|
|
|
|
No. 70 Music & Medicine |
|
A basic concept underlying the use of music as a therapeutic agent is that a phenomenon able to generate tension can also assist in reducing it. In other words, music can relieve stress and promote relaxation. Emotional states and pain sensitivity are also susceptible to modification through music. Facilitated by trained musical therapists, many patients by either actively making music or listening to it can achieve significant therapeutic goals. The Development of Modern Music Therapy since 1945 It was in the United States after the two world wars that music therapy as we know it today began to take shape. Musicians visited veterans’ hospitals around the country to play music for the thousands suffering from post-war physical and emotional traumas. Doctors and nurses observed the benefits of these activities and requested the hiring of musicians by the hospitals. It was recognized that they required training in how to apply music for therapeutic purposes, and so colleges and universities began to set up specific music therapy curricula and programs. In 1944 the first music therapy program in the world was founded at Michigan State University, and 1950 saw the founding of the first professional association for music therapists, the National Association for Music Therapy (NAMT). Subsequent changes in the structure of the American health care system necessitated the fusion in 1998 of the NAMT with the second-largest association at that time to create the American Music Therapy Association (AMTA), still today the country’s major professional organization for music therapists. The first European association, the British Society for Music Therapy (BSMT), was founded in 1958. The first World Congress for Music Therapy took place in Vitoria, Spain, in 1973. The ground for a global association of music therapists was prepared in 1976 at the next World Congress in Buenos Aires, Argentina, and the World Federation of Music Therapy (WFMT) finally saw the light of day at the fifth World Congress in 1985 in Genoa, Italy. A European Music Therapy Confederation (EMTC) was formed in 1990. One of the major goals of the EMTC was to bring on a par with one another the various training programs within Europe and especially within the European Union. The application and validation of music therapy as an officially recognized form of medical treatment varies greatly among national health care systems. In most countries, music therapy is still not regarded or accepted as an independent medical discipline. Instead, most music therapy approaches are offered within the context of health care and welfare clinics and institutions that treat and cater for a broad spectrum of conditions and diseases. There are exceptions. In Austria in 2008, the draft of occupational licensing regulations for music therapy was unanimously accepted by parliament, laying the foundations for legal recognition of the profession. Given the absence of such statutory provisions when the various associations were first established, the ways in which music was applied for therapy to begin with were shaped by the various and competing schools of psychotherapy, ranging from cognitive behavioral therapy to approaches based on depth or gestalt psychology. Gradually, though, music therapy developed an independent identity, and with a growing awareness of the specific features and qualities of music, music therapists began to distance themselves from the domination of existing psychotherapeutic premises in their theory and practice. In addition, attention was increasingly paid by basic research to the specific modes by which music acts on the mind and the person. Thus, after years of differentiation, a new professional unity has now been achieved. This is reflected and underpinned by, for example, the fusion of the two American associations in 1998, and the merging in 2008 of the largest German music therapy associations into the German Music Therapy Society. The Current Definition of Music Therapy According to the WFMT and the AMTA, music therapy can be defined as the clinical and evidence-based use of music and/or its elements (sound, rhythm, melody, harmony, dynamic, tempo) by a qualified music therapist to accomplish individualized goals within a therapeutic relationship with one client or a group. The aim of music therapy is to develop potentials and/or restore functions of the individual so that he or she can achieve better intrapersonal and/or interpersonal integration, which may include a better quality of life, through prevention, rehabilitation or treatment. Besides its scientific orientation, modern music therapy defines itself as a resource- and relational-based approach. It is an established health profession in which music is used within a therapeutic relationship to address individuals’ physical, emotional, cognitive and social needs. After assessing the strengths and needs of each client, the qualified music therapist provides the indicated treatment including creating, singing, moving to and/or listening to music. Through musical involvement in the therapeutic context, clients’ abilities are strengthened and transferred to other areas of their lives. Music therapy also provides avenues for communication that can be helpful to those who find it difficult to