Strike a chord

Mimi Mo asks whether music therapy has practical applications in clinical practice

It is hard to imagine how Beethoven must have felt when he composed one of his masterpieces, Symphony No 9. It was at the time when he had gone completely deaf. As I listen to the last movement, Ode to Joy, I try to think about the sensory journey that Beethoven must have gone through: the vibrations of the piano keys that became the "music" he experienced and how the orchestral piece came from his own musicality.

Beethoven's story shows that music can be in any form, in any kind of composition, and can be interpreted in a million different ways. This applies not only to classical music but extends to the things that we have taken for granted: the sound of falling raindrops or the voice of our loved ones could be music to our ears. On the other hand, the honking noise when we are stuck in traffic and the clock ticking during sleepless nights could equally elevate our bad mood. Music has the power to strike a chord in our bodies and minds. Perhaps to people with disabilities, the simplest sound could be an efficient way of communication and a key to improving their wellbeing.

Cameron collection

Music therapy is now allied to what we might think of as traditional bedside medicine. This comes from my personal observations. I have come to the final year of my doctorate degree, researching on dopaminergic neurones in Parkinson's disease. However, my study does not require me to see any patients. Even if I become the world's expert on this subject, what good will it serve if I cannot translate my knowledge to help people?

In the popular US medical drama House, Dr Gregory House explained that his job was to "cure a disease, not patients." It is obvious that many scientists, medical students, or even senior doctors are frustrated by such disconnection between the practice of medicine and seeing actual results in patients. Many doctors and medical scientists are well qualified musicians and can contemplate how music might relate to medicine. But I am sure plenty of questions still come to mind. How does music therapy work? Is it just an "alternative medicine"? What is it like being a music therapist?

Do re mi

For many people, music therapy may sound like some advertisement for bargain compact discs on a television shopping channel: "Listen to the sound of birds humming and oceanic harmony in this splendid collection. A box set of five discs costs only £19.99, and you can sit back, relax, and immerse yourself in the world of nature." Perhaps you visualise music therapy as people in meditation classes, sitting in a circle with an instructor lighting aromatic incense and playing music in the background. Lots of misconceptions surround music therapy. Stephen Sandford, a music therapist at South West London and St George's Mental Health NHS Trust, explained, "Music therapy in the United Kingdom uses improvisation as the main tool for clinical work as opposed to prerecordings. The music created between the therapist and the client is a unique, non-verbal dialogue."

In a typical room for music therapy, clients from different cultures can access various kinds of ethnic instruments-for example, gongs, drums, or bells. A music therapist is trained to listen attentively; picks up cues from the client's music; and, in playing with the client, supports their expressions. Such freedom of expression encourages the client to convey emotions and feelings beyond the need for words within a safe therapeutic relationship. The universality of music also means that music therapy is practised in all continents. The awareness of music therapy seems to be booming-the first Asian music therapy symposium was held in Japan in 2005 and the 12th world congress on music therapy will be held in Buenos Aires, Argentina, in 2008. In Europe courses have been offered in increasing numbers of universities and colleges, including the University of Aalborg in Denmark, which provides a research doctorate degree in music therapy. In North America, more than 3800 people hold current membership of the American Music Therapy Association. The online journal Voices gives a detailed outline of music therapy practice in many countries.

How scientific is music therapy?

Since the early inception of music therapy in the UK by pioneers such as the cellist Juliette Alvin, the pianist and composer Paul Nordoff, and his associate Clive Robbins, much research has shown the efficacy of assessment and treatment and improved the techniques and the theoretical models that underpin clinical practice. Areas of focus include working with children and adults with emotional and communication difficulties,¹ and research findings have generated detailed knowledge to highlight the scientific basis of music therapy. Music therapy has been shown to be effective in conditions that compromise the cerebral systems of collaborative learning, to give targeted support to weakened motive states and awareness of self and others. For example, psychosocial or interpersonal techniques used in music therapy have shown to improve development of skills and attention in autistic children.²

In children with Rett syndrome, songs in music therapy have also been shown to promote and motivate communication and learning. Rett syndrome is a neurological disorder resulting from an X linked mutation, affecting mainly girls and found in various racial and ethnic groups worldwide. It leads to a severe impairment of receptive and expressive communication.³ Video analyses of music therapy sessions with children with the syndrome showed functional hand use, eye referencing, and motivated and intentional communication.⁴⁵ Other case studies include music therapy and dyslexia, indicating its considerable positive effect on copying rhythm, rapid auditory processing, phonological ability, and spelling ability. These timing related skills may play a key role in the transfer of musical abilities to language abilities.⁵

