Running Header: MAKING MUSIC WITH MOMMY AND ME “Making Music with Mommy and Me”: A Perinatal Music Therapy Program Alicia Drexel Berklee College of Music MAKING MUSIC WITH MOMMY AND ME Abstract Making Music with Mommy and Me is a perinatal music therapy program designed for mothers who want to connect more with their infants. This program aims to use the technique of songwriting and other music based bonding techniques to tap into the creativity of the mother as a way for her to bond with her baby and form healthy maternal-infant attachments. An accompanying guidebook provides music therapists with a pre-questionnaire, assessment forms, a post-questionnaire, as well as session outlines, a list of suggested songs, and options for songwriting. By the end of this threesession program, the mother will have learned techniques to bond with her baby, and created a bonding song, which she can sing to her newborn baby. Keywords: music therapy, postpartum depression, attachment, bonding, perinatal 2 MAKING MUSIC WITH MOMMY AND ME 3 Acknowledgments I would like to thank everyone who helped shape this project. First to my amazing chairperson, Dr. Suzanne Hanser, thank you for your unending support in first helping me form my original ideas into this project and then for your guidance in developing the guidebook and pushing me to articulate everything clearly. Thank you to Dr. Joy Allen, and Heidi Lengel for coming aboard my committee and providing insight and knowledge regarding this area of music therapy. To my family, thank you for all your love and support as I went through this journey and for always believing in me. I am grateful to have been a part of the second graduating class of the graduate music therapy program at Berklee College of Music and to have been among many inspiring music therapists. My experience has changed me as a music therapist, and I will always be thankful for the connections I made. Lastly, I acknowledge that I would not have been able to complete this without the help from above. “I can do all things through Christ who strengthens me” ~Philippians 4:13. And that this was all part of His plan for me. “For I know the plans I have for you, declares the Lord, plans to prosper you and not to harm you, plans to give you a hope and a future” ~Jeremiah 29:11 MAKING MUSIC WITH MOMMY AND ME 4 Table of Contents Abstract……………………………………………………………………………………2 Acknowledgments…………………………………………………………………………3 PART A: Background and Development of the Guidebook- Making Music with Mommy and Me: A Perinatal Music Therapy Program ……………………………………………5 1. INTRODUCTION……………………………………………………………………...7 2. LITERATURE REVIEW………………………………………………………………8 2.1 Pregnancy Stressor and Postpartum Depression.……………………………...8 2.2 Attachment. …………………………………………………………………...9 2.3 Music and Pregnancy………………………………………………………...11 2.4 Music Therapy and Pregnancy……………………………………………….12 2.5 Music and Early Infant- Mommy and Me Programs ………………………..14 2.6 Rationale and Purpose………………………………………………………..15 3. METHODS……………………………………………………………………………15 3.1 Qualifications and Training.………………………………………………....16 3.2 Settings and Materials……………………………………………..................17 3.3 Session-by-session……………………………………………………...……17 3.4 Evaluation Tools……………………………………………………………..19 4. CONCLUSIONS AND RECOMMENDATIONS.…………………………………...21 5. REFERENCES………………………………………………………………………..23 PART B: Guidebook- Making Music with Mommy and Me: A Perinatal Music Therapy Program…………………………………………………………………..……………... 28 MAKING MUSIC WITH MOMMY AND ME PART A Background and Development of The Guidebook- Making Music with Mommy and Me: A Perinatal Music Therapy Program 5 MAKING MUSIC WITH MOMMY AND ME 6 Part A contains background information and details of the development of the guidebook- Making Music with Mommy and Me: A Perinatal Music Therapy Program. This program was developed to address a key area of development in neonate: attachment and bonding. The introduction and literature review explain the need and importance of the bond between a mother and infant, as well as the challenges that may arise during pregnancy and postpartum that can hinder this process. A brief look at the current research in music therapy, as well as current programs available for this population is also discussed. An explanation of each part of the guidebook is described as well as the selection of the bonding techniques. The guidebook can be found in Part B - Making Music with Mommy and Me: A Perinatal Music Therapy Program. The guidebook provides music therapists with a prequestionnaire, assessment forms, a post-questionnaire, as well as session outlines, list of suggested songs, and options for songwriting. The guidebook also contains resources for postpartum depression and details of the four bonding techniques that are implemented in the three sessions. MAKING MUSIC WITH MOMMY AND ME 7 Introduction Music is universal! People of all ages and cultures can listen, perform, create and enjoy music (Davis, Gfeller & Thaut, 2008). Music is multisensory: auditory, visual, tactile and kinesthetic (Bruscia, 1998). Music is unique to humans and is part of the culture and history. Music is both active and receptive in nature; composition, improvisation, performance and listening each have significant roles (Bruscia, 1998). Music is fundamental in bringing people together. Whether in a communal fashion with many or in more intimate family gathering, music has had a role and impactful power to bring people to bring people together for centuries (Davis, Gfeller & Thaut, 2008). It not only brings people together but can also create relationships and bonds between people. Forming these attachments is crucial for our survival as humans; we need to feel connected and a part of something. It is a human need to develop close emotional bonds as a biological function of survival (Bowlby, 2008). These relationships and attachments begin early in our lives. It is therefore important for mother and baby to form healthy attachments in order to promote growth and health in both baby and mother postpartum or after birth. These healthy attachments are not only crucial during the perinatal stage of pregnancy, but will impact the future relationship between baby and mother (Maddahi, Dolatian, Khoramabadi & Talebi, 2016). Research supporting the challenges inherent during pregnancy and during postpartum are presented here, along with findings regarding the role of music in pregnancy and after the birth. As can be seen in the literature, the universal, multisensory, unique phenomenon that is fundamental in bringing people together may also aid and support this process of maternal-infant attachments. MAKING MUSIC WITH MOMMY AND ME 8 Literature Review Pregnancy Stressors and Postpartum Depression Both pregnancy and postpartum period can bring many challenges for baby and mother. Pregnancy can be a stressful time in a woman’s life. Mothers may be experiencing changes in emotional, physical and social aspects of life (Shin & Kim, 2011). These stressors can increase when the pregnancy becomes a high-risk pregnancy or the mother experiences any form of trauma during pregnancy. In addition to “normal” stressors, mothers may experience stress related to hospitalization, their risk status, and concerns over the health of the baby (White et al., 2008; Shin & Kim, 2011). The transition into parenthood can also be stressful and mothers and/or caregivers may experience other challenges during this time. Mothers may experience anxiety and depression during their pregnancy and this can continue postpartum as well. Postpartum depression affects up to 1 in 7 women, according to the American Psychological Association (Postpartum Depression, n.d.). The DSM-V recognized that anxiety and depression may occur both during and after pregnancy and has revised the once called major depressive disorder with postpartum onset to major depressive disorder with perinatal onset (Wenzel & Kleiman, 2015). Postpartum anxiety and depression can take on various forms including generalized anxiety, panic attacks, social anxiety, obsessions and compulsions, and posttraumatic stress. While there are risk factors any mother may experience these symptoms. Other stressful life events can also cause postpartum depression. A study done by Salm, Kanu, & Robb (2017) examined how SLE’s were related to postpartum depression. They looked at three SLE’s: arguments with partner, trouble paying bills, and MAKING MUSIC WITH MOMMY AND ME 9 separation/divorce. It was concluded that experience high stress significantly predicted postpartum depression. Postpartum depression not only affects the mother, but can have a lasting effect on the child as well. Closa-Monasterolo et al. (2017) looked at the effect of postpartum depression and current mental health problems of the mother on child behavior at eight years. They concluded that maternal postpartum depression and current mental health problems, separately and synergistically, increase children's psychological problems at 8 years. Postpartum depression is also associated with decreased