Patient Perspectives on Active vs. Passive Music Therapy for Cancer in the Inpatient Setting: A Qualitative Analysis

Abstract

Context.

Music therapy (MT) is a nonpharmacologic therapy where licensed therapists provide active (e.g., singing, playing songs) or passive (e.g., listening) music-based interventions. Both active and passive MT are effective techniques for treating cancer-related symptoms. However, the influence of active vs. passive MT techniques on patient-reported perceptions and experiences of care have yet to be explored.

Objectives.

To understand how active and passive MT is perceived and experienced by patients with cancer.

Methods.

We conducted a retrospective analysis of semistructured interviews collected as part of a quality improvement study (n = 20) with patients in the inpatient setting who had received active or passive MT within the past 24 hours. Transcripts were analyzed using thematic content analysis.

Results.

Four themes emerged: 1) Different articulations of benefit for recipients of active vs. passive MT; 2) patient choice as a form of empowerment; 3) changed perception of hospital experience; and 4) differing recommendations for future MT. Recipients of active MT emphasized the session’s interactive elements, finding the sessions stimulating by providing opportunities for joyous social interaction not centered on their diagnosis. Passive MT recipients focused on the calming therapeutic effect of the session, easing anxieties through focus and reflection on the music itself.

Conclusion.

This analysis builds on current MT literature by providing insights specifically from oncology patients treated in the inpatient setting. Patients experience active and passive MT in different ways and perceived unique benefits for coping with cancer from each technique. Our findings can inform development of specific MT for symptom control in hospital settings.

Introduction

Cancer and its related treatments are often accompanied by significant symptom burden that contributes to poor cancer-related outcomes.^1–3 Patients’ unmet needs in symptom management, coupled with their desire to use holistic approaches for health improvement, have created a demand for integrative medicine (IM).^4,5 Based on emerging research supporting the efficacy of IM therapies (e.g., yoga, acupuncture, and music therapy [MT]) to manage treatment-related side effects,^6–9 professional organizations now recommend IM therapies for management of disease-related symptoms.^10,11 As such, developing interventions to address symptom management that incorporates patients’ needs and preferences is an important priority in oncology.

MT is a nonpharmacologic approach in which music-centered interventions are delivered by credentialed music therapists to accomplish specific goals within a therapeutic relationship and is offered at approximately 50% of the National Cancer Institute-designated Comprehensive Cancer Centers in the U.S.^11,12 In the oncology setting, MT has been used to treat depression,¹³ anxiety,¹⁴ emotional distress,¹⁵ and mood disturbances¹⁶ and is delivered via active (i.e., the patient is involved in creating the musical experience through singing, playing instruments, writing lyrics, or, selecting music and listening, moving, and/or discussing their musical experience) or passive (i.e., where the patient is the recipient of the music experience, where live music is directed and played by therapist and the patient tends to provide less input) techniques.

Although previous studies have indicated that both listening and playing music positively influences coping with a cancer diagnosis,¹⁷ evidence suggests that active vs. passive MT may have differential effects on patient engagement and receptivity to integrative treatment. In one study, children actively engaged in MT demonstrated better feelings toward MT and more engagement in activities than those with passive participation.¹⁸ However, it is unclear whether variations in engagement translate to differences in how patients perceive the therapeutic benefit of active vs. passive MT. A recent cross-sectional analysis of inpatient adults with diverse cancer disease types found that active MT was associated with greater reduction in cancer-related fatigue and increased reporting of positive effect/emotions compared with passive MT,¹⁹ indicating a need for a qualitative study to understand how active vs. passive MT patients perceive their experience. Thematically rich qualitative evidence may provide insight into how different MT interventions impact patient perception of therapeutic benefit, needs, and preferences. Understanding these differences is necessary to inform tailored MT interventions as a critical component of patient-centered oncological treatment. Therefore, the present analysis aimed to analyze a data set of previously collected interview transcripts to understand how patients receiving active vs. passive MT perceived and articulated their MT session experiences.

Methods

Data Source

Data were collected as part of a quality improvement study of the IM service at a National Cancer Institute-designated comprehensive cancer center. A retrospective research protocol was approved by the institutional review board (IRB#20-119).

