Ricardo López de la Vega is transforming the vertical relationships that currently exist between hospital staff and patients in psychiatric institutions. His approach–one based on participatory music therapy–helps patients in Bolivia build self-esteem and successfully reintegrate into their families and society.
A nova ideia
In his community-based therapy model, Ricardo brings family, medical staff, patients, and former patients together in joint musical activity. By encouraging all individuals to participate as equals, Ricardo's approach touches patients in a nonthreatening way. The therapy breaks down existing vertical relationships, opens patients up to other therapies to facilitate recovery, and better prepares patients for reintegration into their families and society. The social-leveling effect of making music together is empowering for patients and builds self-esteem and hope for rejoining their communities.
Ricardo's approach is low-cost, easy to implement, and easily transferred across a wide spectrum of institutionalized populations. Currently, he is implementing the model in mental health institutions and plans on expanding to other institutions including centers for drug rehabilitation and centers for the physically disabled and the elderly.
Institutionalized populations have difficulty reintegrating into mainstream society once they have been taken out of normal social roles and obligations. Psychologists relate this difficulty to the isolation patients often face in institutional settings.
Isolation is often compounded by a patient's low self-esteem. The current relationships that exist between doctors and nurses and their patients in psychiatric and other health institutions are generally extremely vertical. These vertical, often overly authoritative relationships undermine patients' self-esteem and decrease their chances for reintegrating into society. The unequal relationships also cause patients to be more closed off and less responsive to therapy, thus increasing the time and cost of their treatment. Therapies in institutions tend to be limited to doctors and institutional staff and do not tend to include people from the "outside" like family members or volunteers. This lack of outside participation makes a return to life outside the institution all the more dramatic a transition. For this reason, patients frequently have relapses once they leave.
While music therapy is used in other parts of the world to help guide cerebral function in neurological disorders and to stimulate healing of other physical problems by focusing a patient's mind on music rather than on pain, this treatment is practiced on individual patients, rendering it a costly therapy. Mental health is not a priority in Bolivian institutions. State-run clinics that serve the poor have few economic resources and deteriorating facilities. According to the Minister of Health, this is because "no one dies of mental illness," hence it is not an issue to which the state can dedicate funds for research or extra care. It is estimated, however, that 8 percent of the Bolivian population suffer from some disability related to mental health and that only 1 percent receive specialized care.
Ricardo has already established himself in one public and one semiprivate hospital in Bolivia where he provides weekly music therapy sessions that include patients, families, medical and administrative staff, and former patients. He is ready to begin working with other institutionalized and transitional patient populations.
Building on the needs and interests of all those who have a stake in patients' reintegration, Ricardo encourages all participants to express their own music. Ricardo uses simple instruments that need no instruction–mostly percussion instruments made from llama nails, hardened pea pods, and tambourines. Patients are allowed to choose the music they want to play to ensure that the music has particular meaning to them. Often they choose traditional national songs that have a universal meaning to patients of all classes and backgrounds.
Participation and respect are key elements of Ricardo's approach. Everyone is either seated or standing at the same eye level to indicate equality among all members of the group. Everyone present must also participate in the sessions. If staff members show resistance, Ricardo talks directly to them. With patients, however, he must motivate them without language so they do not feel reprimanded or imposed upon. For example, Ricardo may sit next to a patient and play an instrument to motivate him to do so as well. The group dynamics also make it difficult to decline to participate. By including former patients and family members in the group, patients begin the process of reintegration into society. It also helps family members relate to the patients better and gives them tools to easily reproduce in their own homes.
As follow-up, Ricardo is creating a medical staff-debriefing program to be implemented immediately after music therapy sessions to discuss how the session went, identify which elements were particularly successful, and determine what aspects could be improved. Reflection will allow him to track progress and improve the process.
Ricardo has already seen the positive impact music therapy has on some psychiatric patients. After taking part in the therapy, patients become more participative in other activities within the institution. For the anniversary of the Psychiatric Ward at the Caja Nacional, 90 percent of current patients and some former patients planned a performance of music and the tinku, a traditional Bolivian dance. They found someone to teach them how to dance and held a raffle to raise money for the costumes. Music therapy has been such a positive influence that many former patients are still involved, coming back on their own free will to act as leaders in the sessions. Even more significant, Ricardo has linked former patients' participation to a notably reduced rate of relapses.Ricardo's music therapy program is attractive to institutions not only because of its utility in the treatment of the patients, but also because of its low cost. In terms of personnel, Ricardo works primarily with interns, who are fairly easy to find because psychology students at the two major universities in Bolivia are required to do one-year internships. He also intends to recruit student interns from the conservatory in order to maintain the psychological and musical components for his work. He already has been invited to the conservatory to make a presentation, and he has made initial steps toward bringing music students and staff into the process. The percussion instruments Ricardo uses are simple and economical. He has his own stock of instruments that he intends to provide initially, but he plans on having interested institutions put up the small amount of funding to buy instruments in the future. The fact that Ricardo's program is so inexpensive and effective makes it easy to spread and gives hope that helping the mentally ill is not a lost cause.
