... eColumns >> music and health >> views

Can music-making and music education evoke health benefits in human beings?

Is it possible that playing instruments, singing, composing music, and learning how to do them, can result in either physical or "mental-emotional" harm to human beings, or both?

Based on integrated findings from the neuropsychobiological sciences, there is gradually growing evidence for the neuropsychobiological benefits of music involvement for human beings. These benefits include immunological and restorative health benefits. Researchers in the field of music therapy have generated most of such scientific research, frequently in partnership with medical researchers.

While recognizing music's benefits, however, it is also true that people who are involved in the performing arts, and in performing arts education, can and do develop physical injuries, disorders, and diseases that are directly or indirectly related to their performing and teaching. AND, the "mental-emotional" health of some people can be adversely affected by how they experience their music learning. In other words, at all levels of music-making and music education, among both teachers and students, physical injuries, disorders, and diseases can and do occur, and "mental-emotional" harm can and does occur in human beings. This introduction will focus on the harm aspects of the eColumn's topic. A future introduction will focus on the benefits of music involvement.

Here are three true-story "reality checks":

Everyday I would plant myself in a tiny cubicle of a practice room and I wouldn't get up for fear that someone else would take my room. Easily, three or four hours would pass. Eventually, my left arm began to hurt.

I had embraced the prevailing mentality&that physical discomfort was an outcome of time well spent: "No pain, no gain." So I continued to play with a sore arm with the rationalization that the discomfort would just miraculously go away as I got into better shape as a 'cellist. But the pain did not go away. It got worse.

I could no longer ignore the pain and loss of function and dexterity. My pain became so acute that I couldn't use a knife and fork, or turn a doorknob, wash my hair or hold a telephone&.I had developed a major case of what we now call overuse or repetitive strain injury (RSI).

I went to about a dozen doctors and tearfully explained my problem. Their shrugging, unhelpful responses ranged from disbelieving to insulting.It's all in your head, was one diagnosis.

Immobilized by pain, fear and despair, I didn't touch my instrument for three months&. [Complete report in Horvath, 2002]

A dedicated, enthusiastic, elementary school music educator teaches eight half-hour classes in a row every morning, five days per week--with no break. She has a 30-minute lunch period (10 to 15 minutes of which are spent wrapping up the morning classes and setting up for the afternoon). She then resumes teaching five half-hour classes in a row--with no break. She asks the school principal for a schedule adjustment and is told, "I just can't do that. The classroom teachers need their preparation breaks."

Over several months, the teacher experiences increased discomfort, then increasing pain, in her vaginal area, especially during urination. Her family practice physician diagnoses urethral stenosis. [In women, the urethra is the small, 3-cm. tube through which urine drains from the bladder. Stenosis (Greek: stenos = narrow; osis = condition) refers to an abnormally narrowed or constricted passageway or opening in a body structure.] The physician comments that he sees this condition somewhat frequently in teachers who have schedules like hers. It develops because the bladder-urethra muscles must close intensely for long periods of time in order to retain large accumulations of urine in the bladder.

In addition, the clarity and pitch range compass of the teacher's untrained soprano voice slowly deteriorates (she was a keyboard major), and eventually, she "loses her voice" (aphonia). A cooperative voice treatment team (ear-nose-throat physician, speech-voice pathologist, and a specialist voice educator) observed moderate-sized vocal fold nodules, severe swelling, and considerable over-efforting by her larynx, pharynx, and neck muscles. She took a six-month leave of absence from her job. Medications, increased hydration, and immediate urinations when needed helped her nervous system normalize her bladder-urethra function. Several months of voice therapy helped her vocal fold tissues to heal and normal vocal function returned. She resigned her teaching position and vowed never to teach school music again. [Reported in Thurman & Welch, 2000]

Singing in public when you've always thought you couldn't, must be more like undressing after you've had some mutilating surgery, like a mastectomy or an amputation. You know you won't measure up, you'll be a disappointment to yourself and your audience, and, worst of all, you fear you'll be the object of malicious humor. The miracle of singing classes is the discovery that I am not disfigured, that my voice can be a source of pleasure, and amazingly, the "limb" can regrow. [Private communication between S. Knight and Brenda, aged 44, a student in a class for adults, "So You Always Wanted to Sing?", cited in Knight, 2000]

The above statements and true stories beg the following questions:

1. Does the pre-service education of general, instrumental, and choral music educators include knowledge and practice that enables them to prevent, and get help for, the physical injuries and adverse "mental-emotional" effects that can occur in themselves and their students?

2. Does the in-service education of general, instrumental, and choral music educators include knowledge and practice that enables them to prevent, and get help for, the physical injuries and adverse "mental-emotional" effects that can occur in themselves and their students?

3. How might the necessary health-focused knowledge and practice be identified, organized, and disseminated for practical use during the pre-service and in-service phases of general, instrumental, and choral music educator careers?

4. Will music educator organizations mount a campaign to insure that school administrators will provide support and humane schedules for all music educators?

Context

Sports are disproportionately valued by people who live in the land mass now known as the United States of America. Over the past about two-plus decades, large amounts of money have been devoted to initiating and then "mushrooming" an area of medical research and clinical treatment that has come to be called "Sports Medicine". It is now a recognized subspecialty in the medical profession. Sports medicine research has a double focus: (1) optimization of athletic performance, and (2) prevention and treatment of diseases/injuries/disorders associated therewith. This medical subspecialty has not just been applied to professional sports, but to the millions of amateur athletes as well.

A large amount of that research, and the methods used, are applicable to people who are involved in creating "the arts" and in arts education. The elevation of Arts Medicine into a recognized subspecialty category in the medical profession has been underway for over 20 years, but lower social valuing of the arts (compared to sports) has restricted funding for the research that brings higher status in the medical profession. The Performing Arts Medicine Association (PAMA) has been a key organization in this process since about the mid-1980s. PAMA publishes a research journal, Medical Problems of Performing Artists. There is an International Foundation for Performing Arts Medicine, an International Arts Medicine Association, and an International Journal of Arts Medicine. [See this eColumn's links.] A book on performing arts medicine was published in 1991, and its second edition was published in 1999 (Sataloff, Brandfonbrenner, & Lederman, 1999).

In 1971, James Gould, MD, a renowned Ear-Nose-Throat physician in New York City, established The Voice Foundation. For over 35 years, the Foundation has raised money for voice science and voice medicine research and presents an annual symposium, Care of the Professional Voice. The symposium brings otolaryngologists, speech-language pathologists, voice scientists, and singing teachers together to elevate the scientific knowledge base of all the voice professions. In 1985, Ingo Titze, Ph.D., a world-renowned voice scientist at the University of Iowa, USA, established the National Center for Voice and Speech (NCVS) with grant funding from the National Institute on Deafness and Other Communication Disorders, one of the U.S. federal government's National Institutes of Health. NCVS carries out scientific research and education in all aspects of vocal anatomy, physiology, and acoustics, and is now headquartered at Denver Center for the Performing Arts, Denver, Colorado, USA.

