Using Sounding Bowls in the care of people living with dementia

A section on Sounding Bowls from the book: “Living Well with Dementia through Music”
A Jessica Kinglsey book Assembled and Edited by Cathy Richards, Due out late summer 2019
One of various books from the UK, France and Australia and the USA to feature Sounding Bowls.

Introduction

Sounding Bowls are circular, bowl-formed, wooden instruments with tuned strings inside – just below the rim.⁽¹⁾

Varying in size from 30 to 60cm (a foot or two) across and 6 to 8cm deep they are surprisingly light in weight. A strong, wide rim curves down into a thin base that carries the sound producing an unexpectedly large volume for such a small instrument.

Each Sounding Bowl is hand-made, they are smooth to the touch. Being highly polished and not varnished they have the warmth of wood. The strings are ordinary guitar strings, easy to pluck a note from. Underneath the surface of most models has been carved to a soft ripple-texture increasing the breadth of sensation from sight and sound to the touch as well.

therapeutic advantages

In therapeutic situations Sounding Bowls have a number of advantages over other stringed instruments:

1. Easier initial engagement and introduction of music as a therapy or as pass-time. ⁽²⁾
   • Many people who believe they are not interested in music become interested in Sounding Bowls when shown one. This advantage arises initially from their visual beauty and from their uniqueness. Being an unknown instrument removes the frequent restriction of belief: “I can’t play that.” Interest piqued can be built on and the music begins.
2. Deeper emotional response than other stringed instruments. ⁽³⁾
   • The tonal quality of a Sounding Bowl is unlike any other stringed instrument. Each note has a richness of its own from the harmonics in that string and the sympathetic response of other strings in the bowl, enriched through the acoustic shape.
   • There is a long sustain on each note, sound does not die away quickly as with most stringed instruments.
   • There is a subtle pulse in the sound reminiscent of Himalayan singing bowls. This pulse holds the attention and refreshes the senses.
   • Together these seem to open up feelings in the player that are not usually easily accessed.
3. Easier physical engagement than most stringed instruments.
   • The small size of the Sounding Bowl makes it easy to handle, it is light on the lap for the bedbound and most sizes fit between the arms of chairs and wheelchairs.
   • Having no neck makes the instrument easy to manoeuvre.
   • No neck also means no fingering to be learnt, each note sounds good as it is, simply by plucking.
4. Sustained interest through ease of play and positive musical feedback
   • The quality of sound is rewarding in itself. With no need to play tunes, individuals who feel thwarted in musical skills can get satisfaction from simple rhythms and sequences.
5. Added value as sound/vibrational therapy within music therapy. ⁽⁴⁾
   • The value of music therapy is well established. Sound therapy is about how sound-vibrations affect the body. The wood of a Sounding Bowl carries the vibrations very strongly, if your client has at least some physical contact with the bowl the haptic feedback⁽⁵⁾ adds significantly to the effect of the heard sound, drawing the attention even more deeply into the effects of the harmonics.
   • The tonal quality of the harmonics in the notes is similar to that in Himalayan Singing Bowls creating a subtle pulsing in the note. This pulsing is very unusual in western musical instruments and greatly valued by sound therapists. There have been frequent reports of increased wellbeing.
   • Even apart from the pain-management technique in 7. below there have been frequent reports of increased wellbeing and cessation of physical symptoms following repeated Sounding Bowl use. Such reports have not been systematically tested but continue to flow back to the makers.⁽⁶⁾
   • It is worth noting here that there are no recorded side-effects from regular, repeated or continuous use of Sounding Bowls nor contra-indications around any other treatment protocols.
6. Stimulating listening and calming down emotions.
   • Some therapists use Sounding Bowls to gain the attention of distracted individuals. Where someone is not able to listen to requests or instructions, playing a Sounding Bowl to them has proven more effective than other instruments. ⁽⁷⁾
   • Often a person being played to will reach out to touch the bowl, adding the haptic feedback to the aural sound intensifies the response. Where the reach-out does not occur it can be encouraged verbally or sometimes physically by lifting a hand onto the rim or by leaning in to touch an arm or body with the bowl as it is played.
   • Where an individual is pacing and unresponsive to words, walking alongside playing a bowl can be effective. Matching the rhythm of play to the walk can help. Again encourage contact if it is not spontaneous.
7. Pain management.
   • Music therapist Mary Aillan, working at a research unit in France, has described sounding Bowls being used as a form of pain relief, with bandage changing being one example. Where there is a nervous response to bandage changing Sounding Bowls were used in place of sedatives and anaesthetics with remarkable results.⁽⁸⁾ Combining sung instructions and reassurances with continuous play, improvisation, even simple strumming can distract the patient and focus their attention on beauty to such a degree that they can allow a bandage change swiftly and simply without any added assistance, sedatives or anaesthetics.

