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In much the same way that bodily movements can be produced – consciously or semi-consciously – in relation to musical properties, so, too, a range of bodily processes can be entrained in relation to other temporally organized environmental media. Entrainment may involve regularizing and/or modifying physiological states (for example, oxygen levels in the blood or heart rate), behaviour (at any level of detail – for example, blinking, fidgeting, jumping or sleeping), the temporal parameters of mood and feeling (as described in chapter 3), and social role and action style, which are discussed in chapter 5. Musical entrainment and its observable character thus provide a clear example of how environmental materials and their properties may be said to a ord or provide resources for particular kinds of bodies and bodily states, states that are regularized and reproduced over time. Of special interest here, in relation to the neonatal body, is the way in which music is currently being employed to mediate tensions between endogenous (bodily) and exogenous (environmental) processes within neonatal intensive care units. Examining this issue, via the neonatology literature, advances the conception of ‘human–music interaction’ and musical ‘a ordances’ as developed in previous chapters and applies it to the earliest phase of human life.

Paradox of cure in the neonatal unit – the body’s sonic resources

Neonatal infants are often state-disorganized. In extreme situations of bodily distress, they thrash their extremities and head, they grimace, exhibit fluctuations in heart rate, blood pressure and skin coloration, they may be intolerant to feeding, their muscles may be flaccid or rigid, they may cry, and the oxygen levels in their blood may be low. All these things are taken as symptoms of ‘state instability’, that is, ill health. In the face of this instability, a range of neonatal devices are deployed to regularize physiological processes and behavioural states. Within the neonatal ICU, mechanical ventilators, heart monitors and intubation (for administrating drugs and nourishment) are, often literally, life supporting.

A neonatal infant is exposed to few stimuli, apart from those that derive from medical devices. Confined to crib or incubator, unable to be touched, the neonatal infant may also not yet be able to see, and if even if she is able to see, she is not at liberty to move her head freely, to direct her gaze freely. Given these limitations, it seems reasonable to suggest that the sonic dimension of the neonatal environment is heightened.

Like temperature or lighting, the sound of a unit – with or without musical intervention – is a ubiquitous environmental feature; it is also one that the infant cannot escape. And yet, the routine sound of a neonatal

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intensive care unit is frequently cacophonous; it consists mainly of sounds that are the random byproduct of medical technologies (for example, the sound of respirators or the sounds of bottles clanking on the incubator top), the sounds of other infants in distress, or, perhaps worse, amplifications of the infant’s own disorganized state through devices such as the heart monitor, whereby an infant’s (possibly erratic) heartbeat is amplified and mirrored back as an audible beeping.

Paradoxically, then, the very environment in which neonates exist, and upon which they are dependent for life support, may also serve to inhibit an infant’s autonomous capacity for, as Kaminski and Hall put it (1996, quoted above), ‘harmonious integration’ of body with environment in a way that can produce state regulation. Not only is the infant’s auditory environment lacking ‘salient recurrent features’ (that is, sonic resources for embodied regularization), but the very machinery of life support may lead to the disruption of state lability, biorhythms and sleep (Kaminski and Hall 1996:46). The ‘cure’, in other words, brings some problems in its train.

The neonate’s paradox is not unlike the situation faced by creative music therapeutic clients such as Gary, described in chapter 1, or Mandy in chapter 3, for whom the unassisted elaboration of identity and entrained (mutually co-ordinated) interaction was problematic. Gary’s and Mandy’s distress is related to and exacerbated by their inability to appropriate environmental-cultural materials for self-organization (identity, comportment, physiology). Neither can engage in the normal modes for co-ordinating and interacting (such as verbal communication). Moreover, because they have other disabilities (for example, Gary is visually disabled), the mundane environment presents a barrage of stressful, often apparently chaotic, events (for Gary, having his incontinence pad changed can be, according to how it is undertaken, a frightening ordeal). Music therapy sessions, on the other hand, o er a means of mitigating distress in so far as the therapist is engaged in strategic manipulations of music so as to enable them to ‘compose themselves’, constructively mirroring their gestures and engaging in musically ‘supportive’ activity. Within the sessions, their self-composition arose from their production of musical gestures that spanned time; engaging in this production they also produced themselves as actors – that is, as actors who were engaged in continuous activity – the activity of producing music. Within the realm of music therapy, then, they were able to form and hold themselves as producers of expressive forms, to engage in symbolic interaction. Thus the musical therapeutic environment allowed them to achieve something denied to them in daily life. Without this kind of musical support, as o ered by the therapeutic session, Gary and Mandy are caught in a

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vicious circle within which the environment and its perceived lack of regularity impede the process of self-composition.

