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Music Therapy Intervention
Power of Music by Louis Gallait.
A brother and sister resting before an
oldtomb. The brother is attempting to
comfort his sibling by playing the violin,
and she has fallen into a deep sleep,
"oblivious of all grief, mental and physical."
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Music therapists are found in nearly every area of the helping professions. Some commonly found practices include developmental work (communication, motor skills, etc.) with individuals with special needs, songwriting and listening in reminiscence/orientation work with the elderly, processing and relaxation work, and rhythmic entrainment for physical rehabilitation in stroke victims. Music therapy is also used in some medical hospitals, cancer centers, schools, alcohol and drug recovery programs, psychiatric hospitals, and correctional facilities.
History
Music has been used as a healing force for centuries. Apollo is the ancient Greek god of music and of medicine. Aesculapius was said to cure diseases of the mind by using song and music, and music therapy was used in Egyptian temples. Plato said that music affected the emotions and could influence the character of an individual. Aristotle taught that music affects the soul and described music as a force that purified the emotions. Aulus Cornelius Celsus advocated the sound of cymbals and running water for the treatment of mental disorders. Music therapy was practiced in biblical times, when David played the harp to rid King Saul of a bad spirit. As early as 400 B.C., Hippocrates played music for his mental patients. In the thirteenth century, Arab hospitals contained music-rooms for the benefit of the patients. In the United States, Native American medicine men often employed chants and dances as a method of healing patients. The Turco-Persian psychologist and music theorist al-Farabi (872–950), known as Alpharabius in Europe, dealt with music therapy in his treatise Meanings of the Intellect, in which he discussed the therapeutic effects of music on the soul. Robert Burton wrote in the 17th century in his classic work, The Anatomy of Melancholy, that music and dance were critical in treating mental illness, especially melancholia. Music therapy as we know it began in the aftermath of World Wars I and II, when, particularly in the United Kingdom, musicians would travel to hospitals and play music for soldiers suffering from war-related emotional and physical trauma.
Forms
Approaches used in music therapy that have emerged from the field of education include Orff-Schulwerk (Orff), Dalcroze Eurhythmics, and Kodaly. Two models that developed directly out of music therapy are Nordoff-Robbins and the Bonny Method of Guided Imagery and Music.
Music therapists may work with individuals who have behavioral-emotional disorders. To meet the needs of this population, music therapists have taken current psychological theories and used them as a basis for different types of music therapy. Different models include behavioral therapy, cognitive behavioral therapy, and psychodynamic therapy.
One therapy model based on neuroscience, called "neurological music therapy" (NMT), is "based on a neuroscience model of music perception and production, and the influence of music on functional changes in non-musical brain and behavior functions." In other words, NMT studies how the brain is without music, how the brain is with music, measures the differences, and uses these differences to cause changes in the brain through music that will eventually affect the client non-musically. As one researcher, Dr. Thaut, said: "The brain that engages in music is changed by engaging in music." NMT trains motor responses (i.e. tapping foot or fingers, head movement, etc.) to better help clients develop motor skills that help "entrain the timing of muscle activation patterns".
Children
Music therapy for children is conducted either in a one-on-one session or in a group session. When a therapist meets with a child for the first time, customarily the therapist assesses the child's level of functioning in all developmental areas and then develops specific goals and objectives to be met during the duration of their sessions. Music therapy can help children with issues regarding communication, attention, and motivation, as well as with behavioral problems.
The therapist typically plays either a piano or a guitar, which allows for a wide variety of musical styles to suit the client's preferences. The child is usually encouraged to play an instrument adapted to his or her unique abilities and needs. These elements are designed to improve the experience and outcome of the therapy.