Easy to Use

Jan & Julie felt their lives changed when they discovered Sounding Bowls. Julie’s increasing pain disrupted night and day. Playing the Sounding Bowl changed the focus, particularly in the dark hours and brought such relief that Julie was frequently able to keep from disturbing Jan’s sleep. In a card to Tobias Jan described their previous unsuccessful forays into music and said.  “When (the music therapist) first brought one into our house it was SO beautiful it made me cry. Cry as a soldier when he hears a songbird on a battlefield. For the past couple of years we feel we have been walking blindly through the Valley of Darkness but meeting (these) has been like the start of a new journey.”

These features of Sounding Bowls can be used in a wide variety of ways, from simple mood assistance to fully integrated therapy. In group sessions it can sometimes be enough simply to improvise on a Sounding Bowl to draw attention and introduce a harmonious mood. Within this setting you can also have a play and pass-on activity that can stimulate conversation and listening.

As Sounding Bowls are a new instrument there is no set history of right and wrong, no established method or wrong technique to fall foul of.  Whether you wish to hold the instrument up and play with one hand, to have it on your lap or a table and play with thumbs or just with little fingers, to play with a plectrum or whatever, remains entirely a matter of choice. The best technique is the one that gets you the sound you want to hear.  Working in Lyon with a bed bound man whose hands were continually clenched, music therapist Mary Aillan found a soft rubber kitchen spatula 15cm (6inches) long that could be grasped in his fist. With this he was able to select notes and make beautiful sounds. Even without speech he was able to communicate his joy verbally and in facial expressions that were very rewarding.

Music as conversation

No musical knowledge is required because each note has such a richness of overtones that it is beautiful in itself. With most musical instruments ‘learning to play’ means producing a recognisable song or tune whereas with a Sounding Bowl the most popular learning process consists of seven simple steps:

1. By playing a range of notes, choose a favourite for this moment
2. Discover how many different ways that note can be made to sound, finger plucking, thumb plucking, nail plucking, maybe a plectrum, edge of bowl or centre of string each create a different sound.
3. Set up a rhythm on that note using different types of pluck to create a pattern, almost a one-note-tune.
4. Next choose one other note to complement the first note, again by listening to each note on the bowl and deciding which one sounds ‘best’ for this moment with the first note chosen.
5. Play a tune on two notes, noticing how long and short notes, rising or descending intervals change the mood.
6. Next choose a third note. Again, make up a tune. With three notes it is usually possible to express joy or sorrow quite distinctly by using both rhythm and interval in changing patterns.
7. Adding a fourth note in it becomes really clear just how much music you can make and just how much emotion you can express with so few notes.

Once the client has got this experience under their belt they typically become enthused for simple music making, enthused to realise how they can express their emotions using simple rhythms and intervals, changing to accommodate the moment.

Each step of this process deepens a person’s listening focus. The ongoing repetition of act/listen/act creates presence of mind and presence in the feeling heart, integrating emotional and intellectual awareness with distinct therapeutic results.

During this process the client begins to feel about each note as though it were a personality in its own right. For some this will be about the key note and intervals, for others it will be about C, E, D, as sound types. What matters then is that each note begins to speak to the other notes, music becomes a conversation among notes. For many Sounding Bowl owners repeating this process becomes a meditation.⁽⁹⁾  Once upon a time, tuning required this level of engagement and only a personal intimacy with the notes allowed you to tune an open-stringed instrument. Today the auto tuners that come with each Sounding Bowl have lights and a screen that show you which note and how close to accurate it is. That way the eye reveals what the ear is still learning. You can even download an app. Search ‘Chromatic string tuner’

Choosing

Choosing a Sounding Bowl can be at first confusing due to there being six different types, however there is a clear preference for the Melody Bowl amongst people working with dementia and related conditions. The sequential tunings⁽¹⁰⁾ familiar on western instruments are found only on this type of Sounding Bowl, other types have bilateral tunings in common with many African instruments.⁽¹⁰⁾

Melody Bowls start at around 30cm with seven strings. This size, called the Baby Bowl due to its popularity in neo-natal music therapy is tuned to the ancient Celtic pentatonic scale. This tuning leaves out the dissonant 4^th and 7^th note of modern scales. Without these notes there is no sense in the player of having hit a ‘wrong note’ and many people have discovered to their joy that they ‘can make music after all.’  Some find them useful with older clients but many memory-jogging songs need more notes than this size offers.

