Friday, February 1, 2013

Structure

In case you've been wondering how live as a music therapy intern in Thailand is going, here are a couple of great stories from the clinic this week:

Client P; a 9-year old boy with autism who communicates non-verbally:

A few days before the second session with Client P that I would be a part of, we sat down as a team to brainstorm what we could do to provide a successful environment for P. Something just wasn't working. Generally, P smiles when he sees the music therapists and is excited to walk with them to the treatment room, but screams and cries for the majority of the session or lays on the couch. Clearly he wants to be there but something is causing him some pretty serious discomfort. When handed an instrument to try, he plays the instrument extremely loudly and then throws the mallets and covers his ears. The team has found that he likes to try novel instruments but generally quits and screams in a matter of minutes or seconds. His mother explained to the team that he has a "sound sensitivity" that has developed only in the last year.

After a few seconds of watching a video of a previous session, Dr. D said, "This boy needs structure!" Aha! Of course... P. wasn't sure what he was supposed to do, where he was supposed to sit, and how long he was supposed to do any of the things we were asking him to do. Perhaps what we interpreted as "sound sensitivity" was merely a reaction to the lack of structure; he was trying to tell us but wasn't sure how. Supposing that he was reacting inappropriately and not really having an uncomfortable physical reaction to sound, we decided to start with a restructure of the environment and applications but maintain our original goals.

We added a sequence board where he would get to choose the order of the session, a visual timer set at 2 minutes, and improvised floor mats (cushions) to show where we were supposed to sit. We also arranged the room so that each application had it's own space that we could move to during the transition song. While dancing, we danced to recorded music with a pre-determined length (which we faded in and out), and with instrument playing, we added a song or chant with a pre-determined and predictable length. We also decided that we would allow him as many choices within structure as we could but we would be more insistent about appropriate behaviors (sitting up, carefully placing instruments in a basket, etc.) to avoid manipulation attempts and increase progress toward goals and objectives.

Results: No more crying, no more screaming, and no more laying down. In fact, Client P smiled and laughed the whole time. He seemed to love every application and adapted quickly to the new changes in the environment. The cushions worked well for him once we insisted that he did not lay on them and the schedule board and iPad combo provided a wonderful outline for the session that both he and I (with my limited Thai) could follow.

Children with autism typically need structure in their environment-- predictability, preparedness, well-sequenced events, a clear start and stop, a smooth transition from one thing to the next, etc. You know who else needs structure? I do! In preparing for the session, my Thai friend was pointing out that my need to have the room ready very early and know the session order was much like the needs mentioned above. But my structure may be just what some clients need. A healthy balance of structure and open-mindedness is something I continuously seek.

Pretty amazing story, right? I'm pretty sure the videos of the session, seen back-to-back with footage of the previous session, would prove to anyone watching that musical structure and an appropriate environment can all the difference for a child with autism.

Here's one more story for you:

Client S; an adult male, from England, receiving chemotherapy in an oncology ward at Thailand's oldest and biggest hospital: 


We arrived at the oncology clinic thinking that we would repeat last week's performance; providing "therapeutic music" in the environment for a ward of 15-20 patients receiving chemotherapy treatment while the patients mostly slept or watched with a smile from their beds (the music was a duo consisting of a traditional Thai instrument like a hammer dulcimer and a guitar). Things were going as planned when a man arrived, introducing himself as a plastic surgeon who had just finished his surgeries for the day and wanted to see what we were up to. We had just packed up to leave but he asked if we would get out our instruments again for another song. The next thing I know, he is singing along! The surgeon then walks over to an observing man who is clearly a "farang" like me--from England, actually-- and asks him if he has any requests. The man wants the Beatles! Knowing that I had many Beatles tunes in my "mini songbook", I whipped it out and we all sang a tune together. Afterward, the same man asked for our guitar and starts singing/playing "Yesterday", perfectly, from memory and with amazing musicianship (while laying in bed receiving chemo, might I mention).  The other patients were thrilled-- sitting up in their beds and clapping along-- and all of the nurses stopped to watch. Therapy all around! But seriously, talk about a tear jerker.... what a privilege. It was a humbling experience that I certainly won't forget.

Know that I would post some amazing pictures and videos of these experiences if I could. I apologize for the  monotony of a long story without pictures. 




Here's our MT team at a different site-- an "adult day care" rehab clinic in Bangkok. It's great fun each week! We came here during out 2011 trip for practicum experiences and I now know some of the same patients again :)

1 comment:

  1. It's coincidental that you write about structure how you and your client both needed it right after I decide that my life needed more structure.

    I liked reading this, though. Keep them up!

    ReplyDelete