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Music therapy research:A review of references in the medical literature

David Aldridge, PhDChair of Qualitative Research in MedicineUniversity Witten HerdeckeAlfred Herrhausen Strasse 50,58448 WITTEN, [email protected]

http://www.musictherapyworld.net/

Music therapy research: A review of references in the medical literature

David Aldridge

Music therapy research:A review of references in the medical literature

David Aldridge

Music therapy is widely reported in the medical literature. There has beensubstantial progress in the establishment of research strategies for supportingclinical practice.

IntroductionMusic therapy has risen to thechallenge of research in recent years.Not only is there a tradition ofquantitative research but qualitativeresearch approaches have been alsoincorporated within the discipline as isnecessary for an clinical approach thatinvolves science and art (Aldridge1996a; Dileo 1999; Pratt andErdonmez-Grocke 1999; Pratt andSpintge 1996; Wigram, Saperston, andWest 1995b).

See also music therapy world.net

Hospital based overviewsAfter the second world war musictherapy was intensively developed inAmerican hospitals. Since then somehospitals, particularly in mainlandEurope, have incorporated musictherapy within their practice carryingon a tradition of European hospitalbased research and practice.

The nursing profession has seenthe value of music therapy,particularly in the United States ofAmerica, and championed its use asan important nursing interventioneven when music therapists are notavailable. Indeed, it is a clinical nursespecialist has made an overview of

fourteen articles on audioanalgesia(Bechler-Karsch 1993). She reports aconfusing picture of changes relatedto heart rate but a clearer pictureemerges on physiological parametersrelated to pain and anxiety and sheconcludes that music has no adverseeffects on ill patients when used as anadjunctive non-invasive therapy.

Standley (Standley 1995; Standley1986) has consistently reviewed theliterature relating to music therapyapplications in medical settings madea meta-analysis of the current findingsfrom 55 studies utilizing 129dependent variables (Standley 1995).Standley concludes (1195 p4) that theaverage therapeutic effect of music inmedical treatment is almost onestandard deviation greater thanwithout music (.88). From these resultsshe generalizes that women reactmore favorably to music than men, asdo children compared with adults.While music is less effective forsevere pain it is indicated for chronicpain. Live music administered by amusic therapist has a greater effectthan recorded music and the effectsizes vary according to the dependentmeasure being used, physiologicalmeasures being stronger thansubjective assessment.

http://www.musictherapyworld.net/


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During the last 1990’s there hasbeen a collection of writings relatedto the clinical application of musictherapy, often from symposia (Prattand Erdonmez-Grocke 1999; Pratt andSpintge 1996), and the developmentof research strategies suitable toclinical application (Aldridge 1996a;Wheeler 1995).

Psychiatry and PsychotherapyThe published work coveringpsychiatry has its basis in hospitaltreatment (Wigram, Saperston, andWest 1995a).

In a study of chronic psychiatricpatients who exhibited disruptive andviolent behavior at meal times, theplaying of taped music as abackground stimulus with theintention of providing a relaxedatmosphere reduced that disruptivebehavior (Courtright, Johnson,Baumgartner et al. 1990). Meschedeand colleagues (Meschede, Bender,and Pfeiffer 1983) observed thebehavior of a group of chronicpsychiatric patients over eight weeksof active music making sessions anddiscovered that the subjectivefeelings of the patients had nocorrelation with the observations ofthe group leaders about the outwardexpression of those feelings.

Continental Europe hasencouraged the use of musicparticularly in terms of individual andgroup psychotherapy for theencouragement of awakening theemotions of the patient, and inhelping them cope with unconsciousintrapsychic conflicts. This situation isnot surprising given that the roots ofpsychoanalysis are middle European.Group psychotherapy has been usedon an inpatient and outpatient basis.

SchizophreniaSchizophrenia has been the subject ofvarying studies in applied musictherapy (Aigen 1990; Glicksohn andCohen 2000; Hadsell 1974; Pavlicevicand Trevarthen 1989; Pavlicevic,Trevarthen, and Duncan 1994; Tang,Yao, and Zheng 1994).

Within recent years researchershave attempted to understand themusical production of schizophrenicpatients (Steinberg and Raith 1985a;Steinberg and Raith 1985b; Steinberg,Raith, Rossnagl et al. 1985) in terms ofemotional response. The underlyingreasoning in this work is (i) that toproduce music depends upon themastery of underlying feelings, and (ii)in psychiatric patient’s musicalexpression is negatively influenced bythe disease. Steinberg and colleaguesfound that in the musical playing ofendogenous-depressive patientsthere were weakened motoricqualities influencing stability andrhythmicity, while manic patients alsoexhibited difficulties in ending aphrase with falling intensity. Tempoappeared uninfluenced bydepression, but was susceptible to theinfluence of medication.Schizophrenic patients exhibitedchanges in the dimensions of musicallogic and order.

More recently Pavlicevic andTrevarthen (Pavlicevic and Trevarthen1989) have compared the musicalplaying of 15 schizophrenic patients,15 depressed patients and 15clinically normal controls. Significantdifferences in musical interactionbetween therapist and patient werefound between the groups on a self-developed scale to test musicalinteraction. This musical interactionscale was developed to assess theemotional contact between therapist


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and partner according to musicalcriteria based upon six levels ofinteraction ranging from no contact(Level 1) to established mutual contact(Level 6). A critical element of themusical contact is the establishmentof a common musical pulse that isdefined as a series of regular beats.

In the above study, schizophrenicpatients appeared musicallyunresponsive and idiosyncratic in theirplaying which correlates with otherstudies of schizophrenia (Fraser, King,Thomas et al. 1986; Lindsay 1993).The depressed patients appeared tomake fewer initiatives in the musicalthough it was possible for thetherapist to make contact with them.Controls were able to enter into amusical partnership with the therapistand take musical initiatives. The lackof reciprocity from the schizophrenicpatients seemed to be the factor thatprevented contact and therebydisturbed communication. However,this finding with individual patients isin contrast to the previouslymentioned group studies that refer to‘open’ communication within thegroup. The strength of the Pavlicevicpaper is that it is firmly grounded inempirical data and, unlike many of thegroup therapy papers, gives clearevidence of how conclusions arereached.

The peculiarities of languagewhich accompany some forms of theschizophrenia has led to the inevitablelink between speech disorders andmusical components of language andthe processing of language andmusical information. Fraser’s study(Fraser et al. 1986)suggested that thespeech of schizophrenics had fewerwell formed sentences, oftencontained errors with many false startsand was simpler than the speech of

controls which was fluent, error freeand complex. Lindsay (Lindsay 1980)argues that social behavior isdependent upon social language skillsof communication. Withdrawnpatients speak with less spontaneousspeech utterances, and their speech isimproved by matching theirutterances and building up dialoguesfrom simple interactions to complexsequences; which is a feature ofdialogic playing in improvised musictherapy.

Adolescent psychiatryGroup music therapy is the principlemusic therapy approach to thetreatment of adolescent problems.Friedman (Friedman and Glickman1986) recommends the use ofcreative therapies in general for thetreatment of drug abuse inadolescents as it encouragesspontaneous activity, motivates theclient’s response and fosters a cultureof free expression.

Phillips (Phillips 1988), aspsychotherapist and jazz fan, providesan overview of improvisation inpsychotherapy and the way in which itrelates to adolescent patients. Heidentifies four important qualities asbases which enable the therapist toimprovise in clinical practice: (i) tohave access to his or her past; (ii) to beable to focus attention solely on thepresent; (iii) to be comfortable enoughto give up control over the outcomeof the task to experiment during thesession, and (iv) recognize thesignificance of accidental expression(p184). He relates this ability toimprovise to the therapeutic task oftreating adolescents who call upon awide range of responses which relateto the past experience of the therapist


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and which may require quite novelsolutions.

CultureMost of the references to the use ofmusic therapy in medicine arepredominantly Western, although theuse of music as a therapeutic mediumis found in most cultures. Two papers(Benjamin 1983; Devisch andVervaeck 1986) describe the use ofmusic in African hospitals, bothlocating the use of music within acultural context, and combining thismusic with drama and dance. As inother group therapy methods, music isused as a vehicle to reach those whoare isolated and withdrawn andreintegrate them into socialrelationships.