The nine-string size is around 38cm and has sufficient notes for either the ‘no-wrong-notes’ pentatonic scale or the more emotionally complex modern scales. This size can be easily retuned between both of these tunings which is an advantage for music therapists. It is also light enough for frail and bed-bound clients.

At around 42cm the ten-string Melody Bowl is the most popular. Standard tuning on this size allows both major and minor moods within one tuning and still fits between the arms of a chair or wheelchair. We also make eleven and twelve string sizes at around 47 and 52cm which last is particularly popular with singers. The more strings you have, the richer and more harmonious each string sounds. Prices are competitive with other handmade stringed instruments, varying from around £1700 to £2600. Some users like to specify particular woods. Sounding Bowls are unique in being cut from a single piece of tree and not built up from little bits of various trees. This allows the character of the tree to speak through the wood such that cherry has a spring-time joy in the character of its sound while sycamore has a welcoming, embracing sound and ash a youthful enthusiasm within the notes. Every Sounding Bowl has the same richness of overtones, the same gentle pulsing in its sound, the same unique response since they first went to work in an Oxford hospice in 1991.

Supporting the experience

People can experience a strong emotional response to a Sounding Bowl, even before it has been touched or played. Clients may feel surprised or overwhelmed by a response, such as tears, to a musical instrument, and try to minimise or dismiss their reaction. A little confirmation of the validity of the response can allow that experience to live, also immediately bringing client and carer into deeper relationship.  Thus the sounds of a Sounding Bowl can change the mood of the moment even without engaging the direct co-operation of the client. Tears are a more extreme response but you may very frequently see a pinking of the cheeks and a moistening of the eyes that indicate an increased heart rate and heightened emotions. It is worth picking up on these and verbally or otherwise supporting the validity of the experience. If the client is in coma be alert for changes in the breathing, in facial expression and in muscle tone which show a response.⁽¹¹⁾ A common technique with unconscious or less conscious clients is to address them by name, to describe the instrument and the process as if full engagement were still possible and then to play. E.G. “Hello Martha. I have come to play to you. I am going to play a Sounding Bowl. It is a round instrument with strings. Would you like to feel the wood while I play?”  Then, ensuring that some part of the client’s body is in contact with the bowl, a few simple chords, a short melody or even a few strums of the strings can make a profound difference. There’s good evidence that indicates hearing is frequently the last sense to go.⁽¹²⁾ Having confidence that the client will hear is possibly a valuable part of reaching them. If the client is attached to monitors you may well see the response there also, in the heart beat, blood-oxygen or breathing lines.

If the client is conscious but has little movement, it can be very valuable to add in to the above the possibility for them to generate a sound for themselves. Even if this is an assisted movement and only one finger can pluck a few strings, the result can be surprisingly memorable for the client. “the experience of actively creating a beautiful sound makes a huge difference to those clients most in care whose days are filled with being done-to. It can literally transform the week”.⁽¹³⁾

If the client can manage all the above with some ease a further step in engagement is to create a conversation in sound. For this you can simply place the bowl between yourself and the client and choose a note or short phrase in response to what the client plays. Particularly for withdrawn clients this type of engagement can be very valuable. To create beauty, to participate in call and response, to be on a level with another maker of beauty is very important for those of us who are caught up in a care situation, unable to stand in our former greatness.

Giselle, living in a home for those with advanced dementia, was mostly withdrawn and unresponsive. She had bouts of calling out for help but would not respond, nor even look up when someone came to ask what she needed, thus she would be alone in her chair shouting out “Help, help” at short intervals. A music therapist brought in a Sounding Bowl and sitting in front of her placed it across between their knees. As she played the cries slowly changed, an element of surprise entered Giselle’s voice and she began to focus on the bowl. The cries changed into semi-articulate sounds of interest, then pleasure and with it Giselle’s breathing noticeably changed, slowed and deepened. Her facial expression, habitually one of pain and distress also completely changed, showing real engagement.  At this the music therapist guided Giselle’s hands onto the strings on her side of the bowl. Each sound that Giselle made the therapist responded to with another, engaging her in a conversation-of-sounds. Giselle’s body language completely changed. Though she seemed unable to form many words there was a clear sense of conversation, as though memories were being stirred and shared. The music therapist used a few words but responded to most verbalisations with musical phrases. This caused visible joy on Giselle’s face and the interaction lasted for over 20 minutes before she tired. Giselle was visibly relaxed for the rest of the day with more contented breathing and expressions, with no return of the calling for help.