MT Intervention

Patients are referred to MT by medical providers (e.g., oncologists, nurse practitioners, physician assistants, certified social workers) via a hospital electronic order form, which includes diagnosis, symptoms, evidence of cognitive impairment, comorbidities, and treatments. Referrals are then screened by an IM inpatient care coordinator and assigned to 1 of 3 licensed and board-certified clinical music therapists.¹⁹ Through discussion and observation at bedside, music therapists assess symptoms, mood, energy level, and music preference on a case-by-case basis and involve patients as much as possible in the selection of active or passive MT. Table 1 displays the various active or passive MT techniques that were used during a session. In passive MT sessions (i.e., sessions that use music-assisted relaxation or receptive listening), the music therapist provides music to promote relaxation and a calm meditative state as the patient listens.²⁰ In these sessions, live music is directed and played by the therapist, with the patient providing little input; they may have higher symptomatology and therefore are less involved in decision making during the session. In active MT sessions (i.e., sessions that use interactive music making or active listening), the music therapist guides the patient to engage with the music through hands-on sound exploration, improvisation, playing an instrument, singing along, composing lyrics, and/or participating in other forms of activity. Both sessions involve engagement with the therapist: the therapist and patient define session goals and preferences at the beginning of each session, and songs are suggested and discussed by both the patient and therapist.

Table 1.

Active and Passive MT Techniques

Active MT	Passive MT
Active listening	Receptive listening
• Live familiar music, patient selected, often includes verbal process, patient may move/dance, sing along	• Live soothing music played at bedside on guitar, harp, or keyboard
Interactive music making	Music-assisted relaxation
• Live sound exploration, improvisation, recreation of familiar music	• Live music and guided meditation or imagery
Instruments
Harmonic
• Guitar
• Keyboard
• Lap harp
Percussion
• Hand drums
• Shakers
• Bells
• Claves
Vocals
Genres
• American popular
• Folk
• Western traditional classical
• Improvisational
• Spontaneous and interactive (i.e., drumming, vocalizing)
• Songs that are familiar to patients and therapists

MT = music therapy.

The therapist plays live music at the patient’s bedside in both active and passive sessions. Table 1 includes information about common instrument and genres selected in the sessions. In interactive music-making (active) sessions, the therapist will lend patients an instrument of their choice. In music-assisted relaxation (passive) sessions, the therapist selects instrumental music with characteristics to facilitate relaxation, including consistent, steady, slow tempo; predictable melodic line with phrases to match intake and exhalation of breath, predominantly legato; tonal harmonic structure with few dynamic changes; supportive baseline; use of repetition, and consistent texture.²⁰ MT sessions typically last 20–40 minutes depending on patient/caregiver preference, patient stamina, music therapist availability, and flow of other hospital activities.

Interview Procedure

Individuals treated in the inpatient setting identified by their music therapist were approached for a one-on-one in-person interview within 24 hours of the conclusion of a single MT session. A convenience sampling approach was used, aiming for a balance between recipients of active vs. passive MT to gain diverse perspectives for quality improvement. Participants were interviewed until thematic saturation was obtained, defined as the point at which all relevant themes were fully explored, with no new themes emerging from at least 2 subsequent interviews.²¹

All interviews were conducted by a trained research assistant (M. B., O. N., and N. E.). To minimize bias, the music therapist was not present. At the start of each session, the interviewer described the project and steps to maintain confidentiality. Interviews were conducted using a semistructured interview guide focusing on the single MT session (Table 2), covering general topics for quality improvement and subsidiary probing questions to enable participants to elaborate on specific aspects of their MT experience.²² All interviews lasted 15–45 minutes, based on ability or willingness to talk and necessary simultaneous health-related procedures. All interviews were audiore-corded and transcribed. As interviews were originally conducted for quality improvement purposes, no demographic or symptom-related data were collected.

Table 2.

Qualitative Prompts

Interview Domains	Sample Questions
Reflection on session	What were your overall impressions of the session? What are some of the reasons you decided to participate in MT today? What kinds of activities did you do during the session? (Probe: what kind of songs did you listen to? Did you use any instruments?)
Perception of benefit	How did you feel during the session? How do you feel now? Did you have a favorite moment from today’s session? In your experience, in what ways has MT affected how you feel during your treatment? Are there any ways MT has impacted how you feel about being at the hospital?
Unmet needs or recommendations	Is there anything you think would need to change before you would participate in another session? Thinking back, is there anything you wish your therapist knew before you began the session? Do you have any other suggestions for how the MT program can better support patients?

MT = music therapy.

