Music Therapy Benefits for Clients with Depression

Depression is one of the most common mental disorders in the U.S. with more than 3 million cases per year (National Institute of Mental Health, 2018). Depression is defined as a mood disorder that affects virtually every facet of an individual’s life. Depression affects the way in which a person thinks, feels, and executes daily activities of living, such as sleeping, eating, and working (National Institute of Mental Health, 2018). It is normal to feel depressed due to various life circumstances. However, if these symptoms continue for a prolonged period of time, the depressive episode may be diagnosed as a depressive disorder. Depressive disorders refer to the amount of time that symptoms have been present in an individual’s life. An individual is typically diagnosed with clinical depression when they have experienced symptoms continually for at least two weeks (National Institute of Mental Health, 2018).

The most well known symptom of depression is a feeling of overwhelming sadness. However, depression includes many other symptoms that affect an individual’s ability to function. An individual with depression may show a decreased energy level and loss of interest or pleasure in activities that they previously found intriguing. An individual with depression may also show signs of irritability, restlessness, and difficulty concentrating on a task. Depression may also manifest itself in an individual’s sleep schedule and changes in appetite. Finally, depression may lead to thoughts of death and suicide, and may potentially lead to suicide attempts (National Institute of Mental Health, 2018).

Major risk factors for depression include major life changes, trauma, or stress (National Institute of Mental Health, 2018). For the majority of this year, COVID-19 has altered life as we know it. Schools have closed and transitioned to online learning. Businesses have also been affected, resulting in job loss among many individuals. Social distancing has affected the ways in which people can congregate and fellowship. These major life changes may lead to feelings of isolation and depression. 

Music therapy has been shown to be effective in addressing emotional, social, and cognitive needs. Music therapy provides a non-threatening environment for the client to express themselves in a healthy way. Music therapists work to enhance the client’s self-awareness and environmental awareness, address problem solving skills, and increase the client’s attention span. Music therapists assist the clients in developing individualized coping skills, problem solving skills, and decision making skills. Additionally, music therapy sessions support healthy feelings and behavior (American Music Therapy Association, 2006). 

Receptive music therapy has the ability to modulate a client’s mood through music relaxation (Eyre, 2013, p. 342). Music relaxation interventions involve listening to music for the purpose of effecting a relaxed response. Music relaxation interventions may include guided imagery accompanied with relaxing music as well as progressive muscle relaxation. The overarching goals of music relaxation interventions are to release physical tension and increase a sense of well-being (Eyre, 2013, p. 343). In an ideal music relaxation intervention, the client’s preferred music will be utilized to facilitate a relaxed state, as evidenced by a slowing breathing rate, a slowing heart rate, and an adjusted mood (Eyre, 2013, 344). 

Improvisational music therapy involves the spontaneous creation of musical dialogue in music therapy sessions. One study evaluated the effects of short-term improvisational music therapy sessions on the severity of depressive symptoms (Aalbers, Spreek, Bosveld-van Haandel, & Bogaerts, 2017). The music therapy researchers administered a questionnaire before and after music therapy treatment to measure if this form of treatment was effective for clients experiencing depression. Improvisation interventions utilized during music therapy treatment assisted clients to express their feelings, thoughts, and actions in daily life. Over the course of music therapy sessions, the music therapist gradually related improvisation experiences to stimulate healthy thoughts and behaviors through active music playing and discussion (Aalbers, Spreek, Bosvel-van Haandel, & Bogaerts, 2017, p. 262). Results of this study showed an overall reduction in identified depressive symptoms and a significant benefit from music therapy sessions (Aalbers, Spreek, Bosvel-van Haandel, & Bogaerts, 2017, p. 262).

Songwriting in music therapy sessions provides clients with opportunities for self-expression and self-awareness. Songwriting interventions focus on the dialogue created in the creation of the song as well as the final product of the intervention (Silverman, 2013, p. 134). In addition to emotional benefits, songwriting in group settings can allow clients to foster and develop social skills. Silverman (2013) examined the effects of group songwriting among clients with depression and other mental health concerns. Group songwriting, combined with psychoeducational discussion, allowed the clients the freedom to express themselves and interact with others in an appropriate manner. Topics addressed during the songwriting interventions, such as coping skills and support systems. Results of the study found that the group songwriting interventions benefited the participating clients in the social and emotional domains (Silverman, 2013, p. 141). 