Music therapy offers the potential for communication with people with dementia, when language is no longer possible. Aphasic people may be able to sing a song even though they are incapable of ordinary speech. Whereas cognitive functions decline in disease progression, receptivity to music may remain until the late phases of dementia.⁶⁷ The famous neurologist and writer Oliver Sacks testified before the US Senate's special committee on ageing on the therapeutic powers of music in treating neurological disorders, after seeing a patient with Parkinson's disease. He said, "When she plays [the piano] her Parkinsonism disappears, and all is ease and fluency and freedom and normality...Music liberates her from her Parkinsonism for a time-and not only music but the imagining of music."⁸ Dr Michael Thaut, professor of neuroscience and music therapy at Colorado State University, has written more than 120 scientific publications, with particular focus on neurological rehabilitation of cognitive and motor function using rhythms. His research group studied prefrontal correlates of conscious and subconscious motor adjustments to changing auditory rhythms using regional cerebral blood flow measurements.⁹ Together with imaging techniques such as magnetic resonance imaging and positron emission tomography scans, researchers will be able to assess the effect of music therapy on brain function.

A clinician's perspective

Like many music therapists, Stephen Sandford originally studied music at university. After his undergraduate degree he applied to the Guildhall School of Music and Drama for postgraduate training in music therapy. This course was the first training in the UK, starting in 1968. All courses are now at masters degree level. Training in music therapy is open to other professionals from non-musical backgrounds, such as social workers, nurses, or psychotherapists, provided they have the necessary level of musical skills required. Since Sandford's graduation, music therapy in the UK has evolved and now has a strong career path with job security. Music therapists in the UK along with their colleagues in art therapy and drama therapy have been the first in the world to be granted state registration by an act of parliament in 1999 in recognition of their work. The title "music therapist" in the UK is now protected by law and can only be used by practitioners who have completed one of the seven UK approved courses. The recent pay reform across all discipline in the NHS-Agenda for Change-recognises training in music therapy and the level of skill and responsibility clinicians can hold, establishing parity of pay commensurate with other disciplines, such as clinical psychology and child psychotherapy.

Sandford works full time in the NHS holding two posts-one as consultant music therapist at South West London and St George's Mental Health NHS Trust and another as a music therapy clinical specialist at Chelsea and Westminster Hospital in London. At South West London, he works in a specialist child and adolescent mental health service multidisciplinary team, which provides assessment and treatment to families, children, and adolescents who present with a wide range of mental health problems. As a consultant music therapist, Sandford's time is divided between clinical work and managerial tasks. A typical day may start by offering supervision to music therapists, followed by management meetings with professionals from other disciplines, as well as providing expert consultation. Sandford says he spends most of his time in clinical work.

Robin Scholz/ap/empics

At Chelsea and Westminster, the setting is the Cheyne Child Development Clinic, where children present with autistic spectrum disorder, developmental delay, and paediatric problems. There are about 60 music therapy appointments offered a month at the busy music therapy department. Referrals are accepted from psychologists, speech and language therapists, and paediatricians.

Sandford also lectures at Trinity College of Music in London for its introductory music therapy course. This is an elective module for final year students taking Trinity's four year music degree. Surprisingly, Sandford sometimes finds medical students more receptive to the notion of music therapy than music conservatory students. In their quest for establishing a suitable relationship with their patients, doctors in training are open to thinking about forms of expressions beyond words. Sometimes it is not easy for musicians because they have had years of practising their craft and learning the correct way to play. Sandford says that the process of training for music therapy for a musician could be considered as one of freeing up and meeting the challenge of "unlearning" perceptions about what music is and establishing how it can work to help people in distress.

Music therapy has come a long way in gaining recognition within medicine and in the UK health service. Future challenges lie ahead, such as meeting the ongoing need for evidence based practice and providing further evidence for development of music therapy's place as an integral treatment option. I wish to use the sound of music to make a difference in other people's lives. Do you?

1. MusicSpace Trust. http://hsc.uwe.ac.uk/musicspace/musicspace.htm.
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