Historically, these organizations have focused on professional vocal arts performers (especially "stars"). The "health stakes" are highest for them and they carry "entrée" status with them into doctors' and researchers' offices and into the financial support resources of government agencies, philanthropic organizations, and wealthy individuals. The great mass of people who make and teach music have gotten a lot less attention but often are in great need, e.g., amateur vocal arts performers, music educators, choral conductors, non-university singing teachers, speech teachers, and school and community theatre directors. This perspective was presented at the 1984 Voice Foundation symposium (Thurman, 1985, p. 459) but little or no interest ensued. For example, in 1992 my speech pathologist colleague and I were asked to write a chapter on "young voices" in a voice medicine book (Thurman & Klitzke, 1994; favorably reviewed in the Journal of the American Medical Association, our chapter was singled out for special mention). The title of the book, however, "subverted" our chapter's opening plea to attend to all the millions of amateur vocal arts performers and their teachers who use their voices "athletically" most days per week, many of whom develop voice disorders.

This past trend is beginning to change. The National Center for Voice and Speech (see links), the Texas Center for Music and Medicine (University of North Texas, see links), and the Performing Arts Medicine Association (see links) are creating programs that seek to formalize the inclusion of health and harm-prevention information in the education of all musicians and music educators. In October, 2001, an article in Teaching Music (MENC) focused on "Music and Medicine: Preventing Performance Injuries". A photograph of a leading ENT physician, Dr. Robert Sataloff, was featured on the cover as he videotaped a patient's vocal folds, but the article comprehensively addressed all types of performance injuries.

Can Music Education Really Result in Physical and/or "Mental-Emotional" Harm?

Diseases, injuries, and disorders that affect music-making and music teaching do happen, and with some frequency. They occur in both teachers and their students. With considerable frequency, they are "self-diagnosed", at first, and are endured and untreated until the symptoms reach some degree of severity. Typically, that results in more extended therapy if therapy is prescribed by a physician or paid for by health insurance companies. In most such diseases, injuries, and disorders are preventable with appropriate knowledge of what to do and what to avoid doing. The fact that they are preventable, but are not prevented because of ignorance, reveals an absence of appropriate education.

I. Physical harm can occur among music-makers and music educators from three main sources, ie, (1) suboptimal states of the body (eg, disease, fatigue), (2) injuries and extent-of-use disorders, and (3) learned neuromuscular inefficiencies in the physical coordinations that are undertaken when making music or teaching.

1. Suboptimal states of the body, including diseases, can affect neuromuscular function and/or soft tissue status. Examples include deconditioning, dehydration, herpes simplex virus-1 on the lips, multiple sclerosis, upper and lower respiratory infections, allergies, and laryngo-pharyngeal reflux disease. Also included in this category are disease states that occur because job requirements and so-called lifestyle choices have inhibited optimum physiochemical functioning of bodies.

Suppression of immune system functions can be produced by extended and/or intense stress-demand load over time on key neuropsychobiological resources of the body (allostatic load). When allostatic is greater than the body's innate restorative resources, then bodies are more susceptible to various disease states and to reduced behavioral-emotional-cognitive function (e.g., McEwen, 1998).

Significant irregularities in sleep-wake cycles, as well as insufficient sleep, diminish optimum synchronized functioning of the nervous, endocrine, and immune systems. Sleep debt can result in, among other conditions, disruption of chronobiological homeodynamics, that is, fluctuations in physiochemical states of the body that affect behavioral-emotional-cognitive function (e.g., Huber, et al., 2004; Hairston & Knight, 2004; Irwin, et al., 1994). "Jet lag" is only one example.

Insufficient and irregular intake of foods and liquids (nutrients and hydration) for optimum metabolic processing also can lead to suboptimal physiochemical body states such as: (1) diminishing quality of bodywide cellular replacement, (2) increase of dysfunctions in genetic production of physiochemical homeostasis (e.g., pH imbalances in GI tract influencing reflux of stomach acids, cholesterol imbalances leading to plaque buildup in arteries), (3) incidence of type 2 diabetes mellitus, (4) endocrine disruption, (5) weight gains, and (6) reduced behavioral-emotional-cognitive function (Evans, 1991; Gershwin, et al., 1985; Margen, et al., 1995; McCardle, et al., 1991; Olefsky, 1988; Puczynski, et al., 1990).

Diminishing respirocardiovascular and neuromuscular fitness can result from circumstances like insufficient body movement (exercise), weight gains, poor indoor air quality, and inhaling tobacco smoke or other substances (Gammage & Berven, 1996; James & Cone, 1989; Lioy, et al., 1985; Mannino, et al., 2001; Margen, et al., 1995; McCardle, et al., 1991).

Among music educators, the above suboptimal states of the body can be created by poor indoor air quality in working areas and allostatic load from: (1) sleep debt, (2) insufficient nutrition, (3) very heavy teaching or class schedules over longer periods of time, (4) extra-curricular school commitments, (5) other-than-school commitments such as family, religion, community, and jobs, (6) emotional turmoils related to threats to well being that are embedded within those experiences, and so on. Suboptimal states of the body occur in music students due to the above circumstances and by combinations of school course load, part-time work, non-school social commitments, emotional turmoils related to threats to well being that are embedded within those experiences, and so on.

2. Injuries and extent-of-use disorders can result from: (1) extensive and vigorous neuromusculoskeletal coordinations during music-making, or (2) prolonged and/or excessive high-volume music-making (including talking in the case of voice disorders), or (3) performing and/or listening to music that is sufficiently loud over time (see the eColumn's bibliography for documentation).

During music-making, the demands (stresses) that are placed on neuromusculoskeletal anatomy and physiology, or on impacting and shearing tissues, can be greater than the levels of demand for which that anatomy and physiology has been conditioned. Consistently exceeding that degree of conditioning can result in such debilitations as repetitive stress injuries, bursitis and other skeletal joint disorders, blisters, muscle tension-fatigue syndromes, vocal fold swelling or nodules or polyps or hemorrhages, and so on. Some general factors for music educators are: number and length of rehearsals, amount of time spent practicing, degree of vigor or strenuousness in muscle contraction intensity while rehearsing or practicing, insufficient "recovery time", absence of stretching for connective tissues, sequence and intensity used in conditioning or reconditioning muscles and tissues that are underconditioned for the level of demand that is necessary for goal achievement.

