* Lian Horenblas * Nohemi Jasso * Tammy Smith * Megan Wulf * Becky McCurley *



A Case for Music Therapy


Historical Foundations (Lian Horenblas)


    It is well known that the idea of music as a healing element goes back at least as far as the famous Greeks Plato and Aristotle; if not significantly farther. While it is clearly depicted in the remnants of the civilizations that used music for what

it was capable of doing, the earliest written reference appeared in 1789 in an unsigned article entitled “Music Physically Considered” that was published in Columbian Magazine (musictherapy.org, para. 2).  In the coming years, the early 1800s, there were more medical dissertations published discussing music therapy.  As it turns out, both of the dissertations were written by students of a Dr. Benjamin Rush, a physician and psychiatrist “who was a strong proponent of using music to treat medical diseases” (musictherapy.org, para. 2).
    The 1800s continued to be a burgeoning time for music therapy with the first ever recorded music therapy intervention at Blackwell’s Island in New York as well as the first recorded systematic experiment in music therapy by Corning, in which he used music to alter dream states during psychotherapy (musictherapy.org, para. 2).
From that point forward, interest in music therapy continued to snowball.  There were several small associations that formed that did not gain much momentum but were integral parts of keeping music history alive
and moving forward. First, in 1903, Eva Augusta Vescelius’ formed an organization called the National Society of Musical Therapeutics. Second was an organization called the National Association for Music in Hospitals, founded by Isa Maud Ilsen in 1926. Finally, in 1941, Harriet Ayer Seymour founded the National Foundation for Music Therapy.  These organizations contributed the first journals, books, and educational courses on music therapy and were founded entirely by women.

Music therapy as the profession that we recognize today developed during World Wars I
and II where music was used in Veteran’s Administration Hospitals in addressing soldiers with traumatic war injuries.  Veterans were engaged both actively and passively in musical activities that focused on relieving their experience of their pain. It was clear to all of the hospital staff that the music had a very real effect on the psychological, physiological, cognitive, and emotional states of the veterans they were caring for.  From that point forward, colleges and universities across the country began developing programs to train musicians in how to use their music for therapeutic purposes (musicasmedicine.com, para. 2).

In 1950 a professional organization was finally formed by a group of music therapists that worked across a range of disciplines: with veterans, those with cognitive disabilities, those with hearing and vision impairments, as well as those
with psychiatric conditions.  This collaboration was the birth of the National Association for Music Therapy and from 1950 until 1998 they operated under that name.  In 1998 the National Association for Music Therapy organized with another music therapy organization to become what is now known as the American Music Therapy Association. (musicasmedicine.com, para. 2).


Concepts    (Nohemi Jasso)

Theoretical Underpinnings
Music therapy is the clinical and evidence-base use of music for interventions for individuals trying to accomplish a goal in a therapeutic setting, and involves a lot of multidisciplinary theories that have been working along with individuals

specializing in music therapy to help individuals who suffers from varies diagnosis such as: Parkison’s disease, dementia, stroke victims, autism, addiction treatments, and aging individuals. “Since the establishment of the National Association for Music Therapy in the mid-20th century, music therapists have recognized the importance of interdisciplinary collaboration (e.g., Biology, Psychology, Sociology) in the practice of music therapy” (Cohen, 2014), showing that bringing together different theories can maximize results for a client. “Music therapy has been employed and welcomed as a safe alternative approach because of its ability to alleviate some symptoms of dementia” (Ahn & Ashida, 2012).
 