express themselves in words. A distinction needs to be drawn here between music therapy, which always involves the participation of a qualified music therapist, and the concept of music medicine, in which music is employed as an ancillary therapy by those who are not necessarily specialized in the field. How Does Music Exert Its Effects? Until the 1990s, scientific evidence for the value of music therapy was sparse and unsatisfactory. Up to that point, the majority of publications were case studies, and these were only complemented in the last decade of the 20th century by a growing number of clinical studies and reviews. This growth continues, and a search for relevant titles in databanks such as PubMed or PsycINFO reveals that about one-third of the articles on music therapy have appeared within the last decade. The first Cochrane meta-analyses [1] and systematic reviews [2] have demonstrated that music therapy works and that it is as effective as recognized psychotherapeutic approaches. In their review of ten meta-analyses and four reviews from 1986 to 2005, Argstätter and colleagues [2] found that music therapy was especially effective when applied with neonates, children with autism, and children and youths with psychopathologic problems. Music therapy also demonstrated good but less consistent success with other conditions, including dementia and psychosis, and for stress reduction. Recent imaging studies, such as those employing positron emission tomography (PET), have shown that some of music’s effects are specifically elicited by the sites and ways in which it is processed by the brain’s neuronal network. Such processing can influence and alter, for example, our emotional experiences [3] and the perception of pain [4]. One of the biggest surprises during early observations of those with brain damage or of healthy subjects with amusia (the inability to recognize and replicate musical tones or rhythms) was that there is no special music center in the brain. Rather, when listening to or making music, several areas distributed throughout the brain are activated, including some that are typically engaged in other cognitive functions, such as the Broca area, which is responsible for the comprehension and production of the grammatical aspects of language. In his book published in 2003, Musik im Kopf [Music in the Brain] [5], the psychiatrist Manfred Spitzer describes graphically the results of a study first published in Nature in 1993, which came to be known as the ‘Mozart effect.’ In fact, it would be more accurate to ascribe this effect to the publication of the article rather than the research findings themselves: on the day after the article appeared, sales of Mozart recordings – and in particular of the Sonata for two pianos in D major (KV 448) used in the study – soared. What had been studied, and does Mozart’s music have clinically relevant effects? Rauscher and his colleagues [6] investigated whether listening to music had an impact on the processing of spatial perception. Thirty-six students were divided into three groups. One group listened to the Mozart sonata for 10 minutes. The second group were played relaxation music for the same period. The third group received no acoustic stimulation. Afterwards, the subjects’ spatial intelligence was evaluated with a standardized test. Students who had been listening to Mozart achieved significantly higher scores than those in the other two groups. This study provoked various responses. US schools began to play Mozart in the background during lessons, while a flood of studies and a critical re-examination of the Mozart effect appeared in the scientific press. So, is there a Mozart effect? In a strictly scientific sense: no; that is, specific pieces of music have no effect on cognitive development. Nevertheless, the processing and production of music are highly complex activities that place great demands on our brains. Simply consuming music is unlikely to promote mental abilities without additional individual input or initiative. Furthermore, making music challenges us at many other levels, including our fine motor skills, memory and responsiveness to stimuli. It trains not only human cognition, but at the level of personality, how we deal with our emotions, and it is an important resource for learning self-discipline. From a therapeutic perspective, particularly interesting are the events that take place in the brain when we react emotionally to music. Most people experience somatic reactions when they respond strongly to pieces of music. In a study by Sloboda in 1991 [7], the most commonly mentioned reactions were a shiver of goose bumps running down the spine, laughter, a lump in the throat, tears, or an increase in heart rate. Music does not merely evoke emotions, for many it is a vital component of a full emotional life. Patients often describe how since childhood, as well as during serious illnesses, music has helped them to work through emotional stresses. Just a few minutes sitting at the piano playing a piece of music can relieve emotional strain. Serious physical illness is often accompanied by a marked degradation of one’s sense of well-being, which in turn undermines and interferes with a person’s usual involvement with music. Being able to make music again is often experienced by music