Being in ballistic sound environments that exceed 100-deciBels or more, or in ambient environments that frequently exceed 85-dB and are extended over a few hours per day, can injure and/or destroy hair cells within the inner ear (cochlea). Hair cells convert mechanical vibratory motion into nerve impulses that flow through the vestibulocochlear nerve and eventually into the cortical areas of the brain. Injury to or destruction of hair cells in response to music listening can produce music-induced hearing loss (MIHL can create 70 year-old ears in 25 year-old people). Acoustic trauma to the ears can result in temporary or permanent conductive or sensorineural hearing losses and other auditory disorders such as tinnitus. This is not just a problem for young people who listen to very high-dB music, but also to people who perform in any kind of band, or who conduct bands, orchestras, or choirs. This also is a problem for pregnant mothers, parents of infants, toddlers, and pre-school children, and for teachers and their students (Hogikyan, Feakes, et al., 2000).

According to the most recent U.S. Census Bureau data (2002), school teachers make up about 4.2% of the U.S. working population. According to statistics compiled by the National Center for Voice and Speech, teachers are 32 times more likely to experience voice problems than members of any other profession. Nearly 20% of all teachers undergo clinical treatment for voice disorders. That is by far the highest percentage among all categories of U.S. workers who develop voice disorders that require medical-therapeutic treatment. So far, NCVS scientists have not distinguished between the voice demands and injury rates of school teachers in general viz a viz school music educators. [The NCVS (www.ncvs.org) has constructed a voice health education website for all educators at www.voiceacademy.org].

3. Inefficiencies in the learned neuromusculoskeletal coordinations that are used when playing musical instruments, singing, speaking, or when conducting a performing ensemble, are a major source of physical harm to music-makers and music educators. The most fundamental skill of all music-making is how the whole body functions when learning, reproducing, refining, and teaching musical abilities. Other fundamental skills relate to such learned behaviors as embouchure, fingering, bowing, breathing, phonation, intonation, vocal tract "shaping", conducting and cueing patterns, and the like.

The most fundamental skill of all is how players, singers, conductors, and teachers coordinate their whole bodies when playing, singing, conducting, or teaching. Posture is the common label for upright whole body arrangements that can influence, for good or ill, the relative efficiency with which playing, singing, conducting, and teaching movements are produced. In pre-scientific playing and singing pedagogies, a "focus-on-the-parts" and "correctness" tendency is exemplified by instructions about "holdings" or "arrangements" of the skeletal frame.

The term posture has etymological roots in setting, fixing, or holding of one's body in a place [Latin: positura = formation; which is a stem of pono, ponere, positum = to post, put, place, set, fix, or stake]. Common postural expressions reflect this static, positional semantic history, e.g., "Sit up straight", "Put your thumb here, ", "Keep your beat pattern inside a rectangle that is centered in front of your torso", "Place your feet shoulder-width apart", "Keep your sternum up and your shoulders back and down," or "Hold your head up regally." In the 20th century, several advances in "body pedagogy" have completely invalidated these postural orientations because they actually induce significant inefficiencies in the physical coordinations of instrument playing, singing, conducting, and teaching.

General music, band, orchestra, choral, and private lesson teachers have learned playing, singing, conducting, or teaching "techniques" from prior teachers. Those techniques are substantially based on culturally transmitted "traditional" practices or "methods" that were devised one, two, or more centuries ago. They were devised, then, without the benefit of knowing how bodies are actually made, how they most efficiently function to carry out purposeful, goal-directed behaviors, and how teaching "procedures" can affect, for good or ill, musical skill and expressiveness. For example, the nonverbal gestures and "body language" used by most conductors actually "teach" inefficient playing and singing coordinations to players and singers.

II. Mental-emotional harm can occur among music learners, music educators, and music-makers. The most commonly researched and discussed form of mental-emotional distress among music-makers and music educators is labeled musical performance anxiety or stage fright (see section V of the eColumn bibliography). In the opinion and research literature, musical performance anxiety is described, at minimum, as an inhibitor of expressive abilities, and at maximum, as debilitating. In some people, the distress is so intense that they stop making music altogether. In my personal and professional experience, I still encounter adults as well as current school children who express--sometimes with tears--how critical or disparaging comments from a parent, sibling, peer, or music teacher brought them to their emotional knees or diminished their self-identity.

We need to ask:

How is it that human beings become anxious or frightened to express themselves musically for their fellow human beings?

How is it that human beings become anxious or frightened to help other human beings express themselves by playing or singing music?

Where do such distresses "come from"?

Can music learning experiences induce that kind of distress in people?

If so, what can we do to stop it from happening?

Can people, for instance, learn to sing or play music for and with each other with no more "concern" than they would have if they were just conversing with friends?

The above questions (and the true story at the beginning) place the topic of mental-emotional harm in music education into a broader, more society-wide context. It gets us to the very question of why music (all the arts, really) exist in the first place, and thus, why music education is regarded as such a "weakling" in school education. Did not nearly all school administrators and school board members experience music education when they were in school? Why, then?

The following is a context for deeper understanding.

Inside all of us human beings, there are integrated, high-speed neuropsychobiological processes that are constantly carrying out a threat-benefit appraisal of the people, places, things, and events that we encounter (e.g., LeDoux, 1996, pp. 174-178; Ellsworth & Scherer, 2003; Schore, 1998). These appraisal processes occur in millisecond and submillisecond time frames, 24 hours a day, seven days a week, and are almost entirely outside of our conscious awareness. If those appraisals were responses to evaluative questions, the questions might be:

Are my surroundings literally threatening to my well being? (I have memories&)

Are my surroundings potentially threatening to my well being? (There are unfamiliarities&)

Are my surroundings literally beneficial to my well being? (I have memories&)

Are my surroundings potentially beneficial to my well being? (There are familiarities&)

Am I in neutral safety, neither threatening nor beneficial?

All human beings have experiences that we interpret as threatening and we have experiences that we interpret as beneficial, and we evolve reactive behavior patterns in response to them. Threats to well being are an inevitable part of human living, and when we perceive literal or potential threats to our well being, extensively documented physiochemical changes occur inside our bodies (e.g., see Andrews, et al., 1992; LeDoux, 1994, 1996; McEwen, 1998; Sternberg, 2000). The most threatening experience of all is possible loss of life. The next most threatening experience is abandonment (desertion, rejection). Threats to well being produce feeling-emotion states that may range from minimally unpleasant (e.g., an emotional ouch or shove) to intensely unpleasant (e.g., an emotional hit, cut, stab, or slash). When received, three categories of protective behavioral reactions then follow that match in intensity the degree of perceived threat.

1. Escape-Avoid: We get away from the source(s) of the literal or potential threat to well being (withdraw from people, places, things, events) and tend to avoid same in the future when possible. This behavioral reaction can take numerous forms in music education, such as "shutting out", "daydreaming", being "unresponsive", leaving a choir or band, or avoiding an administrator.

