Music Therapy in Mental Health Care for Adults
Abstract and Keywords
The promotion of mental well-being is an overarching aim of music therapy as a psychosocial practice. Music therapy is offered from a key principle that central to a person’s well-being is their need for meaningful relating. Music therapy can offer an alternative pathway of expression and connection with others that can help develop one’s capacity to engage with and maintain relationships outside of the therapeutic work. Music therapy can be offered as a stand-alone therapeutic process or as an adjunct to other standard mental health treatment. In the early years of music therapy’s development as a profession in Europe, Australia, and the US, it was introduced in large institutions through programmes that focused on the treatment of mental illness. Music therapy has now become a diverse practice that encompasses preventative care through community based models, wellness programmes, as well as continuing to provide services within mental health care contexts.
Music may offer the only bridge from inner world to outer reality. It may provide the only means to give expression, in a safe way, to inner feelings…. It is important that the music therapist’s sphere of interest be the inner life of the patient—that the main concern be with the use of music as a vehicle by which this inner reality can be brought to the surface, to be heard, experienced, and examined in the presence of another.
Tyson 1981, p. 24
The promotion of mental well-being is an overarching aim of music therapy as a psychosocial practice. Music therapists work with the principle that central to a person’s well-being is their need for meaningful relating (Odell-Miller 1995). Music therapy can offer the individual an alternative pathway of expression and connection with others that can help develop one’s capacity to engage with and maintain relationships outside of the therapeutic work. Therefore music therapy is characterized by its relational and social capacities that foster improved mental well-being and quality of life of service users. Music therapy may be offered as a stand-alone therapeutic process or alternatively as an adjunct to standard pharmacological mental health treatment. As music therapy developed as a profession in Europe, Australia, and the US through the mid-twentieth century to the present day, it was initially introduced in large institutions through programmes that primarily focused on the treatment of mental illness (Davis 2003; Kramer 2000; Tyler 2000). Today, music therapy has become a diverse practice that encompasses preventative care through community based models, wellness programmes, as well as continuing to provide services within mental health care contexts (Meadows 2011).
(p. 250) Mental health
When introducing the topic of mental health diagnoses such as “depression,” “schizophrenia,” “psychosis,” “anxiety” are often mentioned. These terms refer to mental disorders as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM V) and in the ICD-10 classification of mental and behavioral disorders (ICD 10). Yet health is described as “a state of complete physical, mental and social well-being, and not merely the absence of disease” (WHO 1978, p. 1). Therefore, the aim of this chapter is to consider music therapy’s capacity to promote mental well-being for people receiving mental health services in ways that exceed the limitations of psychiatric diagnosis and symptomatology.
Mental health care is an umbrella term that is used to define a multitude of health practices and models of care that are designed to address the needs of people experiencing psychological distress. Healthcare practice can be situated within an illness-wellness paradigm where healthcare professionals’ area of practice, training, and personal philosophy influence how such distress is conceptualized and addressed. Reviewing the terminology employed in the mental health literature is a starting point from which to contextualize music therapy service provision. The term “mental disorder” (American Psychiatric Association 2013) is sometimes used instead of related medical terms such as “mental illness” (Anthony 1993). Other terminology includes “mental ill health” (Kai and Crosland 2001) or “mental health difficulty” (Lau and Cheung 1999). Similarly, the term “patient” (Mental Health Commission 2012) may be replaced with that of “client” (Clark et al. 1999), “customer” (McDonald 2006), “consumer” (Chinman et al. 2006) or “expert by experience” (Shepherd et al. 2008), “survivor” (Sweeney et al. 2009) or simply “person with a mental health difficulty” as employed by the National Institute for Mental Health (UK). The term “service user” will be employed in this chapter as it is consistent with a mandate from consumerist and democratic traditions that emphasize the development of participation within health services (McLaughlin 2009).
Psychiatry is a discipline that has specific way of understanding mental health problems and is concerned with the assessment, diagnosis and treatment of disorders of the mind (College of Psychiatry of Ireland 2013). In psychiatric care mental disorders are considered to belong to the patient who is treated by a mental health expert, or treatment team, with a focus upon identifying the symptoms that can be treated when targeted within a specific intervention, resulting in curing the disease or ailment (Wampold 2001).
