Music Therapy

15th November www.lel.ed.ac.uk/~s0897956/MusicPsych.html

Plan
What role does music play in health? Different ways of looking at music therapy Physical and emotional rehabilitation Case studies - Alzheimers, Autism, Williams Syndrome, Parkinsons Music Medicine

Worth reading
www.guardian.co.uk/lifeandstyle/2011/sep/26/music-for-surgery www.salon.com/life/feature/2011/03/07/poprx_music_in_operating_room www.sciencedaily.com/releases/2010/05/100512112314.htm Institute for Music in Human Social Development (IMHSD), Edinburgh: www.ed.ac.uk/schools-departments/edinburgh-college-art/music/research/ imhsd/about

What roles does music play in health?

Three areas to consider, with perhaps overlapping denitions Music Therapy: e.g. Music used to lower the heart rate of a premature baby, leading to increased oxygen intake, and eventually to the baby leaving hospital Music Medicine: Music used to calm the nerves of a patient before and during a surgery, meaning less drugs are needed Performing arts medicine: Medicine which is tailored towards performancerelated injuries - doctors who specialise in this area

Three areas (Adapted from Hodges & Sebald 2011: 285)

Music Therapy Specially trained musicians

Music Medicine

Performing Arts Medicine

Practitioners

Doctors, Doctors, audiologists, nurses, music speech therapists, therapists counsellors

Clients/ Patients

Performing musicians People of all ages, variety of physical Surgical & Pain experiencing hearing, vocal, bodily, or & mental health patients psychosocial health needs issues

Music Therapy
Music therapy is the clinical and evidence-based use of music interventions to accomplish individualised goals within a therapeutic relationship by a credentialed professional who has completed a music therapy program (American Music Therapy Association 2007) Structured use of music to bring about changes in behaviour Systematic process of intervention Psychotherapeutic, educational, instructional, behavioural, pastoral, supervisory, healing, recreational, activity, and interrelated arts applications of music Mental and physical changes

Patients/ Clients?
People of all ages, and abilities/ disabilities Mental health, developmental and learning disabilities, Alzheimers and agerelated conditions, substance abuse problems, brain injuries, physical disabilities, acute or chronic pain Psychiatric hospitals, rehab facilities, hospitals, outpatient clinics, day care treatment centres, prisons, community mental health centres, drug and alcohol programs, senior centres, nursing homes, hospices, halfway houses, schools, private practice

History of music therapy/ music healing

Almost all societies have used music in collaboration with healing, often with religious aspect Shaman, witch doctor, medicine man/woman was a spiritual healer who often used music as a mode of treatment - Still found in some parts of the world today Modern music therapy began in WWII - veterans returning home with horric injuries 1944: rst music therapy curriculum devised, Michigan State Uni 1950: National Association for Music Therapy established, Kansas 1964: Journal of Music Therapy began publication

Principles of music therapy (Gaston 1968/ Sears 1968)

1) The establishment or reestablishment of interpersonal relationships 2) The bringing about of self-esteem through self-actualisation 3) The utilisation of the unique potential of rhythm to energise and bring order Experience in relating to others Experience in self-organisation Experience within structure

Models of Music Therapy (Bunt 1997)

1) Medical: Emphasizes impact of music on physiological aspects: heart rate, breathing, etc Early literature focuses on this, as music therapy began in hospitals Problems: neglects emotional aspect Focuses on temporary effects, perhaps to the detriment of long-term health 2) Psychoanalytical: Emphasizes the symbolic nature of a clients musical behaviour. Overt behaviours are interpreted as indicative of internal states which must be addressed

Models of Music Therapy (Bunt 1997)

3) Behaviour Therapy Focuses on rewarding of desired behaviour, punishing undesired Effective in school environments, to enhance academic performance Problems: ignores unobservable psychological traits Treats physical symptoms rather than psychological cause of disorders 4) Humanistic Psychology Self-actualisation, making the most of ones potential Emphasizes relationships, treatment of whole person Focuses on concious processes such as hope, acceptance, volition Different approaches may suit different people, different situations, different needs