infant bonding, impaired child development, marital discord, suicide, and infanticide (Wilkinson, Anderson, & Wheeler, 2016). There are various pharmacologic and non-pharmacologic treatment methods for postpartum depression. In 2007, Msri & Kendrick (2007) conducted a literature search on the treatment modalities used in the treatment in postpartum depressions. They found that women with perinatal depression and anxiety disorders require timely and efficient management with a goal of providing symptom relief for the suffering mother while simultaneously ensuring the baby's safety. They also stated that although knowledge in the area of appropriate intervention is constantly evolving, rigorous and scientifically sound research in the future is critical. The purpose of the guidebook in this document is to provide mothers with a resource to work on improving their bonds with their babies, addressing one of the issues common in postpartum depression. Attachment Attachment is defined as “a close emotional bond between two people” (Santrock, 2008, p.360). Many theorists have views on why infants become attached to their mother MAKING MUSIC WITH MOMMY AND ME 10 or caregiver. For example, Freud notes that infant become attached to the person or object that provides oral satisfaction, whereas Erikson believed physical comfort and contact play a role in developing those attachments. Bowlby (2008), however, believed that infants and their caregivers are predisposed to form attachments and that there are four phases in developing the attachments. He believed that infants develop an internal working model of attachment, a simple mental model of the caregiver, their relationship, and the self as deserving of nurturing care (Bowlby, 2008). Another set of theorists (Fonagy et al., 1995) believed in the theory of reflective functioning (RF). Reflective functioning is the capacity to understand that one’s own or another’s behaviors are linked in meaningful ways to underlying mental states such as feelings, wishes, thoughts, and desires. Fonagy and colleagues suggested that secure attachment is the direct outcome of successful containment, which is the parent’s ability to reflect the infant’s internal state and represent that state for the infant as a manageable experience. So not only does the mother have to understand the behavior demonstrated by the infant, but she also must communicate that in a way that is a model for the infant. Grienenberger, Kelly and Slade (2005) studied the correlation between mental states and observed caregiver behavior in the intergenerational transmission of attachment. The results of their study supported this theory of attachment, and further explained that infants rely on their mothers to respond at the behavioral level relative to the mother’s affective state. Forming healthy attachments is crucial for infants and a necessary part of their growth and development. It is both a physical and psychological need of babies that provides comfort and protection. The mother is typically the first emotional attachment MAKING MUSIC WITH MOMMY AND ME 11 of the child and therefore will have an impact on all future attachments the infant develops (Perrelli, 2014). This bond, however, may not come naturally for the mothers, but is an ongoing process starting during pregnancy and continuing once the infant is born. How can parents support this process? What can they do to promote healthy attachments? Some studies have shown that singing lullabies to the infant promotes maternal-infant bonding (Persico et al., 2017), while others focus on eye-to-eye contact (Robson, 1975). The benefit of singing is that is can be done during pregnancy. Mothers can sing to their babies and babies can begin to recognize their mother’s voice. A study by Damastra-Wijmenga (1991) concluded that babies pay special attention to their mother’s voices over other women’s voices and even to a lullaby, which the mother had played for them. Babies begin to respond to sounds during the third trimmest of development at about 32 weeks (Santrock, 2008). Therefore, these attachments can begin during the beginning of the perinatal phase of pregnancy. While there are various opinions on what the perinatal phase consists of, this protocol will be focusing on the postpartum end of the spectrum and will include birth to one-year. Music and Pregnancy Music can have a role in reducing stressors associated with typical and high-risk pregnancies. Active music making, listening to music and singing can reduce the stress of the mother and therefore promote healthy development of the neonate (Arabin & Jahn, 2013). In addition to reducing the stressors, mothers are able to “interchange emotions with their infants” (p 357), and increase the bond between them. While neonates will not understand the meaning of words, they are able to comprehend elements of the music, MAKING MUSIC WITH MOMMY AND ME 12 such as the musicality and rhythm of language, and begin to from a bond with the mother and her voice. Music Therapy and Pregnancy Music therapy has also played a role in perinatal phases. It has been used to promote relaxation during labor and delivery (Hanser, Larson & O’Connell, 1983; Clark, McCorkle & Williams, 1981) and during transvaginal ultrasounds (Shin & Kim, 2011) and has addressed areas, such as alleviating stress during antepartum hospitalization (Bauer et al., 2010) and the psychological health of women during pregnancy (Mei-Yuah, Chung-Hey & Kuo-Feng, 2008). However, there is little research on the effects of music therapy in regard to maternal-fetal attachment. Chang, Chen & Chen (2015), recommend further study investigating the long-term effect of listening to music on childbirth outcomes and postnatal psychology of women. Music therapy has also played a role during the postpartum phase. Researchers such as Jayne Standley and Joanne Loewy have both pioneered various techniques and interventions for use of music therapy with premature infants. In her book, “Music Therapy with Premature Infants” (2010), Standley describes three techniques to be used in the NICU. They include sustained live music, music and non-nutritive sucking (NNS) and music and multimodal stimulation. While all of these techniques require the implementation by a NICU trained music therapist, the multimodal stimulation can be done with the parent facilitated by the music therapist. Joanne Loewy pioneered another music therapy training called First Sounds RBL (rhythm, breath, lullaby). Through this intensive training music therapist learn various techniques to be implemented in the NICU, which emphasizes on healthy dyadic or triadic relationships, trauma amelioration, MAKING MUSIC WITH MOMMY AND ME 13 and neuropsychological development (“The development of,” n.d.). The focus in both of these NICU training is primarily on the hospitalized infant, while both do include the mother or caregivers, the emphasis is on infant outcomes and typically takes place in the hospital. Joanne Loewy also edited a book titled “Music Therapy in the Neonatal Intensive Care Unit” (2000) in which chapters inform readers of the current research and clinical practice of music therapy in the NICU. Areas of content include how to institute a NICU Music therapy program, the effects on feeding, research on infant-directed singing and clinical techniques using both live and taped music in the treatment of neonates and their families. Another resource edited by Jane Edwards is, “Music therapy and parent infant bonding” (2011). This book includes three sections: (i) music therapy research and practice to ameliorate vulnerability in infancy; (ii) descriptions of successful group music therapy programs; and (iii) music therapy work with parents and infants in medical settings (Edwards, 2011). As stated in the introduction, “this text aims to fill a much needed gap to provide further support for teaching, practice and ongoing evaluation of parent-infant bonding in music therapy; ultimately presenting a greater awareness of the need for funded research that can inform policy and practice” (Edwards, 2011). There is little music therapy literature focusing on the mothers during postpartum period. One study done by Keith, Weaver, Vogel (2012) focused on the effect of musicbased listening interventions on the volume, fat content and caloric content of breast milk. The results of this study showed that mothers in the experimental group produced significantly more milk with significantly more fat content. Another study, non-music therapy related, done by Norouzi, SeyedFatemi, and Montazeri (2013) focused on the MAKING MUSIC WITH MOMMY AND ME 14 implementation of music during kangaroo care. The results of this study showed there was evidence that kangaroo care had an effect on the severity of maternal anxiety state but there was no significant difference when music was implemented. This investigation suggested a need for more research to document the effectiveness of selected or familiar music during kangaroo care on state anxiety in early