Book Review
by
Shannon O’Gorman BMus(Ther)Hons, RMT
Child and Youth Mental Health Service;
Mater Children's Hospital, Brisbane
in
The Australian Journal of Music Therapy (2005)

Nöcker-Ribaupierre, M. (Ed.). (2004). Music therapy for premature and newborn infants (S. Weber, Trans.). Gilsum NH: Barcelona. US$28:00, 226 pages, ISBN 1-891278-20-7.

Music Therapy for Premature and Newborn Infants is a translation of the 2003 German text, Horen – Brucke ins Leben. Musiktherapie mit Fruh – und Neugeborenen Kindern: Forschung und Klinische Praxis. [Listening - Bridge into Life. Music Therapy with Premature and New Born Infants: Research and Clinical Practice] published in Göttingen, Germany, Vandenhoeck & Ruprecht. This book presents the writings of sixteen international authors who contributed to the overall presentation of basic theories, research, and clinical practice in the area of music therapy as applied to the care of premature and newborn infants within the Neonatal Intensive Care Unit (NICU).

Music therapy for premature and newborn infants begins with a preface by Editor, Monika Nöcker-Ribaupierre, who states that one of the aims of this book was to provide a single point of reference for those seeking a broad understanding of the application of music therapy in neonatal care. The Forward by Mechthild Papoušek gives the reader a sense that this book may well provide such a point of reference, as Papoušek briefly touches on many of the areas which are later explored and developed in further depth. The following twelve chapters are written by authors who are already known in this field. These authors are of a number of nationalities including from Australia, the United Kingdom, the United States of America, and Western Europe. The significance of the Editor’s nationality is perhaps most interesting when comparing Helen Shoemark’s description of family-centred care with M. Nöcker-Ribaupierre’s experience of NICUs in Germany, where parents were discouraged from entering the unit.

This book is divided into two sections, with the first containing five chapters detailing the basic theories that inform music therapy interventions. Chapter one, by Christine Fischer and Heidi Als, provides a relatively detailed, yet easy to read summary of fetal and infant neurosensory development. This chapter considers the impact of preterm birth upon development and proposes a model of care that considers the needs of these vulnerable infants. The second chapter, authored by Kenneth Gerhardt and Robert Abrams, specifically details the development of fetal and infant hearing and makes specific reference of the significance of sound in utero and in the NICU environment. Shifting from a medical and developmental approach, chapters three to five are informed by attachment and psychoanalytic theory. In chapter three Tine Gutbrod and Dieter Wolke detail attachment formation in preterm infants. Contributions of key theorists, including Bowlby and Ainsworth are noted, with the authors considering the possible impact of prematurity upon infant-mother attachment. Additionally, Suzanne Maiello’s chapter details a psychoanalytic understanding of the meaning of prenatal auditory perception and memory upon the development of the mind. Finally, in chapter five Gisela Lenz and Dorothee von Moreau draw on Stern’s theory of implicit knowing and consider the role of resonance and synchronisation as a regulating factor in relationships.

The second part of this text contains seven chapters that each look specifically at individual music therapy approaches. Each of these chapters refers to research and clinical practice whilst also offering practical advice. The first chapter in this section, authored by Fred Schwartz, provides a review of the literature pertaining to the premature infant within the NICU. In chapter seven Nöcker-Ribaupierre outlines a quantitative research study that examines the short and long term effects of (recorded) auditive stimulation on premature infants and their mothers.

The use of the mother’s voice as a source of auditory stimulation is again the focus in Marie-Luise Zimmer’s chapter that presents detailed case vignettes, thus serving to complement the material presented previously by Nöcker-Ribaupierre . In chapter nine, by Elizabeth Dardart, an overview of life in the NICU is provided, with specific reference to the role of music in this setting. This chapter also describes the use of kangaroo care, touch, and massage as additional interventions. Interestingly, case material within this chapter makes a rare reference to the role of the father in the NICU, a theme that is further explored in following chapter by Helen Shoemark. Her chapter contrasts with those preceding it as it details a family-centred model of practice and focuses on meeting the needs of infants with complex medical and surgical needs through both live singing and pre-recorded music.