Role of musical expression in therapy

Most important to music therapy is the development of non-musical behaviours I.e. the role of music therapy is not to make a musician, but to help someone who needs help, to learn appropriate behaviours, get on in the world etc As such, musical skill is subordinated to other skills - social, communication, motor, academic However, music expression is important at all levels, and all people have a need for aesthetic expressions Music is non-verbal - therefore people who are unable to use/ threatened by language, can communicate musically

Eventual aims
Music therapy doesnt aim to cure or heal patients Communication and social interaction is the focus of much of music therapy Making peoples life easier through learning of behaviours through music There has been a distinct move away from a discourse of healing ( or curing) to one where, for music therapists today, communication itself is a more modest therapeutic aim (Ansdell & Pavlicevic 2005:194) Music therapy is a psychosocial intervention, rather than a curative medical intervention (Music medicine)

Effectiveness of Music Therapy (Standley 1995)

Meta-analysis of 55 studies - actual patients undergoing treatment for dental and medical disorders Music had been used in attempts to treat 129 different variables, and had been effective in 125 of these Music less effective for male than female Children responded more positively that adults and infants Live music more effective than recorded

Effectiveness of Music Therapy

Effects greatest for dental patients, those experiencing chronic pain, least for obstretric, coma and cancer patients Pain relief greater when pain was temporary (dental, headaches) than resulting from deep tissue injury (childbirth, surgery, cancer) Largest effect from this meta-analysis was Podiatric pain (>3.28 standard deviations from non-music control), paediatric respiration (3.15), Blood pressure (2.25) Least effect (though still effective) was length of labour, amount of anaesthesia required, number of days for which patient is hospitalised, measures of neonates behaviour

Means of Music Therapy (Standley 1995)

1) Passive music listening - reduce pain, anxiety, stress - enhance effects of drugs, reduce length of hospitalisation Patients favourite music played prior to event causing pain/ anxiety 2) Active music participation - focus attention on exercise - reduce pain from from joint movement, shorten labour Selection of appropriate exercises, music to help specic movements 3) Music and counselling techniques - reduce stress among patients who are dying, seriously ill, permanently disgured or disabled Playing music to provide opportunities for pleasure, reminiscence, closure, or to initiate discussion 4) Music and developmental or educational objectives - using music to reinforce learning among hospitalised children Playing music to children if theyve achieved an educational aim

Means of Music Therapy

5) Music and stimulation - auditory stimulation to make patients aware of stimuli in other senses - reduce depression due to lack of stimulation in medical environments Music played at the same time as other senses are stimulated 6) Music and biofeedback - used to reinforce physiological responses in order to increases patients awareness, self-control, self-monitoring Participants favourite music played as a reward for reaching a physiological state 7) Music and group activity - Promote positive interpersonal interactions reducing depression, increasing happiness Using a variety of musical activities appropriate to age-group and abilities Focused listening and music making

Discussion Questions
There are lots of different approaches to music therapy, ways of dening different forms etc Do you think all this philosophising is relevant? Does it impact on the effectiveness of music therapy? Are you convinced by music therapy at this stage?

Alzheimers Disease
Most common form of dementia Decline in mental abilities: Loss of memory, mood changes, problems with communication and reasoning Patients with Alzheimers improved on tests concerning social and emotional behaviours following music therapy - music listening, singing, playing instruments, movement and dance (Brotons & Marti 2003) Social and emotional gains, but what about mental gains - retention of memories, and learning?

Alzheimers & Music Therapy

Patients with Alzheimers who had 4 weeks of music therapy showed signicant increases in melatonin, norepinephrine, epinephrine - melatonin levels remained raised 6 weeks after music therapy ended (Kumar et al 1999) Melatonin seems to be important in learning and memory Norepinephrine associated with alertness and arousal - inuences on reward system Epinephrine (adrenaline) increases heart rate, constricts blood vessels, dilates air passages - ght or ight

Alzheimers
www.youtube.com/watch?v=MdYplKQ4JBc&feature=related

Why does Music therapy work in Alzheimers?