Of course, if the client turns out to have some musical ability and still has the capacity to play an instrument in any fashion alone, then accompanying the sounds they make with any other instrument – even a little bell or a drum (rhythm is the fundamental element of music) – can support valuable feelings of empowerment and social existence in the client. Throughout these methods of engagement the visual aspects of the Sounding Bowl, the clear evidence of love for beauty and care for process that have gone into a Sounding Bowl, support the feeling that care and beauty are being offered to the client. The vibrations in the wood give important haptic feedback that is actually more important, though on an everyday level less consciously noticed, than sight and sound. People who are disconnected or even dissociated from their daily experience connect through haptic feedback more closely than we imagine,⁽¹⁴⁾ making it a very important tool for working with those harder to reach clients. Haptic feedback is closely connected with touch. Reaching out to touch is a fundamental expression of sympathy and when the hand of a carer touches without functional purpose, the recipient can experience a sense of care, of being present in the life of another in a way that words cannot achieve. When a touching hand and the touch of a Sounding Bowl occur together, special moments can follow. To feel music and touch at once can be profoundly helpful.

Vocalising the moment.

The human voice is perhaps the ultimate instrument. Even if you do not have previous experience of singing, you can add a great deal to the moment. Singing along, humming or toning (somewhere between chanting and humming) to the sounds of a Sounding Bowl can add to and enhance the moment in different ways but with equal importance to touch. There is no need for a recognised song, no need for words even, simply to add in the sound and vibration of your own voice to the sounds of the instrument enriches the musicality and adds a new level of caring to the sounds. As a further step, encouraging the client to vocalise can also bring people up out of withdrawal or down from agitation creating a safe space in the harmony of the moment.

Music is well known to excite other areas of the brain than speech. There are innumerable instances of people who have not spoken for months uttering meaningful sentences during musical engagements.⁽¹⁵⁾ A logical and useful extension of this is using song in place of spoken instructions. This is an important means of engagement with people who find it difficult to respond to spoken communication, it can lift the mood for the carer and for the client. It takes a little preparation to break our cultural barriers of shyness but in practice it is very simple: Take a very short tune, such as you might hear in any playground and apply to it the words you wish to be heard. For example. “Would you like to sit down” spoken to a pacing individual may have no result but when sung as a ditty can have an excellent response rate. Examples for this sort of approach can be found in Musical Intonation Therapy which is used to help stroke victims regain speech. Note and rhythm are used there to help a patient express words and phrases. Similar techniques can be used to help dementia clients comprehend words and phrases. Another source of simple songs is children’s nursery rhymes. You can take a single phrase from such songs as Old MacDonald or even use the entire two line ditty.  Another common ditty in use starts with the minor third descending, then rising to a fourth-to-third and returning to the key note. (E.G.  F to D then G-F and back to D.) It may be that the very ubiquity of this ditty lends it part of its power but like any music, spontaneity has a power of its own and your choice of notes in any moment may be the very best. When used in conjunction with the Sounding Bowl, sung communications can reach those who may not have been able to listen or respond to previous attempts.

history

Sounding Bowls have a short history. Their developer Tobias Kaye was working wood as sculpture, emphasising the expressive nature of simple curves and flow, when he was inspired by an image occurring spontaneously in a meditation: a bowl with a tuned string stretched inside.  Tobias chose to develop this, using the naturally occurring acoustic of the Fibonacci curves⁽¹⁶⁾ he was using in his sculpture. Most stringed instruments have a box resonator, Sounding Bowls are unusual in having the resonator wide open and unique in having the string inside the resonator. This new departure underlies the Intellectual Property copyrights⁽¹⁷⁾ Tobias holds. Sounding Bowls now have a sound-quality that combines the warmth of a harp with the brightness of a Himalayan singing bowl. Aware that they bridge sculpture and music Tobias felt a sea-change when, in 1991 music therapist Rachel Verney of Nordoff Robbins chose one for her new appointment to Sobell House Hospice in Oxford – the first palliative care music therapy placement in the NHS. Since that time the remarkable effects of Sounding Bowls in music therapy and for people in psychological or physical pain have been noted and celebrated in ever increasing circles, both in the UK and internationally. Today there are five trained and qualified makers of Sounding Bowls in three countries, all of whose work is available through the Sounding Bowls website, and the Bowls’ presence in five continents continues the work of reaching and touching human souls. Tobias says:  ‘As their maker I am still in awe of what happens when people engage with Sounding Bowls but the feedback from users in all categories continues to remind me that there is clearly something happening here.’