The final two chapters of this text focus on providing practical advice to those interested in establishing a music therapy program within the NICU environment. In chapter eleven Joanne Loewy describes a clinical model of music therapy in the NICU and provides specific advice around issues of proposals, referrals, and assessment. Chapter twelve, by Deanna Hanson Abromeit, focuses on providing a resource guide for establishing a music therapy program and includes a proposal outline, short list of relevant references, and list of useful websites.

Finally, this text provides a basic five page index and an extensive twenty-nine page bibliography that serves as the reference section for all contributing authors. The bibliography makes reference to significant contributors in the fields of attachment, developmental, and medical theory, music therapy, and psychoanalysis.

When considering that this text is only 226 pages in length, the range of theoretical and clinical information is comprehensive. However, one striking limitation is the limited reference to the potential for adverse responses to auditory stimuli for this population. Whilst the first chapter makes reference to individual relationship-based developmental care and outlines some observable signs of infant distress and disorganisation, subsequent authors make minimal or no reference around this theme.

In summary, Music Therapy for Premature and Newborn Infants is an easy to read academic text. Through the comprehensive collation of different theoretical, clinical, and research material, Music Therapy for Premature and Newborn Infants serves as an excellent overview for those with an emerging interest in this field. For the more experienced clinician this book offers a point of reference with short chapters by well-respected authors. When considering the specialised nature of this text, it offers value for money to those seeking to broaden their understanding of the role of the clinician working in the NICU.

Nocker-Ribaupierre, Monika (Ed.) (2005). Music Therapy for Premature and Newborn Infants. Gilsum, NH: Barcelona Publishers. 225 pages, ISBN 1-891278-20-7.
Reviewed by Dikla Kerem, PhD student, Aalborg University, Denmark.

From the realm of MusicMedicine/Music therapy, which encompasses all relationships between human health and music (Lippin, 1992), has come this excellent and comprehensive book, edited by Monika Nocker-Ribaupierre, on the benefits of music and music therapy for premature and newborn infants and their families in Newborn Intensive Care Units. Seventeen international music therapists and other professionals contributed their approaches in research and clinical practice to this interdisciplinary book, which elaborates on different issues from medicine, developmental psychology, psychoanalysis, bonding research and music therapy.

The book is very well organized and is comprised of two parts. In the interest of brevity, rather than writing about each of the 12 chapters separately, I prefer to cite concisely from Nocker-Ribuapierre's preface:

"The first part deals with the basic theories- current research on auditive development, the meaning of the mother's voice from the onset of the prenatal life and attachment formation with these very low birth weight infants. The treatment concept, NIDCAP, which is also based on the infant's development and the significance of the auditory system, leads to the second part of the book on music therapy. This presents an overview of individual music therapy approaches in research and clinical research with functional and psychotherapeutical aspects, using a wide palette of music and/or musical elements" (p. xiii).

The book begins with an excellent foreword by Mechthild Papousek about the preterm infant's experiences as well as the family's, and the strong impact of music as a non-verbal communication when it is used in early intervention programs in neonatal care. At the end of the book (rather than for each chapter), there is a rich and comprehensive bibliography and subject index, but no author index.

There is a balance, in my opinion, between theory, practice and research, between the different perspectives and the room given for each of them. Some of the chapters include case studies that are very interesting and present different perspectives of working with these infants and their families. Some of the cases are really touching e.g., the case of Sandra (p.151), Dylan (p.155), or that of Ms. R's son (p.114).

This relatively small area of applying music therapy in neonatal care is rapidly growing. What is fascinating to see is that music therapy (as well as touch and baby massage), is especially well suited for these infants. The documented researches' short and long-term results in this book speak for themselves, e.g., decrease of stress response, improvement of sleep, increase of oxygen levels and weight gain, faster growth of head circumference, decrease in length (3-5 days) of hospital stay, advanced motor and verbal development, etc. The mothers' benefits are described as well, e.g., greater frequency of breast feeding, less emotional burden, more stability, etc.