In South Africa (Benjamin 1983)the group consists of about 100female patients sitting in a circledirected by a doctor. Music, throughincreasing tempo in singing anddancing, is used as an activator for thepsychodrama techniques of Moreno(Moreno 1946).

A Tunisian approach is far moreradical in terms of psychiatry. Through‘art group therapy’ (Devisch andVervaeck 1986) utilizing dance,painting, therapy using clay, role playand singing, patients are encouragedto integrate personal experiences andemotions within a social context ofrelationships. The explanatoryprinciple behind this work is that of‘the door’ whereby fixed barriersbetween experiences are brokendown, but the concept of thresholdbetween experiences remains. Insupport of this integration familymembers of patients can be includedin the singing and dancing to facilitatethe patient returning to a family orwider social environment. For the

individual patient it is argued thatindividual expression, when given theform of a work of art (to includesinging and dancing), allows theperson to experience themselves assomething orderly and subjective;and, like a door, be able to opened orclosed to others and participate ininteraction. This ability to discriminatebetween activities is called by theauthors (who are socialanthropologists), “the liminal orthreshold function of the body andthe door” (p543). Such an approachattempts to establish a meaningfulrelationship between the innerrhythms of the body, outer rhythms ofpersonal interaction and broaderpatterns of cultural activity.

The Arab tradition, which regardsthe body as the meeting place ofpsyche and soma, and locatespsychiatric illness within socialrelationships, gives cultural support tothe ideas practiced in such aninstitution. Culture is a source ofmeaning that does not only actthrough cognition, but also throughpersonal interaction. The way in whichpeople greet each other, listen toeach other, and play with each otherstructures the meaning of thatinteraction and has a directexperience on the body. Similarlybodily experiences shape socialcontact. The act of kissing as agreeting, for example, has an externaleffect on relationship and an internaleffect on the emotional experiencesof the body. This symbolic reality isnot restricted solely to cognitiveactivity. We can further infer that theplaying of music, and encouraging aperson to express themselves in anarticulate form within a relationship,promotes experiences that integratethe person inwardly within themselves


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and outwardly with othersindependent from cognition.

RehabilitationStrategies for rehabilitating psychiatricpatients using group and familyapproaches are not solely confined toAfrican traditions (Barker and Brunk1991; Glassman 1991; Longhofer andFloersch 1993) and music therapy hasa broad base within the tradition ofpsychiatric and general rehabilitation(Aldridge 1993b; Pavlicevic et al.1994; Pratt and Spintge 1996; Purdieand Baldwin 1995; Purdie, Hamilton,and Baldwin 1997).

Haag (Haag and Lucius 1984)discusses theories includingpsychosocial factors involved in thedevelopment of, and in coping with,disability. Psychological interventionapproaches are set out, focussing ontheir particular relevance torehabilitation. Music therapy is alsorecommended for the rehabilitation ofpatients who have difficulty inexpressing their feelings andcommunicating with other.

PsychosomaticsWhere both physical and mentalprocesses overlap within medicine,i.e. the field of psychosomatics, thenindividual and group music therapyappears to play an important role.

Multiple sclerosis is a chronicneurological disease of unknownorigin that can result in severe neuro-psychological symptoms. Symptom-orientated medication orphysiotherapy does not easily relievedifficulties of anxiety, resignation,isolation and failing self-esteem seenin this disease. Lengdobler andKiessling (Lengdobler and Kiessling1989) set out to treat in a clinic, over atwo-year period, 225 patients with

multiple sclerosis with group musictherapy. Each treatment period lastedfor 4 to 6 weeks. A further part of theirwork was to discover the musicalparameters of the playing of suchpatients using methods which werebased on active improvisation; groupinstrumental playing, singing, listeningand free-painting to music.Unfortunately the size of the groups isnot recorded, patient attendance atthe groups was uncontrolled and thereports made by the patients wereunstructured. Those reports werevague and have promoted cliniciansto pursue more rigorous research(Magee 1998; O'Callaghan 1996;O'Callaghan and Turnbull 1987).

ElderlyThe psychosocial rehabilitation ofolder persons is one of the mainproblems in health policy. About onequarter of the over 65-year-olds facepsychic problems without receivingadequate treatment and rehabilitativecare. Substantial deficits exist aboveall in the outpatient and non-residential service sector, and thedevelopment of ambulatory,community-based services as well asintensive support for existing self-helpefforts are necessary. Music therapyhas been suggested as a valuable partof a combined treatment policy forthe elderly (Aldridge 2000).

Music and dementia in the elderly

The responsiveness of patients withAlzheimer’s disease to music is aremarkable phenomenon (Aldridge1993a; Aldridge 1994; Aldridge 1995;Aldridge and Brandt 1991). Whilelanguage deterioration is a feature ofcognitive deficit, musical abilitiesappear to be preserved. Beatty


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(Beatty, Zavadil, and Bailly 1988)describes a woman who had severeimpairments in terms of aphasia,memory dysfunction and apraxia yetwas able to sight read an unfamiliarsong and perform on the xylophonewhich to her was an unconventionalinstrument. In a doctoral thesis Foster(Foster 1998) demonstrated animprovement in autobiographicalmemory in dementia suffererscompared to normal controls with anauditory background condition ofmusic. He suggests that it is thearousal due to experiencing music thatfacilitates improved cognition and thatthe patient is dependent uponenvironmental cues.

Certainly the anecdotal evidencesuggests that quality of life ofAlzheimer’s’ patients is significantlyimproved with music therapy,accompanied by the overall socialbenefits of acceptance and sense ofbelonging gained by communicatingwith others. Prinsley (Prinsley 1986)recommends music therapy forgeriatric care in that it reduces theindividual prescription of tranquilizingmedication, reduces the use ofhypnotic on the hospital ward andhelps overall rehabilitation. Musictherapy is based on treatmentobjectives; the social goals ofinteraction co-operation;psychological goals of moodimprovement and self-expression;intellectual goals of the stimulation ofspeech and organization of mentalprocesses; and the physical goals ofsensory stimulation and motorintegration. Such approaches alsoemphasize the benefit of musicprograms for the professional carersand families of elderly patients.

There has been recent researchrelated music and its influence upon

patients suffering with various formsof dementia and particularly theinfluence of music therapy in thetreatment of Alzheimer’s disease(Aldridge 2000).

Research approaches to newtreatmentsUntil recently, psychotherapy andcounseling techniques had rarelybeen used with people with dementia.However, the change in emphasiswithin dementia care towards aperson-centered approach, and oftennon-pharmacological approach, hasmeant that there is a growing clinicalinterest in their use(Beck 1998;Bender and Cheston 1997; Bonder1994; Cheston 1998; Johnson, Lahey,and Shore 1992; Richarz 1997). Thishas also meant an increase in studiesusing creative arts therapies (Kamar1997; Mango 1992) and overviews ofmusic therapy as a treatment approachto Alzheimer's disease have alreadybeen written (Aldridge 2000; Brotons,Koger, and PickettCooper 1997;Brotons and Pickettcooper 1996;Smeijsters 1997). What music therapyoffers is an improvement incommunication skills for sufferer andspousal caregiver, and possibilities formanaging the disruption and agitationensuing in the later stages of disease.

Individuals with Alzheimerdisease often experience depression,anger, and other psychologicalsymptoms. Various forms ofpsychotherapy have been attemptedwith these individuals, includinginsight-oriented therapy and lessverbal therapies such as music therapyand art therapy. Although there arefew data-based outcome studies thatsupport the effectiveness of theseinterventions, case studies anddescriptive information suggest that


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they can be helpful in alleviatingnegative emotions and minimizingproblematic behaviors (Bonder 1994).

Although there is a developingclinical literature on interventiontechniques drawn from all the mainpsychotherapeutic approaches, therehas been little research into theeffectiveness of this work and suchresearch as does exist often usesmethodologies that are inappropriatefor such an early stage of clinicaldevelopment. While some authors(Cheston 1998) argue that clinicalresearch should adopt case study orsingle-case designs, some researchersare also planning group designs forevaluating new clinical developments.My argument is for a broad spectrumof research designs that will satisfydiffering needs. We know fromexperience that music therapy bringsbenefits to sufferers and the challengeis to convert this knowledge intoevidential studies.