postpartum. The current project focuses on the development of a music therapy program aimed to promote maternal-infant attachments. The primary music therapy intervention is songwriting. This is a technique used in music therapy for many purposes. In some cases, the therapist is writing an original composition to use in therapy; in others, the patient/client is involved in the songwriting experience as therapy (Baker & Wigram, 2005). The Mommy and Me program presented here aims to use techniques, including songwriting, and tap into the creativity of mothers as a way for them to bond with their babies and form healthy maternal-infant attachments. Other bonding techniques, such as auditory stimulation, jingles for everyday task, singing songs of kin and multimodal stimulation, will also be introduced, and are explain further in the session-by-session plan section found in Part B. Music and Early Infant- Mommy and Me Programs There are various Mommy and Me music programs that exist. Some include: Music Together (Music Together, 2018), Sprouting Melodies (Sprouting Melodies, 2018), and Programs at Carnegie Hall such as The Lullaby Program (Carnegie Hall Education, 2018). Music Together is an early childhood music and movement program for children from birth through age eight and mothers, father, grandparents, nannies, etc. They value the concept that children learn best from the role models in their lives, which MAKING MUSIC WITH MOMMY AND ME 15 is why those individuals are a part of the groups. Classes are offered all over the country at various locations through trained Music Together teachers. The program contains nine different collections that contain a mix of original and traditional tunes (Music Together, 2018). Sprouting Melodies is another early childhood music program developed by music therapist and offers a development-based approach to infant and toddler music classes. These groups are offered through music therapists who have completed the Raising Harmony Early Childhood Training Program. Age-specific classes for infants, toddlers, siblings and preschoolers include experiences that encourage musical, social, physical, and emotional growth (Sprouting Melodies, 2018). The Lullaby Project at Carnegie Hall pairs pregnant women and new mothers with professional artists to write and sing personal lullabies for their babies. This program recently released a CD with some of the original lullabies titled Hopes & Dreams (Carnegie Hall Education, 2018). Making Music with Mommy and Me: A Perinatal Music Therapy Program incorporates ideas and principles from each of these programs. It is designed and should be implemented by a music therapist; it is aimed to work with mothers and their infants; and it includes the songwriting as the primary medium to promote bonding between the mother and infant. Rationale and Purpose There is little music therapy literature on the use of songwriting within perinatal populations. So it appears that a protocol needs to be created and tested in order to serve this sensitive population. The aim of the suggested music therapy protocol in this project MAKING MUSIC WITH MOMMY AND ME 16 is to provide new mothers the opportunity to use therapeutic songwriting as a way to form healthy attachments with their neonate. Outcomes may include: positive effects on neonate and maternal stress, lowered maternal anxiety, and promotion of social development in the neonate. In a second phase beyond the scope of the author’s culminating project, this perinatal music therapy protocol would be implemented and evaluated. This would contribute to evidence on the impact of music therapy after the birth of the baby, specifically in building maternal-infant attachments to promote health and growth in the neonates and mothers post-pregnancy. The protocol appears as a guidebook in Part B of this document. It describes objectives and session plans for a perinatal music therapy program to build maternalinfant attachment in new mothers. Methods The guidebook was designed for individual music therapy sessions, as this process is an intimate experience shared between the mother and baby, facilitated by the music therapist. This guidebook focuses on the creation of a bonding song, which aims to increase maternal-infant attachment, and promote bonding between the mother and neonate. Target recipients include: (1) mothers over 18 years of age; (2) mothers in the postpartum period of pregnancy, post birth to one year; and (3) mothers without hearing impairment (based on self-report). Qualifications and Training Music therapists who have completed a degree program in music therapy and passed the music therapy board exam administered by the Certification Board for Music Therapist are qualified to implement this guidebook. Specialized training in NICU music MAKING MUSIC WITH MOMMY AND ME 17 therapy is recommended, but not required. It is also recommended that the therapist have additional training in the area of perinatal music therapy. The author may consider developing a training program for music therapists to implement this guidebook in the future. Setting and materials This program would be implemented in a quiet space where the music therapist can meet with the mother, if feasible in the mother’s home. Mothers would be invited to bring their babies along to the sessions. Required materials include: instruments of the mother’s choice e.g., guitar, piano/keyboard, ocean drum, etc., which will be provided by the music therapist; and recording device provided by therapist. Each session description page contains a list of equipment/materials needed for that session (see Part B). Session-by-session plan A detailed set of session plans is articulated in the guidebook. These include specific instructions for the music therapist to conduct a preliminary meeting, musicmaking and songwriting guidelines, and the recording of a bonding song. The protocol is for three sessions that last approximately 60 minutes each. For each session, there is a description page, including goals/objectives, equipment/materials required, procedure and take-home tips. During the preliminary meeting, the therapist explains the songwriting process and the purpose of the intervention. The therapist explains that this is a three-session program. During each session, the mother is given various bonding techniques to use with her baby. She also creates her own bonding song with the music therapist. At the end of each session, there will be take-home tips that are mini tasks for the mother to try MAKING MUSIC WITH MOMMY AND ME 18 during the week before the next session. These techniques and the bonding song are ways to promote healthy attachments and improve bonding with her baby. The therapist also explains that it is necessary for the baby to be present so the music therapist can demonstrate the various techniques during each session. The therapist also administers the pre-questionnaire, Maternal Infant Bonding Scale and Postnatal Bonding Questionnaire (see Evaluation Tools below). Sessions thereafter include music making, such as singing of familiar songs and songs of kin, and eventually, the creation of a bonding song. The therapist supports the mother as much as needed in this process. The music therapist provides templates, formats and options for creating a bonding song. Those include: lyric substitution, song recreation, original songwriting done by mother and therapist, or original songwriting done by the therapist. A recording of their special bonding song is provided for the mother to use. She will be encouraged to sing this song to the baby when she wishes to soothe the baby or herself. Other bonding techniques will also be introduced throughout the three sessions. These include auditory stimulation (Nocker-Ribaupierre, 2013), singing mother’s song of kin (Loewy, 2000), jingles for everyday tasks (Hanser, 2016), and multimodal stimulation (Standley, 2010). Auditory stimulation encourages the mother to speak to her baby, using her voice as a way of telling her baby she is there and that she loves him/her. The mother may choose to read a book, poem or verse to her baby, and will be encouraged to create a jingle that includes an intention for her baby. Singing mother’s songs of kin encourages the mother to sing her own favorite music to her baby, and the therapist shows her ways to change and alter the song to be more appropriate to sing to an MAKING MUSIC WITH MOMMY AND ME 19 infant. These can include changing the tempo, time signature, volume and articulation. Jingles for everyday tasks encourages mother to create little jingles for everyday tasks, such as changing the diaper and clothing, feeding, washing and playing. The mother is asked to create her own jingles for each of these tasks. The multimodal stimulation encourages the use of singing with massage and rocking. There is a progression for the massage that is listed in the guidebook. These techniques developed by Standley and Lowey for use in the NICU have been adapted to use in this guidebook. The focus of the