The music therapy material throughout the book is relevant to clinical work as well as to research and includes: The rationale for developing a program, examples of referral and assessment forms, physiological and psychological effects of various forms of music therapy, practical ideas and techniques, the different roles of the music therapist, guidelines for implementing a program, therapeutic interventions and reflections of therapists.

Having related to the overall aspects of the book, I would like to turn to several issues that are more specific:

In the chapter written by Hanson Abromeit, she writes: "A more non traditional form of documentation is videotaping...these tapes provide a vivid description of the music therapy program and individual infant's response during a session. They provide a visual documentation, offering another valuable tool to evaluate the music therapy program" (p.184). If one or more of these authors have done any videotaping, it is a pity that in our high tech. life, a DVD demonstrating clinical examples was not included along with the book. It could have been a wonderful addition to the written material. I am stressing this point because when it is possible, it also validates our work. It is exactly as if an art therapist was to present the clinical work without presenting examples of the artwork.

I found the writing style of all chapters clear and flowing, but there are many medical terms mentioned in some of the chapters. As an interdisciplinary book, which is directed to music therapists and to other professionals who do not necessarily have this specific medical knowledge, I would have expected that a glossary, in which terms are defined as clearly and simply as possible, would have been included at the end of the book. Such a glossary would make the material readily accessible instead of having to seek it out in a medical dictionary. Including such a glossary is becoming increasingly common nowadays.

As mentioned before, the book is comprised of chapters written by different authors. Therefore, the reader sometimes meets the same cited references in the literature reviews. Rather than considering these citations as redundant material, I consider them as valuable insights into what the authors find central to the issues at hand.

My last comment relates to a piece of information mentioned in the study of Nocker-Ribaupierre about auditive stimulation with the mother's voice. She touches on the fact that only two mothers out of more than 200, were able to sing to their babies in such an extremely desolate situation (p.105). Especially for the music therapists, it would have been very interesting to read more about these mothers and their singing- maybe as separate case studies- because those two mothers presented such a unique experience (The other mothers chose to read something personal written for their babies or from a book, and recorded it for listening while they were absent).

In summary, the book provoked in me much thought about related topics, e.g., the non-auditory experience of the deaf fetus and its meaning for mother-child interaction later on in infancy; the complexity of working with families in general; the whole concept of intuitive parenting; the position of the father; death of a premature baby or of clients in general, as well as many other thoughts and insights.

As a music therapist, I feel I got deep theoretical and practical information from this book. The book succeeds in delivering the message of the importance of this work. This field has become increasingly important. I highly recommend the book to music therapists, to other professionals who work with these vulnerable babies and to colleagues from the other creative art therapies in general as well.

Reference
Spintge, R., & Droh. R. (Eds.) (1992). MusicMedicine. St. Louis, MO, USA: MMB Music, Inc.

This bookreview was released August 31, 2005. ©2005 Nordic Journal of Music Therapy

Music Therapy for Premature and Newborn Infants
Edited by Monika Nöcker-Ribaupierre
Barcelona Publishers (2004)
226pp. Pbk. $28.00
Available in the UK from the BSMT £20.00
ISBN 1 891278 20 7

Reviewed by Jacqueline Robarts

This book provides a comprehensive introduction to music therapy with premature and newborn hospitalised infants on the threshold of life. It merits the attention of a wide readership, not only of specialists in Neonatal Intensive Care, but also music therapists and other professionals working with all kinds of clients, children and adults, where there has been a difficult start in life. Monika Nöcker-Ribaupierre has assembled an international collection of twelve chapters from leading clinicians and researchers in music therapy, child psychoanalysis, developmental psychology and psychiatry, communication sciences, obstetrics and gynaecology, anaesthesiology. Following a foreword by the internationally known infancy researcher, Mechtild Papousek, endorsing this pioneering area of music therapy, the book is divided into two sections: Part One, The Basics; Part Two, Research and Clinical Practice.

