Singing with Parkinson’s – More than Just a Choir

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I consider it a privilege to be able to witness and play a part in The George Center’s Singing with Parkinson’s – a therapeutic choir designed specifically to address the needs of people with Parkinson’s disease (PD). It has been less than a year since the start of the choir, and yet the impact it has had on its members to me is impressive and exciting. Many think of Parkinson’s as a motor disorder – which it is! – but “motor” encompasses more than just the movement of your fingers, arms and legs. Speech is a motor function, along with breathing. In addition to motor symptoms, people with PD often battle apathy and depression. A therapeutic choir is a wonderful way to address all of these issues! Do not take my word for it. Let’s look at the research.

In addition to discussing their own study, Yinger and LaPointe talk about the needs of people with PD and present compelling points from previous research in their article “The Effects of Participation in a Group Music Therapy Voice Protocol (G-MTVP) on the Speech of Individuals with Parkinson’s Disease.” A common speech symptom associated with PD is hypokinetic dysarthria, which makes their speech softer, more monotone, hoarse and unclear. Additionally, people with PD experience lower vocal range and voice arrests. Thus, speaking can be a struggle. Multitasking can also be difficult and even dangerous (p. 26).

Thus far, the most effective treatment for speech impairments of PD has been speech therapy, specifically the Lee Silverman Voice Treatment (LSVT). Yinger and LaPointe suggest that the success of the technique is largely due to its five principles that promote neural plasticity: (1) intensity, (2) complexity, (3) saliency of treatment, (4) “use it or lose it,” and (5) timing of the intervention (p. 26).

Music therapy, however, is emerging as another effective treatment modality. Music therapist Haneishi (2001) began developing a music voice protocol (MTVP) based on the same principles as LSVT to improve the speech characteristics of people with PD in individual sessions. The 60-minute protocol includes opening and closing conversation, facial and breathing warm-ups, vocal exercises, singing exercises, practice sustaining vowel sounds, and speech exercises. Both Haneishi and another music therapist, Perez-Delgado, who adapted MTVP for Spanish-speaking individuals with PD, found that the treatment “increased breath control, voluntary speech production, and voice volume” (p. 28). Other music therapy studies have found a background of singing can delay the age-related decline in speech skills; that stimulative songs decrease the rate of speech while sedative songs improve “rhythm, initial consonants, final consonants, and continuity of speech”; and that singing can improve intelligibility of speech, as much as 21% (p. 27).

Yinger and LaPointe in their study used MTVP in a group setting and found improvements in intensity (loudness) of speech, especially in men, and prosody of speech in conversation in women, in spite of the progressive nature of the disease! (p. 29-30).

Looking at how these ideas relate to The George Center’s Singing with Parkinson’s choir, I see Claire Morison, who currently directs the choir, does an excellent job at incorporating the research-based format and techniques into the weekly rehearsals. These are things that I will need to keep in mind if I ever have the opportunity to lead a choir with a similar population. For example, I will need to make adaptations during rehearsals to accommodate for the needs of individuals with PD, which may include limited mobility, impaired vocal functioning, and potential neuropsychiatric complications related to PD or the medications used to manage the disease. Because multitasking is difficult and potentially dangerous, I may need to simplify tasks for choir members so they can focus on the quality of their singing. Multitasking is typical in the choir setting, such as when flipping through music while reading lyrics and singing. Hence, Claire displays the lyrics and music on a TV, at times scrolled by an assistant to eliminate the need for visual tracking. Lastly, I will need to be familiar with the vocal changes that may occur as a result of age and disease.

There are always ways we can make something good even better, especially as the choir continues to grow and thrive. For example, the fourth principle of neuroplasticity mentioned above, “if you don’t use it, you lose it,” emphasizes the need to regularly practice speech skills. In LSVT, clients are sent home with homework and exercises. In our choir, perhaps sending our members home with a recording of the accompaniment to vocal warm-ups as well as music in print to practice may encourage them to continue practicing at home and hopefully further aid in slowing the decline.