Data Analysis

Deidentified interview transcripts were evaluated using an iterative process of thematic content analysis.²³ Two members of the research team with training and experience in qualitative analysis who were not present for the MT sessions (K. A. L. and N. E.) independently coded each transcript according to a set of a priori and interpretive codes, meeting regularly to build consensus on the identification of themes and resolve coding discrepancies. Transcripts were coded as active if the participant reported engaging in active listening or interactive music making and as passive if they reported receptive listening or music-assisted relaxation, and the coding was confirmed by the study’s music therapist (K. P.). A subset of transcripts (n = 5) were double coded to solidify the codebook and ensure inter-rater agreement. The coding team then engaged in a secondary analysis, grouping codes within categories of interest and recoding quotes to identify primary themes, paying special attention to the presence or the absence of a theme across active and passive MT transcripts. Primary themes were those observed across most transcripts per subgroup. Themes were then finalized in a consensus meeting between coders and members of the study team with expertise in integrative therapies, including MT (K. P., K. T. L., and J. J. M.). Qualitative software NVivo Pro 12.0 (QSR-International [2019], Doncaster, Australia) was used to facilitate the analysis.²⁴

Results

Interviews were conducted from June to September 2019. Saturation was reached after reviewing 20 transcripts (n = 9 passive MT; n = 11 active MT), consistent with previous literature on qualitative sample sizes for single-site exploratory studies.²¹ A list of major codes used to identify thematic content is included in Table 3. The 4 major themes are described in detail later; a summary of the contrast between active and passive MT perspectives within each theme is presented in Table 4.

Table 3.

Major Themes and Associated Codes

Theme	Code Category	Major Codes
Different articulations of benefit in active vs. passive MT	Perception of benefit	Calming effect: soothing
		Relaxing
		Stimulating
		Joyous
Choice promotes a sense of empowerment	Patient participation	Significant or meaningful song
Subtheme: Music fosters connection/relationships not centered on disease state		Feeling in control
		Relationship with therapist
Changed perception of hospital experience and redirection of focus	Attitudes toward treatment of clinical experience	Benefit: Not focused on pain
		Benefit: Interaction
		Effects of therapy last postvisit
		Hospital experience
Recommendations for MT differ by active vs. passive participation	Needs and recommendations	Patient suggestions
		Unmet needs

MT = music therapy.

Table 4.

Summary of Contrast Between Active vs. Passive MT Patient Perspectives

Theme	Active MT	Passive MT
Articulations of benefit	MT is stimulating and interactive	MT is calming and relaxing
Choice promotes a sense of empowerment	Choice of instrument	Choice of song
Changed perception of hospital experience and redirection of focus	Social benefit: focus on positive feelings outside illness experience	Listening benefit: meditative, reflect on music
Recommendations for future MT	No change to session length to avoid overstimulation	Lengthen sessions to promote relaxation

MT = music therapy.

Theme 1: Active vs. Passive MT Perception of Benefit: MT Perceived as Stimulating or Relaxing

Passive MT participants frequently spoke about the immediate therapeutic effect experienced during the session, such as how MT eases anxiety and facilitates falling asleep.

So if I lie back and close my eyes, it just takes me away from all the pain and suffering I’m going through, and so to listen to her, it’s very soothing.

(Passive MT)

In contrast, active MT participants more often described the social benefit of shared music making with the therapist, noting that sessions elicit feelings of joy.

I did have a few concerns going on at the time. Like, major concerns that I had in my head […] When [the therapist] came in, and we got so into you know, that silliness, dancing with each other, and dancing in the bed. That meant a whole lot.

(Active MT)

Passive MT patients feel that the session is calming, whereas active MT patients find the interactive effect of the session stimulating. Moreover, although both groups articulated that MT allowed them to focus, for a moment, on feelings outside their illness experience, active MT patients attributed this to the interactive elements of the session, whereas passive MT patients credited this feeing to their experiences listening and reflecting on the music and lyrics.

Theme 2: Choice Promotes a Sense of Empowerment

In both active and passive MT, participants expressed that playing a role in the song, genre, and/or instrument selection enhanced the meaning of the sessions. Having a sense of control over the major components of the session allowed participants to build rapport with the therapist, elicited happy/warm memories, and reminded patients of a selfhood outside the hospital.

You know, now when I see her, my heart takes a little jump. I know I’m going to have a good hour or two […] she’ll play anything I ask if she knows what it is. So, it’s not like I have to listen to something I don’t want to listen to. Oh, I like having an input, and I like her ability to just roll with it.

(Passive MT)

Active MT patients specifically noted the power of choosing their own song or instruments: by contributing directly to music making with the therapist, patients felt an increased sense of control that is seldom experienced in other aspects of cancer treatment. Often, the ability to select a specific instrument reminded patients of their life outside the hospital.