It is normal to experience depression in response to severe, unexpected life changes. COVID-19 has altered the way many of our lives in ways that were previously unimaginable. It is essential during this uncertain time to take care of both our physical health and our mental health. Music therapy has been shown to be effective in facilitating relaxation, improving mood, and fostering coping skills. 

-Jasmine Bailey, Music Therapy Intern

References 

Aalbers, S., Spreek, M., Bosveld-van Haandel, L., & Bogaerts, S. (2017). Evaluation of client progress in music therapy: An illustration of an N-of-1 design in individual short-term improvisational music therapy with clients with depression. Nordic Journal of Music Therapy, 26(3), 256-271. 

American Music Therapy Association (2006). Music therapy and mental health. Retrieved May 18, 2020 from http://www.musictherapy.org/assets/1/7/MT_Mental_Health_2006.pdf

Eyre, L. (2013). Guidelines for Music Therapy Practice in Mental Health. Barcelona Publishers.

National Institute of Mental Health (2018). Depression. Retrieved May 18, 2020 from https://www.nimh.nih.gov/health/topics/depression/index.shtml

Silverman, M. (2013). Effects of group songwriting on depression and quality of life in acute psychiatric inpatients: A randomized three group effectiveness study. Nordic Journal of Music Therapy, 22(2), 131-148.

#HowAreYouReally: Mental Health in Caregivers and Parents

May has come to be known as the Month of Mental Health. On May 15 the Mental Health Coalition started a new online campaign using the hashtag “How are you, really?”. Its purpose? To be more transparent about everyday mental health struggles and open up a dialogue about honest and real feelings. 

While a large concentration has been on maintaining and supporting children’s mental health during this crisis, acknowledging the strains of caregivers’ and parents’ mental health is equally important, especially if there is a child with special needs involved. The Mental Health Coalition estimates that 1 in every 4 people will experience some type of mental health condition at some point in their lives (The Case for Mental Health, para. 1). With this in mind, knowing how to best give or recommend support to caregivers and parents of children with special needs is crucial.

With school and business closures, online work has been a hallmark of COVID-19. Parents and caregivers have become full-time teachers overnight, therapy facilitators, and entertainers in addition to job responsibilities. Despite the World Health Organization and American Academy of Pediatrics recommendations that children ages 6-10 only receive 1-1.5 hours of screen time a day with that limit increased to 2 hours for children 11-13 (EyePromise, 2019, para. 3 &4), an increased amount of screen time for everyone–children and parents alike– has become inevitable. In a 2018 study, researchers found that an increased amount of screen time in children correlated with lower psychological well-being and less emotional stability, as well as increased anxiety and depression (Twenge, 2018, pg. 272). Additionally, a 2017 study found that the amount of TV watching and computer use can predict the depression level among adults (Madhav et. al, 2017, pg. 68). To combat these effects,  Amy Kelly– Devereux Advanced Behavioral Health National Director of Family Engagement– recommends “unplugging” from screens for set periods of time for the entire family (Kelly, para. 10). 

Juggling various responsibilities can be overwhelming. Having times dedicated to engaging in realistic self-care practices can help alleviate feelings of anxiety and stress. While yoga and mindful meditation are effective strategies, it can be difficult to block out set amounts of time. Seattle Children’s “Realistic Ways for Parents to Manage Stress” article suggests going on a short walk outside or 5-minute stretching or single-song dance party as a quick self-care practice (Ibarra, 2020, para. 23). Taking 5 deep breaths periodically as well as bringing awareness to water intake and posture are additional easy self-care practices as well (Ibarra, 2020, para. 24 &25).

For those families who desire for self-care practices to be inclusive of all family members, board-certified music therapist  Stephanie Leavell’s “Yoga Song” is intentionally written for children and is family-friendly. Stephanie’s song is based on 11 different yoga poses that are easy for beginners and children. During the song, she slowly counts to 10 before transitioning to the next pose. At the end of the song, she focuses on breathing before gently ending. Her song is part of her album “Move It, Move It!” and can be found on Spotify and iTunes music, as well as YouTube (with visuals of the poses). The song can help decrease heart rate, increase oxygen, and encourage mindfulness for all parties participating. 