1) Music processing networks may be preserved longer than other networks, as dementia progresses 2) Music heightens arousal which improves focus and memory Simmons-Stern, Budson & Ally 2010

Parkinsons
Chronic degenerative disorder of the nervous system Loss of cells in the substantia nigra - produces dopamine Dopamine transmits signals within the brain which controls coorediation of movement Loss of dopamine means that neurons re without normal control - patients unable to control movement Genetic and environmental factors - Some rare cases that seem to be purely genetic (caused by single gene mutation), some which are purely environment (1980: heroin users took contaminated heroin). Most people probably have a mix of genetic and environmental factors

Neurologic Music Therapy

Neurologic Music Therapy (NMT) - aimed at improving motor movements in people with Parkinsons, strokes Involves rhythmic entrainment - gives people back the rhythm of walking, moving NMT study (Thaut, Rice & McIntosh 1997) - 20 stroke patients were provided with rhythmic cueing in which the beat matched the step rate Improvements in gait were sustained, and signicantly greater than gains made from conventional physical therapy Evidence for music therapy as more than just complementary?

Parkinsons
www.youtube.com/watch?v=9nnLTPPDRXI

Discussion of Oliver Sacks video

He discussed the adaptability of music therapy for diseases such as Parkinsons Perhaps usual music therapy (in situ, in home) can be complemented by simply having an iPod with you? Have appropriate music cued up, to assist with rhythmic movement May not even need external cue - lady who remembered Chopin Fantasie in F minor could mentally rehearse it, and it broke her out of her frozen body

Autism
Developmental disability Genetic - some discussion about environmental cause, but no proof Affects information processing in the brain - by altering how nerve cells and synapses are organised and connect Affects communication and relation with the social world Chidren show less attention to social stimuli, dont look or smile at others much Lack of language - between 33% and 50% dont have enough language to get by day-to-day

Autism and Music Therapy

Music can be used both to encourage language skills, and also to teach appropriate behaviour Songs: Do you eat an apple? Yes, yes Do you eat an apple? Yes, yes Do you eat an apple? Yes, yes Yes, yes, yes Do you eat a pencil? No, no Do you eat a pencil? No, no Do you eat a pencil? No, no No, no, no www.autism.com/edu_music_therapy.asp

Autism & Music Therapy

Autistic people are susceptible to musical affect (Heaton et al, in press, Allen et al, submitted) Autistic people sometimes achieve remarkable abilities in music - savants So, music seems a clever way to help these people - socially, emotionally, linguistically Seems to have great effects on sociality, as child builds up relationship with therapist, learns appropriate behaviour However, results less clear than other cases

Cerebral Palsy
Neurological condition causing physical disability in movement and coordination Caused by damage to the brain - 1 in every 400 babies born? Can cause the body to become like a living prison cell One aim of music therapy with Cerebral Palsy is to aid in communication some patients are unable to negotiate the complex motor control needed for speech or sign, and so music can aid with emotional expression Another aim might be help with coordinating movement, similar to Parkinsons patients

Cerebral Palsy & Music Therapy (Miller 1982)

Study with three teenagers with CP Non-verbal, only communication a nod yes, shake no Unable to express emotions because of lack of motor control Remember: these were teenagers, with every drama and emotional upheaval which that entails! Music therapy aimed to enhance emotional expression

Cerebral Palsy & Music Therapy (Miller 1982)

Music therapy started by expressive with expressive sounds, playing the organ using a head stick Discussions of emotion in music Eventually wrote a story with musical accompaniment Since their communicative abilities were quite limited, music therapy provided an outlet for feelings the children ordinarily had no way to express (Miller 1982: 30-31) Kwak (2007): Rhythmic Auditory Stimulation (like Parkinsons, Stroke) to improve gait control in children with spastic CP

Music Therapy
So far, weve seen that music therapy can be useful in helping with physical movement, emotional engagement, and social/ behavioural skills What about higher cognitive functions? Language? So far weve seen that music therapy can help with communication, but can it directly help language/ speech?