therapy patients as a way back to (an often readjusted) normality. In a PET imaging study, Blood and Zatorre [8] were able to show that music stimulates neuronal systems that otherwise respond to food intake, sex or narcotic drugs. The body’s reward system is stimulated, leading to the release of endogenous opioids and the neurotransmitter dopamine. Furthermore, music that is experienced as pleasant inhibits central nervous system structures that signal anxiety, aversion or pain. In parallel, Blood and Zatorre also found activation of structures important for wakefulness and attention. This is interesting given that, strictly speaking, music is necessary neither for survival nor reproduction and is not itself a pharmacological substance. Their study, however, underscores the experiences described above: we may be able to live without music, but without music our psychic health may be considerably impaired. Another approach in music therapy research and one that is closely related to chronobiology is the study of heart rate variability during music reception and active music making. Changes in relevant physiological parameters are measured with small instruments that do not, or only slightly, interfere with the subjects’ mobility. The variation in our pulse is an indicator of our degree of relaxation and physical equilibrium. In sports medicine and competitive sports this measurement is used, e.g., to monitor an athlete’s condition and to prevent excessive training. If the variation drops off and the heart beat takes on the characteristics of a metronome, these are interpreted as danger signals. People in stressful situations exhibit less heart beat variation than those who are relaxed. Studies of pulse variability of patients in palliative care show that towards the end of life, the heart beat becomes increasingly regular, with virtually no variation. As far as music is concerned, both listening to music and active music making, like singing, raise heart rate variability and contribute to somatic recovery and a reduction in stress and tension. Musical activity can alter not only the variability of the heart beat. In a study with cancer patients suffering from chronic pain, Reinhardt [9] showed that the patients’ pulse synchronized with the beat of slow relaxation music. In addition, over the course of several sessions with this music, the patients self-administered significantly less analgesic medication. Two synchronization relationships were found: 1:2 (music 50 bpm, heart 100 bpm) and a particularly stable one of 2:3. The latter was found when the music had a tempo of 42–48 bpm – the heart responded with a pulse of 63–72 bpm. Those patients who enjoyed the music most tended to show the greatest degree of synchronization. Important information about the effects of music can also be obtained by directly interviewing patients or giving them questionnaires to fill out. A study with patients undergoing oncological rehabilitation in the Clinic for Tumor Biology in Freiburg showed that the relatively monotonal but overtone-rich sounds of a monochord (a 30-stringed instrument with three tonic notes) promote a feeling of calm and equilibrium [10]. Especially noteworthy here is that the music exerts its effects almost immediately and the patient does not have to practise a listening technique. Music as Therapy There are fundamentally two types of music therapy: active and receptive. In active music therapy, the patient makes music either alone, with a therapist or within a group. In receptive music therapy, the therapeutic goals are pursued exclusively by listening to music. Music therapists work with the underlying assumption that everyone is endowed with a basic musicality, a hypothesis that, as Michael Thaut has shown in his opening article, is now substantiated by a significant body of research. Music therapy, and this point needs to be stressed, requires no prior musical knowledge – such as the ability to play an instrument – on the part of the patient. In fact, when trained musicians are in therapy, there is often the danger of their running into conflicts with their personal aesthetic standards. Having an open mind about music and how it is employed in therapy is, rather, much more likely to lead to a successful outcome.
When, for example, patients in an active group therapy at the Clinic for Tumor Biology in Freiburg are able to stop worrying self-critically about how well they are performing and are simply able to enjoy what they are doing, they are then able to achieve a greater sense of composure, can actively reduce the stresses they are experiencing and, in general, reach a higher degree of self-acceptance. In the oncological context this often also means a new relationship to the injured self, or even a new body identity – important healing outcomes when coming to terms with a cancer illness. The areas in which music therapy can be applied can be broadly subdivided into clinical, pedagogic and gerontologic applications. The clinical scope is wide and includes psychosomatics, psychiatry, neurology, oncology, pediatrics, gerontology and palliative medicine. Table 1 shows the clinical fields and medical conditions in which music therapy is applied, and rates the value of the two therapeutic forms – active and receptive – for the different fields.