2. Countering: We counter-threaten, counter-control, or counter-attack the source(s) of the threat. This behavioral reaction also can take numerous forms in music education, such as sarcasm, being "smart-mouthed", threatening aversive actions, cursing, slapping, hitting, and vandalism.

3. Demobilization: If the consequences of the first two options are heavily aversive to us--we can neither escape nor counter-control--then we will go into some form of demobilization as our neuropsychobiological processes become constrained. Examples of consequences include tensed muscle groups, elevated blood pressure, diminished digestive motility, restriction of blood flow to some parts of the brain, all of which can impede sensory perception, cognitive processing, social-emotional self-regulation, human-to-human communications, and skilled behaviors. Most of such symptoms are characteristics of musical performance anxiety.

These experiences form both explicit and implicit bodymind memories (including associated bodily sensations called somatic markers; Damasio, et al., 1991; Damasio, 1994, pp. 165-201). They also decrease the probability that human beings will choose to re-experience the people, places, things, and events that were part of the perceived threat. When threat experiences have occurred frequently over time, neuropsychobiological processes are altered toward what we refer to as: (1) anxiety, (2) emotional suppression (the nervous system's "vagal brake" is engaged; Porges, et al., 1994, 1996), (3) "burnout" (depression), (4) tense bodies, and (5) a reluctance to deliberately encounter new experiences and learnings, except for new ways to protect oneself. These are conditions that support optimal learning of protective ability patterns.

When we human beings experience a world that is frequently threatening to personal well being, we are more likely to display behaviors that can range from: passive, reticent, withdrawn, helpless, disinterested, untrusting, discouraged, and dependent; to tense, anxious, afraid, immobilized, and frozen; to uncooperative, disruptive, disrespectful, imposing, and counter-controlling; to resistant, belligerent, rebellious, smart-mouthed, manipulative, and cynical; to angry, rageful, counter-attacking, and violent. These are learned protective ability patterns. When we human beings frequently behave in these ways, we are said to have either a vulnerable or a protective self-identity, low self-esteem, and to be self-focused, self-conscious, self-denying, self-defeating, defensive, anti-social, or destructive.

Distress reactions to predominantly threatening life circumstances generate a variety of physiochemical demands on bodyminds. The physiochemical reactions to threat are clearly linked to the modulatory effects of bodywide transmitter molecule systems (neural, endocrine, immune; e.g., see Sternberg, 2000). As societal circumstances become increasingly threat-laden, more of what Dr. Michel Odent (1986) calls "diseases of civilization" occur, such as asthma, gastric reflux, sleep apnea, type 2 diabetes, chronic fatigue syndrome, widespread heart disease, AIDS, and the various cancers.

On the other hand, when we human beings experience predominantly familiar and safe surroundings, our inborn tendency is to explore those surroundings, empathically interact with the people in them, and imitate (try out) their behaviors as a part of making sense and gaining mastery of our world and of ourselves in it (Ashby, et al., 1999; Aspinwall, 1998; Csikszentmihalyi, 1990; Isen, 2000; Ryan & Deci, 2001). When those explorations have resulted in frequent, non-threatening perceptual-conceptual categorizations and actions, we commonly experience a range of pleasant feeling states (e.g., emotional lifts, or floats, or tickles, or caresses, or ecstasies). Those states point our attention and motor systems toward the development of more explorations that lead to self-mastery, a process that has been referred to as a "broaden and build" theory of positive emotions (Fredrickson & Branigan, 2001). Social-emotional self-regulation and prosocial responding are other aspects of self-mastery (Schore, 1994; Eisenberg, et al., 2003). These are conditions that support optimal learning of constructive ability patterns. Those patterns can be described as: productive, cooperative, purposeful, engaged, alert, attention-focused, competent, involved, optimistically connected, respectful, empathic, altruistic, expressively communicative, humorous, divergent and convergent thinking as needed, creative, innovative, resourceful, self-starting.

During constructive learning experiences, bodyminds also form explicit and implicit bodymind memories (including somatic markers) that increase the probability that we will choose to re-experience the people, places, things, and events that were part of the original experience. When we act in constructive ways most of the time, we are said to have a strong, resilient self-identity, high self-esteem, self-confidence, self-reliance, and self-realization. Such experiences increase the likelihood that we will: (1) engage in experiences with unfamiliar people, places, things, and events, (2) seek new experiences and new learnings, and (3) overcome challenges creatively. Vigilance by parents and teachers in continually providing optimal support for learning is important. Even when optimal abilities have been learned, if suboptimal support for learning occurs or re-occurs, previously learned abilities may revert to a more functional level (Fischer & Rose, 1994, 1996).

A theoretical ratio of learned protective and constructive behavior patterns evolve in all human beings. People who have lived in predominantly threatening circumstances, however, cannot behave in the same way as people who have lived in predominantly safe and beneficial circumstances. In any human being, changing a protective-prominent ratio toward a constructive-prominent ratio means that threats to well being have to be consistently minimized while benefits are optimized. Creating predominantly safe surroundings and providing interesting, constructive involvement in mastering one's real world and self are the primary modus operandi.

Researchers in the cognitive, affective, and behavioral neurosciences (neuropsychobiological sciences) have made substantial progress in identifying innate, universal human needs and learning capabilities. Three universal human needs for constructive self-development are:

(1) empathic relatedness,

(2) constructive competence, and

(3) self-reliant autonomy.

[e.g., see Deci & Ryan, 2000; Ryan & Powelson, 1991; Thurman & Welch, 2000, Book I, Chapter 8, pp. 148-150, and Chapter 9, pp. 244-249).

Three prominent capability-ability clusters, among others, are innate to all human beings and are the basic source of all lifelong learning. They are:

(1) expressive-interactive,

(2) imitative, and

(3) exploratory-discovery.

[For a brief description and documentation of human capability-ability clusters, see Thurman & Welch, 2000, Book I, Chapter 8, pp. 135-137; see Chapter 9, pp. 255-286 for practical applications.]

When any of the symbolic self-expressions called "the arts" are experienced in non-threatening, intrinsically rewarding situations, then those experiences can help build up the lifetime constructive-prominent ratio and thus help fulfill the innate human needs for constructive self-development. But if they are frequently experienced in threatening situations, then the people, places, things, and events that are included in those situations will be formed into memory with unpleasant feeling-emotion tags. Those experiences, then, will contribute to fulfillment of protective self-development needs (detached relatedness, protective competence, self-focused autonomy) and the building up of a protective-prominent ratio of learned behavior patterns.