Disengagement theory and Music therapy
Cohen concentrated specifically on sociological theories to correlate with music therapy for aging adults. An example of Cohen’s sociological theory of aging, is the disengagement theory in which aging adults become withdrawn from society and become more secluded, as a way to help society stay efficient, running smoothly, and in a state of equilibrium. This is to get the clients involved in some sort of activity outside in the community and become less isolated. “Making music is a powerful way of engaging a multisensory and motor network and inducing changes and linking brain regions within this network. These multimodal effects of music making together with music’s ability to tap into the emotion and reward system in the brain can be used to facilitate therapy and rehabilitation of neurological disorders” (Altermuller & Schlaug, 2013),

 “In respect to parkison’s disease, Rhythmic Auditory Stimulations (RAS) has been proven to be particularly efficient” (Altenmuller & Schlaug, 2013), which focuses on a neurodegenerative disease, and showing positive outcomes. This is an example of neurorehabilitation. This is focused on the biology of the brain and its response to music therapy. Music therapy has shown to provoke motions and emotions, increasing interactions and an increase in neurohormons such as serotonin and dopamine, making it a rewarding activity (Altermuller & Schlaug, 2013).

Damasio’s theory of consciousness    
Neuropsychologist Antonio Damasio, made a “distinction between different forms of consciousness, which corresponds to different forms of self” (Dimitriadis & Smeijsters, 2011), focusing on the autistic spectrum disorder. Damasio identified three different forms of self: The unconscious proto-self, the conscious core-self, and the conscious autobiographical self. The proto-self involves the biological sensory reactions from the nervous system. Secondly, the core-self focused on the organism with the sense of self about the moment (now) and about one place (here)

(Dimitriadis & Smeijsters, 2011), it is neither non-verbal nor related to cognition. This self is not dependent on conventional memory, working memory, reasoning, or language. Finally, the autobiographical self, who corresponds to elaborating sense of self-identity and a person, and it, evolves across the lifetime of the organism. Autistic individuals have been shown to communicate better through music, “there is an analogy between being in music and being in the experience. Active or creative music therapy takes place in the experience, in the present moment, and involves the core-self/core consciousness (Dimitriadis & Smeijsters, 2011), with music therapist can help autistic individuals move through the different steps of self, changes, and communication through playful exchanges. This is important because autism affects the coherence and flexibility of motivation and consciousness (Dimitriadis & Smeijsters, 2011).

Assessment and intervention techniques
Assessments for music therapy include but are not limited to identifying roles, self-assessments, understand where the client is, meet the client where the client is most comfortable, and different goal settings. There are large amounts of intervention techniques for music therapy, depending on the results the client and therapist are seeking. What is done for aging would not necessarily

be done an individuals undergoing music therapy that is autistic. “Interventions would need to be tailored to address specific stages of dementia, various types of settings, and demographic sub-groups” (Ahn & Ashida, 2012), proving that even when music therapy is focused on dementia the intervention has to be modified to best serve the client. No two interventions will be the same, but will involve goals, and results.

Termination
Termination of music therapy will be as any other individual in therapy. The results will be measures according to the therapies requires and assessed to benefit the client. There is a mixed method “mixing the two research methods is also used to enhance understanding of a particular phase of the research process” (Bradt, Burns, & Creswell, 2013), which can include quantitative and qualitative results. This is beneficial due to various intervention methods and goals for different diagnosis; the results might not be quantitative, but qualitative. An example being a child with autism, result might be more in interactions and communications than statistical findings, as for the therapist, they might want the statistical aspect of results for their research.


Evidence-Based Knowledge    (Tammy Smith)

    
    A meta-analysis of 21 studies was performed to measure the effectiveness of music therapy on several types of ailments.  This is an SR (systematic review) of SRs based on RCTs (random controlled trials).  The studies had to be randomized controlled trials (RCTs) to be eligible for this meta-analysis.   Several databases were used in locating eligible studies. The following databases were searched with a timeline from 1995-October 1st, 2014:  MEDLINE, CNAHL, Web of Science, Global Health Library, and Ichushi-Web.  Also, all Cochrane Database and Campbell Systematic Reviews were searched as well.  (Kamioka, Tsutani, Yamada, Park, & Okuizumi, 2014).

