Resumen de La experiencia musical como factor curativo en la musicoterapia con pacientes con esquizofrenia crónica

Juan José Sánchez Sosa, Esther Murow Troice

• español

  Este artículo tiene por objeto examinar el empleo de la musicoterapia en la percepción de bienestar, según las respuestas de un grupo de pacientes de esquizofrenia durante y como con-secuencia del tratamiento con musicoterapia. Un propósito adicional es describir cómo evoluciona la percepción del empleo y de la utilidad de la experiencia musical como recurso terapéutico y su relación con los cambios en los síntomas negativos obtenidos en evaluaciones con el PANSS.

  Para ello se estudiaron 15 sujetos con diagnóstico de esquizofrenia en fase crónica, de varios tipos. Este grupo formaba parte del Programa de Rehabilitación Integral de Pacientes con Esquizofrenia del Instituto Nacional de Psiquiatría Ramón de la Fuente, en la Ciudad de México. Los sujetos del estudio formaban parte de una muestra mayor (N = 42) de pacientes con esquizofrenia asignados aleatoriamente a tres tipos de tratamientos psicosociales, de los cuales uno fue la musicoterapia. Los pacientes asistieron a un promedio de 35.8 sesiones de un total de 40 que incluía el programa (89.5%). Estas se llevaban a cabo dos veces por semana y duraban una hora. El trabajo del grupo lo conducía una musicoterapeuta certificada. En el trabajo con musicoterapia se emplearon técnicas de improvisación musical clínica. La improvisación musical clínica tenía por objeto mejorar la comunicación verbal y no verbal, brindar un medio a la autoexpresión, fomentar la interacción interpersonal, desarrollar habilidades para la interacción grupal, brindar estimulación sensorial y desarrollar la creatividad.

  Para evaluar tanto el bienestar de los pacientes a lo largo del tratamiento como su percepción de la experiencia en el trabajo con la música, se desarrolló una breve forma del registro de bienestar en la sesión de musicoterapia, que era llenado por los pacientes al principio y al final de cada sesión. En la primera parte del cuestionario, se les pedía que calificaran en una escala de 1 a 10 (de muy mal a muy bien), cómo se sentían al iniciar la sesión y cómo se habían sentido en la última semana. La segunda parte del cuestionario se respondía al final de la sesión, y en ella se le pedía al paciente que calificara cómo se sentía después de la misma y que señalara para qué le había servido el trabajo de improvisación con instrumentos musicales.

  A los pacientes también se les aplicó la escala de Síntomas Positivos y Negativos de la Esquizofrenia (PANSS).

  Los resultados indican, en general, que los pacientes informan de una mejoría en su sensación de bienestar a lo largo del tratamiento. Las respuestas muestran que, a partir del tercer mes de tratamiento, se encuentran diferencias significativas entre cómo se sentían cuando iniciaron y en ese momento del tratamiento. Esta sensación de bienestar permanece hasta el final del tratamiento.

  Aunque no se encontraron diferencias significativas en las puntuaciones del PANSS antes y después del tratamiento, sí se observó una tendencia y cercanía a la significancia en la escala de síntomas negativos. Asimismo, la correlación significativa entre la sensación de bienestar reportada por los pacientes y la disminución de los síntomas negativos indica que, cuanto menos síntomas negativos había, mayor era la sensación de bienestar. Los resultados de las evaluaciones de los pacientes de este grupo permiten afirmar que la musicoterapia ayuda a disminuir los síntomas negativos, como lo han informado Tang y colaboradores.

  En cuanto a la percepción de para qué les sirvió tocar los instrumentos, los porcentajes correspondientes permanecieron estables. Los aumentos más importantes incluyeron ¿divertirme¿, con un aumento de 26.7% al final del tratamiento, y ¿encontrar una solución a mis problemas" (27.7% de aumento). Puede ser que sentirse mejor les permita disfrutar más de las actividades musicales lo cual, en este tipo de pacientes, es importante por la anhedonia que caracteriza a la enfermedad y que tanto afecta el funcionamiento social. La respuesta de que tocar los instrumentos les permite encontrar soluciones a sus problemas puede resultar del aprendizaje que se adquiere a lo largo del tratamiento y de experimentar el trabajo con la música como medio de mejoría. De ser así, éste podría considerarse como uno de los factores curativos en la musicoterapia, en que la música se considera un elemento principal más que secundario. La disminución en el porcentaje de las respuestas relacionadas de «relajarme» y «expresar mis sentimientos» podría indicar que el trabajo con la música, además de "catártico" como suele ser al inicio del tratamiento, permite un empleo más dirigido al desarrollo de habilidades sociales y a encontrar una forma de resolver algunas dificultades, sobre todo en el área interpersonal.