Yet to me, the most unexpected and impressive benefit of the choir is the emotional enjoyment it brings to the clients and their families. I am sure most of the appointments that our clients must attend on a weekly basis can be tedious and discouraging. We encourage caretakers to join in on rehearsals, elevating the choir to more than a therapy but also a socially enriching activity that can boost their confidence in their existing abilities. It is heartwarming to watch as choir members linger after rehearsals, talking and joking and sharing their stories with one another. Music does not just treat the physical ailments but the whole person and community. More than that, the choir gives clients a sense of achievement in ways they did not think still possible. One client commented that the choir has allowed him to sing again, a gift that he thought he had lost forever. Now, one of the major sources of his joy is within reach again. He is not the only one. Many have thanked us for the choir saying, “You don’t know how much it means.” Such moments are priceless.

Yinger, O. S. & LaPointe, L. L. (2012) The Effects of Participation in a Group Music Therapy Voice Protocol (G-MTVP) on the Speech of Individuals with Parkinson’s Disease. Music Therapy Perspectives. 30. 25-31.



Welcome to our student interns!

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We are ecstatic about the launch of our student internship program this past fall! It has long been a dream of ours to not only provide the support through music therapy for our clients that give them the opportunity to generalize life skills, but to provide practical application of those skills in the form of an internship program. We are pleased to announce that our current interns, Angad and Cole, have been the perfect candidates to help us pioneer this program and have provided vital support to our team through the jobs they complete weekly. When we get new members of our team, we like to introduce them so everyone knows who they might meet when they visit our office, but also to give you some insight on what makes everyone on our team so special and valuable. It is only appropriate that our student interns get the opportunity to introduce themselves, and if you see them around the office make sure to say ‘Hi!’

Angad

What is your role at The George Center?

  • I scan, and shred paper, and help Ms. Jamie and Ms. Jeannie set up. 

Why is this opportunity important to you?

  • To learn how to be an intern. 

What is your favorite part about being on The George Center team?

  • It is my favorite thing to do to work here, to play music, and help the whole team. 

What is something you'd like everyone to know about you? 

  • I am good, happy, and proud. I like to make my family happy. I have a brother and a dog Abby, and my mom and dad. 

What is your favorite hobby? 

  • Vacuum, clean the house, feeding the animals food, cleaning the stairs, bathroom, sink, and making the bed. 

What is your favorite thing to do for fun?

  • Play video games. My favorite is Just Cause 4.

Cole

What is your role at The George Center?

  • I I file papers.

  • I clean the waiting room.

  • I work on the computer. 

Why is this opportunity important to you?

  • It is important because I am learning wonderful job skills. I am happy that everyone is taking me seriously.

What is your favorite part about being on The George Center team?

  • I love working in such a positive environment.

What is something you'd like everyone to know about you? 

  • I want everyone to know that I am a hard worker.

What is your favorite hobby? 

  • I love music and I love to sing.

Welcome, guys! We love having you on the team!

An Introduction to Music Therapy Advocacy

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Webster's defines advocacy as - “the act or process of supporting a cause or proposal : the act or process of advocating something.”

When I started studying my career in school and as I entered the workforce, I don’t think I fully understood what it meant to advocate for my music therapy. Mainly, I’m not sure I knew how many aspects of it would need advocacy.

I entered a young profession that is only officially 6 or so decades old. Which means that there is still a large population of people who have never heard its name, music therapy.

Inherently, music therapy can conjure images of circle singing and hand holding and maybe even a peace sign or two. Rather than the accurate alternative of therapists in scrubs or professional attire who have a guitar and several alternative pitched and unpitched musical items to address non-musical goals with patients from the NICU to hospice and everywhere in-between. The first thought about music therapy is one of the hardest obstacles to overcome, to be heard speaking scientifically about musical qualities when an assumption keeps you from being heard as a licensed and certified allied health profession. And fun fact: contrary to popular belief, I have never sung kum-by-yah in any of my sessions.

So as the first obstacle is the name, the second comes from the true motivations behind using music as the modality to address a patient's goals. While there are several ways to use music therapeutically to address emotions and psychiatry, the list doesn’t even come close to stopping there. My day in and day out focuses more on the regulation, sensory, motor, and cognitive skills of my patients. I work mainly with populations that have neurologic dysfunction and due to music having such great ability to access the brain and an to simultaneously engage many aspects of functioning, you allow the plasticity of the brain to have optimal opportunities to reroute through damaged areas. Whether you’re addressing gait, fine motor skills, visual tracking, cognitive concepts, or awareness of body you are able to exercise the brain using music to support its most efficient means to recovery.