Annenmiek Vink, (Aldridge2000), focuses on the treatment ofagitation in Alzheimer’s disease usingmusic therapy and her current work isin the administration of a controlledstudy in Holland. The success of sucha venture may have a profound effectupon the political acceptance of musictherapy as a non-pharmacologicaltreatment modality should the resultsbe of significance. I am tentative aboutsuggesting how strong the impact ofsuch research trials will be as there isnever any guarantee that such studieswill be heeded. More importantly, ifsuch a study discovers that a controlmusical condition is almost as effectiveas music therapy then there may besupport for using “music” in treatmentsettings but not necessarily musictherapists. Given that music therapistsare a professional groups with their

own pay scales then while theargument for using musical initiativemay be strong, the argument foremploying music specialists may beweak. Research, and its results, arerarely neutral in their effect.

However, a qualitativeunderstanding of how musical playingchanges also offers profound insightsinto the relief of suffering. We simplycannot restrain our endeavors to oneparticular form of understanding.Differing research approaches willinform one another and the challengeis for us to co-ordinate our approachessuch that the knowledge gained ispooled and shared. It is to such an endthat this book is aimed.

The patient and his caregivers indementia careThe absence of definitive treatmentsfor Alzheimer's disease and relateddementias, researchers in a variety ofdisciplines are developingpsychosocial and behavioralintervention strategies to help patientsand caregivers better manage andcope with the troublesome symptomscommon in these conditions. Thesestrategies include cognitiveinterventions, functional performanceinterventions, environmentalinterventions, integration of self-interventions, and pleasure-inducinginterventions. Although we have seenthat more research is needed tofurther develop these strategies andestablish their best use, psychosocialand behavioral interventions holdgreat promise for improving thequality of life and well-being ofdementia patients and their familycaregivers (Beck 1998).We know that people who aresuffering do not suffer alone (Aldridge1998; Aldridge 1999). It is in a primary


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care setting where dementia isrecognised, and early recognition isimportant for initiating treatmentinterventions before a personbecomes permanently or semi-permanently institutionalized and tominimize disability (Larson 1998).

Recent research on care-giverstress focuses extensively on itspredictors and health consequences,especially for family members ofpersons with dementia, Gwyther andStrulowitz (Gwyther and Strulowitz1998) suggest four areas of care-giverstress research: caregiver healthoutcomes, differential impacts ofsocial support, care giving for familymembers with dementia, andbalancing work and care-givingresponsibilities.

In a study by Harris (Harris1998), in-depth interviews with 30sons actively involved in caring for aparent with dementia elicit theunderstanding of a sons' caregivingexperiences. Common themes thatemerge from such narratives are asense of duty, acceptance of thesituation and having to take charge aswell as issues regarding loss, a changein relationships with other brothersand sisters, the reversal of role frombased on having to take charge andthe necessity to develop copingstrategies.

In another study of thepsychological well-being of caregiversof demented elderly people (Pot,Deeg, and VanDyck 1997), threegroups of caregivers were identified;those providing care for two yearsafter baseline; those whose care-recipient died within the first yearafter baseline, and those whose care-recipient was institutionalized withinthe first year. All groups of caregiversshowed a great amount of

psychological distress compared to ageneral population sample, with anoverall deterioration of psychologicalwell-being. As the elderly patientdeclined, and the caregiving at homecontinued, then psychological distressincreased. For caregivers whosedemented care-recipient had died orwas institutionalized in the first yearafter baseline then there was nodeterioration. There is, then, a highlevel of psychological distress anddeterioration in psychological well-being among informal caregivers ofdementia patients and we may have toreconsider the personal and socialcosts of demented older people liveon their own as long as possible if weare not able to release adequateresources to support the caregivers.

Part of this support will includesharing information and developingmethods of counseling appropriate tocaregivers. Increasing publicawareness, coupled with the wideravailability of drug therapies for somedementing conditions, means thatcarers are often informed of thediagnosis of dementia. However it isunclear how much sufferersthemselves are told about theirdiagnoses. In a study of how sufferersof dementia were given diagnosticinformation of 71 carers recruitedthrough old age psychiatry services inEast Anglia, half of the sufferers hadlearned their diagnosis, more fromtheir carers than their doctors (Healand Husband 1998). The age of thesufferer was found to be related towhether or not doctors told them theirdiagnosis, which supports a suspicionthat there is a prejudice amongstdoctors regarding the elderly andabout what they can understand. Only21% of carers were given anopportunity to discuss the issues


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involved and younger carers weresignificantly more likely to feel thatsuch an opportunity would have beenuseful. Most of the carers who hadinformed the sufferer said that thesufferer had wanted to know, orneeded a meaningful explanation fortheir difficulties, rather than givingmore practical legal or financialreasons. Carers who had not disclosedfeared that diagnostic informationwould cause too much distress, or thatthe sufferers' cognitive impairmentswere too great an obstacle.Emotional context and abilityAs the course of degenerative diseaseprogresses there is a decline in theability to comprehend and expressemotion that is linked with mentalimpairment (Benke, Bosch, andAndree 1998). The creative artstherapies have based some of theirinterventions on the possibility forpromoting emotional expression andretaining expressive abilities.DepressionDepression is a common disorder inthe elderly (Forsell, Jorm, and Winblad1998). The rate of treatment ofdepression in the very elderly is low,exaggerated amongst dementiasufferers, and the course is chronic orrelapsing in almost half of the cases.The interface between depression anddementia is complex and has beenstudied primarily in Alzheimer'sdisease (Aldridge 1993b) wheredepressive depression may be a riskfactor for the expression ofAlzheimer's disease in later life(Raskind 1998). A contributory factorto this depression is the patients'perceptions of their own deficits,although these may be ill-founded(Tierney, Szalai, Snow et al. 1996).Emotional context is an importantfactor and this will be linked to the

way in which the patient sees his orher current life situation and anunderstanding of what life holds in thenear-future.Hearing impairmentIf depression is a confounding factor inrecognizing cognitive degeneration,then hearing impairment is anothercontributory factor. Central auditorytest abnormalities may predict theonset of clinical dementia or cognitivedecline. Hearing loss significantlylowered performance on the verbalparts of the Mini-Mental StateExamination, a standard test for thepresence of dementia (Gates, Cobb,Linn et al. 1996). Central auditorydysfunction precedes senile dementiain a significant number of cases andmay be an early marker for seniledementia. Gates et al. recommendthat hearing tests should be includedin the evaluation of persons older than60 years and in those suspected ofhaving cognitive dysfunction. If this isso then we may have to include thisconsideration in designs of researchstudies of music therapy as maybe thepatients themselves are not actuallyhearing what is being played butresponding to social contact andgesture. However, encouragingmusical participation may fosterresidual hearing abilities and thoseabilities that the tests cannot measure.Returning to the developmentally-challenged children, where hearingdisability was ever present, it was thejoint attention involved in makingmusic that brought about animprovement in listening thatappeared as an improvement inhearing. This is perhaps a feature ofactive music therapy that needs to befurther investigated.


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What happens in treating dementiapatients with music therapyMost music therapists haveconcentrated on the pragmatic effectsof music therapy. As we will see, bothpractitioners and researchers alike areconcerned with demonstrating thebenefits of music therapy for dementiasufferers. However, how musictherapy actually achieves its effects isrelatively unresearched.

My hypothesis is that musicoffers an alternative form forstructuring time that fails in workingmemory. Just as developmentallydelayed children achieve a workingmemory that enhances their cognitiveability, then the reverse processoccurs in dementia sufferers.