Seattle Children’s also recommends 5 steps for caregivers and parents to take during times of frustration (Take 5 When You’re Overwhelmed or Frustrated, 2020): 

1. Stop and step away

2. Take a short break to breathe

3. Remind yourself “I can do this” or “It’s important to stay calm.”

4. Ask yourself, “How can I handle this situation in a way that I will feel good about?”

5. If possible, ask for support from a partner or family member. Call or text a friend or neighbor. It’s ok to ask for help. 

Per step 5, speech-language pathologist Jim Mancini from Seattle Children’s recommends to “practice physical distancing, not social distancing” (Ibarra, 2020, para. 38). He points out that regularly talking–via phone call, via video chat, or text message– can help all individuals regulate during this time of quarantine and isolation. Affirming feelings and checking in by asking “How are you, really?” can let others know that they are not alone. 

-Sarah Deal, Music Therapy Intern 

References: 

Eyepromise (2019). Screen Time Guidelines by Age. Retrieved May 16, 2020 from https://www.eyepromise.com/wp-content/uploads/2019/05/Screentime-Recommendation-Chart-Final_AAP-WHO.pdf 

Ibarra, R. (2020). Don’t Have an Hour for Yoga? Realistic Ways for Parents to Manage Stress. Retrieved May 16, 2020 from https://pulse.seattlechildrens.org/dont-have-an-hour-for-yoga-realistic-ways-for-parents-to-manage-stress/ 

Kelly, A. (2020). COVID-19: Helping families with special needs during a public health crisis. Retrieved May 16, 2020 from https://www.devereux.org/site/SPageServer/?pagename=helping_families 

Madhav, K. C., Sherchand, S. P., & Sherchan, S. (2017). Association between screen time and depression among US adults. Preventive Medicine Reports, 8, 67–71. 

The Mental Health Coalition (2020). The Case for Mental Health. Retrieved May 16, 2020 from https://thementalhealthcoalition.org/cases/ 

Twenge, J.M. & Campbell, W.K. (2018). Associations between screen time and lower psychological well-being among children and adolescents: Evidence from a population-based study. Preventative Medicine Reports, 12, 271-283.

Behavioral Strategies in Music Therapy for Children with an Emotional-Behavioral Disorder

Emotional-behavioral disorders (EBD) is an umbrella term that encompasses a vast range of diagnoses. In the educational setting, this term is used to describe a child or adolescent whose behavior is viewed as disruptive and whose actions inhibit the individual’s academic performance (Jacob, 2018). The emotional component of EBD is that the child/adolescent is unable to effectively control their emotions. Examples of emotional disorders include anxiety disorders and depression. The behavioral component is thus the manifestation of emotional dysregulation. Behavioral disorders include oppositional defiant disorder (ODD), conduct disorder (CD), and obsessive-compulsive disorder (OCD). Symptoms displayed can be categorized into externalizing behaviors and internalizing behaviors. Externalizing behaviors include acting out, fighting, using inappropriate language, destruction of property, and other deleterious behaviors. Internalizing behaviors are focused inward and may include being withdrawn, exhibiting nervousness, physical symptoms such as headaches and stomachaches, changes in sleeping patterns, and changes in eating patterns (Jacob, 2018).

         Since each individual is different and thus displays symptoms differently, it may be difficult to pinpoint which disorder a child or adolescent may suffer from. This may be why EBD is used as an umbrella term to describe multiple diagnoses (Jacob, 2018). Although there are common behaviors displayed, each child/adolescent requires individualized attention and care in regards to treatment.

An emotional-behavioral disorder affects virtually every facet of a child/adolescent’s life, including school, family, and community functioning and performance (Bakken, Obiakor, & Rotatori, 2012). A common thread amongst children/adolescents diagnosed with EBD is their lack of social skills. They are unable to form and maintain interpersonal relationships with both school-aged peers and adults. This incapability can present a major challenge in social development and emotional wellbeing.

Behavioral theories suggest that human behavior is shaped through conditioning and observational learning (Gfeller & Thaut, 2008, p. 225). A main premise of behavioral theories is that an individual is more likely to display a certain behavior if it is consistently rewarded or reinforced. A child or adolescent may be inclined to display a disruptive behavior if it is constantly acknowledged by their teacher or caregiver. Positive Behavioral Support (PBS) is a range of preventive and positive interventions designed to create a supportive and successful environment for individuals who demonstrate behavioral issues (Adamek & Darrow, 2018, p. 196). The ultimate goal of PBS is to improve the daily lives of individuals in all settings, such as school, home, and community (Adamek & Darrow, 2018, p.196).