A similar vicious circle typifies the situation of the neonatal infant. It is well known to clinicians and well reflected in the literature. For example:

neonates must synchronize their behavioral states and physiologic adjustments with an environment where there is no clear, pronounced diurnal rhythm in noise level or in caregiving activities. This is significant because, for the neonate, one of the primary biorhythmic elements is the distribution and flow of sleep–wake states over a 24-hour period. In the nursery environment, continuous noise a ects neonatal biorhythms, and this a ects sleep regulation and state lability. (Kaminski and Hall 1996:46)

For a neonate, this contrast is stark. Prior to birth, the infant’s environment is characterized by sonic regularity, by rhythm. Moreover, the auditory environment was probably not associated with traumatic events. As some researchers have remarked, ‘one of the most stressful changes that occurs during the transition from intrauterine to extrauterine life is the loss of rhythm that the foetus has become accustomed to through months of being exposed to maternal movements, breathing, and heartbeat’ (Collins and Kuck 1990:24).

This is where music can make a di erence, can be used to break out of the vicious circle of a neonate’s dependency upon technology, much as it does for creative music therapy clients. First, auditory stimuli, which can waft through the unit or be employed through pillow or mattress speakers, can actually ‘reach’ the infant where other types of entrainment materials, such as touching, may not. Music is simply an available, practical medium in the intensive care unit for delineating a patterned and stable or predictable environment. In addition, it can be used to mask the unit’s auditory baseline of technical equipment and other ‘stressing’ noises. It is with these ends in mind that recent innovations in neonatal care have involved musical interventions. Music is increasingly seen by neonatal professionals as an e ective means for modulating the array of physiological states and micro-behaviours associated with instability into an array associated with stability – stable heart rate, blood pressure, colour, feeding, changes in posture, muscle tone, less frantic movements, rhythmic crying, cessation of grimacing and an ability to sleep and/or become animated and intent. For example:

Baby B, a 2,665 gm, 34-week gestational age male . . . exhibited respiratory distress at birth . . . Fentanl [a respiratory depressant] was given every two to four hours as needed for agitation associated with the mechanical ventilation. Baby B’s response . . . consisted of brief periods of apparent sleep, which did not last more than 30 minutes. To provide comfort . . . we played the

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‘Transitions’ tape for periods of one to two hours. During these periods, Baby B was able to use his pacifier for self-quieting, and he appeared to be sleeping. (Leonard 1992:47)

The introduction of music (a combination of intrauterine sound and synthesized female vocals, produced by Placenta Music Inc.) to the neonatal unit would thus appear to create, with minimal cost or e ort, a modified and regularized environment. According to the medical criteria and medical observations, this musical environment helped to regularize the sleep patterns of the neonatal infant.

Such use, of which this was an instance, is increasingly common within neonatology. It is becoming more common in other realms of medicine as well; Cheryl Dileo Maranto has delineated music’s use in a range of medical procedures. These include surgery, where music listening has been linked with, among other things, a reduction of stress hormone levels, diminished need for anaesthesia, lowered pulse and stable blood pressure rates, reduction in postoperative pain and the need for analgesic medication (1993:161). Music has also been used in conjunction with respiratory care, for entraining respiration, in burn care, and in labour and delivery to compress time during labour, to distract or serve as a focal point, to regulate breathing, to enhance Lamaze procedures, to enhance the ‘euphoria’ of birth and to decrease the length of labour. It has also been used widely in the area of pain management, to increase pain threshold and tolerance levels and to enhance relaxation. In relation to joint mobility, music can be used to profile movement. (For example, waltz music may be used to encourage ‘fluid’ movements and dexterity, whereas disco numbers will be used when the client needs to build up strength through more powerful and energetic movements (Bunt 1997).)

There would appear to be little doubt that music therapy holds considerable promise for clinical medicine. To be sure, it has received increasing attention in recent years, spurred on by the fact that it is highly cost e ective (Maranto 1993). At its present state of development, however, music therapy still lacks a theoretical base and has a relatively undeveloped explanatory vocabulary for specifying how music operates – as opposed to what it can produce – in relation to body organization.

How does music work? Key questions

For example, how does music come to have ‘e ects’ upon body composition? With regard to neonatology, what exactly does it mean to speak of an infant’s interaction with the recurrent sonic features of his or her environment? Indeed, is it music’s regularity that leads to self-regulation, to an infant’s ability to shift her/himself to a more stable state? Or is it simply