Aphasia
Language difculties - often caused by a stroke - lesions in the brain Two main areas, named after man who discovered them Brocas aphasia: Slow, laboured, difculty nding words Wernickes aphasia: word salad - uent speech, but nonsensical

Brocas Aphasia

Wernickes Aphasia

Brocas Aphasia extra video

Aphasia and Music Therapy

First evidence of music and speech interaction - 1871 Singing by Speechless Children, Dr. John Hughlings Jacksons People who have speech disrupted in some way, developmentally or through a pathology, may learn to use speech again through musical training These patients "have some words somewhere," but must be "tricked or seduced into discovering them," - Oliver Sacks

Famous example of Aphasia & Music Therapy

Gabrielle Giffords (US Congresswoman) shot - severe brain injury Struggles to nd words, but can sing. Therapists use music to encourage language
Because of the damage to Giffords' language pathways in the brain, from the very beginning of rehabilitation therapists would use songs as a different way to retrain her brain... The songs also offer a chance for moments of levity and fun in what could often be grueling rehab sessions
abcnews.go.com/Health/w_MindBodyNews/gabby-giffords-nding-voice-music-therapy/story? id=14903987#.TsI8GVbrWO0 abcnews.go.com/US/gabby_giffords/humor-determination-key-congresswoman-gabrielle-giffordsrecovery/story?id=14944407&singlePage=true#.TsIuoFbrWO2

Aphasia
www.youtube.com/watch?NR=1&v=dFSE9E38vKk

Aphasia & Melodic-Intonation Therapy

Melodic Intonation Therapy is recognised by the American Academy of Neurology as an effective treatment for aphasia MIT: patients taught to intone speech with exaggerated rhythm and pitch stress Gradually the music part is phased out, leaving improved language skills Brocas aphasia: lesion to left-side of brain. Prosodic (music part of speech) are in right-side, so left intact Studies have shown that MIT activates Brocas area and left prefrontal cortex Seems to be re-activating the language areas, in an indirect way (Belin et al 1996)

Williams Syndrome
We saw last week that people with WS have incredible musical skills, despite severe cognitive decits Music is a key part of their lives, yet many cant count, tell the time, or tie their shoe laces Daniel Levitin (last weeks video) said that music could perhaps be used ot teach these skills - if WS people can learn a song about tying shoelaces, with coordinated actions, theyve learned a new skill, without really noticing

Music Therapy in prison (Romanowski 2007)

Curing in this sense means to help patients to survive their sentence with as little (bodily and mental) damage as possible Both surviving their sentence, and rehabilitation - dealing with emotional problems, learning whats appropriate in society Normal/ healthy forms of behaviour exercised in music therapy
Listening to music Joint singing and music-making Improvisation (free or within a given framework) with easy-to-handle instruments (percussion) Singing of songs to learn the language Rhythmic work (e.g. with shaman drums and other percussion instruments) Movement to music Guitar lessons in single therapy Spontaneous interventions as response to a clients reaction (e.g. role play with instruments, acting out an emotional situation or an experience) Conversation with clients as additional intervention outside group sessions, e.g. in case of disciplinary problems

Aims of Music Therapy in Prisons

Generally improved condition through benecial effects of joint music-making Stimulation of breathing and vital functions through singing and movement Improved mood Distraction from problem-oriented thinking and worries Emotional release through discharge of affect (e.g. loud drumming gets rid of rage) Experience of compassion and comfort in the group

Aims of Music Therapy in Prisons

Raised self-esteem through experience of success Improved motivation for participation Resources are discovered Expansion of mental horizon through new experience Promotion of creativity ability to nd solutions Improved self-perception and self-condence, e.g. through orientation to experience of ones own voice and effects of personal activities on others

Aims of Music Therapy in Prisons

Improved perception of environment through directed listening (perception of instruments in concert) Improved perception of others, attention directed to other group members Experience and awareness of group dynamics Awareness of behaviour patterns Changes in behaviour (wrong attitude, antisocial behaviour)

