Abstract
Music therapy is gaining increasing recognition for its benefit in medical settings both for its salutary effects on physiological parameters and on psychological states associated with medical illness. This article discusses the role of a music therapist in consultation-liaison psychiatry, a specialty that provides intervention for medical and surgical patients with concomitant mental health issues.
We describe the ways in which music therapy has been integrated into the consultation-liaison psychiatry service at Hahnemann University Hospital, a tertiary care facility and major trauma center in Philadelphia. The referral process and some of the techniques used in music therapy are explained. Anecdotal observations illustrate how a music therapist incorporates the various elements of music as well as the experiences of engaging in music-making to bring about changes in mood and facilitate expression of feelings and social interactions in patients who are having difficulty coping with the effects of illness and hospitalization. These methods have also been observed to have positive effects on the hospital staff by making available a means with which staff can express pressures inherent in direct patient care.
Keywords: music therapy, consultation-liaison psychiatry, hospital staff support
“Those who organize programs designed to treat people rather than to cure disease will find creative arts therapists invaluable.”1
—Israel Zwerling, MD, PhD former Chairman of the Department of Psychiatry, Hahnemann Medical College and Hospital, Philadelphia, Pennsylvania
Introduction
Consultation-liaison psychiatry provides an important service in busy general hospitals. Many medical and surgical patients are in need of treatment for pre-existing psychiatric conditions or for those that arise during hospitalization. Ideally, the consultation-liaison team consists of multiple specialists who provide various types of therapeutic modalities, including pharmacotherapy and cognitive/ behavioral/insight-oriented therapies. Music therapy is one such specialty that is utilized by the consultation team at Hahnemann University Hospital of the Drexel University College of Medicine. The collaboration between music therapy and the consultation-liaison service at this facility was established in the early 1980s, building on a solid foundation established many years earlier between the creative arts therapies and the Department of Mental Health Sciences.1,2 Currently, music therapists complete supervised internships on the consultation team as part of the Drexel University Creative Arts in Therapy Program, which offers graduate studies in music therapy.
This article presents a picture of music therapy as it is used at Hahnemann University Hospital in the treatment of medical and surgical patients who are in need of psychological support. The role and approach of the music therapist on the consultation-liaison psychiatry service is described, and we detail the process of patient referral, assessment, and evaluation. Narrative examples of music therapy sessions with patients, as well as the spontaneous music-making experiences of hospital staff, are provided in order to further clarify the use of music in this capacity.
Definition of Music Therapy
The American Music Therapy Association (AMTA) defines music therapy as “the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.”3 Elements of this definition are clarified by the AMTA in the following manner:
Clinical and evidence-based: There is an integral relationship between music therapy research and clinical practice.
Music interventions: The process is “purpose-driven” within a productive use of musical experience based on the AMTA Standards of Clinical Practice.
Individualized goals within a therapeutic relationship: This process includes assessment, treatment planning, therapeutic intervention, and evaluation of each client.
Credentialed professional: Each credential or professional designation (i.e., MT-BC, RMT, CMT) requires a set of professional competencies to be fulfilled and maintained according to established professional standards.
Approved music therapy program: A degreed program with AMTA approval and the National Association of Schools of Music (NASM) accreditation.3
Bruscia4 describes one of many challenges encountered in attempting to offer an unequivocal definition of music therapy as follows: “As a fusion of music and therapy, music therapy is at once an art, a science, and an interpersonal process. As an art, it is concerned with subjectivity, individuality, creativity, and beauty. As a science, it is concerned with objectivity, universality, replicability, and truth. As an interpersonal process, it is concerned with empathy, intimacy, communication, reciprocity, and role relationships.”