  El empleo de la musicoterapia en pacientes con esquizofrenia ha mostrado ser una intervención que genera resultados positivos para mejorar el funcionamiento de este tipo de pacientes. Los resultados obtenidos con los participantes del presente estudio muestran que los pacientes se van sintiendo mejor a lo largo del tratamiento. Los informes de los pacientes indican que cada vez se sienten mejor, frecuentemente aun desde el principio del tratamiento. Esta percepción de mejoría puede funcionar como factor para facilitar la permanencia y la participación activa en el tratamiento.

  La mejoría en la sensación de bienestar y su asociación con la mejoría en los síntomas negativos es uno de los efectos que ha mostrado tener la musicoterapia en pacientes con esquizofrenia. El hecho de que este efecto se presente gradualmente y permanezca a lo largo de los seis meses, o más, puede considerarse como un efecto importante de la musicoterapia.

  Asimismo, que muchos pacientes puedan emplear la experiencia musical como elemento curativo puede entrañar dos implicaciones relevantes. Por un lado, es probable que con la musicoterapia aparezcan cambios correctivos (sensoperceptuales, interpersonales, etc.), ligados precisamente a la experiencia con la música; por otro, las observaciones clínicas informales sugieren que los pacientes adquieren paulatinamente mayor capacidad para entender algunas de sus dificultades y tratar de encontrarles solución.

  Como ya se ha mencionado, la anhedonia es uno de los síntomas que más afectan el funcionamiento social. Si los pacientes son capaces de divertirse y disfrutar de esta experiencia, no es exagerado sugerir que han ocurrido cambios en su capacidad hedónica, con la concomitante disminución de algunos síntomas negativos.

  Es muy probable que la experiencia de la improvisación musical en una situación de grupo, en un ambiente relativamente relajado y de aceptación, sea un factor que fomente la sensación de bienestar como inicio de un mejor funcionamiento psicosocial. En este caso es de considerarse que la experiencia musical y la improvisación musical clínica, con todas sus características, cons-tituyen importantes factores curativos, quizá esenciales en el empleo de la musicoterapia en pacientes con esquizofrenia crónica.