In addition, if extrinsic rewards are frequently presented, even in non-threatening situations, research strongly indicates that intrinsic reward and interest will be diminished or eliminated, and the "broaden and build" constructive-prominent ratio will be constrained at best (including creativity) (e.g., see Deci & Ryan, 1985, 2000; Deci, et al., 1982; Harackiewicz, et al., 1987; Kohn, 1993; Lepper, 1983; Ryan & Deci, 2001; Ryan, et al., 1995).

What could be threatening to human well being in music learning experiences? Worded another way, how can "mental-emotional" harm happen in music education? And in general, what music educator practices could lead younger and older people to turn away from music making (and what might alternative practices be)?

Here are three possibilities.

1. Emanating from an adversarial "mind-set", many music educators use adversarial interactions (historic roots in military training) and extrinsic rewards (historic roots in behaviorist psychology) to get and maintain focused attention to music-making and music-responding. Because these practices frequently induce perceived threats to well being in learners, the intrinsic rewards of music-making and music-responding are thus inhibited or prevented. The reaction categories listed earlier are then evoked: Escape-avoid, Countering, and Demobilization. [Details of these practices and reactions can be found in Thurman & Welch, 2000, Book I, Chapters 2 and 7-9.]

The most common manifestation of an adversarial "mind-set" and its attendant interactions occurs when music educators engage in "discipline techniques". The goal of such techniques is to coerce learners into compliance with learning and behavioral objectives (standards) that have been predetermined by school administrators and/or teachers (no collaboration with learners). The consequences of violating such objectives have been described as either "punishment heavy" or "punishment lite" (Kohn, 1996). These practices are threat-based, abandonment-related, commonly result in the three reaction categories listed before, and fulfillment of the three universal human needs listed below is impeded. Various such techniques are taught during the pre-service and in-service education of music educators. [A more detailed treatment of "discipline" and its consequences can be found in Thurman & Welch, 2000, Chapter 9, pp. 234-255.]

Alternative practices in music education would be to design and lead music learning experiences that fulfill the universal needs for constructive self-development that are innate to all human beings and evoke innate learning capabilities. Music educators would rely almost entirely on intrinsic rewards to "motivate" interest in expressive music-making and music-responding. These practices can be described as collaborative interactions, emanating from a collaborative "mind-set". These practices demonstrate respect for the innate capabilities and abilities of all human beings, for social-emotional self-regulation, and for human empathy (for a review, see Thurman & Welch, 2000, Book I, Chapter 9, pp. 258-265; also Kohn, 1996).

2. A second common practice in music education is embedded within the adversarial "mind-set". It induces threats to well being with their attendant emotional ouches and hits, and the consequent protective reactions described earlier. It is the practice of drawing the attention of learners to their mistakes, errors, wrongs, incorrects, impropers, and bads. This practice does not just occur among music educators, it is deeply embedded in just about all aspects of most societies.

Researchers in the neuropsychobiological sciences have been learning what actually happens inside human beings when we say that we have perceived through out senses, experienced what we refer to as feelings-emotions, formed and retrieved memories, formed concepts, learned, behaved, expressed ourselves symbolically, and been in and out of health. A parallel layer of curiosity for all educators would be to learn whether or not that knowledge has implications for what teacher-people do in places called schools.

Based particularly on research in the cognitive, affective, and motor neurosciences, the following aphorism has emerged: BRAINS LEARN BY TAKING TARGET PRACTICE. [Actually, whole bodyminds do the learning, not just brains.] A model for this aphorism would be the game of throwing darts at a target. Hitting the bull's-eye is the goal, but the first step for any player is choosing or wanting to play in the first place. If playing is the choice, then the player needs to see the bull's-eye clearly, calculate dart-throwing variables to optimize the chances of hitting the bull's-eye, undertake pathfinding behavior (aiming), throw the dart, observe the tactile-kinesthetic and visual feedback relative to where the dart actually landed, and then decide whether or not to throw again.

Two types of learning are common in education: (1) first-time learning of novel or substantially unfamiliar perceptions, knowledge, or abilities, and (2) altering previous learning of perceptions, knowledge, or abilities. There are mountains of neuroscientific research findings that substantiate, as an essential fact, that during all human learning, BODYMINDS ALWAYS HAVE TO MISS BULL'S-EYES IN ORDER TO FIND THEM IN THE FIRST PLACE, AND TO EVENTUALLY BE CONSISTENT AT GETTING INTO THEM.

Learning means that highly complex, pre-existing neural and biochemical networks (and "layered" parallel networks of networks, and so on) become re-formed, elaborated, extended, detailed, pruned, and the like (e.g., see Fuster, 2003). The "missing" of bull's-eyes (goals) is how human bodyminds determine which elements of the networks need to be altered in order to accomplish the goals and become consistent at accomplishing them repeatedly. That's how we all learned to walk and talk. It's an innate feature of all human beings. We're all born to learn, unless universal need fulfillment is thwarted or threats to our well being inhibit or stop us.

There is a stunning implication of "brains learn by taking target practice" that is backed by numerous findings in the neuropsychobiological sciences. When people are learning new patterns of thinking-feeling-behaving, or are altering habitual patterns, THERE IS NO SUCH THING AS MISTAKES, ERRORS, WRONGS, INCORRECTS, IMPROPERS, BADS, NOT GOOD ENOUGHS, AND FAILURE. They actually do not exist and never have. Those nominalizations represent concepts that human interpreters "made up" millennia ago. The essential consequence of those labeled concepts is that they enable us human beings to rehearse over and over again how inadequate we are.

Nothing could be further from the truth! Human capabilities for learning are vast (though commonly underestimated). Even though there are changes in the ease with which we learn some things over our lifespan, our capabilities for learning are enormous. [A review of human capability-ability clusters appears in Thurman & Welch, 2000, Book I, Chapters 2 and 7-9; an explication of the "target practice" metaphor, and why mistakes and wrongs do not exist, appear in Chapter 9, pp. 195-199.]

When learners are beginning to sense "where targets and their bull's-eyes are", and they are told that they made a mistake or error, or they did it wrong, incorrectly, improperly, or badly, then a threat appraisal is inevitable, along with an unpleasant feeling-state and memory tag. A self-imposed sense of inadequacy or incompetence may then be filed away in memory, or a some sense of unfairness may be felt, usually outside conscious awareness. When learners do have a sense of where targets and their bull's-eyes are, and some ways to get there, they usually perceive very quickly when a bull's-eye has been missed. Do they then need an outside person to confirm how inadequate or incompetent their performance was? "You played that rhythm wrong", "You made two pitch errors", "You're singing sharp", "Your tone is pinched", and so on.