A number of developments during the twentieth century contributed to the burgeoning of the field of psychiatry in partnership with the pharmacological industry, along with neuro-scientific discoveries, and behavior-based therapy interventions which have primarily focused on symptomatic management of mental disorders (Unkefer and Thaut 2005). These factors have propelled psychiatry and ultimately, its underlying medical model, to become the dominant discourse within mental health care. Yet, this model has been subject to much criticism for its’ scientific underpinnings, which can overlook personal, social, and economic factors impacting upon a person’s mental health (Wallcraft et al. 2009). Further discussion of this in relation to music therapy practice will be pursued later on in this chapter.
(p. 251) Music therapy in mental health
The promotion of mental well-being is an overarching aim of music therapy as a psychosocial practice. Music has the potential to mirror cultural, relational, and historical aspects of the self in therapy. It additionally affords access to thoughts and feelings that can be inaccessible via the spoken word, providing a process by which the individual is guided through personal difficulty or distress in a supportive and non-judgmental environment. Music’s capacity to offer a means of “working through” beyond verbal media is often reason for referral to music therapy in the first instance as, for some people, words may be inaccessible or simply too difficult to voice. The “sounding” of a person’s narrative may be drawn from a range of methods and techniques that gently and gradually build participants’ confidence and capacities in regular supportive sessions over time (McCaffrey et al. 2011). Music is regarded as “the glue” that creates form and structure to such a relationship (DeNora 2002), where new avenues for self-expression and interpersonal connection may be found.
Such opportunities for non-verbal relating can offer an alternative means of communication for those who find words to be inadequate. By offering such therapeutic opportunities there is acknowledgement that more fruitful means of relating may be found outside the dominant verbal discourse. This is particularly important as growing emphasis is placed upon the nurturance of meaningful relationships between service users and providers while embracing the notion that meaning can not only be fostered through words but also through creative pathways such as those offered in music therapy.
Identifying people that may benefit optimally from music therapy is an ethical imperative for music therapy practice (Burton 2009). Mental distress can impact upon emotional and social domains of functioning that in turn can lead to disturbances in interpersonal and intrapersonal relating (Mössler et al. 2012). This may result in “low motivation” for verbal therapies such as psychotherapy or psychological counselling. This has resulted in an increasing focus on process and outcome measures with such client groups (Gold et al. 2005b; Mössler et al. 2012). While efforts continue to ascertain suitable candidates for referral to music therapy it is proposed that the term “low motivation” for verbal therapies is somewhat problematic and limiting about clients. Alternative terminology might consider that music therapy is suitable for those with higher incentive for expressive or arts based therapies than other treatments.
Theoretical orientations in music therapy for mental health
The therapeutic and theoretical orientation of the therapist influences the methods and techniques used, and the ways in which their purposes are conceptualized. Some therapeutic approaches favor cognitive methods, where the client is perceived as having difficulties arising from distorted thinking, while others aim to develop capacities for positive interpersonal relating, or resolving intra-psychic conflicts. Choi’s (2008) survey of five (p. 252) hundred board-certified music therapists identified that diverse traditions including cognitive-behavioral, humanistic, medical, analytic, and eclectic orientations can be found across the profession in the USA. This suite of approaches reflects a range of foundational principles, and contrasting underpinnings. Results from another survey of music therapists showed that approaches such as behavioral, psychodynamic, and eclectic are most commonly used in mental health practice in the USA (Silverman 2007).
Methods in music therapy
There is increased interest in the relationship between process and outcome in music therapy (Burton 2009). Some music therapy literature identifies music processes in sessions as belonging to one of two categories; in active music therapy service users are actively involved in the music making process by playing instruments or singing (Vink et al. 2003) while in receptive music therapy there is an emphasis upon listening and attending to live or pre-recorded music played by the therapist (Grocke and Wigram 2007). Mössler and colleagues (2012) have further nuanced music therapy methods as follows: (a) “Production techniques” that encourage emotional expression and the creation of the therapeutic relationship through musical improvisation between client and therapist where something new is produced; (b) “reproduction techniques” that involve both parties playing or singing recomposed pieces of music, such techniques can also involve learning or practising musical skills and; (c) reception techniques that involve listening to live or recorded music. Programmes may be exclusively feature one or indeed a combination of such techniques depending upon the aims of therapy and orientation of the therapist. The following section will discuss some of the most commonly used methods in mental health practice namely: (a) improvisation as a production technique; (b) songwriting as a reproduction technique and: (c) music listening and discussion as a receptive technique. These discussions are certainly not exhaustive of the possible methods and reception techniques that can be employed in mental health practice.