I was able to play the piano and another [instrument] that sounded like the ocean and just made me think that, you know, when I get out of here, that’s the one thing I want to do, is to go to the beach. […] It does help. And even at my worst, I don’t think I would just let her do everything.

(Active MT)

Subtheme: Music Fosters Connection/Relationships Not Centered on Disease State (Especially in Active MT Patients)

Through building rapport with the therapist and expressing their preferences for session content, MT acted as a conduit for patients to express their feelings and concerns to an empathetic listener who was neither family nor their oncologist.

You know you can talk to her. About things in general, things that are going on in your life, things like that […] So in between music it’s communicating, you know, and I can see her reaction and things like that. You know, you don’t get there anywhere else [at the hospital].

(Active MT)

Having opportunities to have interactions not overtly related to their disease state, where patients felt like an equal party in decision making, was seen as a primary benefit of the sessions.

Theme 3: Reframing of Hospital Experience and Redirection of Focus

Both active and passive MT participants noted that their MT sessions enabled them to feel connected to a life outside the hospital; the sessions allowed them to focus, for a moment, on feelings outside their illness experience. Patients described MT as an activity that takes them outside the day-to-day hospital experience, in some instances, as an escape from the dim, stress-inducing period scans, treatment modifications, side effects, and hospital procedures. Patients noted that positive feelings elicited during the session persisted in the hours afterward (I thought about it all day).

Both active and passive MT patients viewed MT as an integral component of their care to make treatment more bearable, albeit through different ways. The interactive elements of active MT sessions enabled patients to focus on positive feelings outside their illness experience, leading to an acute positive effect on their mental well-being postsession.

You know that was terrific that feeling, joining in and singing with somebody

(Active MT)

It’s just good for the mentality, you know, and your wellbeing and your brain. So, you’re getting a little conversation, you’re getting a little bit of music, you know, you’re getting interaction, a change of, you know, scenery. So, there’s a few things going on that help

(Active MT)

In contrast, passive MT patients expressed how listening to the music created space to concentrate on the music, rather than their pain or anxiety levelsdre—irecting their focus and creating opportunities for reflection, as opposed to simply distracting from the pain.

There’re a few minutes of just focusing on that [the song]. Not everything else that’s going on.

(Passive MT)

Active and passive MT provides different forms of escape. Passive MT patients found the music as a method of redirecting their focus away from pain or anxiety, whereas active MT patients used the experience to focus on the social interaction with their therapist. The social interaction played a more prominent role in the active MT group, whereas the music provided the main therapeutic value in the passive MT group.

Theme 4: Recommendations for MT Differ by Active vs. Passive Participation

Recommendations for future MT varied by session type. Active MT patients expressed a desire for a wider song and instrument selection, indicating the importance of choice:

I mean maybe multiple instruments is good […] maybe a flute or a clarinet or something like that. You know the more instruments the more music you can do.

(Active MT)

Both active and passive MT recipients had suggestions for the length and timing of sessions. Passive MT patients overall desired longer sessions:

I would just like to have more, make it longer. I’d like to have more time with her. She just does one or two tunes and she’s gone

(Passive MT)

In contrast, some active MT participants felt that longer MT sessions could be too tiring:

I don’t think you should make it longer than that. ‘Cause people get tired, you know.’

(Active MT)

Both groups desired regularly scheduled MT sessions that exist separately from other aspects of treatment and care. For active MT patients, this helps avoid potential overstimulation from the combination of music participation and clinical activity:

So, to be honest, sometimes if there’s more medical stuff that has to be concentrated on [… the therapist could] come back at a later time, so that [medical] stuff could be primary, but otherwise, when they leave I’m all for it. Just—don’t like it to be over stimulating all at the same time

(Active MT)

Passive MT patients also preferred regularly scheduled sessions:

I think that [MT] should be part of a daily routine.

(Passive MT)

The desire for separate and regularly scheduled MT sessions aligns with the third theme, indicating that MT is perceived as a necessary escape from the daily inpatient experience.