        

These studies were meant to include several ailments.  Of the 21 studies, eight were focused on mental and behavioral disorders; the others were on the diseases of the nervous system, respiratory system, endocrine, nutritional, and metabolic disorders, circulatory disorders, pregnancy, and childbirth.  (Kamioka, et al., 2014).

The meta-analysis concluded that music therapy had greater results for people with schizophrenia and other serious mental disorders as long as it was in addition to their normal treatment and that an adequate number of sessions were provided by a qualified music therapist. (Mossler, Chen, Heldol, Olav, & Gold, 2011). Music therapy helped with their global and social functioning.  It also helped people with depression, and sleep issues.   

According to Gold, Voracek, & Wigram (2004), music therapy helped children and adolescents with psychopathology.  Age of the child, the type of music therapy, the psychiatric diagnosis all played together to determine the level of benefit from music therapy.  The analysis showed that the music therapy had a medium to large positive impact on the children. Music therapy also helped children with pain and anxiety during dental or medical procedures. (Klassen, Liang, Tjosvold, Klassen, & Hartling, 2008).
Depressed adolescents showed a significant reduction in levels of the stress hormone, cortisol, after listening to music. (Fields, Martinez, Nawrocki, Pickins, Fox, & Shanburg, 1998). Pre-adolescents with depression responded favorably as well.  “Music therapy clients significantly improved on the Aggression/Hostility scale of Achenbach's Teacher's Report Form, suggesting that group music therapy can facilitate self-expression and provide a channel for transforming frustration, anger, and aggression into the experience of creativity and self-mastery”. (Montello & Coons, 1998).

In a study to determine whether music therapy was beneficial in reducing anxiety for patients having day surgery.  There were 60 people that were having day surgery and were randomized into one of three groups.  The first group would listen to New Age music before surgery, the second would get to choose out of four types of music, and the third (control) group would not listen to music.  The study concluded that patients that listened to New Age music prior to surgery had lower levels of cortisol than before surgery, and the group that got to choose their own music did had even lower levels of cortisol and improved immune stress response to surgery.  The control group had higher levels of cortisol after surgery.  (Leardi, Pietroletti, Angeloni, Necozione, & Ranalletta, et al., 2007)

In multiple sclerosis patients, music therapy appeared to improve the patients’ acceptance of the disease, and help with anxiety and depression. (Ostermann & Schmid, 2006).  Parkinson’s patients also showed improvement in gait,

and related movements. 

One study showed that there was no evidence that music therapy, or auditory integration therapies were effective as treatments for those with autism spectrum disorders. (Sinha, Silove, Hayens, & Williams, 2011). 

In the area of pregnancy and childbirth, “meta-analysis described results that justified strong consideration for the inclusion of neonatal intensive care unit (NICU) MT protocols in best practice standards for NICU treatment of preterm infants: examples of these therapies were listening to music for pacification, music reinforcement of sucking/feeding ability, and music as a basis for pacification during multilayered, multimodal stimulation.” (Standly, 2012).

In mechanically ventilated patients, (Bradt, Dileo, & Grocke, 2011) found that music was beneficial to the heart rate, respiratory rate, and anxiety.  They also found that music helped the quality of life of cancer patients by reducing anxiety, pain, and increasing mood.  He thought that music therapy may be helpful with end of life care.


Examining the curative effects of music therapy has its own set of challenges.  A review article by Nilsson (2008) described how “nurses face many challenges as they care for the needs of the hospitalized patients, and that they often have to prioritize physical care over the patients emotional, spiritual, and psychological needs.  In clinical practice, music intervention can be a tool to support these needs by creating an environment that stimulates and maintains relaxation, wellbeing, and comfort.  Furthermore, the Nilsson article presented a concrete recommendation for music intervention in clinical practice, such as ‘slow and flowing music, approximately 60 to 80 beats per minute’, ‘non-lyrical’, maximum volume level at 60 dB’, ‘a minimum duration of 30 minutes in length’, and ‘measurement, follow up, and documentation of the effects’.  In addition, music therapy has been variably applied as both a primary and accessory treatment for persons with addictions to alcohol, tobacco, and other drugs of abuse.  However, a systematic review described that no consensus exists regarding the efficacy of music therapy as treatment for patients with addictions”. (Kamioka, et al., 2014).