The last, and to me the most difficult, piece of advocacy comes in the form of advocating for my clients. As I mentioned, my populations mainly fall in the neurological category which can include autism, TBI, parkinson’s, degenerative neurologic disease such as alzheimer's, and more. There is new research everyday that challenges traditional understandings of these diseases and dramatically change treatment. The more you learn about how to treat these varying diseases, the more you learn about the abilities often overlooked due to the outside picture gathered from a simple glance. As you get to know your patients, you learn about their rich lives, their hopes and dreams, and the people that love them. You gain a window into their everyday lives and you not only want to make their lives better using your medium, but you want the world to know who they are. This simple article is more than introduction to music therapy advocacy, but an awareness to what is possible when you believe in what you do, and the people you get to do it with.

M-U-S-I-C

Every year, we are proud to put together a video that features some of the incredible power and science behind using music as a therapeutic modality. We hope you have fun watching and learning and that you’ll share it with a friend! We do not own the rights to this music and have re-written the lyrics to apply to our mission of advocacy for music therapy. Thanks to Jimmy Fallon and the Roots for the stylistic interpretation!

The Giving Tree in the News!


Thank you CBS46 for your coverage of our Giving Tree program! Thanks to The Goddard School for sharing your kiddos with us! And as always, thank you to Arbor Terrace at Crabapple for letting us provide this program in your community! Research shows that intergenerational programs benefit everyone involved. For young people, it provides a positive view of aging, making them less likely to stigmatize the elderly. For older adults, it can reduce the likelihood of depression and social isolation, improve communication, and strengthen feelings of self-worth. #TheGivingTree #MusicTherapy

Drumming for Social Skills

“That looks like fun!” Many may comment as they watch a group of clients in the pavillion beating out rhythms on bucket drums during The George Center’s summer Bucket Drumming program. It certainly is fun, but is that the only purpose it serves?

Ga Eul Yoo and Soo Ji Kim recently published an article in the Journal of Music Therapy addressing that very question, “Dyadic Drum Playing and Social Skills: Implications for Rhythm Mediated intervention for Children with Autism Spectrum Disorder.”

As I read this article, I was excited to see that Yoo and Kim comment on the reclassification of ASD as a a motor disorder rather than a social disorder, justifying the use of rhythm as a tool for treatment. This is a reassuring sign that music therapists as far as South Korea are embracing the new concept of ASD as a neurodevelopmental condition rather than a social disorder. Now, the focus is shifting to how best to treat it as a neurological condition. Because rhythmic cueing - defined as “the provision of regularly paced external stimulation” such as to a metronome or steady beat - has been so effective with other neurological conditions, Yoo and Kim hypothesize that it can be helpful in improving the social skills of clients with ASD through scaffolding their movements with rhythm in drumming.

Drumming is a great tool for working on social skills through rhythm. Dyadic drum playing is defined as when “two individuals coordinate their movements in time with each other” (p. 344). For clients with ASD, this behavior is significant! The client must connect with their partner, perceive their movement, and coordinate his/her own movement to synchronize within the musical context. This type of motor control and joint attention is essential for engaging in social interactions on a daily basis.

Yoo and Kim conducted two studies that are discussed in the article. Study 1 investigates the question, “What is the relationship between dyadic drum playing and social skills performance in children with and without ASD?” (p. 345). Study 2 investigates the next question, “Are there changes in social skills of children with ASD after participating in the developed rhythm-mediated intervention?” Participants in both studies were measured on an electronic drum pad for how closely they could synchronize with another person’s rhythm at varying tempos as well as with and without external rhythmic cueing.

In comparing the results of experimental and control groups for Study 1, Yoo and Kim labelled “factors” to describe the different skill sets required to accurately imitate rhythmic patterns in dyadic drumming. Three “factors” were identified for the control group: (1) Embodied intersubjectivity, (2) Motor representation, and (3) Anticipatory adjustment. Yet, in addition to these three factors, the experimental group received a fourth “factor”: self-regulation (p. 356). Before they could begin to give attention to the other three factors, children in the experimental group had to gain and maintain control over their body movements, just as it is necessary when trying to interact and communicate on a daily basis.