Discussion

MT is increasingly available as an inpatient intervention for the management of cancer-related symptoms. In the present study, participants perceived distinct benefits to active and passive MT modalities. Qualitative interviews yielded important themes related to the similarities (the value of choice) and differences (stimulating vs. relaxing, the escape provided by social interactions vs. the music itself) between these 2 MT modalities. Active MT recipients emphasized interactive session elements, finding the sessions stimulating; easing acute experiences of anxiety by providing opportunities for joyous social interaction not centered on their diagnosis. In contrast, passive MT recipients focused on the calming therapeutic effect of the session, easing anxieties through focus and reflection on the music itself. Passive MT techniques are intended to provide a calm meditative environment, whereas active MT techniques may require more cognitive arousal, thus sparking feelings of stimulation. Playing a role in the song, genre, and/or instrument selection allowed patients to build rapport with their therapist and reminded patients of a selfhood outside the hospital. MT sessions enabled patients to focus on positive feelings outside their immediate illness experience, leading to a perceived positive effect on their mental well-being immediately postsession. The findings can supplement current MT guidelines for a tailored approach to patient-centered oncology treatment.

These results build on previous studies describing how patient perceptions of MT have integrated into their cancer treatment regimen. MT treatment in terminally ill patients with cancer demonstrated that patients rated MT as helpful in 68% of 144 sessions.²⁵ In addition, consistent with observations from passive MT patients in the present study, an inpatient investigation examining patient self-reported symptoms demonstrated that patients with treatment goals of reducing anxiety were less likely to receive active music engagement; music listening was the most common intervention for patients seeking distraction, reduction of anxiety, and relaxation.²⁶ Although previous qualitative studies have explored patient experiences and preferences for MT vs. prerecorded music,²⁷ to our knowledge, the present study is the first qualitative analysis to interrogate variances in how patients experience and respond to the different mechanisms of live MT interventions.

Both active and passive MT patients expressed a sense of empowerment and control of their treatment. Being able to work cohesively with the therapist on the type of music and technique used fostered relationship building and gave the patient an enhanced sense of control over therapeutic decisions and improved feelings of autonomy, which may be especially important for patients with advanced cancers.²⁸ Thus, enabling a sense of choice and allowing for patient-tailored adaptations may be essential for the further development of MT treatment guidelines in oncology.

In a recent analysis of inpatient adults with cancer, active MT was associated with greater reduction in cancer-related fatigue than passive MT.¹⁹ The stimulating and engaging perception of active MT provides insight into research on the treatment of cancer-related fatigue for patients in hospitalized settings.²⁹ The results of the present analysis support these findings, indicating that active music listening and instrumentation may have benefits for managing pain or other cancer-related symptoms.

Finally, differing recommendations on session length from active and passive MT participants highlight an important area for IM research. Information on optimal dosing (e.g., treatment frequency, duration) remains lacking for many IM nonpharmacologic modalities, including MT. Understanding the length and frequency of MT sessions required for effectiveness is critical to guide program development, care coordination, and allocation of resources. Given competing clinical demands in the inpatient setting, clarification of MT dosing will also help hospital providers schedule and coordinate MT sessions with respect to other hospital activities (e.g., procedures, imaging, and physical therapy).

Limitations

This analysis used deidentified retrospective quality improvement data, limiting our ability to follow-up with patients to collect additional demographic data beyond receipt of active or passive MT. Limitations of available data also included a nonrandom sampling approach and a study sample that was only English speaking. There may be selection bias in that only participants who had a strongly positive or negative experience would agree to participate in an interview and share feedback. This study also does not capture the perspective of individuals who declined to participate in an MT session. In addition, all participants were recruited from a single-site tertiary cancer center, limiting generalizability. Sessions were coded as active or passive based on patient self-report and confirmed by a music therapist, but there may be other ways to categorize these data. However, given that this is an exploratory analysis and categorizations of active vs. passive are not uniform throughout the literature, this study contributes to the field by uncovering themes that may further refine these definitions and inform future prospective trials that use stratified sampling across multiple demographic groups.

Conclusions

The themes identified in this study demonstrate the containment of cancer-related symptoms through active and passive MT and highlight how these effects are both experienced and articulated differently by patients. This analysis builds on current MT literature by providing insights into new domains pertaining to the perception of benefit and therapeutic effect stratified by intervention delivery. These results justify further opportunities for the intentional targeting of the therapeutic process for patient-centered outcomes of active and passive MT. Further investigation is necessary to determine whether active and passive MT treatment may validate patients’ autonomy in treatment preferences, establish best practices in the treatment of cancer-related symptoms, and improve overall care delivery. Uncovering differences in how patients experience these nonpharmacologic modalities provides additional evidence that can inform how we approach MT treatment in oncology and may ultimately help provide the most appropriate patient-centered cancer care.

Key Message.

This article describes a retrospective qualitative analysis of interviews with patients who received either active or passive music therapy. Identified themes indicate that patients perceive active and passive MT to have distinct benefits for coping with cancer-related symptoms.