techniques in the guidebook is teaching the mother how to implement these techniques normally done by a music therapist. Evaluation tools The following evaluation tools are administered to inform the music therapist, and to determine whether any changes have occurred over the course of the program. Pre-Questionnaire This form gathers basic information from the mother and including background information on the mother, the mother’s music background and expectations from this program. It is to be filled out during the preliminary session and used during the remaining sessions as a reference. Mother-Infant Bonding Scale The MIBS consists of eight adjectives divided into three aspects: positive, negative and confused attachment. High scores indicate problems in the mother-infant bonding (Perrelli, 2014). This scale is used as a pretest and posttest to evaluate changes in mother-infant bonding. Postpartum Bonding Questionnaire (PBQ) MAKING MUSIC WITH MOMMY AND ME 20 The PBQ, a 25-ietm self-report questionnaire, aims to identify problems in the mother-baby relationship based on four components: 1) weakened bonding; 2) rejection and pathological rage; 3) anxiety about the baby/anxiety about caring for the baby; and 4) imminent abuse/risk of abuse (Brokington et al., 2001). This scale is also be used as a pretest and posttest to assess changes in mother-infant bonding. Post-Questionnaire This form is filled out after completion of the program and the recording of the bonding song. It contains five wrap-up questions evaluating the mother’s experience with the program. It is completed at the end of the third session. MAKING MUSIC WITH MOMMY AND ME 21 Conclusions and Recommendations After fully understanding postpartum depression and all the effects it can have on not only the mother, but baby and family, it is clear that music therapy may have a role in addressing those need areas. This protocol and resulting guidebook in Part B of this document focuses on infant bonding and aims to not only promote maternal-infant bonding, but also provide the mother with concrete tools that she can implement in her everyday life to enhance those bonds. The techniques that are used in the guidebook come from a variety of sources. These techniques are typically used in the medical setting focusing on the baby; however, this protocol’s main focus is on the mother. How can we empower the mother to have these tools to bond with her baby? Making Music with Mommy and Me addresses this important aspect of maternalinfant bonding. This program is aimed to provide mothers with a tool to increase bonding with their baby. These techniques are meant to be tangible tips on various ways to implement music into the mother’s and baby’s life to promote bonding. While the guidebook provides the music therapist with a resource to implement this program with mothers, this protocol can be adapted to use with fathers, grandparents, aunts, uncles, older siblings, or anyone who is looking to build a bond and relationship with this new life that has entered the world. The layout and session outlines are very structured; however, these techniques and tools may be implemented differently, depending on the therapist’s intention. If it is not feasible to do the complete program, the therapist can use and teach the mother one or a few techniques for the purpose of promoting bonding. MAKING MUSIC WITH MOMMY AND ME Other considerations for the future would be the creation of a parent handbook including these techniques to be given to mothers as a resource, after completing the program. The next phase would be to pilot this program to study its effectiveness and validate its outcomes. 22 MAKING MUSIC WITH MOMMY AND ME 23 References Arabin, B., & Jahn, M. (2013). Need for interventional studies on the impact of music in the perinatal period: results of a pilot study on women's preferences and review of the literature. The Journal of Maternal-Fetal & Neonatal Medicine, 26(4), 357362. Baker, F., & Wigram, T. (2005). Songwriting: methods, techniques and clinical applications for music therapy clinicians, educators and students. Philadelphia, PA: Jessica Kingsley Publishers. Bauer, C. 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Music therapy on anxiety, stress and maternal-fetal attachment in pregnant women during transvaginal ultrasound. Asian Nursing Research, 5(1), 19-27. Sprouting Melodies. (2018). Programs and Classes. Retrieved 2018, May 23 from http://sproutingmelodies.com/programs-classes/ Standley, J. M., Walworth, D. (2010). Music therapy with premature infants. Silver Spring, Maryland: American Music Therapy Association, Inc. Wenzel, A., Kleiman, K., (2015). Cognitive behavioral therapy for perinatal distress. New York, New York: Routledge Taylor and Francis Group. White, O., McCorry, N. K., Scott-Heyes, G., Dempster, M., & Manderson, J. (2008). Maternal appraisals of risk, coping and prenatal attachment among women hospitalised with pregnancy complications. Journal of Reproductive & Infant Psychology, 26(2), 74-85. Wilkinson, A., Anderson, S., & Wheeler, S. B. (2017). Screening for and treatment postpartum depression and psychosis: a cost-effectiveness analysis. Maternal And Child Health Journal, 21(4), 903-914. MAKING MUSIC WITH MOMMY AND ME PART B The Guidebook- Making Music with Mommy and Me: A Perinatal Music Therapy Program 28 Making Music with Mommy and Me ð A PERINATAL MUSIC THERAPY PROGRAM GUIDEBOOK ALICIA DREXEL, MT-BC BERKLEE COLLEGE OF MUSIC MAY 2018 Making Music with Mommy and Me A Perinatal Music Therapy Program CONTENTS Introduction ……………………………………………………………………………...3 Maternal-Infant Attachment ……………………………………………………...3 Bonding Techniques ……………………………………………………………...3 Evaluation Tools ………………………………………………………………….4 Suggestions and Considerations ………………………………………………….5 Qualifications and Training….……………………………………………………5 Session Outline Description Page.………………………………………………..6 Session Outlines Preliminary Session ………………………………………………………………7 Session 1: Music-making..………………………………………………………..8 Session 2: Creation of bonding song.…………………………………………....10 Session 3: Completion of bonding song.………………………………………...12 Bonding Techniques.…………………………………………………………………...14 Technique 1: Auditory Stimulation Technique 2: Singing mother’s song of kin Technique 3: Jingles for everyday tasks Technique 4: Multimodal Stimulation Instructions…..………………………….15 Options for Songwriting.……………………………………………………………….17 Steps.…………………………………………………………………………….18 List of Suggested Songs………………………………………………………………...20 Evaluation Tools A: Pre-Questionnaire.…..………………………………………………………..21 B: Maternal-Infant Bonding Scale (MIBS)…………...…………………………23 C: Postpartum Bonding Questionnaire (PBQ).………..………………………...25 D: Post-Questionnaire.……………………..……………………………………26 Postpartum Depression Information.…………………………………………………...28 Postpartum Depression Resources……………………………………………………...29 Edinburgh Postnatal Depression Scale (EPDS)………………………………………...30 Music Therapy Resources………………………………………………………………32 Guidebook References …………………………………………………………………33 2 Making Music with Mommy and Me A Perinatal Music Therapy Program INTRODUCTION Making Music with Mommy and Me is a perinatal music therapy program designed for mothers who want to connect more with their infants. This program aims to use the technique of songwriting and taps into the creativity of the mother as a way for her to bond with her baby and form healthy maternalinfant attachments. This guidebook provides music therapists with a pre-questionnaire, assessment forms, a post-questionnaire, as well as session outlines, list of suggested songs, and options for songwriting. The session outlines contain a description page for each of the three sessions. For each session, there are goals/objectives, equipment/materials required, procedure and take-home tips. The mother will be encouraged to engage with her baby throughout the sessions and will be given various techniques on ways to bond with her baby. She will be asked to sing and make music with the baby and therapist. By the end of this three-session program, the mother will have learned techniques to bond with her baby, and created a bonding song, which she can sing to her newborn baby. Maternal-Infant Attachments Attachment is defined as “a close emotional bond between two people” (Santrock, 2008, p.360). Forming healthy attachments is crucial for infants and a necessary part of their growth and development. It is both a physical and psychological need of babies that provides comfort and protection. The mother is typically the first emotional attachment for the child and therefore, will have an impact on all future attachments the infant develops (Perrelli, 2014). This bond, however, may not come naturally for the mothers, but is an ongoing process starting during pregnancy and continuing once the infant is born. Bonding Techniques One of the interventions used in this program is the creation of a bonding song through songwriting. There are four options for creating a bonding song. Those include: lyric substitution, song recreation, original song writing done by mother and therapist, or original songwriting done by the therapist. A recording of the special bonding song will be provided for the mother to use and she will be encouraged to sing this song to the baby, when she wishes to soothe the baby or herself. 