It is interesting to note that the ASD group synchronized most closely during tapping to rhythmic cueing and synchronized the least during interpersonal synchronization without rhythmic cueing. Yoo and Kim point out that fast tempos increase demand on motor planning, but too slow makes equally makes it harder to plan movements without the presence of a clear beat. A slower tempo with rhythmic cueing enables clients with ASD to synchronize best.

In the second study, Yoo and Kim put these conclusions to the test in individual music therapy sessions with 8 children with ASD.They observed the greatest increase with engagement in joint action and increases in the presence of target behaviors. They conclude that the use of music and rhythmic structure is very effective and immediate in facilitating joint action and engagement, but continued and consistent treatment with the intervention is required to maintain the ability and transfer the effects.

Interestingly, in study 2, the parent-reports on the effects on clients with different levels of functioning varied. Parents of children who were lower functioning expressed a great appreciation for the intervention and remarked a notable difference in their children’s stereotyped behaviors (decreased hand flapping and wandering) and attention to others’ actions. Parents of children who were higher functioning remarked that their children enjoyed music more after the intervention, but some expressed a desire for “more direct changes in social behavior and communication skills.”

As I reflect on how this article can affect my clinical work, I am amazed by how many contexts this article can apply to. I conduct rhythm and drumming activities with all of my individual clients, but normally addressing the motor and cognitive domains of functioning. I also teach a whole drumming class to a group of high-functioning students, many of whom are on the spectrum but are working towards appropriate social skills and behaviors. Yoo and Kim provide interesting suggestions on how to approach designing dyadic rhythm interventions, such as by beginning with exploring rhythmic movement and then beginning a joint activity in rhythmic movements with a partner. Slower tempos with rhythmic cueing will prove the easiest for clients with ASD to synchronize with, but steadily removing supports and increasing the difficulty will challenge them and help them grow over time. Within the design of a single activity, changing the tempo is also an excellent way to assess the client’s engagement with their partner while maintaining the rhythmic structure that supports gross and fine motor planning.

Based on the parents’ responses, I believe a great lesson from this study is how an intervention that has significant and notable effects for one level of functioning may not have as great an impact for another. Yet this is not a reason to abandon the intervention all together. In many cases, augmentation is required to make it more challenging and beneficial for higher functioning students.

Overall, this article renews my confidence that the activities we bring to our clients can have a positive effect in ways that other therapies or lessons may not. How many activities involve every group member doing the exact same thing at the same time, connecting to each other through careful attention and coordinating the motor planning to synchronize with peers? The required careful attention to the other people in the room and the rhythmic framework of the activity make drumming a valuable tool for therapeutic success in the social domain.

Works Cited

Yoo, G. E & Kim, S. J. (2018) Dyadic Drum Playing and Social Skills: Implications for Rhythm-Mediated Intervention for Children with Autism Spectrum Disorder. Journal of Music Therapy. 55 (3). 340-372.

Autism – What It Really Is… and How Rhythm is the Key

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Article Review #2: Autism – What It Really Is… and How Rhythm is the Key

Since beginning at The George Center, I have come to realize that autism spectrum disorder (ASD) is so much more than what appears on the surface. From my undergraduate studies and interactions, I was familiar with some of the common symptoms: hypersensitivity, echolalia, repetitive movements and behaviors, but that was barely the tip of the iceberg. In the past month and a half, I have learned more about ASD than I have in the past 3 years at university. I am realizing how much scientists, parents, and the public know – and don’t know – about autism. For example, many think that people with autism are generally emotionally detached and have little interest in social interactions. However, if you read some of our clients’ blogs, it is very clear the answer is no. Any apparent lack of emotion is more likely due to a difficulty in planning the motor movements to show emotion: to smile, to frown, to speak, to touch gently. Try telling your loved ones how you felt about them if you couldn’t move a muscle with intentionality. Chances are you would smack them in the face or not move at all. If this is news to you, you might be wondering, “It’s a motor disorder? How?”

Lagasse and Hardy present an extensive amount of research into the neurological phenomena in the brains of people with autism. Although they report that the findings are not always consistent, they discuss some common areas of neurological difference in people with autism. (I am about to use some neurological terms, but please don’t run… I’ll explain).