Music is a discourse that can be used as a means of human expression beyond the economy of words (McCaffrey 2013). Improvising in music therapy involves “playing live and extemporaneous music where a multitude of musical media may be employed including voice, body sounds, percussion and instruments” (McCaffrey 2013, p. 307). Pavlicevic (2000) proposed that the purpose of improvisation is not to make good music but rather to create an intimate personal relationship between client and therapist. This is built up gradually over time through regular and supportive play. Maratos et al. (2011) reported that such shared play has esthetic, physical, and relational dimensions.
In mental health care, the non-verbal nature of improvisation can open up alternate avenues of relating and new ways of experiencing oneself and others. Pavlicevic et al. (2000) showed that improvisation can be used to establish one-to-one interaction between therapist (p. 253) and person, in which a dialogue can develop that is based in the here and now. The aim of such shared play is to draw inner experiences and emotions to the musical surface so as to facilitate recognition of one’s own capacities and to engage personal awareness and growth. These may exclusively stay within musical parameters or be reflected upon through verbal dialogue that promotes the service user’s insight and awareness around difficulties that impact their everyday living. This mirrors the view of improvisation operating on a protosymbolic level by triggering unconscious processes beyond pathology and, in a way, prepares the individual for fully symbolic expression and eventual verbalizing (Erkkilä et al. 2011).
De Backer and Van Camp (1999) have written that the provision of choice is fundamental when introducing instruments for improvisation in therapy. Being presented with a variety of instruments is required so that as one seeks to find a medium for musical expression one can sound one’s voice in musical dialogue with others. It is advised that the therapist only introduce an instrument once they themselves have had extensive experience with it and thereafter that the value of individual instruments is judged for its usefulness in therapy on a case by case basis (De Backer and Van Camp 1999). Of course in some cases there may be reason for introducing fewer instruments in sessions so as not to overwhelm service users or where a service user has expressed a desire to play or learn certain instruments. The strength and robustness of instruments need to be considered ensuring that they can bear intensive expressions of human emotion (De Backer and Van Camp 1999).
Improvisation in practice
Pedersen (2003) described a tentative first session in music therapy during which the client was introduced to piano improvisation. The therapist wrote “I instructed him to start to play by striking a key and listening to that sound and to let this sound lead him to the next sound, listen to it and so on” (p. 379). This description of early moments in music therapy reminds us of the uncertainty and perhaps even the demands that service users can encounter as they engage in improvisation for the first time. The leap between solitary experience of an internal world of thoughts, emotions, and impressions, and the expression of such a world with others through symbolic representation in music and sound can be challenging. Therefore, music therapists must be thoughtful and respectful when introducing improvisation.
Odell-Miller (1999) has provided case vignettes describing the way in which the music and the person are inextricably bound up in ways that cannot be separated. This is mirrored in the case study of music therapy with a young man with schizophrenia who appears to be disconnected from the world around him (Jensen 1999). The man’s piano playing is initially described as being absent of excitement, agitation, and movement and reflective of the solitude that he experiences. Here Jensen realizes that it will take time to be allowed to enter this man’s world, an entry that is eventually gained through holding and anchoring the client’s music so as to reach a point in therapy where both individuals acknowledge and connect with each other within shared musical dialogue. This case study provides an example of the connection that can be made with reality through the physical process of playing instruments; firmly rooted within the present moment.
Kaser writes that within a group context improvisation can “address multiple symptoms of … illness while at the same time helping to develop … ability to focus, tolerate others and (p. 254) interact more successfully” (2011, p. 403). It is not surprising that perhaps for those same reasons, that group therapy is a frequently used modality in mental health practice (Silverman 2007). Improvising music with others not only facilitates social interaction and emotional expression but also promotes insight, a psychodynamic term, so that participants can understand more about themselves. This may be facilitated in the music itself, or through group discussion and reflection following instrumental play.
Stewart (2002) discussed the importance of enabling a sense of inclusion and belonging as core aspects of group work with people who have chronic mental health difficulties. Winnicott’s (1965) concept of the “facilitating environment” is regarded as fundamental to the group developmental process. Through “M”s experience of improvising within group therapy, it is explained how for some participants “having a good experience and enjoying it proves as challenging as exploring difficult feelings” (2002, p. 35). Stewart describes his awareness of how the musical parameters of play are vital to holding the group improvisatory process such as; playing a strong group pulse when other’s playing seems dissimilar to the underlying tempo or, tuning into the dynamics of the music as emotionally engaged contributions are made by group members. These events illustrate how the group can communicate within the music while at the same time individuals can experience personal spontaneous “play,” free from the constraints of musical rules and regulations. Ruud (1998) has proposed that group improvisations that lead from a sense of chaos to some consensus around common code or structure can be regarded as examples of the art of social organization, platforms that are particularly poignant for people who find social relating to be challenging. Thus, opportunities to experience such “miniature social systems” can be found in improvisation in group music therapy.