According to Daniel Levitin, the experience of listening to music starts inside the womb when the fetus, surrounded by amniotic fluid, hears sounds. It hears the mother’s heartbeat speed up and slow down, as well as music, conversations, and environmental noises. Alexandra Lamont of Keele University in the UK established that the fetus hears music. She discovered that at the age of one children recognize and express a preference for music they were exposed to in the womb. The auditory system of the fetus is fully functional at about twenty weeks after conception. Music therapy for premature infants is typically targeted at integrating, and increasing the infant's tolerance for, physical and auditory stimulation and at increasing strength and speed of sucking, in order to promote growth.
Adolescents with Mood Disorders
Music and Mood Disorders
According to the Mayo Health Clinic, two to three thousand out of every 100,000 adolescents will have mood disorders, and out of those two to three thousand, eight to ten will commit suicide.[citation needed] Two prevalent mood disorders in the adolescent population are clinical depression and bipolar disorder.
On average, American adolescents listen to approximately 4.5 hours of music per day and are responsible for 70% of pop music sales. Now, with the invention of new technologies such as the iPod and digital downloads, access to music has become easier than ever. As children make the transition into adolescence they become less likely to sit and watch TV, an activity associated with family, and spend more of their leisure time listening to music, an activity associated with friends.
Adolescents obtain many benefits from listening to music, including emotional, social, and daily life benefits, along with help in forming their identity. Music can provide a sense of independence and individuality, which in turn contributes to an adolescent's self-discovery and sense of identity. Music also offers adolescents relatable messages that allow them to take comfort in knowing that others feel the same way they do. It can also serve as a creative outlet to release or control emotions and find ways of coping with difficult situations. Music can improve an adolescent's mood by reducing stress and lowering anxiety levels, which can help counteract or prevent depression. Music education programs provide adolescents with a safe place to express themselves and learn life skills such as self-discipline, diligence, and patience. These programs also promote confidence and self-esteem. Ethnomusicologist Alan Merriam (1964) once stated that music is a universal behavior – it is something with which everyone can identify. Among adolescents, music is a unifying force, bringing people of different backgrounds, age groups, and social groups together.
Referrals and Assessments
While many adolescents may listen to music for its therapeutic qualities, it does not mean every adolescent needs music therapy. Many adolescents go through a period of teenage angst characterized by intense feelings of strife that are caused by the development of their brains and bodies. Some adolescents develop more serious mood disorders such as major clinical depression and bipolar disorder. Adolescents diagnosed with a mood disorder may be referred to a music therapist by a physician, therapist, or school counselor/teacher. When a music therapist gets a referral, he or she must first assess the patient and then create goals and objectives before beginning the actual therapy. According to the American Music Therapy Association Standards of Clinical Practice assessments should include the “general categories of psychological, cognitive, communicative, social, and physiological functioning focusing on the client’s needs and strengths…and will also determine the client’s response to music, music skills, and musical preferences” The result of the assessment is used to create an individualized music therapy intervention plan.
Treatment Techniques
There are many different music therapy techniques used with adolescents. The music therapy model is based on various theoretical backgrounds such as psychodynamic, behavioral, and humanistic approaches. Techniques can be classified as active vs. receptive and improvisational vs. structured. The most common techniques in use with adolescents are musical improvisation, the use of precomposed songs or music, receptive listening to music, verbal discussion about the music, and incorporating creative media outlets into the therapy. Research also showed that improvisation and the use of other media were the two techniques most often used by the music therapists. The overall research showed that adolescents in music therapy “change more when discipline-specific music therapy techniques, such as improvisation and verbal reflection of the music, are used.” The results of this study showed that music therapists should put careful thought into their choice of technique with each individual client. In the end, those choices can affect the outcome of the treatment.
To those unfamiliar with music therapy the idea may seem a little strange, but music therapy has been found to be as effective as traditional forms of therapy. In a meta-analysis of the effects of music therapy for children and adolescents with psychopathology, Gold, Voracek, and Wigram (2004) looked at ten studies conducted between 1970 and 1998 to examine the overall efficacy of music therapy on children and adolescents with behavioral, emotional, and developmental disorders. The results of the meta-analysis found that “music therapy with these clients has a highly significant, medium to large effect on clinically relevant outcomes.” More specifically, music therapy was most effective on subjects with mixed diagnoses. Another important result was that “the effects of music therapy are more enduring when more sessions are provided.”
