unconscious, and unable to
communicate; then we must consider a way of
T
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introducing activities which will stimulate
communion with those patients.
In this paper the ground of consciousness is
considered. It raises questions about the
location of the self in patients who are
comatose, about the nature of communication
with patients who are unconscious and
challenges medicine to realise the human
body as an instrument of knowledge.
Some aspects of modern medicine have
become increasingly technological. Such is the
case of intensive care treatment. Even in what
may appear to be hopeless cases, it can save
lives (Hannich, 1988)

through the application of
this modern technology. However, albeit in the
context of undoubted success, intensive care
treatment has fallen into disrepute. Patients are
seen to suffer from a wide range of problems
resulting from insufficient communication, sleep
and sensory deprivation (Hannich, 1988; Ulrich,
1984) and lack of empathy between patient
and medical staff. Many activities in an
intensive care situation appear to be between
the unit staff and the essential machines, i.e.
subjects and objects. To a certain extent
patients become a part of this object world.
Improvised music therapy can be a useful
adjunctive therapy in such situations both for
the patient and the staff.
The music therapy sessions
At the suggestion of a hospital neurologist a
music therapist began working with patients in
intensive care (Gustorff, 1990). To investigate
this approach further the work was monitored
in the intensive treatment unit of a large
university clinic. Five patients, between the
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ages of 15 and 40 years, and with severe
coma (a Glasgow Coma Scale score between
4 and 7) were treated. All the patients had
been involved in some sort of accident, had
sustained brain damage and most had
undergone neurosurgery.
The form of music therapy used here was
based on the principle that we are organised
as human beings not in a mechanical way but
in a musical form; i.e. a harmonic complex of
interacting rhythms and melodic contours
(Aldridge, 1989a; Aldridge, 1989b; Nordoff &
Robbins, 1977). To maintain our coherence as
beings in the world then we must creatively
improvise our identity. Rather than search for a
master clock which coordinates us
chronobiologically, we argue that we are
better served by the non-mechanistic concept
of musical organisation. Music therapy is the
medium by which a coherent organisation is
regained, i.e. linking brain, body and mind. In
this perspective the self is more than a
corporealbeing. As Sacks (Sacks, 1986) writes,
the power of music or narrative form is to
organize p177. What music and narrative
structure organizes is the recognition of
relationships between elements, not in an
intellectual way, but direct and unmediated .
With coma patients we see signs of activity,
albeit often machine supported, but totally
disorganized. The person exists, sometimes in
what is described as a vegetative state, but
hardly lives.
Each music therapy contact lasted
between eight and twelve minutes. The
therapist improvised her wordless singing based
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upon the tempo of the patients pulse, and
more importantly, the patients breathing
pattern. She pitched her singing to a tuning
fork. The character of the patients breathing
determined the nature of the singing. The
singing was clearly phrased so that when any
reaction was seen then the phrase could be
repeated.
Before the first session the music therapist
met the family to gain some idea of what the
patient was like as a person. On contacting the
comatose patient she said who she was, that
she would sing for the patient in the tempo of
his or her pulse and the rhythm of breathing.
The unit staff were asked to be quiet during this
period and not to carry out any invasive
procedures for ten minutes after the contact.
There was a range of reactions from a
change in breathing (it became slower and
deeper), fine motor movements, grabbing
movements of the hand and turning of the
head, eyes opening to the regaining of
consciousness. When the therapist first began to
sing there was a slowing down of the heart
rate. Then the heart rate rose rapidly and
sustained an elevated level until the end of the
contact. This may have indicated an attempt
at orientation and cognitive processing within
the communicational context (Nordoff &
Robbins, 1977; Sandman, 1984a; Sandman,
1984b). EEG measurement of brain activity
showed a desynchronization from theta
rhythm, to alpha rhythm or beta rhythm in
former synchronized areas. This effect,
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indicating arousal and perceptual activity,
fades out after the music therapy stops.