Notes/References

1. See SoundingBowls.com
2. Compton Dickinson and Hakvoort 2017 “The Clinicians Guide to Forensic Music Therapy”
3. Music therapist Dr Colin Lee RMTH in a letter from an Oxford hospice 1993
4. Music therapist, author and researcher Dr Stella Compton Dickinson in an email to Tobias Kaye 2004 “adding vibrational therapy into the music therapy seems to be an important part of the work the Sounding Bowl does in this hospital”
5. “Haptic” refers to the sense of touch. The latest technology uses haptic feedback in speed learning. The importance of haptic feedback to those no longer able to follow verbal trails is established in the work of the deaf/blind music therapist Russ Palmer quoted below but researchers such as music therapists Adrienne Freeman and Mary Aillan have also found that the more dissociated a person is the more strongly they respond to the vibrations and the carved texture underneath a Sounding Bowl.
6. G. email from choir leader Theresa Verney 2015 “within days of starting to play my eczma reduced to levels I have not seen in decades”
7. G. Email from music therapist Mary Aillan describing repeated experiences in working with advanced dementia clients at a research unit in France.
8. See note 7, above.
9. Letter from a client “My sister and I tried many times to learn meditation. One teacher told us ‘You have monkey minds, always leaping from branch to branch’ Now my sister and I sit under the apple tree playing your bowls and our monkeys hang from a single branch”
10. Sequential and bilateral tunings describe how notes are arranged on strings. Harps have the deep note at one end of the set, rising from there to high notes at the other. Thus in sequence (sequential.) African instruments, such as thumb pianos have the deep notes in the centre, rising to high notes further out, like our two hands together have thumbs at the centre and little fingers at the edges. Being as you have to involve both sides in one tuning this is described as bilateral.
11. Mary Aillan frequently states “I have never failed to get a response with a Sounding Bowl. Even if the client is in coma”
12. Maggie Callanan author of two books, including “Final Gifts” (Bantam, 1997) has been part of the “dying journey” with 2,000 people. In a recent phone interview, she said that it appears from experience that hearing is the last sense to go. She adds: “I’m telling you we have seen this over and over again. Do not say anything you do not want this dying person to hear. Just don’t. Not in the room, but not even down the hall, because it appears hearing becomes acute.” Callanan suggests that those at the bedside of an unconscious patient, or those holding vigil with dying loved ones, act “as if” they can hear their words and voices. http://www.spokesman.com/stories/2011/sep/06/its-easy-to-believe-that-hearing-is-last-sense-to/
13. Zambodhi Schlossmacher: from an email Sept 2011.
14. See the work of music therapists and researchers Russ Palmer and Riitta Lahtinen at http://www.russpalmer.com/
15. G. Music therapist Adrienne Freeman working in a UK research home for advanced dementia describes occasions such as a woman in her 80s who has not spoken for over 8 months and is believed to have lost the capacity due to the brain decay of the illness, reaching out to touch the bowl as it sounded and speaking quite clearly “Don’t stop!”
16. Fibonacci was a renaissance mathematician who identified what is now understood to be the growth pattern of basic life-forms. Since then resolved into a single fraction known as the Golden Mean these sequences also explain why Greek temples look so astonishingly beautiful. The exponential curves that Fibonacci numbers create are used in trumpet bells and certain types of architecture to increase harmony and volume. The maths of harmony in music are similarly exponential such that the inner curves of a Sounding Bowl appear to amplify the inherent harmonies of any sound and drop intervening frequencies.
17. Intellectual Property (I.P.) copyrights refer to works that are qualitatively different to anything before. While common in literary and musical compositions they apply to anything that has no direct precedent. Where normal innovation and improvement copyrights last for 15 years I.P. protections last until 50 to 75 years after the death of the creator depending on country.