Music Therapy
Can take many forms Combination of listening, music making, movement Can be in groups or one-on-one Children with communication problems: typically start solitary, perhaps move towards introducing more members as child improves Adults with physical problems: Typically group-based, dancing, making music together etc Adults with psychiatric problems: Can be on-on-one, with eventuaal aim to interact normally with groups

Importance of Music Therapy

Has huge effects of peoples lives Very effective for those who cannot use language, or fear using it, for whatever reason Music is important for social cohesion, as seen in previous lectures - aids the relationship between therapist and patient Crucially - VERY CHEAP! A fraction of the cost of drugs Can provide therapeutic help in countries which cannot afford expensive drug regimes

Discussion Questions
But how do you think music therapy works? Do you think that music therapy could ever supercede traditional therapies? Is music really a therapy, or on a par with other therapies, which may provide only a placebo effect?

Music medicine
Has many inter-relationships with music therapy One clear difference: music therapy can be an on-going thing, music medicine is often done on a once-off basis Use of music to affect health directly - administered by doctor, nurse or other healthcare professional MusicMedicine is dened through multidisciplinary scientic evaluation, including mathematical, physical, physiological, medical, psychological, musicological, and music therapeutic means, as well as through preventative, curative, and rehabilitative application of musical stimuli in healthcare settings (Spintge 1999: 9)

Music medicine - use

Use of music to control pain, reduce blood pressure, heart rate, or muscle tension, to effect changes in the endocrine system Used in surgery, anaesthesia, acute and chronic pain therapy, intensive care, obstetrics, geriatrics, behavioural disorders, motor dysfunction, cancer care, dentistry Does it work? 160,000 data points have been collected from surgical and pain patients, documenting role of music in reducing pain, anxiety, and length of hospital stay Psychological tests, behavioural observations, self-reports, monitoring of pulse rate, blood pressure, etc

Why does this seem to work?

Psychoneuroimmunology (PNI) = study of interactions of brain, behaviour, and immune system (Maeir, Watkins, & Fleshner 1994) The brain and immune system communicate bidirectionally - nervous system and hormonally Behavioural experiences (e.g. music) may affect the mind/brain, which in turn alters immune function This would explain lowered stress pre-surgery, quicker recovery time, reduced hospital times

Music Medicine
Not as widely used in medical practice as it could be - its a cheap, easy intervention in many cases, and theres hard evidence that it works Proven effects on pain reduction, labour time reduction, reduction in anaesthetic and drugs needed etc etc So why is it now used more widely? Mistrust of using something that medical people dont understand?

Music for surgeons

Aside from music calming surgery patients, it may also calm the surgeon UK: 90% of surgeons listen to music in operating theatre - uptempo rock most common, also pop and classical (11%) Allen & Blascovich, 1994: 50 male surgeons asked to do a complex, stressful subtraction task when listening to music. Heart rate, blood pressure, response times, and task accuracy was recorded Music of their own choice; Pacabels canon in D; silence Self-selected music led to steady vital signals, faster results, more accuracy Listening to Pacabel was better than silence, but not as good as own choice of music

How does this work?

Appears to be increased accuracy, speed, and calmer surgeons when listening to own choice of music Counter example: Junior surgeons were asked to do a virtual operation (laparoscopy) when listening to activating music, deactivating music, and silence (Miskovich et al 2008) Activating music = worst performance (35 points) Deactivating music = 66 points Silence = 91 points So, doesnt work for novices, but does for experts. Effect of experience? Perhaps music aids surgery when the movements have been habituated? Similar to Parkinsons/ stroke patients?