If we consider that cells firing with a
cardiac rhythm have been recorded in the
medullary area of the brain, and that there is a
synchronous relationship between the
contraction of the heart and the ascending
wave of alpha rhythm (Sandman, 1986) of
brain activity, then it is possible to hypothesize
that the rhythmic coordination of the
cardiovascular system with cortical rhythmic
firings is of primary importance for cognition.
What we have is a weaving together of basic
primitive human rhythms, which produce an
interference pattern which itself may be that of
cognition. It is proposed here that the rhythmic
coordination of basic functions in the human
body (Jones, Kidd, & Wetzel, 1981; Kempton,
1980; Kidd, Boltz, & Jones, 1984; Lester,
Hoffman, & Brazelton, 1985; Longuet-Higgins,
1982; Povel, 1984; Rozzano & Locsin, 1981;
Safranek, Koshland, & Raymond, 1982;
Steedman, 1977) is a fundamental healing
activity .
The ward situation
Sleep disturbance is a major problem in
intensive care units and the effect of a
disturbed waking/sleeping rhythm upon other
metabolic cycles is critical (Johnson &
Woodland-Hastings, 1986; Moore-Ede, Czeisler,
& Richardson, 1983; Reinberg & Halberg,
1971). The rhythmic entrainment of
cardiovascular and somatic activities may be
the key ground for recovery. This means that we
must consider the total behavioural (Engel,
1986) activity of the patient such that
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seemingly independent systems are integrated.
The context (i.e. Latin. con textere = weaving
together) of this integration is rhythmical
involving the co-ordination of the major tidal
rhythms of the body and timing mechanisms
within the hypothalamus in the brain.
As an organizational problem we must
look to the way in which staff are employed in
work shifts. It can occur that patients
throughout 24 hours are constantly in contact
with nursing staff who are in their own activity
cycle, no matter what time of day or night. For
rhythmically disoriented patients, no wonder
that there are sleep problems when they must
respond to constant activity with carers who
themselves are physically unsynchronised with
the patient. Nursing staff, while synchronised
with management needs and hospital routine ,
may need to attend to the sleep/ activity
rhythm of the patient.
In response to the music therapy some
ward staff are astonished that patients can
respond to quiet singing. This highlights a
difficulty of noisy, busy, often brightly lit units. All
communication is made above a high level of
machine noise. Furthermore commands to an
`unconscious patient are made by shouting
formal injunctions, i.e. " Show me your tongue",
"Tell me your name", "Open your eyes". Few
attempts are made at normal human
communication with a patient who cannot
speak or with whom staff can have any
psychological contact. It is as if these patients
were isolated in a landscape of noise, and
deprived of human contact.
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A benefit of music therapy is that the staff
are made aware of the quality and intensity of
the human contact. In the intensive care unit
environment of seemingly non-responding
patients, dependent upon machines to
maintain vital functions and anxiety provoking
in terms of possible patient death, then it is a
human reaction to withdraw personal contact
and interact with the machines. While the
machines themselves are of vital importance,
they present data which are independent one
from another, and which are often considered
in isolation whereas the integration of the
systems being measured are the clue to
recovery. This is further exacerbated by a
scientific epistemology which emphasizes the
person only as a material being and which
equates mind with brain.
At yet another level, we must consider the
fixed chronolological pulses of machines. If
human activity is based on pulse, the nature of
those pulses is that they are variable within a
range of reactivity. Those pulses are lively and
accommodate other pulses to form interacting
rhythms. This is not so with machines, they are
fixed in their range. Therefore, what is a
variable in human activity (the tempo of
varying pulses); becomes a constant in these
patients. The task then is to introduce
coordinated variety with the intention to heal,
something which as yet machines cannot do.
Perhaps the key lies in the fact that it is the
consciousness of the therapist which stimulates
the consciousness of the patient, and this
consciousness is not divorced from the living
rhythmic reality of our physiology.