Songwriting is increasingly used in music therapy practice in many countries. It is “the process of creating, notating, and/or recording lyrics and music by the client or clients and therapist within a therapeutic relationship to address psychosocial, emotional, cognitive, and communicative needs of the client” (Baker and Wigram 2005, p. 16). Motives for using songwriting in working with service users in mental health care can be attributed to the tangible end-product it offers but also and even more importantly to the therapeutic process that can be engendered. Multiple reasons for choosing to employ this method in practice have been proposed such as experiencing mastery, developing insight, providing emotional support, improving coping and social skills, increasing self-esteem, in addition to reducing anxiety, anger, and tension (Baker and Wigram 2005). Survey results showed that songwriting is used for a number of different purposes by a large number of practitioners working in psychiatric services whereby the endorsed goals in songwriting are: (a) Choice and decision making; (b) developing a sense of self; (c) telling the individual’s story; (d) clarifying thoughts and feelings and; (e) externalizing thoughts, fantasies, and emotions (Baker et al. 2008).
The songwriting process can be used as a means of promoting expression and exploration of thoughts and feelings around personally relevant topics to the individual where recapitulation of this journey may be found in the final song or product created. Songwriting (p. 255) can offer opportunities to express hopes, dreams, desires, and losses that can be framed within personal narratives that are related to the past, present, or future. As externalized self-expression, songs have the ability to contain and hold feelings that validate human experience in a highly personal manner.
The ways in which songwriting can be introduced to sessions vary from structured to unstructured (Baker and Wigram 2005). Techniques can range from filling in the blanks of pre-composed songs with lyrics offered by service users as described by Robb (1996), or, freely composing a song whereby melody, harmony, lyrics, genre and structured are considered anew as described by O’Callaghan (1997). Another commonly used technique in songwriting is that of song parody where original lyrics of a popular song are replaced with those of the individual while keeping the melodic and harmonic structure of the chosen song as illustrated by Ledger (2001), Edwards (1998) and McCaffrey et al. (2011). It is the experience of the author that sometimes service users in mental health programmes explicitly request their desire to write a song whereas in other instances songwriting comes about by suggestion of either service user or therapist at a point where exploration of a specific topic is prompted in therapy.
Baker (2013) interviewed 43 music therapists about environmental factors that support or constrain the therapeutic songwriting process and found that organizational structures, the physical space, the private space and the organizational culture individually and collectively can either support or constrain their practice. Of particular interest in this study is the voluntary and involuntary status of service users attending music therapy in mental health settings. This means that some people elect to be in care but others are required by law to be receiving care in such a context. One music therapist cited compulsory attendance as exacerbating resistance and voluntary attendance was viewed to fortify engagement in the songwriting process. Environmental factors that can impact upon the songwriting process such as interruptions, privacy, and staff culture (Baker 2013); factors that practitioners may have capacity to reduce and be cognisant of as they consider using this method in music therapy.
Songwriting in practice
McCaffrey et al. (2011) described the steps involved in introducing songwriting in sessions with “Kevin,” an individual with enduring mental health needs. He chose to write his own lyrics to the song No woman no cry (1974) and the therapist outlines how the use of song parody served as a springboard to discussion between Kevin and therapist about his past experiences and the losses that occurred therein.
Improvements in quality of life have been found as a result of group sessions with people who have severe and enduring mental illness living in the community in which songwriting featured as a primary method of working (Grocke et al. 2008). Pre- and post-intervention measures on a Quality of Life scale indicated significant changes in general quality of life, health and support from friends. Focus groups with those participating in this study relayed that producing a positive outcome such as a song was surprising as well as the recognition of creativity that songwriting encouraged and the sense of achievement in producing recordings of the songs that could be shared with others. Analysis of songs written in sessions (p. 256) produced themes relating to; the difficulty of living with mental illness, the strength that is required to cope with mental illness, the healing sense of living in the present, religion and spirituality, concern for the world and, enjoyment in team-working. Vander Kooij (2009) also conducted a thematic analysis of songs written by people with mental health difficulties and writes that despite diversity in cultural and socioeconomic backgrounds, many similarities are to be found therein. Analysis of seventeen songs written by three participants of music therapy offered insight into the needs and experiences of those living with mental illness as well as discoveries into catalysts that promote recovery.