During target practice that enhances goal mastery, the bull's-eyes are not the size of pinpoints. Only perfectionists have learned to make their targets that way. Pinpoint-sized bull's-eyes ensure that emotional ouches, shoves, hits, and stabs will occur during the development of mastery. Welcome to musical performance anxiety and contributions to a sense of personal inadequacy. [I am a founding member of PA (Perfectionists Anonymous).] When these orientations are present in parenting, schooling, or music education, they will almost always contribute to an emotional disconnection between people, places, things, and events (escape-avoid, countering, demobilization).

3. Music educators can communicate goal-setting and feedback to music learners in such a way that threat reactions are induced (escape-avoid, countering, and demobilization). The adversarial "mind-set" expresses a goal-setting language of coercion, control, and dependency in order to induce compliant behavior. Some examples are goal statements that begin with the following words or phrases:

You need to ...

You must ...

You've got to ...

Don't ...

Why don't you ...

Why can't you ...

You really should ...

You have to ...

You ought to ...

You'd better ...

I want to ...

I want you to ...

I need you to ...

Do this for me: ...

Give me ...

This is the sound I want ...

If I were you, I'd ...

Sing/Play for me ...

Try to&/Try hard to&/Try harder to

Work harder to ...

Maintain/Retain/Keep/Hold/Stay

A feedback language of accusative judgment and dependency also emanates from an adversarial "mind-set". Some examples are the following feedback statements (some begin with common words or phrases):

You can't ...

You could have ...

You know better than to ...

You should have.../You shouldn't have ...

You ought to have.../You ought not to have ...

[You messages such as "You got behind the beat" or "You're singing sharp"]

That was good/That was bad

Not bad (a negative compliment?)

That's the right way to.../That's the wrong way to ...

You sang/played that correctly/You sang/played that incorrectly

That was the proper way to play/sing/You're not playing/singing that properly

That was better/That was worse

That's not acceptable

That was dumb/stupid/smart

That was excellent/perfect/wonderful

I like the way you ...

The adversarial "mind-set" also produces nonverbal communications that amplify verbal expressions of coercive goal-setting and accusative feedback. Examples:

Minimal eye contact

Glaring eye contact

Disapproving facial expression (eg, the "evil eye" stare)

Minimal smiling

"No" head movements

Sarcastic "tone of voice"

Uninterested or disengaged "tone of voice"

Yelling

Accusatory finger pointing

Hand palms facing out ("distancing")

Fists

Chopping hand movements

A collaborative "mind-set" and interactions would include a collaborative goal-setting language of respect, exploration, and discovery.

Give it a go.

Let's explore the ...

Let's experiment with ...

How close can you come to ...

Can you just continue to ...

What did you observe when ...

What did you notice when ...

Notice whether or not ...

What would happen if ...

Imagine ...

Wonder how soon you will be able to ...

You may be surprised at how soon ...

Notice what happens when ...

Listen to what happens when ...

Listen closely to your voice when ...

See what happens when ...

Feel what happens when ...

Pay Attention to .../Focus on ...

We can.../The goal is to ...

Invite your voice to come out and play.

What does the music need in order to ...

Voices can do that if they ...

Can you play/sing this in such a way that ...

What is the human "feeling-stuff" in this piece?

How can we play/sing this to bring out its expressive ...?

How can you say these lines to bring out ...? Play out the details ...

A collaborative "mind-set" and interactions would include a collaborative feedback language of mutual respect, self-assessment, and self-reliance. Self-perceived feedback is the most valuable feedback for learners (increases constructive competence and self-reliant autonomy). The most valuable way that music educators can help learners to learn this skill is by asking appropriately worded questions and inviting responses that have no consequent emotional ouches. Even though it appears to be "positive", explicit praise is a form of feedback that actually diminishes the development of self-perceived feedback, and has other unfortunate consequences as well. [Some research-based details may be found in Kohn, 1993, and Thurman & Welch, 2000, Book I, Chapter 9, pp. 221-230.]

Some questions that are likely to facilitate self-perceived feedback are:

How did that seem to you?

Did you notice a difference that time?

Was that closer to the bull's-eye, about the same, or further away?

How did you do that?

How did that feel?

How did that sound?

How did that look?

Did that seem breathy, pressed-edgy, or firm-clear-mellow-warm to you?

Did you hear more of a Ten-Foot-Giant sound, a Bugs Bunny sound, or balanced resonance?

What happened when...?

Did you see/hear/feel a difference when you...?

What changed when you...?

Did you feel what I felt?

What did your throat feel like when you sang that time? (answer) Now do (suggest different approach to voice use). (sing same passage) Did you notice a difference? How would you describe the difference? What did your throat feel like that time? Was there a difference in the sound of your voice? Was there a difference in the feel of your voice?"

Self-perceived feedback also can be facilitated when a music educator models how to simply describe what was observed without evaluation, leaving evaluation to the learner. When learner improvement occurs, the description becomes a form of implicit praise--the only kind of praise that only rarely has unfortunate consequences. Examples:

The old "reach up and squeeze" habit got in there again that time. Did you feel it?

That sounded a little pressed-edgy to me. Did you notice it by any chance?

I heard some inaccurate pitches/rhythms that time. (avoids wrong, bad, and incorrect)

I heard the rhythm being just behind the beat. Check it.

I saw some ceiling breathing that time. Check your body and let your midsection breathe you.

I noticed repeated surges of sound in that phrase. How close can you come to "steady-flow music"?

The music didn't really move me that time. Is that just me, or can we make it more expressive?

I heard some pitches going flat in the bass section. Did you hear that basses? What can we do?

That was closer to the bull's-eye that time. Do it again. (assumes a goal is clearly understood)

That was just inside the bull's-eye that time. What can you do to move it more to the middle?

Bull's-eye!! Yes!!

Your upper register is getting stronger.

Your lower register is lightening more and more as you go higher in pitch.

Your upper/lower register transition is very well blended now.

That flute/falsetto register of yours is just soaring.

There were a lot more accurate pitches that time.

You started singing, noticed that your larynx pulled up, stopped, and changed it right away. Yes!

I heard a smoother, more flowing musical phrase.

That was a goosebump experience.

The collaborative "mind-set" also produces nonverbal communications that amplify verbal expressions of mutual respect, self-assessment, and self-reliance. Examples:

Frequent eye contact

Ready tendency to smile when successes occur

Approving facial expression (eg, the "you did it" look)

Raising of eyebrows for asking "What happened?" or "Did you notice that?"

"Yes" head movements

Shouting in exultation/celebration

Firm-clear-mellow-warm "tone of voice"

Hand palms facing up (invitation, openness to possibilities)

Conclosure

Physical harm and "mental-emotional" harm can and do occur in music education settings. Many teachers and students develop injuries or disorders or limitations to their music-making abilities, and they may never realize that the source of the problem is that the "techniques" they learned to use in the past (often under adversarial duress) violate how the body is coordinated most efficiently.