• English

  This article describes the perception of well-being in a group of schizophrenic patients who attended music therapy. This study also describes the perception of usefulness of the musical experience as a curative factor. The relationship between the perception of the musical experience as a therapeutic factor and the negative symptoms was also examined. The subjects in this study were 15 patients with chronic schizophrenia who attended an outpatients Rehabilitation Program for Schizophrenic Patients at the National Institute of Psychiatry Ramon de la Fuente in Mexico City. Sixty-six point seven percent of the subjects were male with a mean age of 32.1 years (s.d. + 7.7 yrs.) and 13 years of schooling (s.d. + 2.2). The average age of onset was 24:2 years (s.d. + 6.3 yrs.). Fifty-three percent were single, 20% were married, and 26.6% divorced or separated; 66.7% did not have a formal job. Patients attended an average of 35.8 sessions (89.5%) out of 40. Sessions were an hour long and took place twice a week. The therapeutic work was conducted by a board certified music therapist. Music therapy was based on improvisational techniques. The goals of clinical musical improvisation were to improve verbal and non verbal communication, to provide a means for selfexpression, to improve interpersonal interaction, to develop abilities for social interaction, to provide sensory stimulation, and to enhance creativity. To assess the feelings of well-being and the perception of the musical experience, the authors developed a short self-report form to be filled out by the patients at the beginning and the end of every session. In this self-report they were asked to mark in a continuum from one (really bad) to ten (very well) how they felt at the beginning of the session and how they felt during the past week. There was a section where they could mark some specific feelings. The second part of the self-report form was filled out at the end of the session. Patients had to mark on a similar continuum how they felt at the end of the session. They also had to mark what the work with the musical instruments had helped them to achieve. They could check several options. They were also asked to rate on another continuum their participation in the session: 1= participation was very poor to 10= full participation in the session. In order to know if music therapy had any effect on the patients’ symptoms, they were assessed at the beginning and the end of the treatment with the PANSS. An analysis of the data (comparison of the medians before and after the treatment) shows that there were statistically significant differences on how the patients felt at the beginning and the end of the treatment, showing that they felt better after six months. The results also show significant differences in the report of their participation in the session, which had increased. One important part of the study was to identify at what point during the treatment did patients start to have a relatively permanent feeling of well-being. In order to find out when that happened, they had to answer a question about how they had felt during the past week. A comparison between the sensation of well-being at the first session and the reported well-being on the first session of each month was made through the six months of treatment. Results show that although patients report an improvement in their well-being from the beginning of the treatment, there are statistically significant differences (p=.001) from the third month until the end of the treatment. The scores of the PANSS before and after the treatment did not show any statistically significant differences in any of the scales. A correlation analysis between the negative symptoms scale of the PANSS and the well being in the last week of the selfreport was made. Results show that there is a statistically significant correlation (r= -0.623, p=.03) between the feeling of well-being and the negative symptoms scale of the PANSS, between the feeling of well being and the general psychopathology scale (r = -.742, p =.006), and the feeling of well-being and the total score of the PANSS (r =-.714 p =.009). These results may indicate that as negative symptoms decrease, the feeling of well-being increases. In order to find out the perception about the usefulness of the work with music, the answers to the question “the work with the music helped me to…” were analyzed. The percentages to each answer before and after the treatment were examined. The following are the questions that obtained the highest percentages before the treatment: to relax (80%), to let my feelings out (60%), to have fun (53.3%) and to relate to my peer group (53.3%). The answers with the highest percentages at the end of the treatment were to have fun (80%), to relax and to relate to my peers (60%) and to express myself (66.7%). The highest increases were in the questions to have fun (26.7%) and to find an answer or solution to my problems (26.7%). The answers to some questions diminished: to let my feelings out (-20%) and to talk about my feelings (-20%). The way the patients perceived their participation was significantly different before and after the treatment (p= .006). In general, results show these patients report an improvement in their feeling of well-being throughout the treatment. Their answers show that from the third month there are statistically significant differences on how they felt at the beginning of the treatment and through it. The feeling of well-being seems to remain from the third month on. Though no statistically significant differences were found in the PANSS scores before and after the treatment, there was a tendency towards significance in the negative symptoms scale. A significant correlation was found between the feeling of wellbeing as reported by the patients and a reduction in the negative symptoms. This could mean patients feel better as they experience less negative symptoms. This is congruent with other findings reporting that in the long term negative symptoms are more disabling and that they interfere with the psychosocial functioning of the patients. The reduction of negative symptoms allows them to have a better level of functioning. The patient’s answers to the self-report allows us to conclude that music therapy helps to reduce negative symptoms. Throughout the treatment feelings of well-being improved in the patients of this study; this may be related to the fact that the therapeutic process made sense to them. If that is the case, the feeling of well being and the fact that therapy makes sense and is perceived as useful can also be related to a better therapeutic compliance and attendance to the sessions. Participation in the sessions increases through treatment. Informal conversations with the patients indicate that they developed a feeling of belonging to the group, more confidence in themselves and the others, and that the work in the non-verbal realm and in the musical one has helped them to feel better. The former factors may have helped them to feel better and therefore to have a more active participation in the sessions. The perception of the patients about the usefulness of playing musical instruments remained constant. The main changes were on the answers “having fun”, which increased 26.7% at the end of the treatment, and “find a solution to my problems” (27.7%). It may be that the fact that they feel better allows them to enjoy musical activities more. With this kind of patients, this is very significant since anhedonia is one of the characteristics of schizophrenia and has an important effect on their functioning. The answer that playing musical instruments allows them to find an answer to their problems may be the result of a learning process along the treatment but also to the possibility of perceiving the musical experience and working with music as a way to feel better. If that is the case, this could be considered as one of the curative factors in music therapy, in which music is considered as the main element and not a secondary one in the therapeutic process. The decrease in the percentage of answers “playing the instruments helped me to relax” and to “express my feelings” may indicate that working with music goes beyond catharsis, as it may have happened at the beginning of the treatment, and allows for a more purposeful development of social and problem solving skills. The use of music therapy with schizophrenic patients has produced positive changes in their social functioning. The results form this study show that patients feel better along the treatment period . Patients report they feel better with the treatment often from the beginning. This perception of well-being may result as a factor that facilitates and promotes permanence and an active participation in the treatment process. One of the effects of music therapy in chronic schizophrenia patients is the improvement of the well-being experience and the decrease of negative symptoms. Also the fact that this occurs gradually and remains throughout the treatment and probably beyond is a result of music therapy. Also, the fact that many of these patients are able to use the musical experience as a curative factor may have relevant implications for music therapy. On the one hand, it is possible that music therapy promotes several corrective senso-perceptual, interpersonal, and affective changes linked to the musical experience. On the other, clinical observations suggest that patients are able to gradually increase their ability to understand some of their difficulties and to try to find some kind of solution. As mentioned before, anhedonia is one of the symptoms that interfere with social functioning. If these patients are capable of having fun and enjoying the musical experience, it is not unlikely that they may have experienced changes in their hedonic ability. It is very possible that the experience of musical improvisation in a group situation, in an accepting and non-threatening environment, is a factor that promotes the experience of wellbeing as a starting point to a better psychosocial functioning. In this case, it is important to consider clinical musical improvisation, with all its characteristics and attributes, as the essential curative factor in the use of music therapy with chronic schizophrenia patients.