While several components ofworking memory may be affected, notall aspects of the central executivemechanism are necessarily influenced(Collette, VanderLinden, Bechet et al.1998). White and Murphy (White andMurphy 1998) suggest that toneperception remains intact, but there isa progressive decline in workingmemory for auditory non-verbalinformation with advancingAlzheimer's disease. A similar declinewas also noted on a task assessingworking memory for auditorypresented verbal information. This tiesin with what we know about hearingimpairment and again encourages atest of hearing capabilities beforemusic therapy is used as a treatmentmodality but also suggests that musictherapy may promote improvedhearing.Temporal coherenceI argue earlier that music therapy isindicated because it offers an externalsense of temporal coherence that isfailing in the patient. Ellis (Ellis 1996)reports on the linguistic features and

patterns of coherence in the discourseof mild and advanced Alzheimer'spatients. As the disease progresses,the discourse of Alzheimer's patientsbecomes pre-grammatical in that it isvocabulary driven and reliant onmeaning-based features of discourserather than grammatically basedfeatures. Temporal coherence fails.Knott, Patterson, and Hodges (Knott,Patterson, and Hodges 1997),considering the short-term memoryperformance of patients with semanticdementia, suggest that impairedsemantic processing reduces the''glue'' or ''binding'' that helps tomaintain a structured sequence ofphonemes in short-term memory. Wemay speculate that this temporalcoherence, the metaphoric glue orbinding, is replaced by musical form.As we know, some songs stick to ourmemories.Not loss of semantic memoryRepetition ability depends in part onsemantic memory remaining intact. Ifthe conceptual contents of semanticmemory are lost as a function ofAlzheimer's disease, meaningfulnessof stimuli should have progressivelyless effect on the ability to repeat asthe disease worsens. A study by Bayleset al (Bayles, Tomoeda, and Rein 1996)was designed to evaluate the effectsof meaningfulness and length ofphrasal stimuli on repetition ability inmild and moderate of Alzheimer'sdisease patients and normal elderlysubjects. Fifty-seven Alzheimer'sdisease patients and 52 normalsubjects were given six- and nine-syllable phrases that were meaningful,improbable in meaning, ormeaningless. Cross-sectional andlongitudinal data analyses wereconducted and results failed toconfirm a performance pattern


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consistent with a semantic memoryloss theory.

Several lines of evidencesuggest that in Alzheimer's diseasethere is a progressive degradation ofthe hierarchical organization ofsemantic memory. When clusteringand switching on phonemic andsemantic fluency tasks were correlatedwith the numbers of correct wordsgenerated on both fluency tests, butthe contribution of clustering wasgreater on the semantic task. Patientswith Alzheimer's disease generatedfewer correct wards and made fewerswitches than controls on both fluencytests. The average size of theirsemantic clusters was smaller and thecontribution of clustering to wordgeneration was less than for controls.Severity of dementia was correlatedwith the numbers of correct words andswitches, but not with cluster size. Thestructure of semantic memory inAlzheimer's disease is probablydegraded but there is no evidencethat this process is progressive.Instead, progressive worsening ofverbal fluency in Alzheimer's diseaseseems to associated with thedeterioration of mechanisms thatgovern initiation of search forappropriate subcategories (Beatty,Testa, English et al. 1997). This patterncan be interpreted as reflectingsignificantly impaired proceduralroutines in Alzheimer's disease, withrelative sparing of the structure ofsemantic memory (Chenery 1996).No loss of source memoryA source memory task, using everydayobjects in actions performed by eitherthe participant or the experimenter,was given to probable Alzheimer'sdisease and elderly normal individuals.When the overall recognitionperformance of the two groups was

made equivalent by increasing the testdelay intervals for the control group,both groups of participants showedsimilar patterns of correct andincorrect responses. Moreover, bothgroups showed evidence of ageneration effect and of an advantagefor items repeated at study. Thefindings of this study suggest that, fora given level of event memory,memory for the source of the events iscomparable between elderly normaland individuals with Alzheimer'sdisease (Brustrom and Ober 1996).Contextual cuesTwo experiments examined whetherimpairments in recognition memory inearly stage Alzheimer's disease weredue to deficits in encoding contextualinformation (Rickert, Duke, Putzke etal. 1998). Normal elderly and patientsdiagnosed with mild stage Alzheimer'sdisease learned one of two tasks. In aninitial experiment, correct recognitionmemory required participants toremember not only what items theyhad experienced on a given trial butalso when they had experiencedthem. A second experiment requiredthat participants remembered onlywhat they had seen, not when theyhad seen it. Large recognition memorydifferences were found between theAlzheimer's disease and the normalelderly groups in the experimentwhere time tagging was crucial forsuccessful performance. In the secondexperiment where the only requisitefor successful recognition wasremembering what one hadexperienced, memory of the temporalrecord was not necessary forsuccessful performance. In thisinstance, recognition memory for theboth groups was identical. Memorydeficits found in early stageAlzheimer's disease may be partly due


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to impaired processing of contextualcues that provide crucial informationabout when events occur.

Foster (Foster 1998) carried outa series of studies of backgroundauditory conditions that provided sucha context, and their influence uponautobiographical memory. While theuse of background music has no effecton word-list recall in the normalelderly, there is a constant beneficialeffect of music for autobiographicalmemory for patients with Alzheimer'sdisease. This music did not have to befamiliar to the sufferer, nor did itreduce anxiety. The effect of music isstronger in cognitively impairedparticipants thus promoting anotherreason for using music-basedinterventions in treatment initiatives.Foster, like Aldridge (Aldridge 1993c),argues for the use of music inassessment procedures.

As part of a program of studiesinvestigating memory for everydaytasks, Rusted et al (Rusted, Marsh,Bledski et al. 1997) examined thepotential of auditory and olfactorysensory cues to improve free recall ofan action event (cooking an omelet) byindividuals with dementia of theAlzheimer’s type. Both healthy elderlyand volunteers with Alzheimer'sdisease recalled more of the individualactions which comprised the eventwhen they listened, prior to recall, to atape of sounds associated with theevent. Olfactory cues thataccompanied auditory cues did notproduce additional benefits overauditory cues alone. The pattern ofrecall suggests that the auditory cuesimproved recall of the whole event,and were not merely increasing recallof the specific actions associated withthe sound cues. Individuals withAlzheimer's disease continue to

encode experiences using acombination of senses, and that theycan subsequently use this sensoryinformation to aid memory. Thesefindings have practical implications foraccessing residual memory for a widerange of therapeutic activities usingthe creative arts that emphasizesensory abilities.Functional plasticityConscious recall of past events thathave specific temporal and spatialcontexts, termed episodic memory, ismediated by a system of interrelatedbrain regions. In Alzheimer's diseasethis system breaks down, resulting inan inability to recall events from theimmediate past. Using brain scanningtechniques of cerebral blood flow,Becker, Mintun, Aleva et al. (Becker,Mintun, Aleva et al. 1996)demonstrate that Alzheimer's diseasepatients show a greater activation ofregions of the cerebral cortex normallyinvolved in auditory-verbal memory, aswell as activation of cortical areas notactivated by normal elderly subjects.These results provide clear evidenceof functional plasticity in the brain ofsufferers, even if those changes donot result in normal memory function,and provide insights into themechanisms by which the brainattempts to compensate forneurodegeneration. Similarly, it hasbeen demonstrated that Alzheimer'sdisease can effectively learn andretain a motor skill for at least 1 month(Dick, Nielson, Beth et al. 1995)

Both anterograde andretrograde procedural memory appearto be spared in Alzheimer's disease(Crystal, Grober, and Masur 1989). An82 year old musician with Alzheimer'sdisease showed a preserved ability toplay previously learned pianocompositions from memory while


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being unable to identify the composeror titles of each work. He also showeda preserved ability to learn the newskill of mirror reading while beingunable to recall or recognize newinformation.CommunicationCharacteristic features ofcommunication breakdown and repairamong individuals with dementia ofthe Alzheimer's type and theircaregivers have been describedrecently (Orange, VanGennep, Milleret al. 1998). The nature ofcommunication breakdown, how it issignaled, how it is repaired, and theoutcome of the repair process appearto be disease stage-dependent.Couples in the early and middle stageof the disease achieve success inresolving communication breakdownsdespite declining cognitive, linguisticand conversation abilities of theindividuals with the disease. This hasimportant implications forunderstanding the influence of theprogression of Alzheimer’s disease onconversational performance and foradvancing the development ofcommunication enhancementeducation and training programs forspousal caregivers of individuals withAlzheimer’s disease.

Music therapy will have animportant role to play here as theground of communication, as we haveseen, is inherently musical. Dementiasufferers appear to be open to musicalstimuli and responsive to music-making, thus implementation ofmusical elements in facilitatingcommunication and expression can beenhanced as the disease progresses. Ifmusic enhances communicativeabilities –indeed, is the fundamental ofcommunication - and spousalcaregivers are important in managing

the progress of the disease, then haveto return to the idea that it is thecaregivers who will benefit from musictherapy.