Part One introduces aspects of earliest infant development, and shows the complex interplay of neurological, physiological, emotional, developmental concerns that premature birth brings infants and parents. Five chapters offer an ever deepening understanding of the premature or newborn/hospitalised infant’s inner and outer worlds: early neurophysiological development (Fischer and Als), fetal hearing (Gerhardt and Abrams), attachment formation in the neonate (Gutbrod and Wolke), psychoanalytic perspectives on auditory perception and the development of mind (Maiello), and the regulating impact of resonance that assists the stabilising of the infant’s state and the development of the bonding process between parent and infant (Lenz and von Moreau). There are interlinking themes throughout, such as meticulous observation of infant internal and external state, sensitivity of the infant (skin, motion, position, smell, taste and hearing), the specialised input supporting infant-parent and family relationships, and, central to all of this, the well being and psychological development of the tiny infant. Yet each chapter stands alone, offering a choice of starting points for readers from different backgrounds, whether it be a parent, audiologist, paediatric nurse, doctor, psychologist or therapist.

I was immediately drawn to child psychoanalyst Suzanne Maiello’s chapter discussing early relatedness and her original concept of the ‘sound-object’. Maiello describes the beginnings of mind through the generating of shared meaning in relationship where ‘protoforms of an experience of relatedness may develop…. at the auditory level’. She proposes that the rhythmical qualities of this ‘sound-object’ may lie at the core of the infant’s developing basic trust. It is a concept particularly relevant to the field of early trauma, and can help music therapists think about the ways in which music therapy may serve to help repair foundations of being and being-with. I then backtracked to chapter 1 and the territory of fetus brain development and the infant’s behaviour observed as communication. Christine Fischer’s and Heidelise Als’ comprehensive introduction to this field is a tour de force in its copiously referenced and well structured overview of neurophysiological beginnings of life, leading to an account of NICU work where we see how important consistency of caregiving is in terms of the total environment supporting the parents to support the baby. They emphasise the trusting of the baby’s behaviour as revealing important information about its state. This may remind music therapists working with other clinical populations of the minute observations of external as well as internal responses as a central facet of all music therapy approaches, requiring a fine-tuning of our perceptions.

A fineness of attention is evident in every chapter throughout this book. Practical advice is also on hand: for example, Gerhardt and Abrams recommend that bass rather than treble frequencies should be emphasised in music played to a very young infant. I found this very useful information and something of a revelation to me, as infancy research widely reports that infants show a preference for the higher vocal register and melodic contouring of ‘motherese’. I was left wondering at what stage the premature infant’s hearing makes the transition to accommodating the higher frequencies. Tempo was not mentioned in this context, yet this also is an important feature in emotional regulation in very early infant-parent attachment and communication, the adagio of first communications (including movements) speeding up after two months or so to andante (Trevarthen 1984, 1999). I wondered if this principle applies also to receptive music therapy with the premature baby. These and other contributors here triggered my curiosity to explore the auditory world of the foetus and ‘preemie’, and think about its relevance to depth music therapy with children and older people.

My appreciation of being in the hands of these experts in their individual fields grew from chapter to chapter. As a clinician-researcher working with older children and adults, I must confess not a small surge of envy when reading of all the ‘hard’ data that is gathered in the NICU. Necessitated by the critical nature of infant’s state, monitoring is meticulous, with samples taken, machines and tubes watched, measures recorded, the subtlest shifts in behaviour evaluated. This means that the infant’s NICU environment plays host to a proliferation of machines and measuring instruments, a panoply of interventions that impact on the infant’s bodily experiences and emerging consciousness – and those of parents too. What seems a persistent ‘assault’ on natural, normal human experience is almost tangible in Lenz and von Moreau’s chapter and in the clinical chapters of Part Two. Lenz and von Moreau describe misunderstandings and misconnections that impair parents’ relationship with their newborn, and they give a particularly moving account of how the music therapist can work to help the bonding process. As Mechtild Papousek explains in her foreword: music adds ‘something more “natural” to the necessary, but often abounding technology involved in neonatal care.’ This section brings the reader up to date with recent neurological and the earlier, now classic, infant studies, such as those of De Casper and colleagues. However, there is one inexplicable omission: that of any reference throughout this excellent text to the publications of Allan Schore. Schore’s work on early attachment and the significance of affect regulation in the early development of mind and meaning would have aptly drawn together the neurological, psychological, developmental, and psychodynamic perspectives of these opening chapters. Nevertheless, the work of Daniel Stern, Beatrice Beebe, and members of the Process of Change group on procedural memory and the significance of ‘now’ moments are referred to by many of the contributors, and provide a common theoretical thread informing music therapy practice in Part Two. This unity of thinking offers a common point of reference within different disciplines and the different music therapy approaches that follow.