Positive Behavioral Support (PBS) utilizes three features: a behavioral assessment, comprehensive intervention, and lifestyle enhancement (Adamek & Darrow, 2018, p. 196). Similar to music therapy treatment, the assessment stage of PBS involves tracking the child or adolescent’s problem behaviors by observing the frequency and factors leading up to them. A comprehensive PBS plan involves altering the individual’s environment in order to remove triggering stimuli, teaching new skills to replace problem behaviors, and minimize natural reinforcements for inappropriate behavior (Adamek & Darrow, 2018, p. 196). 

 Behavioral techniques can be used in the music therapy setting to promote appropriate, desired behavior among children and adolescents with an emotional or behavioral disorder. Utilizing behavioral strategies in music therapy sessions allow for the client to make progress towards more appropriate behavior in unique, engaging ways. Participating in music-based interventions serves as a distraction from displaying inappropriate behaviors. For example, providing a child or adolescent with an instrument to play may counteract their ability to interact negatively with peers. Secondly, learning to play an instrument or read an instrument requires the child or adolescent to remain focused and engaged. By learning a musical concept, the child or adolescent exhibits appropriate behavior such as remaining seated, holding an instrument, and/or reading music. Finally, music can serve as a contingency for displaying appropriate behavior for a specific length of time. Once the specific time length of desired behavior is reached, the music therapist could reward the client by incorporating the client’s prefered music into the session or allowing the client to play their prefered instrument choice.

Music therapy sessions implementing behavioral strategies would involve structure and expectations set by the music therapist. The music therapist can set the expectation for the session by creating the session’s schedule at the beginning of the session and implementing a reward chart. If the client completes a set amount of interventions during the session, they will be rewarded with a prefered music activity. For example, if the client’s goals measure fine motor skills and remaining on-task, the client would be rewarded after sitting at the piano for a determined time length and isolating their fingers to play piano scales or a piano piece. If the client completes this intervention, the client could be rewarded for their positive and appropriate behavior by being given their prefered instrument. For example, if the client’s prefered instrument is the drum, the client and music therapist could engage in an improvisational intervention that provides the client with an opportunity for self-expression and autonomy by assuming the lead role in an intervention that they favor.

-Jasmine Bailey, Music Therapy Intern 

References

Adamek, M., & Darrow, A. (2018). Students with behavior disorders. In M. Adamek & A. Darrow (Eds.), Music in special education. The American Music Therapy Association.

Brigham, F.J., Bakken, J.P., & Rotatori, A.F. (2012). Families and students with emotional and behavioral disorders. In J. Bakken, F. Obiakor, & A. Rotatori (Eds.), Behavioral disorders: practice concerns and students with EBD (pp. 207-231). Emerald Group Publishing Limited.

Gfeller, K., & Thaut, M. (2008). Music therapy in the treatment of behavioral-emotional disorders. In W. Davis, K. Gfeller, & M. Thaut (Eds.), An introduction to music therapy: Theory and practice. American Music Therapy Association. 

Jacob, L.M. (2018). Emotional and behavioral disorders. Salem Press Encyclopedia of Health. Retrieved from http://eds.a.ebscohost.com/eds/detail/detail?vid=1&sid=feb9e3e5-0cf8-435f-b0ec-7c7493b6d4b2%40sdc-v-sessmgr01&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=93787442&db=ers

Effect of Music and Movement in Older Adults

Exercise is essential for all populations but may be most imperative for older adults. The World Health Organization [WHO] recommends that adults aged 65 and older should get at least 150 minutes of moderate aerobic activity per week (World Health Organization [WHO], para. 1). However, a 2014 study by the CDC reported that 26.9% of adults aged 65-74 and 35.3% of adults >75 had no physical activity outside of work or daily living in the previous month (Watson et. al.,, 2014, 954). The benefits of physical activity are practically endless, reducing the risk for cardiovascular complications, recurrent falls, ADL limitations and cognitive decline, dementia, and depression. Overall, an increased quality life and improved cognitive functioning are the greatest outcomes (Cunningham, 2020, para. 1). 