Strengths of this meta-analysis are that it ranked high on the PROSPERO data base.  This is an open access database to systematic reviews in health and social care.  The analysis was also a comprehensive search across multiple databases.  Lastly, there were high levels of agreement with quality assessment. (Kamioka, et al., 2014).

Limitations were that some criteria were common across studies.  Also, publication bias was a weakness.  Also, the study called for summarization of the effects of music therapy on the different types of health issues.  Because of this, there was no room to discuss the details, such as quality and quantity, type of music, frequency, and time on music therapy. (Kamioka, et al., 2014).

Future research agenda on music therapy to build evidence of its efficacy will include: 

  • Long term effect.  
  • Consensus of the intervention framework such as type, frequency, time for each disease.  
  • Dose-response relationship.  
  • Description of cost.  
  • Development of the original checklist for music therapy.  
                                (Kamioka, et al., 2014).

    Patients with many ailments can benefit from music therapy.  In this meta-analysis, it stated that in their collection of studies that even though there may be no sign of improvement for some cases, or some diseases, music showed no negative impact on those in the studies.  One beauty of music is that it can be taken anywhere.  Whether it be in an iPod, car stereo, at home, and even just memorized in your brain to play whenever you want, music seems to soothe the soul for most.

Implications of the Concepts    (Megan Wulf)


    Research has shown the music therapy provides many great benefits to those individuals who are combating stress. The following are ways that social workers are able to practice music therapy with clients in order to help reduce stress.

  • Cardozo (2004), says that using music therapy in hospital settings, or with critically ill patients, significantly decreases the stress of the situation, as well as alleviating physical and emotional pain that coexists with medical conditions.
  • Chang, Chen, and Haung (2008) state that pregnancy is a period in time that increases stress and anxiety that results in depression. This music therapy, implemented by social workers, can create an environment for the mother in helping with the stress of delivering and also in the post-partum moments, aiding in decreasing mental distress.

  • Bidabadi and Mehryar (2015) state that social workers can use music therapy to help individuals who are suffering from anxiety, depression and OCD tendencies. The study by Bibabadi and Mehryar (2015) shows that music therapy is more effective than medicines such as clomipramine to help treat OCD.

    Social workers must be well acquainted with transmitting the great benefits that music therapy has in association with stress to aid in benefitting clients.
    Many individuals struggle with stress and the social worker who is working with a client struggling with stress has to help the client learn how to cope with everyday life stressors and empower the client to overcome these stressors with a variety of skills and tools. According the National Association of Social Workers (2015) Code of Ethics, social workers must display a sense of competence when providing music therapy to clients. Social workers need to be cautious to make sure that they are not practicing outside of their scope. NASW (2015) Code of Ethics says that social workers should only provide services within the following boundaries:

  • education,
  • training,
  • license, and
  • certification.

Blank (2015) says that music therapists must complete an approved college music therapy curriculum, pass a national exam, and seek training for music therapy. Social workers owe it to their clients to provide them with the most informative and accurate information surrounding the topic of music therapy.