The Methods of Music Therapy Active music therapy can take the form of either a reproductive music therapy using well-known songs or rhythms, or a productive music therapy during which new musical pieces are created spontaneously or are composed. Regardless of the method, the goal is to promote emotional expressivity, accompanied by a general psychophysiological activation and stimulation of the patient’s creativity. For a patient with a chronic disease, for example, these are all processes that will assist him or her to cope with the disease. Receptive approaches may (a) be relaxational and palliative, for example, to reduce pain; (b) be more rehabilitative and psychotherapeutic; or (c) have a functional orientation (see Table 2).
Active Music Therapy Active music therapy usually works with instruments that are very easy to play. The aim here is not for the patient to learn to play an instrument well or perfectly. The goals, rather, of active music making are to improve the patient’s communication and relational abilities, to mobilize and activate the nonverbal expression of emotions, to overcome restrictive personality patterns or simply to experience joy in doing something for oneself. For patients under substantial stress, such as those with a progressive chronic disease, active music making can help them gain some distance or respite from negative thoughts and feelings because their attention becomes totally absorbed by the music making activity. Oncology patients, in particular, have explained how helpful and agreeable this can be. Typical intervention techniques in active music therapy are singing, playing with rhythm, improvisation, and the composition of music or songs. These methods are described in more detail below. Singing Working with songs obviously involves the use of the patient’s own body as the musical instrument. In the therapeutic context, singing can train articulation, breathing and individual expressivity. Group work, in addition, nurtures the development of social skills. In particular, people with dementia can regain some of their lost speech abilities by singing well-known songs. At the same time, singing can help to relieve the anxieties associated with dementia. For patients with an aphasia after stroke, singing can stimulate the brain’s speech centers, leading to a subsequent improvement in speech competence. Rhythm Working with rhythms during therapy enhances fine motor skills and eye-hand coordination. The expressive power that is often released by rhythm work contributes to an active release of tension, flow (the mental state in which a person is fully immersed in what he or she is doing), and in groups to a positive sense of belonging, manifested in pleasure in one’s own activities. Rhythm as well as the experience of an inner metrical beat can be, as mentioned above, beneficial for health-promoting synchronization processes and are even able to stimulate the motor areas of the brain. Improvisation In musical improvisation, patients express thoughts and feelings wordlessly. It is a therapeutic technique in which they can deploy their creativity, responding to and interacting with their own performance or that of a group. Improvisation implies the extempore – something out of time and unprepared – i.e. engaging with the unpredictable, as all of us are challenged to do in our everyday lives when we must draw spontaneously on our own resources, make on-the-spot decisions, or react to situations in unexpected ways. One of the aims when the therapist and patient review what has taken place during an improvisation session is to identify those aspects of the music making that the patient him- or herself experiences as particularly useful. For an outsider, such improvised music often sounds strange, cacophonous. Patients too usually need some time to adjust themselves to and feel comfortable with the improvisation set-up. Improvisation is often used as a psychotherapeutic approach when words fail and emotions are hard to express. It helps to dissolve emotional blocks, and through it patients can relearn to trust their ability to interact with others. Composition Composition is used in music therapy to express feelings, to experiment with music but also to counteract the ephemerality of music by creating a mental and emotional anchor. In the pediatric setting, for example, children may rewrite the words to their favorite songs in order to understand or express their fears and to gain courage in facing them. During terminal care, composition provides a space to explore fundamental questions about life, dying and death. Such patients may write pieces as a legacy for the most important people in their lives, expressing their love, gratitude and appreciation. In work with adults, writing the melodies and texts of songs can help to thematize painful experiences and address traumas. During the composition process, discussion with the therapist helps the patient to assimilate the topics that are relevant to the therapy and then feed these reflections back into the creative artistic practice. During an oncological rehabilitation, one of our patients wrote the song ‘Feeling Well Again.’ Two years later, in good health, he returned to the Clinic for Tumor Biology for consolidation therapy. He had programmed his tune as the ring tone for his mobile phone. Every time he received a call, it reminded him of his resolution to take care of his health and to think well of himself. This raised not only his spirits but also that of his family and friends.