One example of clinical work is that done by music therapists who work with adolescents to increase their emotional and cognitive stability, identify factors contributing to distress and initiate changes to alleviate that distress. Music therapy may also focus on improving quality of life and building self-esteem, a sense self-worth, and confidence. Improvements in these areas can be measured by a number of tests, including qualitative questionnaires like Beck’s Depression Inventory, State and Trait Anxiety Inventory, and Relationship Change Scale. Effects of music therapy can also be observed in the patient’s demeanor, body language, and changes in awareness of mood.
Two main methods for music therapy are group meetings and one-one sessions. Group music therapy can include group discussions concerning moods and emotions in or toward music, songwriting, and musical improvisation. Groups emphasizing mood recognition and awareness, group cohesion, and improvement in self-esteem can be effective in working with adolescents. Group therapy, however, is not always the best choice for the client. Ongoing one-on-one music therapy has also been shown to be effective. One-on-one music therapy provides a non-invasive, non-judgmental environment, encouraging clients to show capacities that may be hidden in group situations.
Though more research needs to be done to ascertain the effect of music therapy on adolescents with mood disorders, most research has shown positive effects.
Heart Disease
According to a 2009 Cochrane review some music may reduce heart rate, respiratory rate, and blood pressure in those with coronary heart disease. Music does not appear to have much effect on psychological distress. "The quality of the evidence is not strong and the clinical significance unclear".
Neurological Disorders
The use of music therapy in treating mental and neurological disorders is on the rise. Music therapy has showed effectiveness in treating symptoms of many disorders, including schizophrenia, amnesia, dementia and Alzheimer’s, Parkinson's disease, mood disorders such as depression, aphasia and similar speech disorders, and Tourette’s syndrome, among others.
While music therapy has been used for many years, up until the mid-1980s little empirical research had been done to support the efficacy of the treatment. Since then, more research has focused on determining both the effectiveness and the underlying physiological mechanisms leading to symptom improvement. For example, one meta-study covering 177 patients (over 9 studies) showed a significant effect on many negative symptoms of psychopathologies, particularly in developmental and behavioral disorders. Music therapy was especially effective in improving focus and attention, and in decreasing negative symptoms like anxiety and isolation.
The following sections will discuss the uses and effectiveness of music therapy in the treatment of specific pathologies.
Stroke
Music has been shown to affect portions of the brain. One reason for the effectiveness of music therapy for stroke victims is the capacity of music to affect emotions and social interactions. Research by Nayak et al. showed that music therapy is associated with a decrease in depression, improved mood, and a reduction in state anxiety. Both descriptive and experimental studies have documented effects of music on quality of life, involvement with the environment, expression of feelings, awareness and responsiveness, positive associations, and socialization. Additionally, Nayak et al. found that music therapy had a positive effect on social and behavioral outcomes and showed some encouraging trends with respect to mood.
More recent research suggests that music can increase a patient's motivation and positive emotions. Current research also suggests that when music therapy is used in conjunction with traditional therapy it improves success rates significantly. Therefore, it is hypothesized that music therapy helps a victim of stroke recover faster and with more success by increasing the patient's positive emotions and motivation, allowing him or her to be more successful and feel more driven to participate in traditional therapies.
Recent studies have examined the effect of music therapy on stroke patients when combined with traditional therapy. One study found the incorporation of music with therapeutic upper extremity exercises gave patients more positive emotional effects than exercise alone. In another study, Nayak et al. found that rehabilitation staff rated participants in the music therapy group more actively involved and cooperative in therapy than those in the control group. Their findings gave preliminary support to the efficacy of music therapy as a complementary therapy for social functioning and participation in rehabilitation with a trend toward improvement in mood during acute rehabilitation.