Similarly to the processes reported in the Grocke et al. (2008) study, there was a sense of achievement on behalf of participants in sharing recordings of their songs with others. This is reminiscent of Turry’s (2005) view of recordings as something that can be held onto. Recordings can live on beyond the music therapy sessions and serve as a reminder of the therapeutic journey.
Receptive methods in music therapy have varying degrees of use by practitioners and are most commonly described in practice accounts from the USA and Australia whereas in the UK receptive methods have been described as used rarely (Grocke and Wigram 2007; Maratos et al. 2008). “Receptive music therapy encompasses techniques in which the client is a recipient of the music experience, as distinct from being an active music maker” (Grocke and Wigram 2007, p. 15). Bruscia (1998) outlined a number of receptive techniques such as; music for relaxation, imaginal listening, song (lyric) discussion, song reminiscence, listening to music preferences, music appreciation, music collage, somatic listening, and eurhythmic listening. In-depth descriptions of each of these techniques are beyond the scope of this chapter but for the overall purposes of providing a supportive framework for broader contexts of music listening in mental health practice, the following section will consider related research findings.
Hsu and Lai’s (2004) controlled clinical trial found that greater improvements can be achieved when music listening is combined with standard care for depression. Participants in the music group listened to soft music of their choice for 30 minutes daily for two weeks and showed improved scores on a self-rated depression scale when compared to the control group that were assigned bed rest for the same daily period. Lin et al. (2011) put forward an explanation of the neuroscience of music and suggested that this medium has positive psychophysiological effects in people who have depression. Field et al. (1998) showed attenuation in frontal EEG asymmentry in people with depression, both during and after listening to popular songs. Positive results have also been shown in a meta-analysis of 19 studies in relation to music listening upon the symptoms of psychosis (Silverman 2003). Of particular relevance to music therapists are the findings of a review of almost 100 studies of music and music therapy in mental health which concluded that:
Music as used by music therapists results in clinical improvement. We found no demonstrable evidence that simply listening to music had the same type of result. Therefore, it may be that a purposeful and professional design for delivering music, coupled with other factors (such as (p. 257) actually making music as part of therapy, or the interaction with a therapist), will potentiate the therapeutic effectiveness of music.
Lin et al. 2011, p. 43
Having briefly discussed some of the evidence that supports the use of music listening techniques in promoting mental wellness, the general practical implications of following receptive approaches in therapy will be considered. It is widely acknowledged in music therapy that the most effective music style and genre to use in practice is that of the service user’s preferred genre (Grocke and Wigram 2007). This resonates with a person-centered model of music therapy that places the interest, desires and capacities of each individual at the heart of the decision-making process (Noone 2008). Employing music that is familiar to adult service users can be particularly helpful in the introductory sessions of therapy as such material can act as a shared common ground that may aid the establishment of rapport between client and therapist. Amir (2012) shared Musical Presentation (MP) as a therapeutic tool she developed to increase self-knowledge and share one’s identity through listening to other’s music selection in group therapy. This concept is closely linked to the notion of identity in music, the expression of personhood and the sounding of one’s narrative through music (Procter 2004; Ruud 1997, 1998). Shared listening of the service user’s selected songs that is conceptualized within an identity framework, has immense potential for therapeutic exploration of self that in turn may facilitate verbal discussion and reflection. Of course, in some instances the individual’s selections may not be suitable for certain purposes in therapy, but reasonable solutions may be found in offering alternative presentations of selected music or indeed providing alternative music choices (Grocke and Wigram 2007).
Music listening in practice
The possibilities that music listening can offer service users in music therapy should not be underestimated. The literature provides us with some striking accounts of how music listening experiences can provide service users with valuable opportunities for connection in therapy. Eyre (2011) recounted her work with Julie, a young woman diagnosed with psychosis who had experienced multiple traumas. In the early stages of music therapy Julie was withdrawn, made minimal verbal communication and did not sing or play an instrument. In this case the therapist liaised with Julie’s mother as to ascertain Julie’s song preferences and this information informed the therapist’s use of pre-composed songs that were sung to the client during bedside sessions. Eyre also described other music listening experiences that were provided for Julie such as vocal improvisation with guitar accompaniment to match her mood, singing songs to help her access soothing feeling states and encourage awareness of self and the other. This is similar to the case of “Ann” who expressed her wish to “just listen” to songs during weekly group sessions in which she often become visibly emotional and would sometimes leave the group (McCaffrey et al. 2011). This suggests that although sometimes brief, such receptive experiences were meaningful to her in some way. This case reminds us of music’s capacity to engage the individual even within fragile circumstances when a more active role in music making is not tenable.