In Part Two (Research and Clinical Practice), we are brought up to date with research in the field of medical music therapy in a substantial opening chapter by Fred Schwartz. He expands on the research into the acoustical environment of the foetus, and draws attention to the consequences of exaggerated stress response for the premature baby: namely, that energy expended by stress response diverts it from serving growth and development. Most welcome is his extended reference to Jayne Standley’s important 1998 study which demonstrates that music and multi-modal stimulation can reduce duration of hospitalisation and is related to an infant’s weight gain. Once more we see that NICU is a field in which progress can be measured in a controlled environment, and where invasive and non-invasive procedures coexist in the service of preservation of life.

Chapters 7 -10 report clinical process within a variety of music therapy approaches. I make no apology for giving a brief overview of each, for every chapter is remarkable for its depth of clinical work and for the moving, incisive reporting of this emotionally difficult clinical field. It made me aware of the emotional fortitude required of the therapist, and, as Helen Shoemark notes in her chapter on work with families, the necessity for regular clinical supervision. Monika Nöcker-Ribaupierre (Chapter 7) explores the use of a therapeutic approach called Auditive Stimulation, which emphasises the fundamental role of the mother’s voice. She reports that most mothers became overwhelmed with emotion when trying to sing to their tiny babies. Auditive Stimulation offers a way of modulating these feelings (containing them perhaps), and a means of bonding as the mother reads to her baby, the music of her voice, its resonance, prosody, and rhythm of speech creating a sonorous feeling mutuality. The overall influence of the mother’s voice is a central theme throughout the clinical chapters especially, showing in various ways how crucial the experience of hearing the mother’s voice is for the infant’s physical and personality growth. There follows a chapter by Marie-Luise Zimmer also reporting on the use of Auditive Stimulation with premature babies and their mothers. From a psychoanalytic perspective, she describes the process of mourning an infant who does not survive and the role that music assumes in this process with the parents. It came as no surprise to learn that Zimmer also works with children with eating disorders and early childhood disorders. Auditive Stimulation seems apt for this population, too, and their families. This is yet another aspect of NICU work that highlights the value of a breadth of clinical approaches in music therapy with clients where there is emotional fragility behind massive defence, where there are invasive treatment procedures, and where life is at risk. Elisabeth Dardart (Chapter 9) gives an account of her use of music and massage in NICU work. She discusses a range of ways in which she uses music, emphasising ways in which music can counteract invasive treatment procedures. She gives case examples of early experiences surfacing from infantile memory in later life, showing how important it is that infant trauma is addressed at the time. The psychological and physical pain that arise in this work was familiar to me from working with children and adults with histories of early trauma and difficult births.

Turning to the whole family’s needs, leading Australian music therapist, Helen Shoemark, then describes family-centred music therapy (Chapter 10). In her clinical setting, music therapy is the first intervention offered to families, and is viewed as a form of empowerment drawing on their pre-existing strengths. Multi-modal stimulation is again emphasised: infant-directed singing as well as selected recorded music. The meticulous observation of infant response brings detailed awareness of musical elements. Shoemark notes a ‘pool’ of elements (melody, pulse, rhythm, harmony, tempo, pitch, timbre, attack, duration, register, dynamics, phrasing and silence) that must be closely monitored in NICU work. The therapist’s musical awareness of speech has to be honed minutely as in the most exacting clinical situations: plosives, such as ‘p’ and ‘ch’, may not be tolerated by the easily over-stimulated infant. She draws from Stephen Malloch’s research on Communicative Musicality in substantiating the clinical significance of these components of music therapy. Many clinicians will recognise the meticulous attention to the effect of music and voice when working with child or adult clients who are easily overwhelmed and who cannot self-soothe/self-regulate.