Within five years, Ricardo plans to have in operation a music therapy center with four components: research, training, promotion, and service. The research component will involve a database on patients to track their progress, both to benefit patients themselves and to provide more quantitative evaluation of the effectiveness of music therapy. Research would also help in building a source of data to track mental health statistics–something that does not currently exist. For the training component, Ricardo is developing methods to train music therapists. This would not only spread the music therapy profession but also serve as a source of income for the center. Ricardo is in conversations with the Psychology Chair at a university about the possibility of music therapy becoming a major there. The university has agreed to start with a seminar and internship program. The promotion and spread of music therapy will be done primarily by using press contacts and through courses and workshops in different centers. This component is important to get other institutions interested in Ricardo's methods. The service component is the implementation of the music therapy model in institutions.
Ricardo's model has taken root in several institutions, including the psychiatric ward of the Caja Nacional de Seguro Social and the General Hospital, as well as at shelters for street children, eldercare facilities, and centers for the mentally challenged. The Psychiatric Ward of the Caja Nacional de Seguro Social is Bolivia's first psychiatric hospital using the therapeutic community approach, which means that therapy is geared toward reintegration by trying to replicate society within the institution. Ricardo first introduced his methods here, where he felt that music, a normal part of life that mobilizes culture, was missing. In expansion to other institutions, Ricardo acts as coordinator, training teams and then leaving them to operate on their own. He then supervises together with those already trained acting as coordinators, as he goes on to expand to more institutions. In addition to the interns on the team, Ricardo intends to train one staff member at each institution to be a permanent team member who will ensure the continuity of the program as interns come and go. He also plans to establish formal agreements with the institutions so that music therapy will be an integral institutionalized component with an established physical space, giving the program status and permanence.
Ricardo has already piqued the interest of the director of all of the state-run drug rehabilitation programs in developing his model in various drug rehabilitation centers. Ricardo hopes to spread the methodology to all of the significant institutions where there are psychologists who can participate. Ricardo's work is facilitated by the fact that he knows almost all of the psychiatrists in La Paz and has ties to associations with a national presence, including the Colegio de Psiquiatras. In addition to his intent to spread his music therapy methods to all of the major institutions in the capital, Ricardo plans to spread to the other large Bolivian cities: Cochabamba, Santa Cruz, and Sucre.
At the age of 8, Ricardo started a band with two friends in the small Bolivian city of Tarija. The three children were not trained to play music, but they were able to learn by playing with each other. This experience taught him about leadership and charisma, characteristics he employed as high school class president and still uses today.
With his ex-wife, Ricardo noticed an unfulfilled need in Tarija, an area where everyone knows how to swim, but no one knows how to swim well or competitively. They started Tarija's first swimming school. That school has since closed, but several others opened as a result of their initiative. At the swimming school, Ricardo began to understand psychology. For example, he saw that children behaved differently when they were in front of their parents–they seemed afraid to swim in front of them or performed poorly in their presence. This reaction, together with his observations on the effect of music on self-esteem in adolescents, sparked Ricardo's interest in psychology. Because it was not possible to study psychology in Tarija, Ricardo moved to La Paz to study at the UMSA. While there, he did a six-month internship with his entire class at an institute for mentally disabled children. The students had to figure out their own way to work with the children; Ricardo came up with the idea of music therapy. He was impressed that even autistic children and those in a near-vegetative state responded to music.
Also while studying at the UMSA, Ricardo wanted to do an internship with the Psychiatric Ward of the Caja Nacional de Seguro Social. Initially, the clinic directors were not interested because they had enough interns from the private Universidad Católica and did not see the need to include students from the public UMSA. Ricardo was able to negotiate an agreement between the Psychiatric Ward and the UMSA by convincing them that he was introducing an important innovation to their program. After his one-year internship, Ricardo continued to volunteer there and build upon his music therapy program. He considers his experience there his "second university."