Musical hallucinationsHallucinations may occur in any of oursenses, and auditory hallucinationstake various forms; as voices, cries,noises, or rarely, music. However, theappearance of musical hallucinations,often in elderly patients, hasgenerated interest in the medicalliterature (Berrios 1990; Brasic 1998;Mahowald, Woods, and Schenck1998; Wengel, Burke, and Holemon1989). When such hallucinations dooccur they are described as highlyorganized vocal or instrumental music.In contrast, tinnitus is characterized byunformed sounds or noises that maypossess musical qualities (Wengel etal. 1989).

The case histories of patients withmusical hallucinations suggest anunderlying psychiatric disorder(Aizenberg, Schwartz, and Modai1986; Wengel et al. 1989); which maybe exacerbated by dementing illnessoccurring with brain deterioration(Gilchrist and Kalucy 1983), or thatpatients with musical hallucinationsand hearing loss become anxious anddepressed (Fenton and McRae 1989).Fenton challenges the association ofpsychosis and previous mental illness,preferring an explanation that reliesupon the degeneration of the auralend-organ whereby sensory input,which suppresses much non-essentialinformation, fails to inhibit informationfrom other perception-bearingcircuits. Other investigators (Gilchristand Kalucy 1983) argue for a centralbrain dysfunction as evidenced bymeasures of brain function. In asample of 46 subjects experiencing


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musical hallucinations musicalhallucinations were far more commonin females; age, deafness, and braindisease affecting the non-dominanthemisphere played an important rolein the development of hallucinations;and psychiatric illness and personalityfactors were found to be unimportant(Wengel et al. 1989).

For these patients the applicationof music therapy to raise the ambientnoise level, to organize aural sensoryinput by giving it a musical sense andcounter sensory deprivation, and tostimulate and motivate the patientseems a reasonable approach.

Music therapy, heart rate andrespirationThe effect of music on the heart andblood pressure has been a favoritetheme throughout history. In an earlyedition of the medical journal“Lancet” (Vincent and Thompson1929) an attempt was made todiscover the influence of listening togramophone, and radio, music onblood pressure. The effects of musicwere influenced by how much thesubjects appreciated music. Differinggroups of musical competenceresponded in relation to volume,melody, rhythm, pitch and type ofmusic. Interest in the music was animportant factor influencing response.Melody produced the most markedeffect in the musical group. Volumeproduced the most apparent effect inthe moderately musical group. Ingeneral, listening to music wasaccompanied by a slight rise in bloodpressure in the listener.

If music produces physiologicaland psychological effects, in healthypersons as listeners then it may beassumed that persons with various

diseases respond to music in specificways. A particular hypothesis, which isyet to be substantiated empirically, isthat people with known diseasesrespond to music in a way that ismediated by that disease. Hence, wemight find that the musical parametersof improvised playing are restricted bydisease. Also, in terms of musictherapy, if music is known to influencea physiological parameter such asheart rate or blood pressure, thenmaybe music can be usedtherapeutically for patients who haveproblems with heart disease orhypertension.

Bason (Bason and Celler 1972)found that the human heart rate couldbe varied over a certain range byentrainment of the sinus rhythm withexternal auditory stimulus whichpresumably acted through thenervous control mechanisms, andresulted from a neural coupling intothe cardiac centers of the brain. Anaudible click was played to the subjectat a precise time in the cardiac cycle.When it came within a critical rangethen the heart rate could be increasedor decreased up to 12% over a periodof time up to 3 minutes. Fluctuationscaused by breathing remained, butthese tended to be less when theheart was entrained with the audiblestimulus. When the click was notwithin the time range of the cardiaccycle then no influence could bemade. Bason’s paper is important forsupporting the proposition oftenmade by music therapists thatmeeting the tempo of the patientinfluences their musical playing and isthe initial key to therapeutic change.

An extension of this premise, thatmusical rhythm is a pacemaker, wasinvestigated by Haas and hercolleagues (Haas, Distenfeld, and


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Axen 1986) in terms of the effects ofperceived rhythm on respiratorypattern, a pattern that serves bothmetabolic and behavioral functions.Metabolic respiratory pathways arelocated in the reticular formation ofthe lower pons and medulla, whereasthe behavioral respiratory pathwaysare located mainly in the limbicforebrain structures that lead tovocalization and complex behavior.There appear to be both hypothalamicand spinal pattern generators capableof synchronizing this respiratory andlocomotor activity. Therefore, Haashypothesized that an externalrhythmical musical activity, in this caselistening to taped music, would havean influence on respiratory patternwhile keeping metabolic changes andafferent stimuli (i.e. no gross motormovements) to a minimum.

Twenty subjects were involved inthis experiment, four of whom wereexperienced musicians and practicingmusicians, six had formal musicaltraining but no longer played amusical instrument and the remainingten had no musical training.Respiratory data including respirationfrequency and airflow volume wascollected alongside heart rate andend-tidal CO2. Subjects listened to ametronome set at 60b.p.m. andtapped to that beat on a microphoneafter a baseline period. The subjectswere then randomly presented withfour musical excerpts · and a period ofsilence with which they tapped alongto. There were no appreciablechanges in heart rate during theexperiment, but there was anappreciable change in respiratoryfrequency and a significant decreasein the coefficient of variation for allrespiratory parameters during thefinger tapping. For non-musically

trained subjects there was little co-ordination between breathing andmusical rhythm, while for trainedmusicians there was a coupling ofbreathing and rhythm. That singershave more efficient pulmonarystrategies than non-trained musicians,even when talking, is supportedelsewhere in the literature (Formby,Thomas, and Halsey 1989).

Auditory cues, then, appear to beimportant in the synchronization ofrespiration and other motor activity. Itis this aspect of organization ofbehavioral events that appears to bethe important aspect of music andcentral to music therapy (Aldridge2000).

Coronary careSeveral authors have investigated thisrelationship in the setting of hospitalcare (Aldridge 1993b; Bonny 1983;Davis-Rollans and Cunningham 1987;Elliott 1994; Fitzsimmons, Shively, andVerderber 1991; Guzzetta 1989; Philip1989; Zimmerman, Pierson, andMarker 1988) often with the intent ofreducing anxiety in chronically illpatients (Gross and Swartz 1982;Standley 1986), for treating anxiety ingeneral (Robb 2000), or specifically inmusicians(Brodsky and Sloboda 1997)

A hospital situation that is fraughtwith anxiety for the patient is theintensive care unit. For patients after aheart attack, where heart rhythms arepotentially unstable, the setting ofcoronary care is itself anxietyprovoking which recursivelyinfluences the physiological andpsychological reactions of the patient.In these situations several authors, invarying hospital intensive care orcoronary care clinics, have assessedthe use of tape recorded musicdelivered through headphones as an


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anxiolytic with the intention ofreducing stress (Updike 1990).Bonny(Bonny 1983) has suggested aseries of musical selections for taperecordings which can be chosen fortheir sedative effects and according toother mood criteria, associativeimagery and relaxation potential(Bonny 1978); none of which havebeen empirically confirmed; althoughUpdike (Updike 1990), in anobservational study, confirms Bonny’simpression that there is a decreasedsystolic blood pressure, and abeneficial mood change from anxietyto relaxed calm, when sedative musicis played.

Rider (Rider 1985a; Rider 1985b)proposed that disease related stresswas caused by the desynchronizationof circadian oscillators and thatlistening to sedative music, with aguided imagery induction, wouldpromote the entrainment of circadianrhythms as expressed in temperatureand corticosteroid levels of nursingstaff. This study found no conclusiveresults, mainly because there was nocontrol group and the study designwas confused highlighting theessential difference between musicwhen applied as a music therapydiscipline, and music as an adjunct topsychotherapy or biofeedback.

Davis-Rollans (Davis-Rollans andCunningham 1987) describes the useof a 37-minute tape recording ofselected classical music * on the heartrate and rhythm of coronary care unitpatients. Twelve of the patients hadhad heart attacks and another twelvehad a chronic heart condition. Patientswere exposed to two randomly varied

* Beethoven Symphony Nr.6 (first movement);

Mozart, Eine kleine Nachtmusik (first and fourthmovements) and Smetana, The Moldau .

42-minute periods of continuousmonitoring; one period with musicdelivered through headphones, theother control period was withoutmusic and contained backgroundnoise of the unit as heard throughsilent headphones. Eight patientsreported a significant change to ahappier emotional state after listeningto the music (a result replicated byUpdike (Updike 1990)), although therewere no significant changes inspecific physiological variables duringthe music periods. A change in mood,however, which relieves depression isbelieved to be beneficial to theoverall status of coronary care patients(Cassem and Hackett 1971).