3 Making Music with Mommy and Me A Perinatal Music Therapy Program Other bonding techniques will also be introduced throughout the three sessions. These include auditory stimulation (Nocker-Ribaupierre, 2013), singing mother’s song of kin (Loewy, 2000), jingles for everyday tasks (Hanser, 2016), and a multimodal stimulation technique (Standley, 2010). Auditory stimulation encourages the mother to speak to her baby, using her voice as a way of telling her baby she is there and that she loves him/her. The mother may choose to read a book, poem or verse to her baby, and will be encouraged to create a jingle that provides an intention for her baby. Singing mother’s songs of kin encourages the mother to sing her own favorite music to her baby, and the therapist shows her ways to change and alter the song, to be more appropriate to sing to an infant. These can include changing the tempo, time signature, volume and articulation. Jingles for everyday tasks include short, affirmative tunes for everyday tasks, such as changing the diaper and clothing, feeding, washing and playing. The mother will be asked to create her own jingles for each of these tasks. The multimodal stimulation technique encourages the use of singing with massage and rocking. There is a progression for the massage that is listed in the guidebook. These techniques developed by Standley and Loewy that have been used in the NICU and have been adapted to use in this guidebook. The focus of the techniques in the guidebook is teaching the mother how to implement these techniques normally done by a music therapist. A description of each technique can be found on page 14 of the guidebook. Evaluation Tools The following post- and pre-tests will be administered. These forms can be found in the appendix of the guidebook. Pre-Questionnaire This form will gather basic information from the mother, including background information on the mother, the mother’s music background and expectations from this program. It will be filled out during the preliminary session and used during the remaining sessions as a reference. Mother-Infant Bonding Scale (MIBS) The MIBS consists of eight adjectives divided into three aspects: positive, negative and confused attachment. High scores indicate problems in the mother-infant bonding (Perrelli, 2014). This scale is used as a pretest and posttest to evaluate changes in mother-infant bonding 4 Making Music with Mommy and Me A Perinatal Music Therapy Program Postpartum Bonding Questionnaire (PBQ) The PBQ, a 25-ietm self-report questionnaire, aims to identify problems in the mother-baby relationship based on four components: 1) weakened bonding, 2) rejection and pathological rage, 3) anxiety about the baby/anxiety about caring for the baby, and 4) imminent abuse/risk of abuse (Brokington et al., 2001). This scale will also be used as a pretest and posttest to assess mother-infant bonding. Post-Questionnaire This form will be filled out after completion of the program and recording of the bonding song. It contains five wrap-up questions evaluating the mother’s experience with the program. It will be completed at the end of the third session. Suggestions and Considerations The guidebook is designed for individual music therapy sessions, as this process is an intimate experience shared between the mother and baby, facilitated by the music therapist. This program should be implemented in a quiet space where the music therapist can meet with the mother. The mother will be invited and encouraged to bring her baby along to the sessions. This guidebook may also be adapted and used with other caregivers including fathers, grandparents, older siblings, and any other caregiver. The author does, however, stress the importance of the maternal-infant relationship, as explained in the introduction. Qualifications and Training A music therapist, who has completed a degree program in music therapy and passed the music therapy board exam administered by the Certification Board for Music Therapists, is qualified to implement this guidebook. Specialized training in NICU music therapy is recommended, but not required. It is also recommended that the therapist have additional training in the area of perinatal music therapy and those without should seek supervision from an experienced board certified music therapist. A list of books and resources if found at the end of this guidebook (page 32). 5 Making Music with Mommy and Me A Perinatal Music Therapy Program Session Outline Description Page Goals/objectives Each session has goals/objectives. The statements all begin with “Mother will…” and provide the therapist with a clear idea of the purpose of the session. There is a preliminary session followed by session 1: music-making, session 2: creation of bonding song and session 3: completion of bonding song. Equipment/materials The required equipment and materials will be listed. Items will include the forms, instruments, and recording equipment. All forms can be found in the appendix. Procedure This section contains a list of steps to take in each session, including bonding techniques for the mother to engage with her baby. The section is presented in a step-by-step fashion; however it does not need to be completed in the numerical order presented on the description page. Take-home tips This section includes suggested tasks for the mother to complete during the week to foster bonding with her baby. The therapist will guide the mother during the session and then ask the mother to try these on her own. At the beginning of the next session, these will be addressed and checked to see how the mother has implemented the take-home tips that week. 6 Making Music with Mommy and Me A Perinatal Music Therapy Program SESSION OUTLINES Preliminary Session Goals/objectives Mother will understand the songwriting process and purpose for the intervention Mother will complete the pre-questionnaire, MIBS and PBQ Mother will be introduced to the options for songwriting Equipment/materials Pre-Questionnaire (evaluation form A) MIBS (evaluation form B) PBQ form (evaluation form C) Procedure: 1. Explain that this is a three-session program and during each session, the mother will be given various bonding techniques to use with her baby. She will also be creating her own bonding song with the music therapist. At the end of each session, there will be take-home tips that are mini-tasks for the mother to try during the week before the next session. These techniques and the bonding song are ways to promote healthy attachments and improve bonding with her baby. Explain that it is necessary for the baby to be present so the music therapist can demonstrate the various techniques during each session. 2. Allow mother to fill out each form (pre-questionnaire, MIBS and PBQ) and collect assessments for scoring. See evaluation forms for scoring of each assessment form. 3. Provide mother with the options for songwriting and explain each option, giving her an overview of what is to come. 4. Answer any questions she may have, and make a plan for future sessions (when & where). 7 Making Music with Mommy and Me A Perinatal Music Therapy Program Session 1: Music-making Goals/objectives: Mother will explore her music interests and be shown how she can present those to her baby Mother will learn two techniques to engage with her baby Mother will choose the option for songwriting Equipment/materials Completed forms Pre-Questionnaire (for reference) Music for songs/bands/genres mother indicated on her intake form Guitar for live music and/or device to play recorded music Procedure 1. Begin by encouraging the mother to hold her baby and talk to him/her. Explain that the mother’s voice is the most familiar sound to the baby and encourage this interaction by developing some mantras (examples can be found in the Take-Home Tips section). 2. Discuss answers on Pre-Questionnaire, focusing on the Music Background section. When discussing mother’s preferred music, sing one of her favorite songs. If the mother or therapist is uncertain of the words, show the mother where she can find them, and then sing the song together. Discuss the meaning and/or significance this song has for the mother. 3. Encourage the mother to sing this song to her baby. This song has great meaning for the mother and she should feel comfortable with sharing this part of her with her baby. Together think of ways that the song could be adapted to sing to her baby: slowing down the tempo or elongating the phrases; changing the time signature to 3/4; changing the dynamics or articulation. Remind mother that babies are sensitive to new stimulation, but encourage them to use her own voice to talk and sing to her baby. Her baby could hear her voice already while in the womb and therefore is the most familiar sound he/she knows. 