Receptive Music Therapy In receptive music therapy, music is used for purposes of relaxation, to reduce pain, relieve anxieties and/or to stimulate illness- and therapy-relevant psychic processes. The patient listens either to music played live by the therapist or to recorded music. Listening to music can also have additional functional neurological effects through the stimulus of rhythm or a metrical beat. Palliative/Relaxational The goal of relaxational music therapy is to procure psychophysical relaxation through listening to music. In the Clinic for Tumor Biology in Freiburg, for such therapy we employ the monochord, a 30-stringed instrument, played live by the therapist. In group work we refer to this approach as sound meditation. It enables many patients who encounter problems with other relaxation modalities to achieve an intense experience of deep relaxation and inner peace. Receptive music therapy can also be applied at the bedside. Especially in situations – such as the approach of death – when anxieties may be strong, music can bring about both physical and psychic relaxation (anxiolysis) and may reduce pain (audioanalgesia). When other senses are closed off (sight for example) or numbed by medication, through the ear, music can often still reach the body and ‘soul’ of the sick person. Rehabilitative Here music is used to support processes of self-discovery and psychotherapy. One established method is guided imagery and music. Usually classical music is employed as a sound setting to bring forth inner images, ideas and memories that are subsequently discussed, assimilated and therapeutically integrated by the patient. Functional Applied appropriately, listening to stimulating music, a simple rhythm or even just a regular beat can have therapeutic benefits. During physiotherapy following a stroke, for example, listening to a metric beat can facilitate the relearning of certain gait functions such as walking speed and step length [11]. Thaut and his colleagues [12] have also been able to show that an acoustic-rhythmic stimulus can improve the movement and speech motor control of patients with Parkinson’s disease.
Coda Today, even in fields of medicine strongly dominated by evidence-based approaches, music, with or without a therapist, has become a scientifically proven ‘remedy’ that offers patients a nondrug, complementary medical treatment. Music can be applied to enhance the sense of well-being, to reduce stress, to express feelings without words, to improve interpersonal communication, to stimulate memory performance and to relieve pain. Music therapy is now rapidly shedding its exotic status and developing into a serious, scientifically based discipline with a broad range of therapeutic options. One of the most important prerequisites for an effective therapy is that the patient enjoys what he or she is doing and hearing. Under these conditions, music can unfold its healing powers.
 Jens-Peter Rose has worked at the Tumor Biology Center in Freiburg since 1999, when he completed his music therapy training in Heidelberg. He works especially with patients in oncological rehabilitation, but also in acute and palliative care. Alongside his therapeutic work, he conducts research on clinical aspects of music therapy in oncology, with a focus on the relaxation effects of sounds, psychological changes associated with active music making in nonmusicians, and the effectiveness of active music making versus listening to music.
Jens-Peter Rose Dipl.-Musiktherapeut (FH) Klinik Für Tumobiologie Breisacher Str. 117 D-79106 Freiburg Germany rose@tumorbio.uni-freiburg.de Homepage  Hans Helge Bartsch is a specialist in internal medicine and hematology/oncology. For 30 years, he has treated cancer patients, from primary diagnosis through to palliative and terminal care. His research focuses on improvements in therapy, especially the development of interdisciplinary therapeutic concepts to ameliorate illness- and therapy-related problems. Since 1993, he has been Medical Director of the Tumor Biology Center at the Albert-Ludwigs University in Freiburg, and spokesman of the board there since 2005. Prof.Dr. med. Hans Helge Bartsch Sprecher des Vorstands u. Ärztlicher Direktor Klinik für Tumorbiologie an der Albert-Ludwigs Universität Breisacherstr. 117 D-79106 Freiburg Germany bartsch@tumorbio.uni-freiburg.de Homepage
|
|
||||||||||||||||||||||||||||||||||||||||