Bolwerk (Bolwerk 1990) set out torelieve the state anxiety of patients ina myocardial infarction ward usingrecorded classical music **. Fortyadults were randomly assigned to twoequal groups; one of which listened torelaxing music during the first fourdays of hospitalization, the otherreceived no music. There was nocontrolled “silent condition”. Whilethere was a significant reduction instate anxiety in the treatment group,state anxiety was also reduced in thecontrol group. The reasons for thisoverall reduction in anxiety may havebeen that after four days the situationhad become less acute, the situationwas not so strange for the patient, andby then a diagnosis had beenconfirmed.

State anxiety is an individual’sanxiety at a particular state in time, asopposed to trait anxiety that is anoverall prevailing condition of anxietyunbounded by time and determinedby personality. The relationship

** Bach, Largo ; Beethoven, Largo ; Debussy, Prelude

to the Afternoon of a Faun.


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between stress and anxiety is thatstimulus conditions, or stressors,produce anxiety reactions; i.e. thestate of anxiety. Anxiety as a state ischaracterized by subjective feelings oftension, worry and nervousness whichare accompanied by physiologicalchanges of heart rate, blood pressure,myocardial oxygen consumption,lethal cardiac dysrhythmias andreductions in peripheral and renalperfusion. Admission to the coronarycare unit is itself a stressor, and theenvironment produces further stress,therefore the importance formanaging state anxiety.

The purpose of a study byGuzzetta (Guzzetta 1989) was todetermine whether relaxation andmusic therapy were effective inreducing stress in patients admitted toa coronary care unit with thepresumptive diagnosis of acutemyocardial infarction. In thisexperimental study, 80 patients wererandomly assigned to a relaxation,music therapy, or control group. Therelaxation and music therapy groupsparticipated in three sessions over atwo-day period. Music therapy wascomprised of a relaxation inductionand listening to a 20 minute musicalcassette tape selected from threealternative musical styles; soothingclassical music, soothing popularmusic and non-traditional music(defined as “compositions having novocalization or meter, periods ofsilence and an asymmetric rhythm”(p611). Stress was evaluated by apicalheart rates, peripheral temperatures,cardiac complications, and qualitativepatient evaluative data. Data analysisrevealed that lowering apical heartrates and raising peripheraltemperatures were more successful inthe relaxation and music therapy

groups than in the control group. Theincidence of cardiac complicationswas found to be lower in theintervention groups, and mostintervention subjects believed thatsuch therapy was helpful. Bothrelaxation and music therapy werefound to be effective modalities ofreducing stress in these patients, andmusic listening was more effectivethan relaxation alone. Furthermore,apical heart rates were lowered inresponse to music over a series ofsessions thus supporting theargument that the assessment ofmusic therapy on physiologicalparameters is dependent uponadaptation over time. Further researchstrategies may wish to makelongitudinal studies of the influenceof music on physiological parameters.

This positive finding above was incontrast to Zimmerman (Zimmermanet al. 1988) who failed to find aninfluence of music on heart rate,peripheral temperature, bloodpressure or anxiety score. However,Zimmerman’s study only allowed forone intervention of music. In thisexperimental study the authorsexamined the effects of listening torelaxation-type music on self-reportedanxiety and on selected physiologicindices of relaxation in patients withsuspected myocardial infarction.Seventy-five patients were randomlyassigned to one of two experimentalgroups, one listening to taped musicand the other to "white noise" °

° “White noise” or “synthetic silence” is an attempt

to block out environmental noise. In this case itwas a tape recording of sea sounds, whichthemselves were rhythmic

Philip, YT (1989) Effects of music on patient anxiety incoronary care units [letter]. 18, 3, 322.

Zimmerman, L (1989) Reply to a letter asking what"white noise" was. 18, 3, 322..


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through headphones, or to a controlgroup. The Spielberger State AnxietyInventory (Spielberger 1983) wasadministered before and after eachtesting session, and blood pressure,heart rate, and digital skintemperature were measured atbaseline and at 10-minute intervals forthe 30-minute session. There was nosignificant difference among thethree groups for state anxiety scoresor physiologic parameters. Becauseno differences were found, analyseswere conducted of the groupscombined. Significant improvement inall of the physiologic parameters wasfound to have occurred. This findingreinforces the benefit of rest andcareful monitoring of patients in thecoronary care unit, but adds little tothe understanding of musicinterventions. Time to listen,separated from the surroundinginfluence of the hospital unit by theuse of headphones, may itself be animportant intervention. AlthoughRider (Rider 1985a) did not reach thispreceding conclusion; he found thatperceived pain was reduced in ahospital situation in response toclassical music delivered throughheadphones, it could be concludedfrom his work that isolation fromenvironmental sounds, canceling outexternal noise, has a positive benefitfor the patient regardless of innercontent, i.e. music, relaxationinduction or silence.

Given that Bason’s study (Basonand Celler 1972) could influenceheart rate by matching the heart rateof the patient, then we must concludethat studies of the influence of musicon heart rate must match the music tothe individual patient. This also makespsychological sense as differentpeople have varied reactions to the

same music. Furthermore, improvisedmusic playing which takes meetingthe tempo of the patient as one of itsmain principles may have an impactother than the passive listening tomusic. In addition, the work of Haas(Haas et al. 1986) mentioned aboveshowed that listening, coupled withtapping, synchronizes respirationpattern with musical rhythm, furtheremphasizing that active music playingcan be used to influence physiologicalparameters and that thissynchronization can be learned. Thaut(Thaut 1985) also found that childrenwith gross motor dysfunctionperformed significantly better motorrhythm accuracy when aided byauditory rhythm and rhythmic speech.

Gustorff has successfully usedmusic therapy in the treatment ofcoma patients in the context ofintensive care (Aldridge, Gustorff, andHannich 1990). This work has alsobeen extended to persistentvegetative state where patients,seemingly unaware of theirenvironment, begin to respond to thehuman singing voice (Aldridge 1991;Ansdell 1995; Gustorff 1990).

AnesthesiaThe ability of music to induce calmand well-being has been used ingeneral anesthesia. Patients expresstheir pleasure at awakening to musicin the operating suite (Bonny andMcCarron 1984) where music wasplayed openly at first, and thenthrough earphones during theoperation. In a study by Lehmann(Lehmann, Horrichs, and Hoeckle1985) patients undergoing electiveorthopedic or lower abdominalsurgery were given either placeboinfusion (0.9% NaCl) instead oftramadol in a randomized and double-


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blind manner in order to evaluatetramadol efficacy as one componentof balanced anesthesia. Post-operative analgesic requirement andawareness of intra-operative events(tape recorder music offered viaearphones) were further used toassess tramadol effects. Althoughanesthesia proved to be quitecomparable in both groups strikingdifferences between the two groupswere shown with respect to intra-operative awareness: while patientsreceiving placebo proved to beamnesic, 65% of tramadol patientswere aware of intra-operative music.The ability to hear music during anoperation is also reported by Bonny(Bonny and McCarron 1984).

Cancer therapy, painmanagement and hospice careCancer and chronic pain care requirecomplex co-ordinated resources thatare medical. psychological, social andcommunal. Hospice care in the UnitedStates and England has attempted tomeet this need for palliative andsupportive services that providephysical, psychological and spiritualcare for dying persons and theirfamilies. Such a service is based uponan interdisciplinary team of healthcare professionals and volunteers,which often involves outpatient andinpatient care.

In the Supportive Care Program ofthe Pain Service to the NeurologyDepartment of Sloan -KetteringCancer Center, New York, a musictherapist is part of that supportiveteam along with a psychiatrist, nurse-clinician, neuro-oncologist, chaplainand social worker (Bailey 1984; Coyle1987). Music therapy is used topromote relaxation, to reduce anxiety,

to supplement other pain controlmethods and to enhancecommunication between patient andfamily (Bailey 1983; Bailey 1984). Asdepression is a common feature of thepatients dealt within this program,then music therapy is hypotheticallyan influence on this parameter and inenhancing quality of life. Althoughquality of life has assumed a positionof importance in cancer care in recentyears and music therapy, along withother art therapies, is thought to beimportant, the evidence for this beliefis largely anecdotal and unstructured.Bailey (Bailey 1983) discovered asignificant improvement in mood forthe better when playing live music tocancer patients as opposed to playingtaped music which she attributes tothe human element being involved.Gudrun Aldridge (Aldridge 1996b), ina single case study, emphasizes thebenefits of expression facilitated byplaying music for the post-operativecare of a woman after mastectomy.