    The NASW (2015) Code of Ethics also states that social workers must practice cautious judgment and take responsible step to ensure the competence of their work and to protect their clients from harm. This includes staying up to date and current with the best evidence-based research that is available to social workers.
    According to Segal (2015) there are a variety of steps to begin music therapy because each one of the clients social workers work with will have different tastes in music and who are also struggling with different stressors. Blank (2014) states that music is a tool of nonverbal communication that is effective for social workers to use because the clients take an active role in being able to choose the music that they want. 
Different styles, genres, sounds, and instruments are used for different purposes. For example, Segal (2015) suggests using instrumental or acoustic selections with a slow tempo, which will help with relaxation and help clients return to homeostasis. Blank (2015) on the other hand, enjoys using drums because drums can be made out of almost anything, they are easy to play, and humans are biologically wired to rhythm. This provides clients who may be dealing with a difficult situation that they would rather not verbalize, to express their feelings through the pounding of the drums and the beat that they can make. Blank (2015) states that drumming has been proven to be helpful with clients experiencing a variety of stressors such as:
  • drug and alcohol recovery,
  • overcoming resistance,
  • aids in the immune system,
  • counters burnout,
  • alleviates mood disturbances,
  • and reduces chronic pain.

    The social worker must also provide a listening environment that is free of interruptions so that the client is able to focus their attention on the music that is playing or the instrument that they are engaging in (Segal, 2015). Bidabadi and Mehryar (2015) suggests that active music therapy, playing various musical instruments with the oversight of the social worker, is proven to yield greater outcomes of less stress, opposed to simply listening to music and meditating.


    As stated earlier, every client will be different in the stress they are experiencing and they type of music they choose to help relieve that stress. This is critical for social workers to pay attention to and evaluate upon meeting with a client.  Social workers need to be knowledgeable in all different areas of music therapy from meditation/listening therapy to instrument playing therapy. 
    Picoult (2011), author of the novel “Sing you Home” (2011), conducted extensive research on music therapy for the purpose of writing her novel. Picoult (2011) states that music can lower blood pressure and reduce stress hormones and heart rate. Music has been proven to release the same chemicals (dopamine) in your brain that are released if an individual has sex or uses illegal drugs (Picoult, 2011). Picoult (2011) shadowed music therapists at the Berklee School of Music in Boston where she learned the techniques of music therapy to help her character, Zoe, in her novel, become a music therapist. In the novel, Zoe works one-on-one with a client (Lucy) who is from a Christian home, whose parents don’t believe in therapy, and is who is also depressed and self-harming by cutting.

    Zoe helps Lucy by using music therapy. At first Zoe tries the soft soothing sounds of music but after about 4 sessions, she realizes that is not what Lucy needs. Zoe is not able to break through with Lucy in sessions so Zoe decides to take different measures. She takes Lucy into the school cafeteria where they are holding their sessions, and sets up pots and pans to use as drums. This is when Lucy finally has a break through and is finally able to open up and share with Zoe.

This is book by Picoult (2011) a primitive example of how social workers need to get to know their client and what will help them to succeed and make strides towards recovery and being stress-free.

Appropriateness/Applications (Becky  McCurley)


    According to the American Music Therapy Association (2015), music therapy interventions can be utilized to:
  • Promote wellness
  • Manage stress
  • Alleviate pain
  • Express feelings
  • Enhance memory
  • Improve communication, and
  • Promote physical rehabilitation
    Music therapy can be used in conjunction with other forms of therapy such as clinical therapy, it can be used as a method of relaxation with the goal for the individual to return to homeostasis in privacy, or it can be used as an active approach or intervention (Seaward, 2014).

How Does Music Therapy Benefit Children with Special Needs?


Music therapy with other forms of therapy:
    Music therapists may work with an interdisciplinary team to assess emotional well-being, physical health, social functioning, communication abilities, and
cognitive skills through musical responses. This can be applied in a hospital or in-patient setting, or in a regular therapy session. The music therapist works with the client to understand the individual and designs an experience that will fit the clients’ needs and abilities. The music therapist will use strategies, which can be instrumental and/or vocal, to facilitate changes that may have nothing to do with music. Every individual will have a different experience with music therapy because
the music therapist tailors and modifies the music activities to that clients’ preferences and needs. For example, a child struggling with autism will have a different experience with music therapy than a veteran struggling with PTSD. Or two veterans who struggle with PTSD may have different experiences because they have a different taste in music, or one feels comfortable singing and the other one doesn’t. Music therapy programs are based on assessments of the client, treatment planning, and evaluation (which occurs throughout therapy). Music therapists implement and create programs with groups and/or individuals to battle anxiety and help the clients discover deeper self-understanding. (American Music Therapy Association, 2015).


