A Matter of Dignity

by Andrew Potok

  What followed was a flurry of publicity that not only enabled Connie and Oliver Sacks to publicize their work, but enhanced Beth Abraham Hospital's image. The New York Times featured Connie in an article, she appeared on the TV news program 48 Hours and was asked to be a consultant for a musical version of the play Wings, about a woman who had a stroke. And she had recently been named the national president of the Music Therapy Association.

  “Hearing about all this,” Connie relates, “the head of the hospital called me in and said, ‘To tell the truth, I didn't quite understand what this music therapy was all about. I had no idea what you all were doing down there. Now that all these people are interested, I should know what's going on.’ Everything was happening at once and the president asked me to speak to the board of directors to tell them some of the clinical stories. They were very taken with it and felt I should get more support and more leeway to do the work I wanted to do.”

  Connie notices that Tobias, at my feet, is panting. We decide that we all need air and find our way to the patio of the hospital, which is crowded with people, a multicultural garden party, the full gamut of race, age and disability. Tubes and bags hang here and there, feeding and emptying. There are loners, facing walls and staring or snoozing in the sunshine. Others are sitting in groups around tables, smoking, drinking coffee, playing dominoes. There are outpatients, day-trippers as well as those who will never leave, people with bandaged head injuries, with leg braces, in wheelchairs, hobbling on crutches or canes.

  There are a lot of young men with shaved heads and tremendous skull scars, mostly from gunshot wounds. Many of the ones in wheelchairs are spinal cord injuries, a lot of inner-city young men caught up in the drugs and violence. Most of them, sometimes perpetrators themselves, sometimes innocent bystanders, come from dire poverty.

  Lulled by the relative quiet of Vermont, I am a bit overwhelmed by the din of planes overhead, the garbage trucks outside, the chugging generators, the never-ending city noises that seem to bother no one else. The smells too are overpowering, garbage mixing with cigarette smoke. A young, hip physical therapist comes by, stops at a wheelchair occupied by a bandaged boy, slips the guy's glasses off his face. “I gotta buy these,” he says. “I really want them.” The kid's laughing. “Let me just borrow them for a half hour, I have to schmooze up a patient.”

  The kid says, “I can't believe he did that to me again.”

  When Connie first came to Beth Abraham more than twenty years ago, teeny pencil-sized wisteria was planted, and now its thick vines are dripping with flowers that give off only a faint scent. But the patio is planted with raised flower and strawberry beds, accessible to people in wheelchairs.

  “I want you to meet Annie,” Connie says. I grab Tobias's harness and we follow her. We stop at a table where a large, handsome woman is sitting alone. Annie suffered anoxia, a serious oxygen deficiency in the brain, as a result of a severe asthma attack. She was in a coma for three months.

  Annie can raise her hands and spread her fingers a little but her hand is deformed. Not seeing this, I put my hand out to shake. Annie raises hers and we touch, my fingers grazing the back of her hand. We don't clasp because she can't clasp. “Well, we made hand contact,” I say.

  “Yes, we did,” she says laughing, forcing the words with difficulty. Perhaps if I had seen I would have held my hand back, fearing the awkwardness of the touch, but as it is, there is no awkwardness, just a couple of innocents making contact.

  “I remember the first sounds as you were coming out of your coma,” Connie says to her.

  Connie tells me that Annie is in her late fifties, very alert, a big woman with a big smile. She has rings on all her fingers, an ankle bracelet, brooches all over her sweater, decked out to beat the band. There is a sign she keeps at her side all the time. It says: “Don't forget to breathe.”

  Annie went through traditional rehab, got some movement in her arms, worked with the speech therapist. She learned to point to letters on an alphabet board and could spell out words. “About three years ago, we had a music therapy group and Annie started making melodies. We began working on exercises where she could match words to music.” After that, speech therapy picked her up again, teaching her to breathe properly, to reinforce the sounds she could make. This got her voice to an intelligible level, then her tracheotomy tube was removed, the hole in her neck closed up and her speech became even better. “Now you speak all the time,” Connie quips, making Annie laugh. “Music helped Annie control her sounds, change and modulate them,” Connie tells me. “The music work encouraged her to turn the sounds into actual words embedded in song. She was very motivated.” She turns to Annie again. “When you heard yourself, you realized you could do it.”

  “That's right,” Annie says.

  “In the spring of 1993,” Connie tells me when we get back to our little table on the other side of the patio, “we planned a music therapy conference at the hospital. It was to be a way of introducing my work to the board as well as trying to network with some of the music industry people like the National Academy of Recording Arts and Sciences to see if they could help us. Until then, Beth Abraham Hospital had never put on a conference and now I made it happen. We had standing room only. It totally blew our board away. They had no idea.The board of governors of the music industry group had also come and, at a brainstorming lunch with them, our president announced that we would start an institute. It was the birth of the Institute of Music and Neurologic Function.