The adversarial "mind-set" and interactions that occur between people who are called teachers and people who are called students is a major source of implicitly learned inefficient neuromusculoskeletal coordinations in instrument playing, singing, speaking, and conducting. It also is a major reason why many human beings become emotionally disconnected from music-making and music educators.

Science-based anatomical and physiological knowledge is now available to enable music educators to teach physically and acoustically efficient "techniques" for music-making. And, the neuropsychobiological sciences are full of studies that can substantiate a human-compatible orientation to music learning.

The challenge is to assemble all the needed knowledge, convert it into human-compatible teaching practices, and begin changing how and what we teachers teach.

As a child, I loved to sing. I sang all the time. One day the music teacher at school had us all sing for her by ourselves, and she divided us into two groups--the bluebirds and the crows.

I was a crow. Well, I grew up on a farm, and I knew what crows sounded like. I haven't sung since.

So, I guess that before I die, I want to learn how to sing. [Interview with an 86-year-old man, a member of a community chorus that was made up exclusively of people who "knew" that they could not sing. He was asked, "Why do you want to be in this group?"; Mack, 1979]

REFERENCES

Andrews, P.L.R., & Lawes, I.N.C. (1992). A protective role for vagal afferents: An hypothesis. In S. Ritter, R.C. Ritter, & C.D. Barnes (Eds.), Neuroanatomy and Physiology of Abdominal Vagal Afferents (pp.279-302). Boca Raton, FL: CRC Press. Ashby, F.G., Isen, A.M., & Turken, A.U. (1999). A neuropsychological theory of positive affect and its influence on cognition. Psychological Review, 106, 529-550.

Aspinwall, L.G. (1998). Rethinking the role of positive affect in self-regulation. Motivation and Emotion, 22, 1-32.

Booth, R.J., & Pennebaker, J.W. (2000). Emotions and immunity. In M. Lewis & J.M. Haviland-Jones (Eds.), Handbook of Emotions (2nd Ed., pp. 558-570). New York: Guilford.

Bugental, D.E., Kaswan, J.W., Love, L.R., & Fox, M.N. (1970). Child versus adult perception of evaluative messages in verbal, vocal, and visual channels. Developmental Psychology, 2, 367-375.

Csikszentmihalyi, M. (1990). Flow: The Psychology of Optimal Experience. New York: Harper Perennial.

Damasio, A.R. (1994). Descartes' Error: Emotion, Reason, and the Human Brain. New York: Avon Books.

Damasio, A.R., Tranel, D., & Damasio, H. (1991). Somatic markers and the guidance of behavior: Theory and preliminary testing. In H.S. Levin, H.M. Eisenberg, & A.L. Benton (Eds.), Frontal Lobe Function and Dysfunction (pp. 217-229). New York: Oxford University Press.

Deci, E.L., & Ryan, R.M. (1985). Intrinsic Motivation and Self-Determination in Human Behavior. New York: Plenum Press.

Deci, E.L., & Ryan, R.M. (2000). The "what" and "why" of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry, 11, 227-268.

Deci, E.L., Spiegel, N.H., Ryan, R.M., Koestner, R., & Kauffman, M. (1982). The effects of performance standards on teaching styles: The behavior of controlling teachers. Journal of Educational Psychology, 74, 852-859.

Eisenberg, N., Lasoya, S., & Spinrad, T. (2003). Affect and prosocial responding. In R.J. Davidson, K.R. Scherer, & H.H. Goldsmith (Eds.), Handbook of Affective Sciences (pp. 787-803). New York: Oxford University Press.

Ellsworth, P.C., & Scherer, K.R. (2003). Appraisal processes in emotion. In R.J. Davidson, K.R. Scherer, & H.H. Goldsmith (Eds.), Handbook of Affective Sciences (pp. 572-595). New York: Oxford University Press.

Evans, W.J., & Rosenberg, I.H. (with Thompson, J.) (1991). Biomarkers. New York: Fireside.

Fischer, K.W., & Rose, S.P. (1994). Dynamic development of coordination of components of brain and behavior. In G. Dawson & K.W. Fischer (Eds.), Human Behavior and the Developing Brain (pp. 3-66). New York: Guilford.

Fischer, K.W., & Rose, S.P. (1996). Dynamic growth cycles of brain and cognitive development. In R. Thatcher, G.R. Lyon, J. Rumsey, & N. Krasnegor (Eds.), Developmental Neuroimaging: Mapping the Development of Brain and Behavior (pp. 263-279). New York: Academic Press.

Fredrickson, B.L., & Branigan, C. (2001). Positive emotions. In T.J. Mayne & G.A. Bonanno (Eds.), Emotions: Current Issues and Future Directions (pp. 123-151). New York: Guilford.

Gammage, R.B., & Berven, B.A. (Eds.) (1996). Indoor Air and Human Health (2nd Ed.). Boca Raton, FL: CRC Press.

Gershwin, M.E., Beach, R.S., & Hurley, L.S. (1985). Nutrition and Immunity. Orlando, FL: Academic Press.

Hairston, H.A., & Knight, R.T. (2004). Neurobiology: Sleep on it. Nature, 430, 27-28.

Harackiewicz, J.M., Abrahams, S., & Wageman, R. (1987). Performance evaluation and intrinsic motivation: The effects of evaluative focus, rewards, and achievement orientation. Journal of Personality and Social Psychology, 53, 1015-1023.

Higgins, E.T. (1996). Ideals, oughts, and regulatory focus: Affect and motivation from distinct pains and pleasures. In P.M. Gollwitzer & J.A. Bargh (Eds.), The Psychology of Action (pp. 91-114). New York: Guilford.

Hogikyan, N., Feakes, D., Thurman, L., & Grambsch, E. (2000). How vocal abilities can be limited by diseases and disorders of the auditory system. In L. Thurman & G. Welch, Eds., Bodymind and Voice: Foundations of Voice Education (Rev. Ed., Vol. 3, Bk. III, pp. 564-572). Denver, CO: National Center for Voice and Speech, The VoiceCare Network.

Horvath, J. (2002). Playing (less) Hurt: An Injury Prevention Guide for Musicians. Minneapolis, MN: Self-published by author www.playinglesshurt.com.

Huber, R., Ghilardi, M.F., Massimini, M., & Tononi, G. (2004). Local sleep and learning. Nature, 430, 78-81.

Irwin, M., Mascovich, A., Gillin, J.C., et al. (1994). Partial sleep deprivation reduces natural killer cell activity in humans. Psychosomatic Medicine, 46, 493-498.

Isen, A.M. (2000). Positive affect and decision making. In M. Lewis & J.M. Haviland-Jones (Eds.), Handbook of Emotions (2nd ed., pp. 417-435). New York: Guilford.