(p. 258) Baines’ (2003) description of music therapy group work within a community mental health setting is based on consumers personal connection to music rather than focusing on a diagnostic problem that needs to be addressed. Program evaluation by service users yielded positive accounts of participation that were set within a therapeutic intervention where people had the choice to listen to personally significant songs if they so wished. Such consumer-directed and partnered programs may prove to be more manageable for those who wish to be amongst others in a social context but prefer to assume a more receptive role therein.
Methods in summary
The above presentation of various music therapy methods is by no means exhaustive and is written with the intention to provide a basic overview of some of the possible ways of working with people who have mental health difficulties. Other factors may impact upon the outcome of the intervention employed such as the relationship between therapist and service user and the theoretical orientation of the therapist. Therefore, there are multiple considerations to be taken into account before choosing to pursue a particular method in music therapy. These all begin and end with the person with whom the therapy is for and it is the role of the qualified therapist to identify indications and contraindications for employing certain methods in practice. Furthermore, the methods section above is presented in a manner that encourages the music therapist to consider the idiosyncratic nature of the individual in therapy rather than embracing a more pathological framework where the choice of method is related to diagnosis. This re-echoes the call to move away from treating service users as “discrete bundles of physiological and psychological functions which can be assessed and treated in isolation” (Procter 2004, p. 215). It also compliments the notion that music therapy is not usually targeted at a specific diagnosis but is rather broad in its aims and methods that aim to address the needs of the individual (Gold et al. 2009).
Music therapy evidence
As an established allied health profession, music therapy is required to produce evidence to justify its role within health care (Edwards 2005). Quantitative research studies, primarily randomized controlled trails (RCTs) that examine efficacy and effectiveness have been increasing since the profession was first founded. In 2005 the first systematic review of music therapy in mental health appeared in the Cochrane Library, a database that is dedicated to disseminating high-quality research evidence to healthcare practitioners. Gold et al.’s review (2005a) was in relation to the treatment of schizophrenia and schizophrenia-like illness which has subsequently been updated by Mössler et al. (2011). These feature alongside an additional systematic review of music therapy in the treatment of depression (Maratos et al. 2008).
The findings above have established music therapy as an evidence-based intervention, a term that carries a significant degree of standing among Western health care providers. (p. 259) Generating high-quality studies to produce reliable evidence that informs decision-making in healthcare is crucial in the establishment of “best practice” in music therapy. Equally important when reviewing main findings is the consideration of the processes and manner of enquiry employed in order to discern the growing trends that are informing music therapy practice in psychiatry and indeed, mental health care.
The majority of music therapy studies that are rooted in psychiatry focus upon music therapy as an intervention used to treat various types of mental disorders. Grocke et al. (2008) concluded that music therapy has demonstrated benefits for people with enduring mental disorders to improve social functioning, global state and mental state. In a review of the findings of such studies that relate to adults who have mental disorders, it was concluded that music therapy is “a structured interaction that patients are able to use to participate successfully, manage some of their symptoms, and express feelings relating to their experiences” (Edwards 2006, p. 33).
The focus upon music therapy as a form of treatment in psychiatry has also been accompanied by the creation of distinct categories of studies that relate to various types of mental disorder. This may be influenced by psychiatry’s use of taxonomies that provide a common language and standardized criteria to psychiatrists in the diagnoses of a mental disorder. In May 2013, the American Psychiatric Association published the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This most recent classification system provides mental health professionals with detailed descriptions of diagnostic criteria. It is used by clinicians and researchers from many different orientations across a multitude of mental health settings (American Psychiatric Association 2013). The following section will apply such categorization and highlight relevant studies that focus upon the outcomes of using music therapy to treat such disorders.