  “When the hospital realized how much we had going for us here, they decided that this music therapy work should be separate, a department of its own. At this point, they realized I was making less money than some regular staff. I was the lowest-paid person on the research team and the development person started advocating for me. We submitted a grant proposal to study music and memory, a grant that had not only been refused in the past but the refusal came with a suggestion that we never apply for this again.

  “I was pregnant at the time. I gave birth in September. By then a very large grant had been approved, enabling the hospital to provide me with a huge salary increase, making life a lot easier for my husband and me. Up until that time we'd not been able to afford full-time day care and suddenly everything changed. I came back from maternity leave in January 1994 to a whole new ball game, a brand new institute and a hospital department.”

  We head back to Connie's office. The halls are packed with physical therapists and attending nurses. Blown-up framed articles from magazines and daily newspapers about Connie and Oliver and the music therapy program decorate the walls. They are the undisputed stars here.

  The hospital is run by United Jewish Philanthropies and is religiously orthodox. On this Friday, there are services ongoing in the chapel. Six old men with yarmulkes are davening around a table laden with Manischewitz wine and cookies. In the hall, the candy machine has a large sign glued to the front. “Absolutely Not Kosher,” it says.

  Back in her office, as Connie looks through a couple of the unpacked boxes for a copy of her dissertation, I ask her when she uses music on a structural rather than a nostalgic level.

  She tells me that music engenders movement of a specifically human type that goes to the roots of our being and takes shape in our gestures, in our deepest and most intimate responses. “The concept of movement to someone who has been left immobile by head injury or stroke is daunting,” she says, “but spontaneous movement in response to music seems to happen as a matter of course. In other words, the potential for movement may be there but the ability to initiate movement is lacking. Thus, rhythmic cueing has the implicit possibility of initiating gait, anticipating and organizing the next step.

  “In parkinsonians,” she continues, “the affected parts are the basal ganglia, the organs of succession. If damaged, a patient has problems with sequences, with consecutive movement. Music can substitute for this basal ganglia function. It can become a template for organizing a series of movements. Because the music
used must move the patient emotionally, it is the music particularly suited to the individual that works.”

  Connie tells me that there is new research coming out now that deals with auditory cueing, especially in Parkinson's and Huntington's chorea and some kinds of ataxia involved with involuntary function like balance, conditions where there's an unrealized connection between the auditory system and the brain stem. In such cases, there's a way of cueing and organizing movement, the musical rhythms driving auditory rhythms. To a metronomic beat, a parkinsonian who can't take a normal step begins to walk perfectly. Different people react differently to rhythm, some to the beat of a marching band, some needing an anticipatory loud beat to get started. For the latter, it's the anticipation of the beat that drives their motor system.

  With Parkinson's, there is now evidence that the brain is setting up some sort of internal clock and responds to the cueing of a beat at a certain frequency. Neuroscientists who are doing CAT scanning also see this happening. This allows the person to anticipate when the next beat is going to arrive. That expectation cues the motor cortex, and here music can play a very big role.

  For people who have had a stroke where the language areas have been damaged, or in the case of expressive aphasia, where comprehension is intact but the ability to execute language has been damaged, it now seems possible to enhance speech function by singing to their right brain. In aphasia, a person loses the ability to communicate verbally but can still sing songs, the centers of speech being dominant in the left temporal area while singing is in the right. There is clinical evidence that people start recovering the ability to use words, to use phrases, spontaneously. “I think that one of the things I'm best known for,” Connie says, “is my studies of music and the auditory function. Everybody else is in psychotherapeutic treatment, early ed and special ed, but my work is really news to a lot of people.

  “Nothing is localized to one part of the brain,” she says of her patients. “There's constant cross-talk. Take the man who couldn't walk but could dance. It isn't just the motor cortex that's involved but a whole group of locations dealing with the subtlety of movement.”

  She tells me about a man who could do little, sat around all day, walking only with assistance. Suffering from extremely poor balance, he stumbled and shuffled, tiring easily. At one point, Connie played some upbeat dance melodies and the man jumped out of his chair and danced for nearly two hours. Later, his daughter told Connie that he used to dance at the Savoy Ballroom. His ability to dance was a lot better preserved than his ability to walk, and dancing eventually aided his physical recovery.

  Neurologically, there are two different types of memory. One is declarative, predominantly cognitive and fast, an exact memory of time and place, which can be declared or brought to mind as an image. Then there is procedural memory, slowly acquired over time from enactments of a skill or task, including motor skills, cognitive skills and simple conditioning. Most music responses can be attributed to this procedural memory. That's why people who used to dance can still dance, no matter what the neurological damage. Those who have lost their memories of other events in their lives can remember music well.

  “My painting probably engages altogether different processes,” I tell her, “but nowadays it's almost entirely based on gestures, which had apparently cut a groove in my brain. In other words, my arms and hands, probably my whole body, remember how I once painted a human figure.”

  “The body does remember,” she agrees. “Neuroscientists are just beginning to do brain imaging technology, to map specific responses to music. By using various types of musical cues, they've begun to identify some of the pertinent networks in the brain for auditory processing.”