In a 2001 music therapy case study, results indicated that there was a significant difference in the adherence to six of 14 various exercises presented with and without music during a physical therapy rehabilitation session for older adults (Johnson et. al, 91). The researchers credit the presence of music and the element of rhythm for increased fluidity and increased range of motion. Without music, the researchers noted that some patients had an increased number of repetitions per movement but some exercises required slower movements to gain maximum benefits (Johnson et. al, 2001, 92). Overall, unsolicited comments recorded during the session by the patients indicated a preference for music in the sessions (Johnson et. al, 2001, 82). 

Neurologic Music Therapy pioneer Dr. Michael Thaut gives further insight as to how rhythm aids in motor processes: “Rhythm provides temporal structure through metrical organization, predictability, and patterning….Rhythmic entrainment provides immediate time regulation but can be accessed to enhance long-term training effects” (Thaut, 2005, pg. 83). The temporal lobes are located on either side of the brain located near the ears. While their most prominent function is auditory processing and encoding memory, the right temporal lobe is involved in learning and remembering non-verbal information. This aids in visuo-spatial material as well as processing the structures of music (Queensland Government, 2017, para. 2). The rhythm of music allows auditory processing and the motor system to work in tandem through rhythmic entrainment, priming of the auditory-motor pathway, and cuing of the movement period (Thaut, 2005, 141). While the rhythmic structure of music can help individuals in real-time–in terms of the 2001 case study, while the individuals were exercising– rhythm can also be used to cue long-term memory recall, aiding in movement. 

While research is limited on examining individual’s music preference and effect on movement, a 2016 study revealed that key features of music preferred by older adults included “duple meter, consistent rhythm, major key, rounded melodic shape, legato articulation, predictable harmonies, variable volume, and episodes of tension with delayed resolution” (Clark, 2016, 364). An outline of songs from the 2001 Johnson et. al study that fit these characteristics and their respective implementation can be found below: 

Overall, fitness and movement is essential for all populations but can greatly increase the quality of life of older adults. Having input from a board-certified music to pair appropriate music selections with fitness routines can help maximize the intended effects of the exercises.

-Sarah Deal, Music Therapy Intern

References: 

Clark, I.N., Baker, F.A., & Taylor, N.F. (2016). Older Adults’ Music Listening Preferences to Support Physical Activity Following Cardiac Rehabilitation. Journal of Music Therapy, 53(4), 364-397. 

Cunningham, C., O’Sullivan, R., Caserotti, P., & Tully, M.A. (2020). Consequences of physical inactivity in older adults: A systematic review of reviews and meta‐analyses. Scandinavian Journal of Medicine & Science in Sports, 30(5), 816-827. 

Johnson, G., Otto, D., & Clair, A.A. (2001). The Effect of Instrumental and Vocal Music on Adherence to a Physical Rehabilitation Exercise Program with Persons who are Elderly. Journal of Music Therapy, 38(2), 82-96.

Thaut, M.H. (2005). Rhythm, Music, and the Brain. Routledge. 

Watson, K.B., Carlson, S.A., Gunn, J.P., Galuska, D.A., O’Connor, A., Greenlund, K.J., & Fulton, J.E. (2014). Physical Inactivity Among Adults Aged 50 Years and Older. Morbidity and Mortality Weekly Report, 65(36), 954-958. 

Queensland Government (2017). Brain Map: Temporal Lobes. Retrieved April 25, 2020 from   https://www.health.qld.gov.au/abios/asp/btemporal_lobes 

World Health Organization [WHO] (n.d). Physical Activity and Older Adults. Retrieved April 25, 2020 from https://www.who.int/dietphysicalactivity/factsheet_olderadults/en/

Music Therapy for Clients with Hearing Impairments

In 2014, it was estimated that about 17% of the American population, or 36 million individuals, have some degree of hearing loss (Lathom & Peters, 2016, p. 175). Hearing impairment affects an individual's ability to hear and process speech, which in turn causes deficits in social and communication skills. Although hearing loss varies among individuals, at least 90% of the individuals who have hearing impairments have some degree of residual hearing (Lathom & Peters, 2016, p. 171). Hearing impairments can affect the intensity in which a sound is heard, the clarity in which the sound is heard, or both (Lathom & Peters, 2016, p. 172). 