As such, he presents the following as a working definition: “Music therapy is a systematic process of intervention wherein the therapist helps the client to promote health, using music experiences and the relationships that develop through them as dynamic forces of change.”4
The use of music in medical settings has become increasingly prevalent in recent years, leading to the necessity for a distinction to be made between music medicine and medical music therapy. Dileo describes the primary differences as, “…in medical music therapy, the music and therapist are with the patient; in music medicine the music is with the patient. At the most basic level, music medicine is practiced by non-music therapists, usually medical personnel; medical music therapy is the domain of trained music therapists.”5
Both music medicine and medical music therapy (in this paper we will be focusing primarily on the latter) involve the use of music to provide patients with relief of symptoms. Music medicine almost always involves a receptive listening experience with some type of pre-recorded music (which may or may not be selected by the patient). This can also include the use of low frequency sounds, often with the aim of inducing relaxation. This approach does not require the presence of a music therapy clinician. In medical music therapy (which we will refer to as “music therapy”), however, there is the expectation of an active musical dialogue, so to speak, and the patient is engaged in a relational process, which develops through various types of music experiences presented within the sessions. It is, thus, clear that this approach necessitates training in the field of music therapy.6 In a manner of speaking, a music medicine approach is usually a solo affair, whereas music therapy involves at least a duet (if not a whole ensemble).
Music therapists are highly skilled musicians as well as having knowledge in developmental, psychosocial, and group theories and practices.
Therapeutic Uses of Music in Hospitals
Music therapy has been utilized extensively in medical settings within a wide range of specialties. These include (but are not limited to) general medicine, surgery, intensive care, pediatrics, pulmonology, cardiology, oncology, and pain management.6–8 To date, however, we have found no literature specific to the use of music therapy or research as to its effect in consultation-liaison psychiatry.
Research has begun to demonstrate the beneficial effects of music therapy in ameliorating stress and mood dysfunctions associated with specific conditions, such as multiple sclerosis and cancer. Schmid and Aldridge conducted a study in which 20 patients diagnosed with multiple sclerosis were divided into a group receiving music therapy or a control group. Utilizing the Beck Depression Inventory, Hospital Anxiety and Depression Scale, and the Hamburg Quality of Life Questionnaire in Multiple Sclerosis, the authors found significant improvements in the scale values of self esteem, depression, and anxiety in the group receiving music therapy.9
In another study, Waldon examined the two conditions of “music-making” (patients were asked to create music) and “music responding” (patients were asked to respond to presented music) within the context of a music therapy group on mood states in adult oncology patients. Using the Profile of Mood States-Short Form, the author found improvement in mood state scores after involvement in music therapy sessions.10
Cassileth, et al., demonstrated that during high-dose autologous stem cell transplantation in patients with hematologic malignancies (a procedure known to cause psychological distress), patients in the music therapy group scored 28-percent lower on the combined Anxiety/Depression Scale and 37-percent lower on the Total Mood Disturbance score compared with controls.11
Pelletier did a meta-analysis of 22 research articles using music to decrease stress in various medical situations, including myocardial infarction, cardiac catheterizations, labor and delivery, pain in the terminally ill, and ambulatory ophthalmic surgery. Results of the analysis demonstrated that music-assisted relaxation techniques brought about a statistically significant improvement in patients who were under an arousal condition caused by stress.12
Hospitalized patients have widely varying levels of tolerance for anxiety as well as having different ways of coping with stressful situations. Studies have demonstrated the positive effects of using taped music for hospitalized patients.13–17 We suggest that such positive effects may be enhanced when patients are able to engage with a live person offering music therapy.
In a study of 50 hospitalized cancer patients, Magill-Bailey presented half of the randomly assigned participants with live music (consisting of her playing guitar and singing) and the other half with a recording of the therapist singing and accompanying herself on the guitar as a part of an individual music therapy session. The Profile of Mood States (POMS) was administered prior to and after the music therapy session. Patients receiving live music were significantly more likely to report an increase in vigor as well as decreased tension and anxiety than those individuals receiving taped music.18
O'Callaghan and McDermott conducted a study in which 128 patients, 41 visitors, and 61 staff members participated in music therapy over a period of three months. Fifty-seven percent of the patients who participated had advanced or terminal cancer. Thematic and content analyses were performed on the music therapist's and the patients' interpretations using qualitative data management software. Findings indicated that the participants' affective, contemplative, and imagined moments in music therapy “affirmed their ‘aliveness,’ resonating with an expanded consciousness in a context where life's vulnerability is constantly apparent.”19
The Role and Approach of the Music Therapist on the Consultation-Liaison Service at Hahnemann University Hospital
Music therapists play an integral role in the consultation-liaison service at our facility. During discussion of patient management following rounds, input is sought from the music therapist as to which new patients may benefit from this treatment modality. Some reasons that a team may choose to request music therapy services are when a patient is not able to engage in verbal psychotherapy, is withdrawn, or does not have a good family support system. The music therapist determines the frequency of sessions as deemed appropriate and provides feedback to the team for the duration of the patient's hospitalization. Notes summarizing the therapist's sessions with the patient are recorded in the chart as part of consultation-liaison visits.