A systematic review of eight music therapy RCTs for patients who have schizophrenia or schizophrenia-like illnesses concluded that the music therapy intervention, in addition to standard care, improved patients’ global state, mental state and social functioning (Mössler et al. 2011). The authors also highlighted the use of music therapy in addressing negative symptoms of schizophrenia. These results support those of Tang et al. (1994) who found that music therapy reduces the negative symptoms of schizophrenia by increasing patients’ ability to converse with others, reducing their social isolation, and increasing their level of interest in external events. General symptom scores have also been shown to improve in those that were randomized to an improvisational music therapy group in study that compared music therapy and standard care to standard care alone (Talwar et al. 2006). These results suggest that music therapy may be a viable option in the treatment of those with schizophrenia. This has been recommended by the National Institute for Clinical Excellence (NICE) who state that in the treatment of schizophrenia, arts therapies are “the only interventions both psychological and pharmacological, to demonstrate consistent efficacy in the reduction of negative symptoms” (NICE 2009, p. 205).
Maratos et al. (2008) conducted a review that examined the efficacy of music therapy with standard care compared to standard care alone in the treatment of depression. A reduction in symptoms of depression was reported in those who were randomized to music therapy in four of the five studies reviewed and low levels of attrition were noted this group. In the first RCT on improvisational music therapy for working-age people with depression, improved symptom scores of depression, anxiety and general functioning were found in those assigned to the treatment group (Erkkilä et al. 2011). Significant variation in the effects (p. 260) of music therapy was not indicated across therapists involved in the study and it is suggested that the overall positive effects are related to the improvisation method employed.
Dose-response relationship in music therapy for people with serious mental disorders has been examined using a mixed-effects meta-analysis model (Gold et al. 2009). Music therapy, when added to standard care, was concluded to have significant effects on global state, general symptoms, negative symptoms, depression, anxiety, functioning, and musical engagement. Significant dose-effect relationships were found for general, negative, and depressive symptoms in addition to functioning when longer therapy programmes or more frequent sessions were provided.
The studies described above exemplify the efforts that have been made to firmly root music therapy within such practice where quantitative methodologies and laws of natural science apply. Silverman (2010) discusses the “psychiatric music therapy” literature base in relation to established levels and evidence concluding that there is a lack of RCTS and an overall low level of evidence therein, adding that such findings are similar with levels of evidence in other psychological treatments in psychiatry.
Cassity (2007) conducted a Delphi poll in relation to the future of psychiatric music therapy. The third most likely scenario rated by the panel was the call for evidence-based music therapy by health care providers. These findings resulted in explicit recommendations being made to the Certification Board for Music Therapists, USA, to continue examination of practitioners’ knowledge of evidence-based music therapy and quantitative clinical research applications. Undoubtedly, there are possibilities in further embedding music therapy in evidence-based practice but it is equally important to reflect upon some of the challenges that arise in using the RCT, as a “gold standard” (Chalmers 1994; Sackett et al. 1996) that informs this mode of practice. The diversity of the music therapy population, the standardization of treatment in relation to person-centered care, and the measurement of outcomes have been raised as concerning issues when employing the RCT in music therapy research (Edwards 2005; O’Callaghan 2003).
As the RCT remains as the gold standard of evidence-based practice there is risk that the controlled and manipulated conditions it features fail to capture real-world music therapy settings and the complex phenomena that emerge between patient and therapist. The RCT method may easily lend itself to statistical evaluation but this does not apply so easily to measuring music therapy interventions. As music therapy research develops in psychiatry it is crucial that methodological tools are chosen based on their suitability towards the phenomenon under investigation, otherwise the profession will be placed in a situation as described by Richards who said that “when the only tool you have is a hammer everything else looks like a nail” (2002, p. 259).
The concept of manualizing therapy has increasingly featured in professional realms in mental health practice (Odell-Miller 2007; Rolvsjord et al. 2005). This involves the therapy process following a structured set of guidelines and techniques that aim to ensure treatment fidelity. However, concern has been raised in music therapy about the potential loss of therapeutic integrity, and the danger of overlooking the individual service user perspective when employing such standardized manuals that are in keeping with the requirements of some forms of research in healthcare. This presents mental health practitioners with “a dilemma between the demand for validity and replicability in relation to research on one side and the need for clinical flexibility on the other” (Rolvsjord et al. 2005, p. 23).
(p. 261) The tension that exists around the manualization debate is fuelled by the long-standing recognition of music therapy as a person-centered intervention, where service users’ individual and unique needs, resources, and strengths directly inform the course of therapy and ultimately the ways in which music is presented in sessions by the qualified practitioner. The rationale for music therapy’s identity as a person-centered and relational healthcare profession lies in its employment of the medium of music which has long been acknowledged as a cultural phenomenon that has the capacity to narrate one’s life story and validate life experience of its listener. As Kramer wrote:
The efficacy of music therapy is a result not of the music but of its apprehension in experience. Due to this dependency on experience, the therapeutic influence of music is necessarily governed by an extant phenomenal framework organizing the music experience for its participants. That is to say that some cultural conditions which legitimate certain therapeutic practices also render the target audience susceptible to the influence of those practices.