4. At the conclusion of the session, review the options for songwriting and have the mother decide which one she would like to work on during the next session. 8 Making Music with Mommy and Me A Perinatal Music Therapy Program 5. End the session by providing the mother with the Take-Home Tips. Take-Home Tips 1. Encourage mother to sing her favorite song to her baby throughout the week and ask her to find a lullaby that she could also sing to her baby 2. Ask mother to write down a jingle as an affirmative intention for her baby. Examples of a mantra include: “I love you” “You are my everything” 9 Making Music with Mommy and Me A Perinatal Music Therapy Program Session 2: Creation of bonding song Goals/objectives Mother will learn two new techniques to engage with her baby Mother will develop the bonding song Equipment/materials Guitar for live music and/or device to play recorded music Notepad or recording device to use during song writing process Print out of the Multimodal Stimulation Technique Procedure 1. Begin the session by reviewing the Take-Home Tips from session 1 and check-in to see how they went. Review the two techniques from session 1 and have the mother sing her favorite song to her baby. Ask the mother what jingles she created and encourage her to sing/say these to her baby. 2. Discuss different times she can sing to her baby, for example when changing the diaper and clothing, when feeding, when washing and when playing. Create little jingles for each of these tasks and any other tasks the mother suggests. 3. Demonstrate to the mother how touch can have a positive effect on the baby too. Multimodal stimulation can help the baby tolerate and process different kinds of stimulation. This stimulation begins with singing and then goes through massaging different parts of the baby’s body. Steps for this technique can be found on the Multimodal Stimulation Instructions page (page 15). Encourage the mother to try this process during the session and point out moments of over stimulation. Provide the mother with a handout of the instruction page for her to try at home. 4. Review the option the mother selected for songwriting. Begin the steps listed on pages 18-19. 5. End the session by reflecting on the songwriting process, and provide the mother with the Take-Home Tips. 10 Making Music with Mommy and Me A Perinatal Music Therapy Program Take-Home Tips 1. Encourage mother to use the jingles created 2. Provide the mother with a handout of the Multimodal Stimulation techniques and ask her to try them at home 3. Encourage mother to sing part of the bonding song that was created during session 2 to her baby throughout the week 11 Making Music with Mommy and Me A Perinatal Music Therapy Program Session 3: Completion of bonding song Goals/objectives Mother will complete the bonding song Mother will create art for cover of CD Mother will complete Post-Questionnaire, MIBS, and PBQ Equipment/materials Post-Questionnaire (evaluation form D) MIBS (evaluation form B) PBQ (evaluation form C) Instruments (i.e. guitar, piano, ocean disc, etc) Recording equipment (e.g., laptop with garage band app and CD port, microphone, speakers) Blank CD and cover Coloring materials for CD cover art Procedure 1. Begin the session by reviewing the Take-Home Tips from session 2 and check-in to see how they went. Review the two techniques from session 2 and have the mother share any new jingles she created. Encourage mother to try the Multimodal Stimulation technique again and check-in to see how she is doing. 2. If the bonding song was not completed during session 2, finish the necessary steps to complete the song. Once completed, encourage the mother to sing the new song to her baby. If she desires, you may record the song, which she can then play for her baby. Remind the mother that the optimal experience is for her to sing live to her baby. While the CD is being burned, have mother create artwork for the CD cover as another expressive outlet. 3. Allow mother to fill out post-questionnaire, MIBS and PBQ and discuss answers to the questionnaire. 4. Review the four techniques and remind the mother that she has all the tools now to interact and engage with her child in a positive, creative way. Encourage her to continue to use the jingles 12 Making Music with Mommy and Me A Perinatal Music Therapy Program that were created and, of course, sing the bonding song. Ask mother if she feels comfortable creating and singing new songs and jingles. 13 Making Music with Mommy and Me A Perinatal Music Therapy Program BONDING TECHNIQUES Technique 1: Auditory Stimulation This technique encourages the mother to speak to her baby, using her voice as a way of telling her baby she is there and that she loves him/her. The mother may choose to read a book, poem or verse to her baby and will be encouraged to create a jingle as a positive affirmation for her baby. Technique 2: Singing mother’s song of kin For this technique, the therapist encourages the mother to sing her own favorite music to her baby. And shows her ways to change and alter the song to be more appropriate to sing to an infant. These can include changing the tempo, time signature, volume and articulation. Technique 3: Jingles for everyday tasks This technique encourages mother to create little jingles for everyday tasks such as changing the diaper and clothing, feeding, washing and playing. The mother will be asked to create her own jingles for each of these tasks. Technique 4: Multimodal Stimulation This last technique encourages the use of singing with massage and rocking. A progression of massages is listed on the following page with instructions on how to implement this technique. 14 Making Music with Mommy and Me A Perinatal Music Therapy Program Technique 4: Multimodal Stimulation Instructions Sit down in a rocking chair with the baby comfortably in your arms. Sit still, not rocking and begin when the baby is calm. Do each step for about 30 seconds. If at any time the baby shows signs of over-stimulation (listed on the following page), stop and wait until the baby is calm again. 1. Sing only 2. Sing and massage a. head – in a line on the sides and back of head b. back- in a line from neck to bottom c. back – in a big circle over the entire back d. neck – in a line on the sides and throat area e. arms – in a line or circle f. chest and belly – in a line from neck to belly button g. legs – in a line or circle h. cheeks – in a line from eye to jaw i. forehead – in a line from left to right or right to left j. nose to ear – in a line 3. Sing and rock – in slow, steady, rocking motion 4. Sing, rock and massage a. head – in a line on the sides and back of head b. back- in a line from neck to bottom c. back – in a big circle over the entire back d. neck – in a line on the sides and throat area e. arms – in a line or circle f. chest and belly – in a line from neck to belly button g. legs – in a line or circle h. cheeks – in a line from eye to jaw i. forehead – in a line from left to right or right to left j. nose to ear – in a line 15 Making Music with Mommy and Me A Perinatal Music Therapy Program Common signs of overstimulation • “Stop” hand - this looks like the baby is saying, “stop” or “wait” with his/her hand. The palm is facing out toward you • Grimace/red face - the baby looks like he/she is about to cry or is uncomfortable, or the baby’s face suddenly gets red or reddish-purple • Crying • Startle reflex - the baby’s whole body jerks • Tense fingers - the baby spreads his fingers out and the fingers are stiff or tense • Arched back - when the baby’s back bends backward and the belly is pushed forward, as if the baby is trying to get away from what is in front of him/her • Hiccups – while they may not be the sign of over-stimulation, it can be stressful and it is best to wait for them to pass before continuing with any stimulation Common positive responses • Faces you – the baby’s head and face is turned toward you, looks like the baby is looking at you, even though baby’s eyes may be closed • Eye contact – the baby’s eyes look at your eyes • Smiling – the baby smiles even if asleep • Vocalization – the baby uses his/her voice by cooing, “talking”, sighing, etc. • Snuggling – the baby gets closer to you or settles into your arms. Tips for infant massage • Use two or three fingers for massage, and a firm but gentle stroke. • The touch should be firm enough so the baby will feel massaged, but not so firm that it would hurt the baby. • Use enough pressure that it doesn’t tickle the baby’s skin, because that may be upsetting. • Your stroke/massage should probably move the baby’s skin a little beneath your fingers. 