Firstly, the cerebellum is significantly smaller in persons with autism. The cerebellum is the “general purpose device” that communicates with other neural systems and prepares for movement (Lagasse & Hardy, 2013, p. 68). Thus, deficits in the cerebellum impede a person’s ability to plan their movements – to smoothly and quickly target an object with the appropriate force and direction or to calculate the path of a stimulus. Also, Lagasse and Hardy highlight that  researchers have noted larger brain volume in the early childhood of people with autism (p. 68). This could indicate inefficient pruning of unneeded synapses. Lastly, connectivity within the brain is often different in people with autism. Both underconnectivity and overconnectivity have been reported, one of the complicated results of ASD being a spectrum disorder. Underconnectivity between parts of the brain that are far away from each other can cause motor delays or deficits, difficulties with motor sequencing, planning, motor inhibition, and motor execution (p. 69). Overconnectivity creates clutter and static that make communication between various brain structures inefficient. A frequently traversed and stronger pathway may “hijack” a signal travelling along a weaker connection. Because of this mixture of underconnectivity and overconnectivity,  a person with ASD may be hyposensitive to some stimuli and hypersensitive to others. Similarly, some movements may be very easy to execute, whereas other are very difficult.

Thus, the neurologic research suggests that autism is a deficit in processing sensory information from the environment and a difficulty in planning movements in response. This information significantly affects the treatment approach that therapists should take to effectively help clients progress. It is not that clients do not understand or care about the world around them. They are just trapped in their own bodies, trying to get the words out!

Music therapy is a unique tool to help my clients with motor planning. Entrainment – the phenomenon of your brain and body instinctively synchronizing to a given beat – has already been extensively explored in the gait regulation of clients with stroke (p. 71). Rhythm provides a framework for planning motor movements. It tells a person exactly how long it should take for them to move their limb from point A to point B, and most importantly how to pace the movement that comes in between.

Other musical elements may also facilitate motor planning (p. 72). For example, dynamics – the loudness or softness of sound – can cue the force of a movement. The range of pitches – how high or low – can cue the size of the movement. And of course, the style of the song itself can increase the client’s motivation to execute the movement.

Now that I understand that autism is a motor planning disorder, I can use the same principle of rhythm for organizing movement to help people with autism to plan their movement as well. Only with this essential foundation can we begin to address their ability to communicate and socialize!

At one time, I might have seen a person with ASD and assumed they were just clumsy and uncoordinated. Yet now, when I think about what really is happening within their brains, I realize it must be a scary experience to navigate their surroundings. Just as it is difficult to move around in your attic when it is full of junk from the past ten years, it can be difficult for signals in the brain to navigate amidst a clutter of synapses. I cannot begin to imagine the feeling of dreading every movement I made, not knowing whether I would hit the person next to me or grab a pencil too hard. For every object that approached,  I would just be hoping it would pass me by and not knock me to the ground.

Remembering how rhythm, dynamics, range, and style can affect motor coordination will be essential in helping me to treat my clients. An important part of my role as a therapist when working with my clients with autism will be to provide steady rhythmic support during activities that require some motor response from them – which is essentially the whole session. Additionally, using live music will enable me to adapt musically to the client’s needs in the moment. Just as I try to help my clients execute intentional movements, every element of my music-making and facilitation will require intentionality.

A touching expression from Peyton Goddard, an autism activist with autism himself, recorded in Lagasse and Hardy’s article captures the need for we therapists to give attention to the motor system before all else: “Trying to be the real me, rhythm helps the motor frenzy madness to stop. You are all too musically gifted to ignore the importance of rhythm. Please know my body  utmost lacks rhythm. In music therapy I’m benefitted by pairing to your upping rhythmic beats to motor my body. Trying to be me in harmony!’’

Reference

Lagasse, A. B. & Hardy, M.W.. (2013). Considering Rhythm for Sensorimotor Regulation in

Children with Autism Spectrum Disorders. Music Therapy Perspectives, 31, 67-77.



Music Therapy: Music with a Purpose

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Returning at The George Center has been something I have been dreaming of for a good while, ever since I first discovered it and started volunteering in 2014. I remember sitting in the group for Any Dream Will Do!, assisting the participants, celebrating their successes as they maintained attention for the whole activity, tapped out a steady beat, socialized with peers, or expressed themselves and contributed to a song. I went home singing the songs, thinking to myself how simple yet effective they were. Would I ever write songs like that? Scaffold and elicit such responses as I saw every Tuesday night?

