Pergamon The Arts in Psychotherapy, Vol. 22, No. 1, pp. S-55, 1995

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BRIEF REPORT

“YOU ARE SINGING BEAUTIFULLY”: MUSIC THERAPY AND THE

DEBRIDEMENT BATH

JANE EDWARDS, M.Mus.. RMT”

Music therapy provides a unique resource to ad- dress the needs of the child in pain undergoing de- bridement procedures for severe bums. Music therapy is effective because it has the particular qualities of being non-intrusive, optional and uses a flexible, adaptive and engaging medium.

The following is a description of the work of a music therapist as a member of a health care team addressing the needs of a 12-year-old boy undergoing a treatment bath in the bums unit of a children’s hos- pital. Description and reflection are employed by the music therapist to communicate the event. The pur- pose of writing this description is to record techniques used by a practicing music therapist as well as to identify a significant application of music therapy for children with bums.

The role of music therapy in addressing the needs of the child with severe bums has received scant at- tention in the literature to date. While music therapy in pain management, particularly for adults, has been recognized as a developing research area (Aldridge, 1993; Bailey, 1986), few descriptions of the ways in which music therapy may be used to address the needs of children in pain following bums exist (Christen- berry, 1979; Rudenberg & Royka, 1989; Schneider, 1983).

The pain that accompanies treatment procedures in

healing a severe bum is often viewed, by adults, as more stressful and painful than the injury itself (Ach- terberg & Kenner, 1988). A child attends a bath at which at least two nursing staff are present. Parents may be in the room also; doctors come in and out; an occupational therapist and physiotherapist may also be present. The child is placed in a bath of water after having the bandages and dressings removed. The dead skin on and around the bum site is then removed with sponges. Following the bath, the bandages are once again applied. This treatment is repeated daily while the child is in hospital.

The child’s ability to cope with this procedure re- quires access to a range of resources for which devel- opmental age, physical, psychological and social as- pects intertwine and impact. It is not always possible to isolate the effect of each of these on the child’s ability to cope. As Maron and Bush (1991) wrote, “ . the physical pain of the injuries and treatment are often coupled with considerable psychological distress, blurring any distinction between physical pain and emotional distress” (p. 275). This is further supported by Schneider (1983) in a study involving burned children who were receiving dressing changes. The outcomes suggest that pain intensity is greater with decreases in health and locus of control and increases in anxiety. Therefore, the degree of

*Jane Edwards is the Lecturer in Music Therapy at the University of Queensland, Australia, Faculty of Music. She is coordinator of the clinical

outreach program from the University based at the Royal Children’s Hospital in Brisbane, Queensland, established in June 1993. Thanks are

due to the staff on O’Connell ward for their support in the introduction of this program.

53

54 JANE EDWARDS

pain experienced is person-specific and is impacted by a group of factors and often, in the case of chil- dren, indistinguishable from the degree of anxiety manifested.

Music therapy can have a role in reducing the anx- iety associated with the debridement procedure. Mu- sic can provide a focus for the child away from the pain and discomfort and provide comfort and psycho- logical support (Edwards, 1994). Choices offered by the music therapist can maximize the child’s sense of control over the experience.

Barker (1991) found that taped music provided during the debridement procedure was helpful in re- ducing anxiety for five people aged from 13 to 66 years in a bum center. At the Royal Children’s Hos- pital in Brisbane, music therapy can play a role in reducing the anxiety associated with the bath and pain and anxiety experienced during the bath. Music is usually played live by the music therapist and music used consists of known songs and improvised songs and music. The following case study illustrates the approach taken by the music therapist in responding to children in pain undergoing this procedure.

Ivan

Ivan, a 12-year-old boy, was admitted to hospital with bums to his right leg and genitalia. Ivan had been playing with matches and his t-shirt and shorts had been set alight. There is some uncertainty regarding the exact circumstances of the accident. Ivan’s mother and sister were working at the time of his admission and were unable to visit him in the hospital. His father was able to visit occasionally in the evenings.

Ivan was referred to music therapy by the Sister in Charge at the beginning of a debridement bath. The music therapist had just returned from annual leave break. It was, by then, the third week of Ivan’s ad- mission. The Sister in Charge came to find the music therapist saying she had offered music to Ivan as he was very distressed, in spite of receiving adequate pain medication prior to the bath. Ivan told her he would try whatever she thought was best.