16 Making Music with Mommy and Me A Perinatal Music Therapy Program OPTIONS FOR SONGWRITING When it comes time to begin working on the bonding song, use this page as a guide to decide which songwriting option the mother will work on. Each option is described and benefits of each are listed. For songs suggestions please refer to the List of Suggested Songs on page 20. Option 1: Lyric Substitution A familiar song is used leaving some words out which the mother then fills in with her own lyrics. This method provides more structure for the mother and is ideal for those weary of songwriting. Option 2: Song Recreation Uses the music of a familiar song, but creates new lyrics or uses lyrics of familiar song and creates music. Also the mother may bring in a poem, verse, or quote which she then sets to music. Option 3: Original Song (by mother and therapist) The mother creates both the music and the lyrics with the assistance of the music therapist. Music therapist may provide themes for lyrics and music and guides the mother to make decisions. Option 4: Original Song (by the therapist) The mother may discuss the lyrics with the therapist, but ultimately the therapist is the one to construct them as a song, also adding the music. 17 Making Music with Mommy and Me A Perinatal Music Therapy Program OPTIONS FOR SONGWRITING Steps Option 1: Lyric Substitution STEP1: Select the song to be used. See the List of Suggested Songs for ideas or use a song from the mother’s interests. STEP 2: Sing the selected song and then decide which words you will keep/replace. STEP 3: Fill in the blank spaces to complete the song. STEP 4: Sing new song and make necessary changes. STEP 5: Give a title to the new song. Option 2: Song Recreation STEP 1: Select the song to be used. See the List of Suggested Songs for ideas or use a song from the mother’s interests. *If the mother chooses to bring in a poem, verse or quote, begin by reading and discussing the meaning and impact it has for the mother. STEP 2: Sing the song and then decide if you are going to keep the words or the melody. STEP 3: If keeping the lyrics, begin discussing new melodies or motifs to use. If keeping the melody discus themes to begin creating new lyrics. STEP 4: Formulate the new melody or new lyrics, add with the old lyrics or old melody, and sing new song. STEP 5: Give a title to the new song. 18 Making Music with Mommy and Me A Perinatal Music Therapy Program Option 3: Original Song (by mother and therapist) STEP 1: Begin by discussing themes for the bonding song and keep notes of the ideas developed. STEP 2a: Using the theme, develop a chorus or hook for the song. STEP 2b: Using the other ideas discussed, develop the verses for the song. STEP 3: Develop the melody for the chorus and verses and decide on accompaniment style and the instruments to use. STEP 4: Sing the song and make necessary changes. STEP 5: Give a title to the new song. * steps 2a/2b and step 3 may switch if the mother chooses to begin by creating a melody and then adding lyrics second. Option 4: Original Song (by the therapist) STEP 1: Begin by discussing themes for the bonding song and keep notes of the ideas developed. STEP 2: Take the ideas and create the verse and chorus of the song as well as the melody, accompaniment style and instrumentation. Discuss all of these elements, however, the music therapist is the one creating them. STEP 3: Bring the created song to the mother and discuss any changes STEP 4: Sing the song and make necessary changes. STEP 5: Give a title to the new song. 19 Making Music with Mommy and Me A Perinatal Music Therapy Program LIST OF SUGGESTED SONGS Below is a list of suggested songs in alphabetical order. These songs should be used for option 1 and option 2 of the Options of Songwriting. For a description of the options, please see page 17. A Dream is a Wish Your Heart Makes- Cinderella Kumbaya All I Have to Do Is Dream- The Everly Brothers Little Boy Blue Cradle Song Little Bo Peep Amazing Grace Mary Had A Little Lamb Angel- Sarah McLachlan Moon Shadow- Cat Stevens Baby Mine- Dumbo My Bonnie Lies Over the Ocean Blackbird- The Beetles My Favorite Things- Sound of Music Danny Boy Once Upon a Dream German Cradle Song Rock a Bye Baby Goodnight, My Angel- Billy Joel Somewhere Over the Rainbow- Israel He’s Got the Whole World Kamakawiwo’ole Here Come the Sun- The Beatles Sounds of Silence- Simon & Garfunkel Hush Little Baby Swing Low Sweet Chariot I Want to Hold Your Hand- The Beatles Too Ra Loo Ra Loo Ral- Bing Crosby The Itsy Bitsy Spider Twinkle, Twinkle Little Star Jesus Loves Me You Are My Sunshine Just the Way You Are- Billy Joel When You Wish Upon a Star 20 Making Music with Mommy and Me Pre-Questionnaire A Perinatal Music Therapy Program GENERAL INFORMATION Mother’s Name: ____________________________________________ Phone number: ____________________ DOB: _________________ Email address: __________________________________ Child’s Name: _____________________________________________ DOB: _________________ Siblings: __ yes __ no if yes, how old ___________________________________________________ MUSIC BACKGROUND What is the typical role of music in your life? (check all that apply) __ I listen to music in the car or at home __ I like to sing, but only in the shower __ I have musical instruments sitting around and dabble with them here and there __ I play a musical instrument if yes, what do you play ________________________________________________________ __ I make music with other people sometimes/often (please circle) __ I turn to music when I am going through a hard time or feeling bad __ Other __________________________________________________________________________ What genre of music do you enjoy: (check all that apply) __ Alternative Rock __ Blues __ Chant __ Classical __ Country __ Death metal __ Disco __ Folk music __ Funk __ Heavy metal __ Hip Hop __ Indie rock __ Jazz __ Musical theatre __ Opera __ Pop music __ Punk rock __ Rap __ Reggae __ Rhythm and blues __ Rock and Roll __ Soul/Gospel __ Spiritual __ Techno What radio stations, songs, or artists do you usually listen to? __________________________________________________________________________________ Songwriting Have you ever written a song? Have you ever written a poem? __ yes __ no __ yes __ no Comfort level on song writing comfortable (1) very (2) some what uncomfortable (3) neutral (4) some what (5) very 21 Making Music with Mommy and Me Pre-Questionnaire A Perinatal Music Therapy Program What are your expectations/wishes for this program? __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Any other information the music therapist should know? __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ _________________________________________________________________________________ Mother’s Name: ________________________ Administered by: _______________________ Date: _____________ 22 Making Music with Mommy and Me Perinatal Music Therapy Program Maternal-Infant Bonding Scale MATERNAL-INFANT BONDING SCALE These questions are about your feelings for your child in the first few weeks. Some adjectives are listed below which describe some of the feelings mothers have towards their baby in the first weeks after they were born. Please make a tick against each word in the box, which, best describes how you felt in the first few weeks. VERY MUCH A LOT A LITTLE NOT AT ALL Loving Resentful Neutral or felt nothing Joyful Dislike Protective Disappointed Aggressive Mother’s Name: _____________________________ Score: ____________ Administered by: ____________________________ Date: _____________ 23 Making Music with Mommy and Me Perinatal Music Therapy Program Maternal-Infant Bonding Scale SCORING VERY MUCH A LOT A LITTLE NOT AT ALL Loving 0 1 2 3 Resentful 3 2 1 0 Neutral or felt nothing 3 2 1 0 Joyful 0 1 2 3 Dislike 3 2 1 0 Protective 0 1 2 3 Disappointed 3 2 1 0 Aggressive 3 2 1 0 24 Making Music with Mommy and Me Postpartum Bonding Questionnaire A Perinatal Music Therapy Program POSTPARTUM BONDING QUESTIONNAIRE Please indicate how often the following are true for you. There are no “right” or “wrong” answers. Choose the answer that seems right in your recent experience. Always Very often Quiet often Sometimes Rarely Never I feel close to my baby I wish the old days when I had no baby would come back I feel distant from my baby I love to cuddle my baby I regret having this baby The baby does not seem to be mine My baby winds me up My baby irritates me I feel happy when my baby smiles or laughs I enjoy playing with my baby My baby cries too much I feel trapped as a mother I resent my baby My baby is the most beautiful baby in the world I wish my baby would somehow go away I have done harmful things to my baby My baby makes me anxious I am afraid of my baby My baby annoys me I feel confident when changing my baby I feel the only solution is for someone else to look after my baby I feel like hurting my baby My baby is easily comforted Mother’s Name: __________________________ Administered by: __________________________ Date: _____________ 25 Making Music with Mommy and Me Post- Questionnaire A Perinatal Music Therapy Program GENERAL INFORMATION Mother’s Name: ____________________________________________ Phone number: ____________________ DOB: _________________ Email address: __________________________________ QUESTIONNAIRE Please answer the following questions based on your experience during “Making Music with