  For example, one group of scientists is investigating the responses to classical piano pieces compared to very rhythmic poetry. Both are rhythmic in nature but one is melodic, one verbal. They're beginning to understand properties in brain function that wouldn't normally be associated with music. This new knowledge concerning the connection between auditory processing, motor function and memory will lead to a better understanding of how the brain works and the role that music may play in enabling such responses to take place.

  “One of the neurotransmitter dopamine's effects is to stimulate motor function,” she says, “so if someone is lacking in dopamine, he may think about wanting to move but can't actually move. He can't switch on the execution of the function. Something about listening to the music and processing it, possibly through another neural network, may cause the release of enough dopamine to turn on the motor system. Brain mapping will eventually explain how it works. For now, we simply know through observation that it does work.”

  It has been shown that speaking lights up certain areas of the cortex, particularly on the left side. But with music, there are subcortical as well as cortical responses to rhythm, harmony, a key signature, instrumentation, range and frequency. It has also been noted that musicians exhibit a more analytical response, a left-brain process, when listening to music, whereas nonmusicians will show more activity on the right side of the brain.

  One area of the brain, the reticular formation, is concerned with the regulation of cortical electrical rhythms. There are many connections between the reticular formation and the auditory pathways, and it may be that the rhythmical component of the auditory input has an impact on the entire cerebral cortex, responsible for all the higher intellectual functioning such as speech and vision. The auditory nerve does have an immediate connection to the midbrain, the lim-bic system, the brain's emotional center, whose action can be observed when a song makes a patient alert, making her smile or cry. First the rhythm helps focus the person's attention, then the melodic line and harmonies stimulate the emotional response. “If we can understand the pervasiveness of music processing in the brain,” Connie says, “then we open up a whole different understanding of how the brain works.”

  She tells me of another client, a young man in his late teens, shot through the neck and spinal cord in a gang fight. Though he seemed totally unresponsive, his parents were convinced that their son was aware enough to warrant the administration of passive exercise, lifting and stretching him to prevent his muscles and joints from becoming rigid should he regain function. “I couldn't tell looking at him if he was aware or not,” Connie says. “His eyes seemed to register nothing. His parents told me he'd recorded his own rap music just for himself and his friends. As we listened to his tapes in the music therapy studio, we noticed that something in him began to change, that his eyes moved and he began to perspire. Moments before we heard a gun fired on the tape—the song being about one of his brothers shot in a gang fight— tears began flowing down his cheeks. He knew what he was hearing, even anticipated what was coming in the song. The scary part was that he was aware but locked into a body unable to respond. But the music was getting in and registering even though nothing else was.

  “As a person develops in childhood and throughout life,” Connie says, “the neurons in the brain continue to form connections with various areas of the cortex and other brain structures so that the learned responses can be saved and recorded for future use. Our neurons develop a series of networks with other neurons to allow a response to take place speedily and faithfully. In neural network theory, there's a lot of interest in how the pattern and connection of these networks form. For example, does the sequential pattern of repetitive signals eventually develop into a stored memory? Because the auditory system has strong connections to sub-cortical neural networks, the signaling that hypothetically takes place when a person with dementia hears a familiar song stimulates these emotional and perceptual centers of brain activity, thus giving access to otherwise lost function. The time-oriented rhythm of our internal nervous system that allows us to remember how to accomplish a task next time around is a predictable sequence, and that's exactly what music is. When this very rhythmic, very well organized outside signal is paired with internal perceptions that need signaling to be activa
ted, the brain is enabled to make sense of it all. The two processes reinforce each other, music and emotion having always been connected.”

  “I have a whole other life,” she says, “and need to be present for my kids, my husband, my musical activities. I have a five-year-old and an eight-year-old at home. But my work really enriches the rest of my life. I tend to be a very quiet, patient person. It takes training to sit back, not control, let things happen. I'm good at that and carry it over to my children. I let them be who they are. I allow their differences to develop instead of yelling and controlling or saying this is the way it has to be. My work situation has allowed me to be very flexible in my life.”

  Later, as we stroll in the Botanical Gardens, I try to imagine the intensity of Connie's work. “Can you leave all ofthat behind when you leave the hospital?” I ask.

  As a professional trumpet and cornet instrumentalist, Connie plays with several ensembles, a church baroque group, a woodwind group and a brass quintet. Working in the schools, she introduces kids to the various brass instruments. Her husband plays baritone horn, trombone and tuba.

  Most summers, from Memorial Day weekend through the first week of August, Connie and her husband join in a Westchester County wind ensemble for two or three concerts a week. “In our White Plains concerts,” she says, “we have no idea what's on the program until we meet for the forty-minute dress rehearsal. Luckily, everyone is an accomplished musician so we rehearse only the nuances with the conductor. I love playing all this music. The only thing I feel bad about is that my kids get bounced around a bit with both of us playing.