Conclusions
Music therapy is a relatively new eld Many ways of viewing it, many different & overlapping aspects Three main aspects: Music therapy, Music medicine, Performance medicine Music therapy and music medicine still seen as complementary Aims of music therapy may be different from conventional medicine communication and assistance, rather than cure But should be investigated for its possible cheap effects, particularly for poorer countries

Readings for next week

North & Hargreaves, p 14 - 22 Hodges & Sebald, 225 - 230

References
Allen, K., Blascovich, J. (1994). Effects of Music on Cardiovascular Reactivity Among Surgeons. Journal of the American Medical Association, 272 (1) 882 - 884 Allen, R., Hill, E., & Heaton, P. (submitted). Hath charms to soothe: An exploratory study of how high-functioning adults with ASD experiences music Ansdell, G. & Pavlicec, M. (2005). Musical companionship, musical community: music therapy and the process and value of musical communication. In D. Miell, R.A.R. MacDonald & D.J. Hargreaves (eds.) Music Communication. Oxford: Oxford University Press: 193 - 213 Brotons, M., & Marti, P. (2003). Music therapy with Amzheimers patients and their family caregivers: A pilot project. Journal of Music Therapy, 40 (2), 138 - 150 Bunt, L (1997). Clinical and therapeutic uses of music. In D. Hargreaves & A.C. North (eds.) The Social Psychology of Music. Oxford: Oxford University Press, 249 - 267

References
Belin, P., Van Eeckhout, P. et al (1996). Recovery from nonuent aphasia after melodic intonation therapy: A PET study. Neurology, 47 (6), 1504 - 1511

Blood, A.J., Zatorre, R.J., Bermudez, P., Evan. A.C. (1999). Emotional responses to pleasant and unpleasant music correlates with activity in paralimbic brain regions. Nat. Neuroscience, 2, 382 - 387

Brown, S., Martinez, M. J., & Parsons, L. M. (2004). Activation of limbic cortical areas during passive listening to music. NeuroReport, 15, 2033 - 2037

Gaston, E. (1968). Music in therapy. New York: Macmillan

Heaton, P., Allen, R., Williams, K., Cummings, O & Happe, F. (In Press). Do social and cognitive decits curtail musical understanding? Evidence from Autism and Down Syndrome. British Journal of Developmental Psychology

Janata, P. (2009). The neural architecture of music-evoked autobiographical memories. Cerebral Cortex

Kumar, A., Time, F., Cruess, D., Mintzer, M, et al (1999). Music therapy increases serum melatonin levels in patients with Alzheimers disease. Alternative Therapies in Health and Medicine, 5 (6), 49 - 57

References
Kwak, E. (2007). Effect of rhythmic auditory stimulation on gait performance in children with spastic cerebral palsy. Journal of Music Therapy, 44 (3), 196 - 216

Maier, S., Watkins, L, & Fleshner, M. (1994). Psychoneuroimmunology: The interface between behaviour, brain, and immunity. American Psychologist, 49 (12), 1004 - 1017

Miller, S. (1982). Music Therapy for handicapped children: Speech impaired. Project Music Monograph Series, W. Lathom & E. Eagle, Jr. (eds). Washington, DC: National Association for Music Therapy

Miskovic, D., Rosenthal, R., Zingg, U., Oertli, D., Metzget, U., & Jancke, L. (2008). Randomized controlled trial investigating the effect of music on the virtual reality laparoscopic learning performance of novice surgeons. Surgical Endoscopy, 22 (1), 2416-2420

Romanowski, B. (2007) Benets and limitations of music therapy with psychiatric patients in the penitentiary system. Music Therapy Today, 8 (3)

Sacks, O. (2007). Musicophilia. London: Picador

References
Simmons-Stern, N., Budson, A., & Ally, B. (2010). Music as a memory enhancer in patients with Alzheimers Disease. Neuropsychologia (in press) Spintge, R. (1999). MusicMedicine: Applications, standards, and denitions. In R. Pratt & D. Grocke (eds.) MusicMedicine 3 Victoria, Australia: The University of Melbourne, 3 - 11 Standley, J.M. (1995). Music as a therapeutic intervention in medical and dental treatment: research and clinical applications. In T. Wigram, B Saperstone, & R. West (eds.). The art and science of music therapy: a handbook. Langhorne: Harwood, 3 - 22 Thaut, M., Rice, R., & McIntosh, G. (1997). Rhythmic facilitation of gait training in hemiparetic stroke rehabilitation. Journal of Neurological Science, 151, 207 - 215