Mommy and Me.” 1. Now that you have completed the bonding song, how comfortable do you feel about songwriting? comfortable (1) very uncomfortable (2) some what (3) neutral (4) some what (5) very 2. Did you enjoy creating the bonding song? yes no Explain: ___________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 3. Have you implemented any of the four bonding techniques? yes no Which one(s): ______________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 4. Do you feel closer to your baby after completing “Making Music with Mommy and Me”? yes no Explain: ___________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 26 Making Music with Mommy and Me Post-Questionnaire A Perinatal Music Therapy Program 5. Were your expectations of “Making Music with Mommy and Me” met? yes no Explain: ___________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Mother’s Name: ________________________ Administered by: _______________________ Date: _____________ 27 Making Music with Mommy and Me Perinatal Music Therapy Program POSTPARTUM DEPRESSION INFORMATION Postpartum depression affects up to 1 in 7 women, according to the American Psychological Association (Postpartum Depression, n.d.). The DSM-V recognized that anxiety and depression may occur both during and after pregnancy and has revised the once called major depressive disorder with postpartum onset to major depressive disorder with perinatal onset (Wenzel & Kleiman, 2015). Postpartum anxiety and depression can take on various forms including generalized anxiety, panic attacks, social anxiety, obsessions and compulsions, and posttraumatic stress. While there are risk factors any mother may experience these symptoms. Music therapists who implement this program may come across mothers who are showing signs and symptoms of postpartum depression. Below is information and resources to provide mothers with, who may be experiencing post-partum depression. While music therapist are not qualified to diagnosis postpartum depression they are ethical responsible to provide the necessary resources for the mother. The Edinburgh Postnatal Depression Scale (EPDS) can be used as a resource as well (see page 30). Symptoms may include: • Feelings of anger or irritability • Lack of interest in the baby • Appetite and sleep disturbance • Crying and sadness • Feelings of guilt, shame or hopelessness • Loss of interest, joy or pleasure in things they used to enjoy • Difficulty bonding with her baby • Feeling regret for having a baby • Possible thoughts of harming the baby or themselves 28 Making Music with Mommy and Me Perinatal Music Therapy Program POSTPARTUM DEPRESSION RESOURCES Postpartum Support International supports all pregnant, postpartum, and post-loss families through regional, state, and national support coordinators; telephone hotlines; chats; forums; and groups. http://www.postpartum.net 2020 Mom engages advocates in maternal mental healthcare to drive change in their communities and states. They’re on a mission to close gaps in care through education, advocacy, and collaboration. https://www.2020mom.org Postpartumprogress.com is the world’s most widely read blog dedicated to maternal mental illness. It offers warm, positive, in-depth information, support and hope for all pregnant and new moms who experience postpartum depression and all other mental illnesses related to pregnancy and childbirth, including postpartum anxiety, postpartum OCD, depression or anxiety during pregnancy, post-adoption depression, postpartum PTSD, bipolar, peripartum onset/postpartum bipolar, depression after miscarriage or perinatal loss and postpartum psychosis. A list of support groups in each state can be found on this page http://www.postpartumprogress.com/postpartum-depression-support-organizations-in-the-uscanada-uk-south-africa-australia-new-zealand Edinburgh Postnatal Depression Scale (EPDS) The EPDS is a 10-ietm self-repot scale used to screen for postnatal depression. Each question is scored; mothers who score higher than 10 are likely to be suffering from depression (Cox, Holden, Sagvosky, 1987). 29 Making Music with Mommy and Me Perinatal Music Therapy Program EDINBURCH POSTNATAL DEPRESSION SCALE (EPDS) Please check the answer that comes closest to how you have felt in the past 7 days, not just how you feel today. Here is an example, already completed. I have felt happy: Yes, all the time Yes, most of the time No, not very often No, not at all In the past 7 days: 1. I have been able to laugh and see the funny side of things As much as I always could Not quite so much now Definitely not so much now Not at all 2. I have looked forward with enjoyment to things As much as I ever did Rather less than I used to Definitely less than I used to Hardly at all 3. 4. 5. I have blamed myself unnecessarily when things went wrong Yes, most of the time Yes, some of the time Not very often No never I have been anxious or worried for no good reason No, not at all Hardly ever Yes, sometimes Yes, very often I have felt scared or panicky for no very good reason Yes, quite a lot Yes, sometimes No, not much No, not at all 6. Things have been getting on top of me Yes, most of the time I haven’t been able to cope at all Yes, sometimes I haven’t been coping as well as usual No, most of the time I have coped quite well No, I have been coping as well as ever 7. I have been so unhappy that I have had difficulty sleeping Yes, most of the time Yes, sometimes Not very often No, not at all 8. I have felt sad or miserable Yes, most of the time Yes, quite often Not very often No, not at all 9. I have been so unhappy that I have been crying Yes, most of the time Yes, quite often Only occasionally No, never 10. The thought of harming myself has occurred to me Yes, quite often Sometimes Hardly ever Never Mother’s Name: _____________________________ Score: _____________ Administered by: ____________________________ Date: ___________ 30 Making Music with Mommy and Me Perinatal Music Therapy Program INSTRUCTIONS AND SCORING Instructions 1. The mother is asked to check the response that comes closet to how she has been feeling in the previous 7 days 2. All the items must be completed 3. Care should be taken to avoid the possibility of the mother discussing her answers with others (answers come from the mother or pregnant woman) 4. The mother should complete the scale herself, unless she has limited English or has difficulty with reading Scoring Questions 1, 2 & 4 Are scored 0, 1, 2 or 3 with top box scored as 0 and the bottom box scored as 3 Questions 3, 5-10 Are reverse scored, with the top box scored as a 3 and the bottom box scored as 0 Maximum score: 30 Possible Depression: 10 or greater *Always look at item 10 (suicidal thoughts) 31 Making Music with Mommy and Me Perinatal Music Therapy Program MUSIC THERAPY RESOURCES Books 1. Music Therapy and Parent Infant Bonding edited by Jane Edwards 2. Music Therapy in Neonatal Intensive Care Unit by Joanne Loewy 3. Music Therapy with Premature Infancts by Jayne Standley and Darcy Walworth 4. Songwriting: Methods, Techniques and Clinical Application for Music Therapy Clinicians, Educators and Students by Felicity Baker and Tony Wigram 5. Integrative Health Through Music Therapy Accampanying the Journey from Illness to Wellness by Suzanne Hanser 6. Cognitive Behavior Therapy for Perinatal Distress by Amy Wenzel and Karen Kleiman 32 Making Music with Mommy and Me Perinatal Music Therapy Program GUIDEBOOK REFERENCES Brockington, I. F., Oates, J., George, S., Turner, D., Vostanis, P., Sullivan, M., & ... Murdoch, C. (2001). A Screening Questionnaire for mother-infant bonding disorders. Archives Of Women's Mental Health, 3(4), 133-140. Cox, J., & Holden, J. (2003). Perinatal mental health: A guide to the Edinburgh Postnatal Depression Scale (EPDS). London, England: Royal College of Psychiatrists Hanser, S. B. (2016). Integrative health through music therapy accompanying the journey from illness to wellness. United Kingdom: Palgrave Macmillan. Loewy, J. (2000) Music therapy in neonatal care unit. New York: Satchnote Press Nocker-Ribaupierre, M.(2013). Premature infants. In Bradt, J. (Ed.), Guidelines for music therapy practice in pediatric care (66-115). Gilsum, NH: Barcelona Publishers Perrelli, J. A., Zambaldi, C.F., Cantilino, A., & Sougey, E. B. (2014). Mother-child bonding assessment tools. Revista Paulista De Pediatria: Orgao Oficial Da Sociedade De Pediatria De Sao Paulo, 32(3), 257-265. Postpartum Depression. (n.d.) In American Psychological Association online. Retrieved from http://www.apa.org/pi/women/resources/reports/postpartum-depression.aspx Santrock, J., W. (2008). A topical approach to life-span development. New York, New York: MGraw-Hill. Standley, J. M., Walworth, D. (2010). Music therapy with premature infants. Silver Spring, Maryland: American Music Therapy Association, Inc. Wenzel, A., Kleiman, K., (2015). Cognitive behavioral therapy for perinatal distress. New York, New York: Routledge Taylor and Francis Group. 33 Making Music with Mommy and Me Perinatal Music Therapy Program 34