James, E., & Cone, M.J.H. (Eds.) (1989). Building-Associated Illness and the Sick Building Syndrome. Philadelphia: Hanley & Belfus.

Knight, S. (2000). Exploring a cultural myth: What adult non-singers may reveal about the nature of singing. In B.A. Roberts & A. Rose (Eds.), Proceedings of the International Symposium, Sharing the Voices: The Phenomenon of Singing 2 (p. 153). St. John's, Newfoundland, Canada: Memorial University of Newfoundland.

Kohn A. (1993). Punished by Rewards: The Trouble with Gold Stars, Incentive Plans, A's, Praise, and Other Bribes. Boston: Houghton Mifflin.

Kohn, A. (1996). Beyond Discpline: From Compliance to Community. Alexandria, VA: Association for Supervision and Curriculum Development.

LeDoux, J. (1994). Cognitive-emotional interactions in the brain. In P. Ekman & R.J. Davidson (Eds.), The Nature of Emotion: Fundamental Questions. New York: Oxford University Press.

LeDoux, J. (1996). The Emotional Brain. New York: Simon & Schuster.

Lepper, M.R. (1983). Extrinsic reward and intrinsic motivation. In J.M. Levine & M.C. Wang (Eds.), Teacher and Student Perceptions: Implications for Learning. Hillsdale, NJ: Erlbaum.

Lioy, P.J., Vollmuth, T.A., & Lippman, M. (1985). Persistance of peak flow decrement in children following ozone exposures exceeding the national ambient air quality standard. Journal of the Air Pollution Control Association, 35, 1068-1071.

Mack, L. (1979). A Descriptive Study of a Community Chorus Made Up of 'Non-Singers.' Unpublished Ed.D. dissertation, University of Illinois at Urbana-Champaign.

Mannino, D.M., Moorman, J.E., Kingsley, B., Rose, D., & Repace, J. (2001). Health effects related to environmental smoke exposure in children in the United States: Data from the third National Health and Nutrition Survey. Archives of Pediatric and Adolsecent Medicine, 155(1), 36-41.

Margen, S., et al. (1995). The New Wellness Encyclopedia. New York: Health Letter Associates. Mayne, T.J. (2001). Emotions and health. In T.J. Mayne & G.A. Bonanno (Eds.), Emotions: Current Issues and Future Directions (pp. 361-397). New York: Guilford.

McArdle, W.D., Katch, F.I., & Katch, V.L. (1991). Exercise Physiology: Energy, Nutrition, and Human Performance (3rd Ed.). Philadelphia: Lea & Febiger.

McEwen, B.S. (1998). Stress, adaptation, and disease: Allostasis and allostatic load. In S.M. McCann, E.M. Sternberg, J.M. Lipton, G.P. Chrousos, P.W. Gold, & C.C. Smith (Eds.), Neuroimmunomodulation: Molecular Aspects, Integrative Systems, and Clinical Applications (Vol. 840, pp. 33-44). New York: Annals of the New York Academy of Sciences.

Odent, M. (1986). Primal Health. London: Century Hutchinson.

Olefsky, J.M. (1988). Diabetes mellitus. In J.B. Wyngaarden, & L.K. Smith (Eds.), Cecil's Textbook of Medicine (18th Ed., Vol. 2, pp. 1360-1381). Philadelphia: W.B. Saunders.

Porges, S.W., Doussard-Roosevelt, J.A., & Mati, A.K. (1994). Vagal tone and the physiological regulation of emotion. In N.A. Fox (Ed.), Emotion Regulation: Behavioral and Biological Considerations (Monograph 59, Serial 240; pp. 167-186). Society for Research in Child Development.

Porges, S.W., Doussard-Roosevelt, J.A., Portales, A.L., & Greenspan, S.I. (1996). Infant regulation of the vagal 'brake' predicts child behavior problems: A psychobiological model of social behavior. Developmental Psychobiology, 29, 697-712.

Puczynski, M.S., Puczynski, S.S., Reich, J., Kaspar, L.C., & Emanuele, M.A. (1990). Mental efficiency and hypoglycemia. Journal of Developmental and Behavioral Pediatrics, 11(4), 170-174.

Ryan, R.M., & Deci, E.L. (2001). On happiness and human potentials: A review of research on hedonic and eudaimonic well-being. In S.T. Fiske, D.L. Schacter, & C. Zahn-Waxler (Eds.), Annual Review of Psychology (Vol. 52, pp. 141-166). New York: Annual Reviews.

Ryan, R.M., Deci, E.L., & Grolnick, W.S. (1995). Autonomy, relatedness and the self: Their relation to development and psychopathology. In D. Cicchetti & D.J. Cohen (Eds.), Manual of Developmental Psychopathology (pp. 618-655). New York: Wiley.

Ryan, R.M., & Powelson, C.L. (1991). Autonomy and relatedness as fundamental to motivation and education. Journal of Experimental Education, 60, 49-66.

Sataloff, R.T., Brandfonbrenner, A.G., & Lederman, R.J. (1999). Textbook of Performing Arts Medicine (2nd Ed.). San Diego: Singular.

Schore, A.N. (1994). Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development. Hillsdale, NJ: Lawrence Erlbaum.

Schore, A.N. (1998). The experience-dependent maturation of an evaluative system in the cortex. In K.H. Pribram & J. King (Eds.), Brain and Values: Is a Biological Science of Values Possible? (pp. 337-358). Mahway, NJ: Erlbaum.

Sternberg, E.M. (2000). The Balance Within: The Science Connecting Health and Emotions. New York: W.H. Freeman.

Taylor, S.E., Repetti, R.L., & Seeman, T. (1997). Health psychology: What is an unhealthy environment and how does it get under the skin? Annual Review of Psychology, 48, 411-447.

Thurman, L. (1985). Voice education in school music education. In V.L. Lawrence (Ed.), Transcripts of the Thirteenth Symposium Care of the Professional Voice (Part II: Vocal Therapeutics-Medical, pp. 455-460). New York: The Voice Foundation.

Thurman, L., & Klitzke, C.A. (1994). Voice education and health care for young voices. In M.S. Benninger, B.H. Jacobson, A.F. Johnson (Eds.), Vocal Arts Medicine: The Care and Prevention of Professional Voice Disorders (pp. 226-268). New York: Thieme Medical Publishers.]

Thurman, L., & Welch, G. (2000). Bodymind and Voice: Foundations of Voice Education (Rev. Ed.). Denver, CO: National Center for Voice and Speech, The VoiceCare Network, Fairview Voice Center.

United States Census Bureau (2002). U.S. Summary 2000: Census 2000 Profile, www.census.gov.

Welch, G. (2001). The Misunderstanding of Music: An Inaugural Lecture. London: Institute of Education, University of London.