The type of music therapy approach used at Hahnemann is based on a supportive psychotherapy model. In using a supportive music psychotherapy approach, the music therapist invites the patient to engage in the therapy process by presenting him or her with music experiences. Through the musical interactions, the therapist and patient are able to develop a therapeutic alliance. This alliance serves as a foundation from which the patient is then supported to make use of personal strengths and resources which he or she already possesses, as well as increasing his or her ability to cope with illness, hospitalization, and adjusting to its effects.4
Music therapy sessions generally take place at the patient's bedside. Some of the more commonly used instruments include guitars, keyboards, large and small drums, assorted rhythm instruments (e.g., tambourines, maracas, rhythm sticks), flutes, recorders, and xylophones. Additional factors in choosing instruments for use in therapy include the sound quality of a given instrument (e.g., tone, timbre, resonance), the shape and size of the instruments, and the physical strength required in order to sound these objects, which tends to be an issue when a patient is confined to his or her beds or unable to sit up for the sessions.
Therapists conduct ongoing assessments through dialogue as well as by inviting patients to engage in spontaneous music-making experiences. Through these types of interactions, the therapist is able to learn about the patient's musical preferences, the level of comfort with regard to the use of music as a therapeutic modality, some of the ways the patient relates to people and to new situations in his or her life, and how the patient is coping with the experience of illness and hospitalization. In addition to improvising music and singing songs, the patient may be presented with opportunities for listening to live music, using imagery and music, or song-writing.
Often the most useful indicator of a positive outcome is a change in the patient's mood or affective presentation. Behavioral changes may be seen in patient's verbalizations (i.e., more hopeful comments, deeper sharing of feelings) or a difference in the patient's level of involvement in the music-making process. Thus, a patient may progress from listening passively to taking an increasingly active role, either by playing instruments or by choosing the next song to sing or actually singing. Other means for noting a decrease in symptoms might be the patient's increasing ability to attend to and manipulate various musical components, such as dynamics, rhythm, or form.
Examples of Music Therapy at Hahnemann University Hospital
Zwerling states, “…the creative arts therapies evoke responses, precisely at the level at which psychotherapists seek to engage their patients, more directly and more immediately than do any of the more traditional verbal therapies. The feelings that are aroused and expressed while singing, or playing an instrument, or listening to music, or moving to a rhythm, or drawing, or painting, become available to the therapist to identify, to develop, and to change.”1
We describe the following case material from our observations on the consultation-liaison service, noting the possible beneficial effects of specific aspects of music therapy interventions. In addition to finding patients to be responsive to the music, we also found that the staff expressed a wish to be involved in music-making.
Music therapists use various musical elements, such as song structure (most songs have verses which are followed by a memorable chorus), rhythmic patterns (i.e., “shave and a haircut…”), or musical styles (e.g., blues, folk music, jazz, gospel, music from the 1950s), in order to bring about a sense of familiarity and focus. This may be especially helpful when patients are trying to cope with anxiety or are disoriented.
Patients who are feeling anxious and depressed because of hospitalization may be able to express these emotions through music. This expression can take place, for example, by playing an energetic drum solo or singing a blues song, the lyrics of which may affirm the patient's inner strength and the knowledge that he or she can cope with the experience of illness. By inviting the patient to take an active role in music—be it singing or playing instruments—the therapist is offering the patient a sense of control (e.g., “Which instrument am I going to use?” “How much do I want to play?” “How do I want to use this time?”) and a perception of “doing” rather than “being done to.”
Whereas medical staff are trained to focus on the illness, music therapists tend to address the positive aspects of the patient (such as the sense of hope, spirituality, and joy). For example, many patients enjoy singing songs expressing their religious faith. Doing so may help patients remember that they are not simply their disease and enable them to regain their sense of wholeness.