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A period of calm is also recognized as
having potential benefit for the patient. What
some staff fail to realise is that communication is
dependent upon rhythm, not upon volume.
We might argue that such unconscious
patients, struggling to orient themselves in time
and space, are further confused by an
atmosphere of continuing loud, disorienting
random noise and bright light. For patients
seeking to orient themselves then the basic
rhythmic context of their own breathing may
provide the focus for that orientation. This raises
the problem of intentionality in human
behavior even when consciousness appears to
be absent. Reflexes do not occur in a vacuum,
they are conditional occurring in a context of
other behavioural activity. If bodily systems are
proactive, as well as reactive, then purposive
behavior and consciousness, may require the
context of human communication to function.
It is also vital that staff in such situations do not
confuse `not acting on the behalf of the
patient with `not perceiving.
We can further speculate that the various
body rhythms have become disassociated in
comatose states and following major surgery.
The question remains then of how those
behaviours can be integrated and where is the
seat of such integration. It is quite clear that
integration then is an organisational property of
the whole organisation in relationship with the
environment and not located materially in any
cell or any one organ. The environment of the
patient includes the vital component of human
contact and there is reason to believe that the
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essential ground of this contact too is
rhythmical.
Communication, contact and consciousness
Improvised singing appears to offer a number of
possible benefits for working in intensive care
both in terms of human contact and promoting
perceptual responses. Human contact as
communication is a creative art form. Although
what we know from machines is valuable, there
are other important subtle forms of knowledge
that are best gleaned through personal
contact with the patient. Mindell (1989) took
the courageous step of attempting process
oriented psychology with comatose patients
accompanying them on their great symbolic
journey. The drama of our contact with such
patients at a time of existential crisis points to a
fundamental aesthetic of living systems
creatively realised such that we, as artist
therapists, can go beyond the confines of a
soulless technology. This is not to deny that
technology and its benefits, simply to remind us
of our human intention as it is realised in art,
play, drama, music.
What we may also need to consider in
future is not how to observe more, but how to
question the quality of what we are observing
and the premises on which this observation is
based. In such situations of intensive monitoring
and machine support, particularly in the case
of comatose patients, we may ask of ourselves
Where is the self of the patient?. Needleman
(Needleman, 1988) reminds us that the power
of scientific thought has been to organize our
perceptions in such a manner that we can
survive in the world. Hence the value of
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scientific medicine and instrumentation.
However, he goes on to say that science has
also neglected the human body as an
instrument of knowledge and as a vehicle for
sensations as direct as ordinary sensory
experience, but as subtle as consciousness. He
writes ..........it is not simply the intellect which
science underestimates, it is the human body
as an instrument of knowledge - the human
body as a vehicle for sensations as direct as
ordinary sensory experience, but far more
subtle and requiring for their reception a
specific degree of collected attention and self-
sincerity p169.
The question still remains for us as clinicians
and scientists when faced with a patient in
coma, or a persistent vegetative state, Where
is the person and how can I reach her? and
then for ourselves as fellow human beings,
Where am I? What part of the therapist is
contacting the unconscious patient? Could it
be that if the musical form of our
communication touches the patient, as singing,
then we can also attend to how we speak with
the patient in their breathing patterns, and the
attend to them with the very form of our own
bodies.
This ability to communicate with
unconscious patients raises further the ethical
issues of decisions about terminating life support
when the brain and the person are no longer
seen as one and the same entity

(Mindell,
1989). When patients are not - responding it
may be that we are not providing them with
the human conditions in which, and with
which, they can respond. We as therapists are
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those conditions which are the context for
healing to take place.
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Acknowledgements: Dr Wilhelm Rimpau for the
initiation of this work. Dagmar Gustorff for her
pioneering of these skills in difficult conditions. Prof H-J
Hannich for his providing the circumstances for the
further exploration of this work.