Hearing impairments are categorized based on age of onset, type of hearing loss, and degree of hearing loss (Gfeller & Darrow, 2008, p. 370). Hearing loss can be present at birth or can occur after birth. Acquired hearing losses can occur before learning a language, while learning a language, or after a language (Gfeller & Darrow, 2008, p. 371). Hearing impairments can ultimately lead to difficulty developing or maintaining communication skills, depending on when it occurs in an individual’s life. 

In addition to potential deficits in communication and social skills, individuals with hearing impairments often struggle academically. Children and adolescents with hearing impairments often have poorer academic performance in comparison to their peers without a known hearing impairment (Lathom & Peters, 2016, p. 176). This may cause children and adolescents with a hearing impairment to become frustrated in the academic setting. Hearing impairments may additionally cause other issues in relation to academic learning, such as a short attention span due to difficulty concentrating on auditory activities (Lathom & Peters, 2016, p. 176). 

Adults who have acquired hearing loss struggle socially, emotionally, and cognitively while executing activities in daily life. Adult individuals with hearing loss are faced with adjusting to their reduced level of hearing. This may cause them to struggle in social settings in which they once thrived due to difficulty hearing and understanding conversations. Difficulty understanding and hearing conversations may lead to an increase in social isolation (Lathom & Peters, 2016, p. 176). Acquired hearing impairments may also affect an individual’s job performance because it has become more difficult to decipher conversations. 

It is a common misconception that individuals with hearing loss cannot engage and enjoy music related activities. Music therapy interventions benefit individuals with hearing impairments by assessing auditory functioning, assisting in auditory training, enhancing speech production, encouraging language development, and promoting social skills (Lathom & Peters, 2016, p. 185). Listening to musical cues allows for individuals to maximize their use of residual hearing. Music therapists working with hearing impaired clients often work to increase the client’s ability to detect the presence or absence of a sound as well as differentiating between different auditory stimuli. Musical elements, such as tempo, pitch, timbre, rhythm, and duration of sound  allow for clients to exercise their auditory discrimination skills in an engaging way.

Rhythm is often used in music therapy interventions to improve speech production in clients with hearing impairments (Lathom & Peters, 2016, p. 187). Music therapists often address speech production with hearing impaired clients by aligning speech production to rhythms. Rhythmic chanting of a word or phrase allows for the client to become aware of their speech rate. Music therapists also work to improve vocal intonation and inflection by increasing awareness of pitch movements (Lathom & Peters, 2016, p. 187). Music therapy interventions can allow for a client with a hearing impairment to become aware of their speech production, improve their vocal quality, and enhance their articulation skills (Lathom & Peters, 2016, p. 189).

Individuals with hearing impairments often self-isolate due to difficulty understanding others in conversations. Music therapy interventions can improve a client’s social skills by allowing for communication in a group setting. Structured music therapy interventions such as songwriting provides opportunities for the client to engage in topic-related interactions and provide targeted responses. Singing in group settings allows for clients to participate, whether they are verbalizing the lyrics, using signed language, or using a communication device. Additionally, group settings may improve the client’s overall comfort level in social settings. 

In order to provide individualized treatment, the music therapist should consult with other professionals involved in the client’s treatment, such as a speech language pathologist or audiologist, to obtain information regarding the client’s receptive and expressive communication levels (Lathom & Peters, 2016, p. 193). Music therapists should have an understanding of how a client’s assistive hearing devices work, if used. Room fixtures, such as carpeting, curtains, and upholstery can serve to minimize environmental sounds. The music therapist should also consider the client’s intensity of hearing and place them closer to sound sources if needed. Finally, the music therapist should consider the use of visual aids, tactile cues, and multisensory strategies to emphasize auditory information.

-Jasmine Bailey, Music Therapy Intern

References

Gfeller, K., & Darrow, A. (2008). Music therapy in the treatment of sensory disorders. In W. Davis, K. Gfeller, & M. Thaut (Eds.), An introduction to music therapy: Theory and Practice, (pp. 365-404). American Music Therapy Association

Lathom, W. & Peters, J. (2016). Music therapy for hearing impaired individuals. In W. Latham & J. Peters (Eds.), Peter’s music therapy (pp. 171-200). Charles C. Thomas.