Kramer 2000, p. 16
An individual’s music narrative is deeply embedded within personal experience and cultural practice. This is a complex affair that impacts upon musical engagement in the present. Therefore it is the role of the therapist to skilfully find musical ways of tapping into such experiences so as to support the sounding of one’s music narrative within a therapeutic context.
Burton (2009) recognized the challenge that music therapy confronts by being increasingly asked to produce “hard evidence” in the form of quantitative data but questions whose needs this really fulfils. Such evidence aids the growth and validity of the profession but these are within a governance of a model that has different epistemological roots to those of music therapy. It is imperative that therapists are aware of the influences of psychiatry, and its adherence to the medical model, within the practice of music therapy. Likewise, future research must not narrow its focus to simply adhere to the boundaries of conventional medicine as in doing so there may be risk of losing some of the quintessential features of music therapy in translation.
Possibilities for and in practice
Recovery in mental health is an approach or indeed movement that places listening to service user voices at the heart of its philosophy, first emerging in the 1980s at a time when people began to voice their experiences of using mental health services that were situated within a medical model. Thus recovery narratives began to appear of people who taught themselves how to live a meaningful life beyond a diagnosis and a “system” that was viewed to limit potential for growth and possibility for wellness (Deegan 1988). Key concepts of this paradigm are hope, positive self image and identity, spiritual connection, relationships, trust in self, self-determination, meaning, confidence and control, personal resourcefulness, and voice (Mental Health Commission 2008).
Recalling a famous logo of the Zanussi electrical company, Patrick McGowan, Expert by Experience said that the recovery approach could be regarded as a response to the “appliance (p. 262) of science” (2012, personal communication). The medical model’s appliance of science in psychiatry and mental health has been the subject of much criticism that has in turn, fortified the recovery movement. Fervent interest in chemical imbalances and neurology has left many people with a mental health diagnosis feeling lost within a dominant and powerful model that fails to acknowledge individuality and personal resourcefulness (Fisher 2009). Opportunities for personal growth and overcoming mental health difficulties are seen to be constrained within such a model that fails to recognize the impact of social relating upon the individual (Campbell 2009).
Central to the recovery movement is the participation and involvement of “service users” at each and every stage of healthcare planning and delivery. The slogan “nothing about us without us” is one that has been adopted by recovery from the disability movement (Walmsley 2004). This promotes collaboration between those who use and provide services so as to enhance the delivery of healthcare provision that is grounded upon an equal footing where the voices of all parties concerned are respectfully listened to and heard.
Recovery in mental health is an area of practice that is slowly beginning to emerge in the music therapy literature (Grocke et al. 2008; McCaffrey et al. 2011; Solli 2012; Vander Kooij 2009). It places the client or service user at the helm of the therapy process where their lead and direction is followed. This of course resonates with music therapy practice as a whole where meaningful connection and collaboration between both parties is fundamental. However, the recovery approach may also conflict with some of the practices in music therapy that are akin to those of the medical model, particularly those that assume a powerful or dominant position towards the service user. Such challenges are not only faced by music therapists but indeed all those who are deemed to be providers of mental health services (Borg and Kristiansen 2004). Thought-provoking suggestions may be found in policy documents such as those featured in Shepherd et al. (2008).
The recovery movement’s call to shift from an illness to wellness paradigm, focusing on capacities rather than limitations, resonates with recent models that have been developed in music therapy. Ansdell and Meehan (2010) point out that “resource-oriented music therapy” (Rolvsjord 2004) and “community music therapy” (Pavlicevic and Ansdell 2004) utilize music as a health promoting resource for people in times of illness. Such models are founded from a sociocultural view of music, health, and illness, and as a consequence, may help to create a possible path for the profession of psychiatry as it deliberates over possible future trajectories (Priebe et al. 2013).
Music therapy has a unique capacity to offer people ways in which to sound their personal narratives in a supportive environment that is centered upon shared human experience in music. It can offer meaningful connections with others in times of distress in esthetically inspired ways that are tailored to meet individual needs, hopes, and aspirations. Such creative pathways towards wellness, as guided by the qualified music therapist, can bridge inner and outer realities while fostering growth and possibility for change.
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