Music therapy with the individuals:
    This can blend with music therapy with an actual music therapist, because a music therapist can recommend or suggest the use of these “individual techniques”. (I clumped these two together because this form of music therapy is typically done when no one else is around).

    Music therapy as a relaxation technique also varies greatly due to each person’s personal preference. The type of music you listen to (or your client listens to) should be conductive to relaxation and to return to homeostasis. For example, I (as a therapist) may enjoy listening to the sound of waves crashing against rocks with piano in the background, however this may cause stress to my client who feels an urgency to urinate to this sound. Or, I may enjoy country music, but my client may feel that country music is annoying. Music therapy only works if you tailor the music to the person who needs the therapy!
    Seaward (2014), suggests that music should be an instrumental or acoustic selection with a slow tempo. This can include jazz, New Age, or any music that falls in this domain. New Age music integrates music and sounds of nature which include the sound of ocean waves, streams, dolphins or birds. It is easy to find CDs with this kind of music in many different stores including Bed, Bath, and Beyond, Target, or Best Buy.
    When an individual is using music as a therapy, that individual should pay close attention to their environment. To fully enjoy the effects of music therapy, all interruptions should be minimized so the individual can pay attention to the music and not be distracted. Steven Halpern states that, “the listening environment is the second in importance only to selection of music. He believes that music therapy is best practiced at home in a peaceful environment.”
   
There are two different postures when it comes to music therapy. The first is the meditative posture and the second is the active posture. The meditative posture is where the individual sits or reclines in a comfortable position with their eyes closed to eliminate distractions. The individual should surround his or herself with the music and concentrate on the different sounds or instruments. The active posture is where the music serves as background sound. The individual may be focused on cleaning, working, driving, or some other task, but the music still acts as auditory stimulation.

    Seaward’s (2014) idea as an active form of music therapy is to create your own music by either humming, singing, whistling, or playing an instrument.
He suggests that playing an instrument can be rewarding, even if there is no audience.


Music therapy as an active intervention:
    As aforementioned, music therapy will be different on an individual basis. In this particular active intervention, the music therapist is helping a client cope with the stresses of aging by applying the Continuity Theory as well as music therapy. According to the Continuity Theory, individual differences produce individual responses to aging. Music therapists should be able to apply different strategies by exploring how specific individuals have coped with past limitations and/or losses. Examples of the
therapy strategies are:

  • The therapist should provide a choice of music or music related events which are both, short-term and long-term, so that the client can maintain a desired level of activity while maintaining personal autonomy. Examples of this include (but are not limited to) attending a symphony, participating in a folk dancing group, or joining a drumming circle.
  • Provide internal continuity for clients living independently in the community by creating and providing social roles that match the clients’ personalities. This may include becoming the archivist for the family’s musical history, running for the president of the senior center choir, or joining the board of directors for the community arts organization).
  • The therapist can also help to provide social interaction opportunities for clients so that they can maintain a desired level of activity. A few examples of this are joining a handbell choir, a women’s drumming group, adult education classes, or the community vocal ensemble. (Cohen, 2014).
Something interesting facts of music therapy not related to social work ☺

  • Increase sales!: Apparently, it has been a known facts in the world of marketing that when slow versions of familiar music are played in stores, consumers tend to stay longer and spend more money!
  • Decrease anxiety: Slow-tempoed music has been introduced in settings of anxiety such as a dentists’ or physicians’ office. This helps to decrease the amount of anxiety a customer may have when entering into this type of environment.

References