A better researched phenomenonis the use of music in the control ofchronic cancer pain, although suchstudies abdicate the human elementof live performance in favor of taperecorded interventions. .

In addition to reducing pain,particularly in pain clinics, music asrelaxation and distraction has beentried during chemotherapy to bringoverall relief (Kerkvliet 1990), and toreduce nausea and vomiting (Frank1985). Using taped music and guidedimagery in combination withpharmacological antiemetics, Frank(Frank 1985) found that state anxietywas significantly reduced resulting ina perceived degree of reducedvomiting, although the nausearemained the same. As this study wasnot controlled the reduced anxiety


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may have been a result of the naturalfall in anxiety levels whenchemotherapy treatment ended.However, the study consisted ofpatients who had previouslyexperienced chemotherapy and wereconditioned to experience nausea orvomiting in conjunction with it. Thatthe subjects of the study felt reliefwas seen as an encouraging sign inthe use of music therapy as atreatment modality.

There is a rapidly developingliterature related to working with childrenwith cancer (Aldridge 1999; Fagen 1982;Standley and Hanser 1995) that alsofocuses on specific issues like themanagement of pediatric pain (Frager1997; Loewy 1997), hospitalization(Froehlich 1996) special needs groups(McCauley 1996) and the use of songs(Aasgaard 1994; O'Callaghan 1996).

Some music therapists work insituations with adult patients (Bunt 1995),or clients, who are living with challenge ofthe Human Immune- deficiency Virus(Aldridge 1993a; Aldridge 1999; Aldridge1995; Aldridge and Aldridge 1999; Hartley1994; Schnürer, Aldridge, Altmaier et al.1995). There is a pioneering literature inthis field of the work that has beendeveloped by Colin Lee(Lee 1995; Lee1996) and Ken Bruscia (Bruscia 1991;Bruscia 1995) and these two chaptersdemonstrate how other therapists have alsobeen advancing the use of music therapy tomeet this challenge.

Neurological problemsIn many cases neurological diseasesbecome traumatic because of theirabrupt appearance resulting inphysical and/or mental impairment(Jochims 1990). Music appears to be akey in the recovery of formercapabilities in the light of what at first

can seem like hopeless neurologicaldevastation (Aldridge 1991a; Jones1990; Magee 1995a; Magee 1995b;Sacks 1986).

For some patients with braindamage following head trauma, theproblem may be temporary resultingin the loss of speech (aphasia). Musictherapy can play a valuable role in theaphasia rehabilitation (Lucia 1987).Melodic Intonation Therapy (Naeserand Helm-Estabrooks 1985; O'Boyleand Sanford 1988) has beendeveloped to fulfil such arehabilitative role and involvesembedding short propositionalphrases into simple, often repeated,melody patterns accompanied byfinger tapping. The inflectionpatterns, of pitch changes andrhythms of speech, are selected toparallel the natural speech prosody ofthe sentence. The singing ofpreviously familiar songs is alsoencouraged as it encouragesarticulation, fluency and the shapingprocedures of language which areakin to musical phrasing. In additionthe stimulation of singing within acontext of communication motivatesthe patient to communicate and, it ishypothesized, promotes the activationof intentional verbal behavior. Ininfants the ability to reciprocate orcompensate a partner’scommunicative response is animportant element of communicativecompetence (Murray and Trevarthen1986; Street and Cappella 1989) andvital in speech acquisition (Glenn andCunningham 1984). Music therapystrategies in adults may be used in asimilar way with the expectation thatthey will stimulate those brainfunctions that support, precede andextend functional speech recovery.Functions, which are essentially


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musical and rely upon brain plasticity.Combined with the ability to enhanceword retrieval, music can also be usedto improve breath capacity,encourage respiration-phonationpatterns, correct articulation errorscaused by inappropriate rhythm orspeed and prepare the patient forarticulatory movements. In this sensemusic offers a sense of time which isnot chronological, which is fugitive tomeasurement and vital for the co-ordination of human communication(Aldridge 1996a).

Evidence of the global strategy ofmusic processing in the brain is foundin the clinical literature. In two casesof aphasia (Morgan and Tilluckdharry1982) singing was seen as a welcomerelease from the helplessness ofbeing a patient. The authorhypothesized that singing was ameans to communicate thoughtsexternally. Although the 'neweraspect' of speech was lost, the olderfunction of music was retainedpossibly because music is a functiondistributed over both hemispheres.Berman (Berman 1981) suggests thatrecovery from aphasia is not a matterof new learning by the non-dominanthemisphere but a taking over ofresponsibility for language by thathemisphere. The non-dominanthemisphere may be a reserve offunctions in case of regional failureindicating an overall brain plasticity,and language functions may shift withmultilinguals as compared withmonolinguals, or as a result of learningand cultural exposure where musicand language share commonproperties (Tsunoda 1983).

That singing is an activitycorrelated with certain creativeproductive aspects of language isshown in the case of a 2-year-old boy

of above-average intelligence whoexperienced seizures, manifested bytic-like turning movements of thehead, which were inducedconsistently by his own singing, butnot by listening to or imagining music.His seizures were also induced by hisrecitation and by his use of silly orwitty language such as punning.Seizure activity on an EEG waspresent in both temporocentralregions, especially on the right side,and was correlated with clinicalattacks (Herskowitz, Rosman, andGeschwind 1984).

Aphasia is also found in elderlystroke patients and music therapy, asreported in case studies, has beenused effectively in combination withspeech therapy.

Gustorff (Aldridge, Gustorff, andHannich 1990; Gustorff and Hannich2000) has successfully appliedcreative music therapy to comapatients who were otherwiseunresponsive. Matching her singingwith the breathing patterns of thepatient she has stimulated changes inconsciousness which are bothmeasurable on a coma rating scaleand apparent to the eye of theclinician.Mental handicapped adultsMusic appears to be an effective wayof engaging profoundly mentallyhandicapped adults in activity (Wigram1988). The functional properties ofmusic have implications for thetreatment of the mentallyhandicapped in that; (i) exposure tosound arouses sensory processes, (ii) amusical event is an organizedtemporal auditory structure with abeginning and an end, (iii) musicfacilitates memory recall andexpectation (“the signature tuneeffect”); and, (iv) a sequence of


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musical themes can enhance memoryrecall and the organization of asequence of cognitive activities (Knill1983).

For a group of profoundlymentally handicapped adults, musictherapy was used to encourage thoseadults to attempt movements andactions, and achieve non-musical aimswithin the music therapy sessions(Oldfield and Adams 1990). Musictherapy was compared with playactivity using two groups of subjects.Each group received either musictherapy or play activity for six months,at which time the groups werereversed to receive the comparisontreatment. As the handicaps were soprofound and varied betweenindividuals then a separate behavioralindex was formulated for eachsubject. It was hypothesized that eachobjective would be achieved to agreater extent in the music therapygroup than in play activity. While thestudy was restricted in terms ofnumbers, and the behavioral indexeswere varied, there was a significantdifference in the performance inmusic therapy than in play therapy.This improved performance was notattributable to greater attention in themusic therapy group. The type ofinput was noticeably different in thetwo groups; in the music therapygroup improvisations were based onthe subjects own musical productions.However, for one subject there wasgreater improvement in the playactivity which came before the musictherapy treatment.

ChildrenMuch of modern music therapy wasdeveloped in working with childrenand the diversity and richness of thiswork is reflected in the literature.

Stern (Stern 1989) emphasizes theimportance of the creative arts ingeneral to child development as theyinvolve the child’s natural curiosity.However, she also proposes that interms of child development thentherapies must involve the family ofthe child particularly in the case ofchild disability. For children withmultiple disabilities there is need forstimulation and this can be achievedusing music which also provides asense of fun and enjoyment. Stern’sapproach suggests that songsstimulate a bond between therapistand patient, and that for one particulardisabled patient “The music enteredSusan’s frame of reference” (p649).An alternative explanation could bethat music was Susan’s frame ofreference by which she co-ordinatedher own activities and those activitieswith another person. It may well bethat families of handicapped childrenneed to learn the rudiments of musictherapy, as organized rhythmiccommunication, such that they canprovide a structure for their mutualcommunications (Aldridge 1989). Inthis sense it make sense for therapiststo work with both parents andchildren.