Current research shows that when music therapy is used in conjunction with traditional therapy, it improves rates of recovery and emotional and social deficits resulting from stroke. A study by Jeong & Kim examined the impact of music therapy when combined with traditional stroke therapy in a community-based rehabilitation program. Thirty-three stroke survivors were randomized into one of two groups: the experimental group, which combined rhythmic music and specialized rehabilitation movement for eight weeks; and a control group that sought and received traditional therapy. The results of this study showed that participants in the experimental group gained not only more flexibility and wider range of motion, but an increased frequency and quality of social interactions and positive mood.
Music has proven useful in the recovery of motor skills. Rhythmical auditory stimulation in a musical context in combination with traditional gait therapy improved the ability of stroke patients to walk. The study consisted of two treatment conditions, one which received traditional gait therapy and another which received the gait therapy in combination with the rhythmical auditory stimulation. During the rhythmical auditory stimulation, stimulation was played back measure by measure, and was initiated by the patient's heel-strikes. Each condition received fifteen sessions of therapy. The results revealed that the rhythmical auditory stimulation group showed more improvement in stride length, symmetry deviation, walking speed and rollover path length (all indicators for improved walking gait) than the group that received traditional therapy alone.
Schneider et al. also studied the effects of combining music therapy with standard motor rehabilitation methods. In this experiment, researchers recruited stroke patients without prior musical experience and trained half of them in an intensive step by step training program that occurred fifteen times over three weeks, in addition to traditional treatment. These participants were trained to use both fine and gross motor movements by learning how to use the piano and drums. The other half of the patients received only traditional treatment over the course of the three weeks. Three-dimensional movement analysis and clinical motor tests showed participants who received the additional music therapy had significantly better speed, precision, and smoothness of movement as compared to the control subjects. Participants who received music therapy also showed a significant improvement in every-day motor activities as compared to the control group. Wilson, Parsons, & Reutens looked at the effect of melodic intonation therapy (MIT) on speech production in a male singer with severe Broca's aphasia. In this study, thirty novel phrases were taught in three conditions: unrehearsed, rehearsed verbal production (repetition), or rehearsed verbal production with melody (MIT). Results showed that phrases taught in the MIT condition had superior production, and that compared to rehearsal, effects of MIT lasted longer.
Another study examined the incorporation of music with therapeutic upper extremity exercises on pain perception in stroke victims. Over the course of eight weeks, stroke victims participated in upper extremity exercises (of the hand, wrist, and shoulder joints) in conjunction with one of the three conditions: song, karaoke accompaniment, and no music. Patients participated in each condition once, according to a randomized order, and rated their perceived pain immediately after the session. Results showed that although there was no significant difference in pain rating across the conditions, video observations revealed more positive affect and verbal responses while performing upper extremity exercises with both music and karaoke accompaniment. Nayak et al. examined the combination of music therapy with traditional stroke rehabilitation and also found that the addition of music therapy improved mood and social interaction. Participants who had suffered traumatic brain injury or stroke were placed in one of two conditions: standard rehabilitation or standard rehabilitation along with music therapy. Participants received three treatments per week for up to ten treatments. Therapists found that participants who received music therapy in conjunction with traditional methods had improved social interaction and mood.
Dementia
Alzheimer’s disease and other types of dementia are among the disorders most commonly treated with music therapy. Like many of the other disorders mentioned, some of the most common significant effects are seen in social behaviors, leading to improvements in interaction, conversation, and other such skills. A meta-study of over 330 subjects showed music therapy produces highly significant improvements to social behaviors, overt behaviors like wandering and restlessness, reductions in agitated behaviors, and improvements to cognitive defects, measured with reality orientation and face recognition tests. As with many studies of MT’s effectiveness, these positive effects on Alzheimer’s and other dementias are not homogeneous among all studies. The effectiveness of the treatment seems to be strongly dependent on the patient, the quality and length of treatment, and other similar factors.