Music is a normal part of most people's everyday lives. To be able to experience music (either by listening or taking part in playing it) in an unfamiliar hospital setting may help put patients into a more “normal” frame of mind, as opposed to one in which they may feel helpless, victimized, and frightened. In an example to illustrate this point, we were referred to a patient who was depressed and withdrawn due to advanced cancer. He presented with a tearful affect and conveyed a sense of hopelessness in his verbalizations. While he was resistant to playing music, he seemed to appreciate the opportunity to listen to the music therapist play songs, particularly enjoying “oldies.” As the therapeutic relationship deepened, his affect gradually changed and he was able to recall, with some pride, that a local band he enjoyed listening to had used one of the photos he had taken of them as an album cover. In a subsequent hospitalization, the patient called to the music therapist as she passed by his room and told her that he had brought his own tape collection with him to the hospital and wanted to show her the album featuring the photograph he had taken. His affect was noticeably more positive, in that he was smiling, and he was, as noted, able to reach out to the therapist (in contrast to his former tendency to withdraw).
Music therapy provides a means by which a patient's family can engage with a loved one who is in the hospital. One such session with the music therapist involved an elderly woman who had suffered a stroke and was unable to speak. The team asked for music therapy services to address symptoms of depression, hoping that the music might also provide her with a means for self-expression. Her son and grandson (a toddler) arrived just as the session began, and they were invited to take part. After an initial silence, in which it appeared that the family was not sure how to interact with each other without the use of speech, the grandson began to explore the instruments. Upon seeing her grandson's interest in the instruments, the patient, who at first had not wanted to play at all, joined in immediately, smiling in response to the child's musical antics. In this instance, it seemed the music served as a familiar go-between in which the family could take an active part in connecting with the patient.
On the consultation-liaison service, we have been utilizing music therapy to provide an alternative or adjunct to medication, but it has also been suggested that medication has been an adjunct to music therapy. Zwerling, in a description of a patient treated by a music therapist, found that an antianxiety medication was “adjunctive” to music therapy.1
Our own anecdotal observations show that music therapy may also give the staff a different way to interact with patients. In one case of of a man who had undergone an organ transplant, which required a prolonged stay in the intensive care unit, the doctors, nurses, and orderlies all took part in making music together with the patient and his family. The staff's feedback was that they were able to see the patient more as a person trying to regain health than as a person struggling with illness, and that they enjoyed this relaxed way of interacting with the patient.
An important aspect of consultation-liaison is the support provided to staff providing direct care. Our team is often asked to meet with personnel who work with patients whose care becomes quite complex. While music therapy is not offered formally to staff, there have been occasions in which staff have spontaneously requested to play instruments that they see on the cart wheeled around by the therapist. Such impromptu sessions of singing and playing appear to dispel tension and seem to provide a brief reprieve from the intense pace on medical and surgical units. Because of this, our team is currently considering offering set times for such sessions that staff can attend.
Conclusion
Because of the difficulty in establishing controls of cohorts with the same diagnoses (e.g., justifying which patients are given the option of music therapy versus those who are not, equalizing durations of therapy) we are restricted to subjective feedback and comments, which is a limitation of our article. Hospital staff report that they see improvements in patients' affect (less depressed and less anxious) as well as decreases in agitated behavior, often without the necessity of utilizing psychiatric medications. It is a therapeutic modality that seems to give patients a sense of control over their illness. It provides a positive framework for caretakers with which to help patients regain health.
A music therapist, through ongoing assessment, can be immediately responsive to an individual patient's needs, provide continuity of care, and extend the therapeutic intervention, thus increasing the effectiveness of the services provided by consultation-liaison psychiatry.
As stated by Zwerling, “There is a visible or audible or tangible link to society in a session involving a creative arts therapist and a patient, and it has a qualitatively more immediate, more real presence than does the person or the thing a patient may talk about.”1
Acknowledgment
The authors wish to thank Janice Dvorkin, PsyD, ACMT for her assistance with this article.
Contributor Information
Roia Rafieyan, Ms. Rafieyan is a music therapist at Hunterdon Developmental Center (formerly Graduate Music Therapy intern in the Hahnemann Creative Arts in Therapy Program at Drexel University College of Medicine, Hahnemann University Hospital).
Rose Ries, Dr. Ries is Clinical Assistant Professor at the Department of Psychiatry at Drexel University College of Medicine, Philadelphia, Pennsylvania.
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