When I arrived at the bath with my guitar a few minutes later, Ivan was distressed and crying. He was sitting naked in a wheelchair beside the tub but would not get in, saying “It really hurts, I can’t do it.” A nurse was assisting him. I approached and asked Ivan if he would like some music to see if it would help. He said “OK.” I began to sing “I get by with little

help from my friends. ” I changed the words to “We’re all here to help Ivan; we’re his friends.” I sang the chorus about three or four times during which Ivan was still distressed and crying. I stopped singing and asked him if he knew the song and he said he had heard it on a popular television show.

The nurse and I then assisted Ivan to get into the tub. He cooperated with instructions and was quieter. The nitrous oxide gas mask was offered, which he accepted. The Sister in Charge came in and held Ivan’s head as he lay back in the bath. I sang “Waltz- ing Matilda” very quietly, trying to match Ivan’s shallow, rapid breathing, slowing the tempo gradu- ally. When Ivan was breathing more evenly, I began to improvise on the guitar around a chord progression; C, Am, G(7), C. At times I vocalized over this, usu- ally in stepwise motion with occasional use of sus- pended notes, singing and playing quietly. The nurse was washing Ivan’s bums including his genitals at this time. He was quiet, lying back in the bath with his eyes closed.

When I began to hum the tune “A little help from my friends,” Ivan lifted up his right arm and gave a “thumbs up” signal. A little later he said, “You are singing beautifully. ” At the end of the bath, which must have taken about 20 minutes but could have taken longer, Ivan told me that he had felt no pain during the bath. He had been imagining himself lying on his bed at home listening to the radio. He ex- pressed amazement that he hadn’t been aware of the nurse touching him during the procedure.

Later in the week, the Sister in Charge told me that the bath described here was the turning point in Ivan’s recovery. He had his first full night’s sleep on the night following the bath. She described him as revert- ing to a pleasant and cooperative boy.

It is interesting to note, however, that when I ap- proached Ivan a few days later to offer music therapy he refused. It seemed that with the return of the strong, independent boy there was no need for the support the music therapist offered. When I reflect on the role music therapy played in Ivan’s bath on that day, the following points reveal themselves as important:

0 Ivan’s stoicism, which had served him so well in previous baths, failed in the face of his anxiety and exhaustion;

l music therapy was offered at a critical time and was able to address immediate needs;

MUSIC THERAPY AND THE DEBRIDEMENT BATH

music was able to rally the psychological resources (through imagery and entrainment) Ivan required to “get through” the experience; music provided a sense of security and safety, re- flected in Ivan’s image of being at home in his bedroom; music provided a bridge from distress and resis- tance to relaxation and calm; it is possible that music enhanced the analgesic effects of the medication or, alternatively, that the medication enhanced the relaxing properties of the music.

Conclusion

Music therapy was used to address the needs of a 12-year-old boy with a bum injury in distress prior to a debridement bath. The playing of improvised music and two familiar songs before and during the bath produced imagery and relaxation and facilitated cop- ing. The development of music therapy as a resource within teams who are dealing with the needs of chil- dren in pain is recommended. Further investigation of the effect of music therapy when used as a psycho- logical support for children to maximize coping dur- ing bum baths is also recommended.

References

Achterberg, J., & Kenner, C. (1988). Severe bum injury: A com- parison of relaxation, imagery and biofeedback for pain man- agement. Journal ofMenra1 Imagery, 12(l), 71-88.

Aldridge, D. (1993). Music therapy research 1: A review of the medical research literature within a general context of music therapy research. The Arts in Psychotherapy, 20, 1 l-35.

Bailey, L. M. (1986). Music therapy in pain management. Journal of Pain and Symptom Management, l(l), 25-28.

Barker, L. (1991). The use of music and relaxation techniques to reduce pain of bum patients during daily debridements. In Ma- ranto, C. (Ed.), Applications of music in medicine. Silver Springs, MD: National Association for Music Therapy.

Christenberry, R. B. (1979). The use of music therapy with bum patients. Journal of Music Therapy, 16, 136148.

Edwards, J. (1994). The use of music therapy to assist children who have severe bums. The Australian Journal of Music Ther- apy, 5, 3-6.

Maron, M., & Bush, J. P. (1991). Bum injury and treatment pain. In J. P. Bush, & S. W. Harkins, (Eds.), Children in pain: Clinical and research issues from a developmental perspective. New York: Springer-Verlag.

Rudenberg, M., & Royka, A. (1989). Promoting psychosocial ad- justment in pediatric bum patients through music therapy and child life therapy. Music Therapy Perspectives, 7, 4043.

Schneider, F. A. (1983). Assessment and evaluation of audio- analgesic effects on the pain experience of acutely burned chil- dren during dressing changes. Dissertation Abstracts Interna- tional, 43(8-B), 271b.