Another meta-study examined the proposed neurological mechanisms behind music therapy’s effects on these patients. Many authors suspect that music has a soothing effect on the patient by affecting how noise is perceived: music renders noise familiar, or buffers the patient from overwhelming or extraneous noise in their environment. Others suggest that music serves as a sort of mediator for social interactions, providing a vessel through which to interact with others without requiring much cognitive load.
Amnesia
Some symptoms of amnesia have been shown to be alleviated through various interactions with music, including playing and listening. One such case is that of Clive Wearing, whose severe retrograde and anterograde amnesia have been detailed in the documentaries Prisoner of Consciousness and The Man with the 7 Second Memory. Though unable to recall past memories or form new ones, Wearing is still able to play, conduct, and sing along with music learned prior to the onset of his amnesia, and even add improvisations and flourishes.
Wearing’s case reinforces the theory that episodic memory fundamentally differs from procedural orsemantic memory. Sacks suggests that while Wearing is completely unable to recall events or episodes, musical performance (and the muscle memory involved) are a form of procedural memory that is not typically hindered in amnesia cases [Sacks]. Indeed, there is evidence that while episodic memory is reliant on thehippocampal formation, amnesiacs with damage to this area can show a loss of episodic memory accompanied by (partially) intact semantic memory.
Aphasia
Melodic intonation therapy (MIT) is a commonly used method of treating aphasias, particularly those involving speech deficits (as opposed to reading or writing). MIT is a multi-stage treatment that involves committing words and speech rhythm to memory by incorporating them into song. The musical and rhythmic aspects are then separated from the speech and phased out, until the patient can speak normally. This method has slight variations between adult patients and child patients, but both follow the same basic structure.
While MIT is a commonly used therapy, research supporting its effectiveness is lacking. Some recent research suggests that the therapy’s efficacy may stem more from the rhythmic components of the treatment rather than the melodic aspects.
Psychiatric Disorders
Schizophrenia
Music therapy is used with schizophrenic patients to ameliorate many of the symptoms of the disorder. Individual studies of patients undergoing music therapy showed diminished negative symptoms such as flattened affect, speech issues, and anhedonia and improved social symptoms such as increased conversation ability, reduced social isolation, and increased interest in external events.
Meta-studies have confirmed many of these results, showing that music therapy in conjunction with standard care to be superior to standard care alone. Improvements were seen in negative symptoms, general mental state, depression, anxiety, and even cognitive functioning. These meta-studies have also shown, however, that these results can be inconsistent and that they depend heavily on both the quality and number of therapy sessions.
Depression
Music therapy has been found to have numerous significant outcomes for patients with major depressive disorder. One study found that listening to soft, sedative music for only 30 minutes a day for two weeks led to significantly improved global depressive scores, and improved scores on individual depressive sub-scales. Like many of the other studies mentioned, the effects were seen to be cumulative over the time period studied – that is, longer treatment led to increased improvement [Hsu]. Another study showed that MDD patients were better able to express their emotional states while listening to sad music than while listening to no music or to happy, angry, or scary music. The authors found that this therapy helped patients overcome verbal barriers to expressing emotion, which can assist therapists in successfully guiding treatment.
Other studies have provided insight into the physiological interactions between music therapy and depression. Music has been shown to decrease significantly the levels of the stress hormone cortisol, leading to improved affect, mood and cognitive functioning. A study also found that music led to a shift in frontal lobe activity (as measured by EEG) in depressed adolescents. Music was shown to shift activity from the right frontal lobe to the left, a phenomenon associated with positive affect and mood.
Experimental-Music-Centered Therapy
Music therapist and researcher Enrico Curreri clinically explored theories and concepts developed by the American composer John Cage. For example, in various music therapy sessions with a patient diagnosed with depression and anxiety disorder, Curreri performed Cage's seminal composition of silence 4′33″ and utilized aleatoric/chance procedures. He also investigated experimental and microtonal music.
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