I have learned a lot since then in my undergraduate studies, but now upon my return to The George Center, I realize there is yet so much to learn! What skill do I need to develop the most? Designing music therapy interventions that are not too general but help achieve my clients’ goals and objectives in a S.M.A.R.T way! (That is, specific, measurable, attainable, relevant, time-oriented).

With this in mind, I reflected on an article that I had heard of in a conference session presented by one of The George Center’s very own interns about a year ago: “A Conceptual Methodology to Define the Therapeutic Function of Music” by Deanna Hanson-Abromeit, PhD, MT-BC. It discusses the function of different elements of music – such as melody, harmony, rhythm and dynamics – in the achievement of client’s objectives. Yet in the midst of the hectic clinical experience, when we are learning the basics of leading activities and writing goals and objectives, it can sometimes be easy to forget how these essential elements of music function in treating specific diagnoses and symptoms. It requires not only an in-depth knowledge and integration of all the musical elements, but also an understanding of the needs of the populations we serve.

To bridge this gap between knowledge and therapeutic intervention, Dr. Hanson-Abromeit has developed the Therapeutic Function of Music (TFM) Plan worksheet, which she provides in her article  and explains its relevance and how to use it. This worksheet is primarily intended to be a training and research tool for a student music therapist who is learning how to get the most therapeutic value out of music’s elements for a given population. Additionally, it can be useful for advocating music therapy to other medical and educational professionals. So often, music therapists must defend their practice when presented with the question, “Why music?” especially when there are so many other alternative therapies available. The TFM helps even the nonmusical reader to see the relationship between elements of music and their effect on human response (p. 26).

The first step of filling out the TFM Plan Worksheet is the “Problem Statement.” This includes the general goal desired for the client or population, such as to “improve speech,” to “improve gross motor skill,” or to “improve cognitive skill,” as well as an explanation of why this goal is appropriate. Next on the TFM are the Musical Elements: timbre, rhythm, tempo, pitch, melody, dynamics, lyrics, form, harmony, and style. For each of these elements, the MT must explain the why, what, and how under three headings. (1) “Theoretical Framework” discusses why the musical element is necessary and includes supporting research. (2) “The Purpose of the Musical Element” describes what the element will do to support the goal. And lastly,  (3) “The Explicit Description of the Music Element” outlines exactly how it will be structured in a given intervention.

By the time the student music therapist or researcher has filled out the TFM Plan worksheet, it becomes clear how music uniquely functions in the achievement of the population’s specific goal. For example, if the goal is “to improve speech” in a client with Down syndrome, a completed TFM will highlight how the musical element pitch can help (p. 33). (1) Why is it necessary?  Children and teens with Down syndrome tend to lack speech affect and speak in a low-pitch range. Yet, they can imitate pitches in melodies they sing (2) What will pitch do? The pitch in the melody should be in an appropriate range and should imitate the inflectional pattern of the each word. (3) How will pitch be implemented? The music presented should be between notes A3 and A4. Each pitch will reflect the inflection of each word, such as in the word “today.” The pitch for “to” should be lower than the pitch on the accented syllable “day.” The emphasized contour will help the client practice accenting the appropriate syllable, and in turn improve speech affect in daily life.

Using the TFM Plan worksheet as a guide, the MT must develop S.M.A.R.T. objectives that utilize the musical elements in optimal ways. From there, the MT will develop therapeutic interventions that give the client opportunities to achieve the objective each session. Only when these objectives are established can the therapist, client and family see measurable progress and determine whether the specific approach/intervention is effective. The TFM plan provides information that is broad enough to help create multiple objectives related to the same long-term goal.

I would really like to use this worksheet as I develop interventions with my various client groups. Being in a private practice has exposed me to more ages and populations than I have ever worked with in all my undergraduate studies, and all at once! Perhaps the greatest challenge with TFM Plan worksheet is the amount of research required to learn about the population and their needs. It can be time consuming, and no student or intern ever has enough of that precious commodity! But the quality of the intervention can be greatly improved when the student MT makes the effort to use this tool. I feel that it will be an investment in my clinical knowledge which will help me to be more effective and more instinctively use the marvelous gift of music to heal people of all sorts.

Works Cited
Hanson-Abromeit, D. (2015). A Conceptual Methodology to Define the Therapeutic Function of Music. Music Therapy Perspectives, 33, 25-38.