The final chapters provide valuable practical information for current and prospective NICU music therapists. Chapter 11 by leading clinician and researcher in this field, Joanne Loewy, describes a clinical model of music therapy in the NICU, from consultation, program proposal and implementation, through to referral criteria, and a helpful paragraph on assessment. It is evident that the NICU music therapist has to have research and clinical skills in equal measure: the capacity for rigorous record-keeping and attention to detail as well as sensitive communication skills and creative musical resources. Loewy also discusses environmental music therapy as a central need of the NICU, with examples of how this can be achieved. Deanna Hanson Abromheit (Chapter 12) deals with the practicalities of setting up a NICU music therapy program, not the least of which is developing skills in professional communications (verbal and written) with the administrative, medical and nursing team. She stresses the importance of the music therapist’s understanding of the issues involved in the premature infant’s medical state and development, and the need for the novice music therapist to communicate with established workers in this field. For any music therapist interested in embarking on this kind of work, Abromheit gives many useful tips on how to formulate a formal written proposal, including seeking financial support. Ending on a practical note, the appendix lists a bibliography and resources, specialist journals and websites in this field.

What is evident from this book is that a particular blend of personal qualities and exacting professional skills are required for NICU and related work. This is a book full of up-to-date information on the knowledge base, clinical and research perspectives relevant in NICU work. It is a practical handbook. Each chapter links theory and clinical practice with an up-to-date referencing of research relevant to this complex field. For clinicians interested in evidence-based, clinically applied research, this is a treasure trove. A moving book to read, and one that I trust will encourage more of us to take up the challenges of this small but growing field of NICU music therapy, it is a worthy companion to existing publications in the field of paediatric music therapy: Jayne Standley’s Music Therapy with Premature Infants: Research and Developmental Interventions (AMTA, 2003), Joanne Loewy’s Music Therapy and Pediatric Pain (Jeffrey Books, Cherry Hill, NJ, 1997), Sheri Robb’s Music Therapy in Pediatric Healthcare (AMTA, 2003), and Wigram and De Backer’s Clinical Applications in Developmental Disability, Paediatrics, and Neurology (Jessica Kingsley, London, 1999). It has been some time since I have been so enthralled by a collection of chapters. Because most of the contributors draw from a common range of interdisciplinary knowledge and clinical experience, the chapters flow with a sense of community and with a sharing of knowledge and expertise, led by the needs of premature and newborn babies and their families. All credit is due to the initiative and editorial skills of Monica Nöcker-Ribaupierre, assisted by the excellent translation of the English edition by Susan Weber.

Jacqueline Robarts is a Senior Therapist and Clinical Tutor at Nordoff-Robbins Music Therapy Centre, London, where she teaches on the Masters program. In her clinical practice she works with children and self-referring adults. She has many years’ experience in inpatient and community-based Child and Adolescent music therapy in the NHS. A recipient of two City University Research Fellowships, her clinical specialisms and research focus on musical, psychobiological-developmental, and psychodynamic processes of symbolization in music therapy with autistic, abused, and anorexic children, and adults with histories of early trauma.

References
Trevarthen, C. (1984). Emotions in infancy: Regulators of contacts and relationships with persons. In K. Schere and P. Ekman (Eds) Approaches to Emotion: pp.129-157. Hillsdale, NJ: Erlbaum.

Trevarthen, C. (1999) Musicality and the intrinsic motive pulse: Evidence from human psychobiology and infant communication. Musicae Scientiae. August Special issue: Rhythm, Musical Narrative and Origins of Human Communication: pp.157- 213