Songs, both composed andimprovised provide the vehicle forworking with hospitalized children(Aasgaard 1999; Dunn 1999).

Songs were also used in thepreoperative preparation of childrenin an attempt to relieve fear andanxiety by transmitting surgery-related information. To ascertain theefficacy of using information alone, orinformation with songs, three groupsof children were prepared on the daybefore surgery; one group withinformation alone, one group withinformation followed by specially


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prepared songs which were based onthat information; and a third groupwhich also had information followedby songs with an additional session ofsongs immediately in the preoperativephase on the day of the operation.The group receiving music therapy onthe morning prior to the induction ofpre-operative medication exhibitedsignificantly less anxiety based on anumber of observed variables.Lessons to be learned from thisresearch may be that althoughinformation is made available it doesnot mean to say that the child will beable to use this information when it isneeded, no amount of information willmake a procedure less painful, and acognitive understanding of pain madeduring a therapy session is notnecessarily translated into physical oremotional relief during the context ofsurgical preparation. Music therapy inits immediacy may have been a criticalfactor in reducing anxiety, asanecdotal reports suggest, but in thisstudy no group received musictherapy alone.

In a general study of musictherapy as applied to newborns andinfants in hospital (Marley 1984),music appeared beneficial as acalming effect inducing sleep andrelaxation. The methods ranged fromsimple tapping on the back tosimulate a heartbeat, through rockingof children in time to played music, toreceptive music therapy. It is difficultto understand the nature of this workas music therapy. The researcherreports that in 13 of the rooms thetelevision was off and in fourteenrooms the television was on. Whenthe television was on in most casesthe sound was either too low or tooloud. It must be added that thechildren were between the ages of 5

weeks and 36 months old. Withcontinuous sound stimulation thenlittle wonder the children respondedto the television being switched offand guitar music being played tothem.

Fagen (Fagen 1982), working withterminally ill pediatric patients, alsoemphasizes the psychosocial settingof the family and the hospital asimportant. Music therapy in thissetting was used to improve thequality of life of the patients in anattempt to broaden and deepen theirrange of living. However neither aquality of life scale was used, nor werethe criteria for assessing the quality oflife in dying children made clear. Thisis not surprising as no quality of lifescales for children with terminal illnessexist at present. In her music therapypractice Fagen was eclectic borrowingfrom various music therapy schoolsbut concentrating on songs toconfront the issues of hospitalizationand dying. These songs often hadimprovised lyrics according to theneeds of the situation, or songs thathad given meanings and wereappropriate to the patient. No attemptwas made to force patients toconfront their own dying.

Aasgard has pursued the theme ofmusic therapy in pediatric oncologyfurther. He uses songs to facilitate areturn to health, where health is seenas a performed activity within ecologyof care (Aasgaard 1999). These songsare no however privatizedproductions, but shared pieces ofmusic that are sung by siblings, familymembers, and hospital staff.

Creative expression, as reportedin the work with children, is generallyaccepted as a means of copingwhereby pain and anxiety arechanneled into activities (Lavigne,


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Schulein, and Hahn 1986). In anattempt to encourage children tocope with the trauma ofhospitalization by verbalizing theirexperiences, Froehlich (Froehlich1984) compared the use of playtherapy and music therapy asfacilitators of verbalization. Whenspecifically structured questions abouthospitalization were asked of thechildren after sessions of musictherapy or play therapy, music therapyelicited more ‘answers’ than ‘noanswers’, and a more involved type ofverbalization involving elaboratedanswers, than play therapy.

AutismMusic therapy allows children withoutlanguage to communicate andpossibly to orient themselves withintime and space. It has developed asignificant place in the treatment ofmental handicap in children.

Children exhibiting autisticbehavior appeared to prefer a musicalstimulus rather than a visual stimuluswhen compared with normal children(Thaut 1987). Although thesignificance of this finding was notstatistically valid; the study doesreport that autistic children showedmore motor reactions during periodsof music than normal children, andthat autistic children appeared tolisten to music longer than theirnormal peers who preferred visualdisplays.

In a later study comparing autisticchildren and their normal peers (Thaut1988), autistic children producedspontaneous tone sequences almostas well as normal children andsignificantly better than a controlgroup of mentally retarded children.Each child sat at a xylophone with twobeaters, after having had a short

demonstration from the researcher,who then asked them to playspontaneously for as long as theyliked until they came to a naturalending. The musical parameters, ofthe first sixteen tones of theseimprovisations, which were assessedand used as the basis for groupcomparisons were; rhythm(representing the imposition andadherence to temporal order);restriction (representing the use of allavailable tonal elements); complexity(representing the generation ofrecurring melodic patterns; ruleadherence (representing theapplication of melodic patterns to thetotal sound sequence); and, originality(representing the production ofmelodic patterns that occurred onlyonce but fulfilled criteria of melodicand rhythmic shape). Autistic childrenperceived and explored thexylophone as normal children did interms of originality and restriction, buttended to play with short recurringmotives rather like the mentallyhandicapped children. Thaut (1988)concludes, “The low performances oncomplexity and rule adherence ofsuch children suggest an inability toorganize and retain complex temporalsequences” (p567). This relationshipbetween cognition and motorbehavior as it is co-ordinated inrhythmical performance, as we haveread above in terms of heart rate,breathing, muscle performance andspeech rehabilitation, would appear tobe worthy of investigation in a widevariety of patients withcommunication difficulties regardlessof the source of those difficulties.

Music therapy has been usedextensively in the treatment ofdevelopmental delay. In a crossoverstudy (Aldridge, Gustorff, and


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Neugebauer 1995), the children inthe initially treated group changedmore than the children on the waitinglist. When those waiting-list controlgroup children were then treated withmusic therapy, and the formerlytreated children rested, then thenewly treated children caught up intheir development. Such changeswere demonstrated at a level ofclinical significance. There was acontinuing improvement in hearingand speech, hand-eye coordinationand personal-social interaction. Whileactive listening and performing wereseen to be central to thedevelopmental process, it was theimportance of hand-eye coordinationskills emphasized in the active musicalplaying which were instrumental inencouraging cognitive change.

ConclusionThere is a broad literature coveringthe application of music therapy asreported in the medical press and agrowing resource of valid clinicalresearch material from whichsubstantive conclusions can be drawn.The obscure observations in the realmof psychotherapy highlight a criticalfeature of music therapy research;well intentioned, and often rigorouswork, is spoiled by a lack of researchmethodology. This is not to say that allmusic therapy clinical research shouldconform to a common methodology(Aldridge 1996; Aldridge 1999;Aldridge 2000), or that it be medicalresearch, rather that standard researchtools and methods of clinicalassessment be developed which canbe replicated, which are appropriateto music therapy, and develop a linkwith other forms of clinical practice. Inthis way we develop working toolswhich allow us to inform others and

ourselves. There is a lively debate inmusic therapy circles aboutappropriate methods and a variety ofbooks have addressed themselves topresenting research material andmethods (Wheeler 1995).

The research that has beenproduced is notably lacking in followup data, without which it is difficult tomake valid statements about clinicalvalue. The assessment instruments aregenerally lacking by which internal orexternal validity can be conferred. Forexample, as ‘depression’ appears tofeature in many chronic diseases thena clinical rating of depression, using avalidated scale, would be appropriateto include in a research design. If thisassessment of depression could becombined with an overall assessmentof life quality then a significant stepforward would be made inestablishing a minimal data set forassessing clinical change.

Much of the research work hasbeen developed within the field ofnursing where the use of music isaccepted as a useful therapeuticadjunct. Not surprisingly, the workfrom this field has concentrated onmedical scientific perspectives. Thereis almost a complete absence of cross-cultural studies, or the use ofanthropological methods that wouldbring other insights into musictherapy. That music has been usedtherapeutically in other culturescannot be denied, and otherperspectives regarding the applicationof music therapeutically wouldhighlight the limitations of modernWestern scientific approaches whenused as the sole means of research.


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