Seidel, Almut (Ed.)(2005). Verschmerzen. Musiktherapie mit krebserkrankten Frauen und Männern im Spannungsfeld von kurativer und palliativer Behandlung [Enduring life in/with pain. Music Therapy with Women and Men Living with Cancer between Curative Treatment and Palliative Care]. Wiesbaden: Zeitpunkt Musik Reichert Verlag.
This is an unusual and very important book. It is based on a research project undertaken in Germany 2002-2004, involving 36 patients (18 male and 18 female cancer patients, most of them suffering from leukemia), three clinicians (two female and one male music therapists) in three different cancer clinics, four external raters and a research team of five (three music therapy researchers and two psychologists).
What makes the book unusual—mostly for the good—is that it presents not only literature reviews, research questions, method, data analysis, results and discussion, but also theoretical chapters and personal reflections of many of the participating clinicians and researchers. And—not the least important—that it addresses not only the question of music therapy as a relevant therapeutic intervention in oncology, but also the question of gender and its influence on conceptualizations, clinical practice and results. This is a highly relevant but sadly under-researched aspect of music therapy in general, and the book offers thought-provoking and even harsh critique of “music therapy as a therapy by and for women” (p.13).
The book is outlined in 10 chapters. In chapter 1 the gender issue is presented as a very important, but surprisingly rarely addressed question of gender influences in music therapy (5 studies are reviewed; the important study by Körlin and Wrangsjö (2001) is not included (Körlin and Wrangsjö 2001)). Chapter 2 focuses on cancer—as a disease in a medical and psycho-oncological perspective, as a challenge for psychosocial interventions in the transition from curative treatment to palliative care, and as a clinical field of music therapy (a small literature review on music therapy in oncology in Germany). Chapter 3 presents research questions and design. The study uses multiple methods: a quantitative investigation based on self report questionnaires (pre/post-tests of patient’s mood, based on the Basler Befindlichkeitsskala), and qualitative investigations of emotional coping types (based on Jungian concepts), combined with musical descriptions and morphological music analyses of selected improvisations. The concept of treatment and the clinical context is presented in chapter 4, while chapter 5 gives a more detailed outline of emotion theory and its operational for analysis and quantification of “levels of consciousness” observed in the protocols and by the external observers.
The outline in chapter 5 is followed by the first results: the distribution of the participants on the four emotional types is identified. It is then followed by the first part of four case studies, illustrating both the method of analysis and three of the four types of emotional coping.
Chapter 6 follows a description and analysis of the same four patients’ music (one selected improvisation from each), made by one of the researchers. Chapter 7 presents an analysis of the verbal interaction in the music therapy, based on principles from grounded theory. Chapter 8 reports the results of the quantitative investigation, using inferential statistics. Reflections from one of the three clinicians and one of the external describers are given in chapter 9. Finally, the project leader and editor writes the discussion section, chapter 10, addressing both methodological questions and the results.
It is impossible here to go through the chapters and give a fair summary of the results. I hope the researchers will publish selected results in English. Chapters 4, 5+6, 7 and 8 could fairly easily be edited as separate articles. A short introduction to the project in English was published by Gaertner and Seidel (2003).
Here I will just sum up a few of the main results and some of the conclusions of the complete study.
The quantitative investigation (p. 169) concludes that a significant and clinically relevant improvement in patients’ mood after therapy was documented (p. 169). However, this improvement could not be confirmed over time (which may be due to the lack of a control group). There seems to be no gender-specific differences in effect over time.
The qualitative investigation identifies 4 coping strategies of the patients (p. 101f). These strategies are identified and documented through triangulations of interviews with patients, music analyses and patients’ self reports. It can also be concluded (p. 184) that the patients, independent of gender, had a clearly positive experience of music therapy (active as well as receptive), and that the therapists observed and supported much expressive potential in the patients as “human beings.” Unfortunately, the music analyses demonstrate that no real understanding of the patients’ suffering and related emotions could be documented, there was no genuine meeting in the music, and so the patients were often left with a feeling of not being understood or rejected. This is reflected in the dominating emotional type identified as “Away from self—The patient is controlled by the surroundings” (p. 185). The editor discusses this result as connected to six “fields of conflict”, of which the first is a music therapy practice dominated by female therapists who seem to stress the harmony and harmonizing aspects of the music in the therapy. The sixth and last is the tension between curative and palliative in the field of oncology, placing the music therapist “between the chairs”, because it “is not clearly a supportive intervention, evoking compliance and enhancing resources, because the results of making music are manifold and therefore often “uncovering” (p. 187). Nevertheless, death and dying was never addressed in the sessions.
Many efforts have been undertaken to secure a valid analysis of the gender issue. The most important design issue was the systematic blinding of the researchers undertaking the analyses. The blinding procedure is illustrated in an interesting way in the book: also the reader is blinded! This happens in chapters 5 and 6, where the gender of the 4 case study patients is not revealed. This provokes the reader (in this case me) to make an informed guess, and my personal guess is that patients A and B are male, C and D female. However, it is not possible to check this: the facts are not provided anywhere in the book!
The blinding procedures make some of the conclusions quite startling. Seidel writes (p. 190) that “female music therapist seek female patients”, and when male patients enter music therapy they are offered primarily verbal interventions (48%), then receptive music therapy (33%) and in least cases active music therapy (19%). Data document however, that there are no gender differences in engagement, motivation and emotional participation. Seidel concludes that the study unfortunately did not contribute to a rejection of the gender mainstreaming movement’s slogan “There is no gender neutral reality” (p. 192).
I find the book somewhat difficult to read. This is quite a paradox since I find it carefully edited and the sequence of chapters quite logical. The main problem is that the research questions are not presented in the beginning of the book, actually not as a whole anywhere in the book. This means that the reader gets information about data and method without the background or context of the actual questions. Nevertheless it is obvious that the research has been governed by specific questions and hypotheses, but they are never presented as such. The only chapter including clear research questions (but not hypotheses) is chapter 8, the quantitative investigation. Another problem is that the four case studies are distributed in two chapters (5 and 6), which may seem logical from a methodological point of view, however, the reader is forced to go forth and back between the chapters to follow the qualitative line of argument. It is somewhat confusing that background information and theory is not only introduced in the first two chapters, theory is also included in some of the chapters reporting results of the study (4 and 5). Likewise, methodology is spread over many chapters. A final thing that puzzled me as a reader: The study identifies four copings strategies (1. away from self; 2. towards self; 3. away from others; 4. towards others) of which one is considered predominant and gender neutral. Yet, in the case study chapters only one of the four patients represents the dominating strategy, while two of the patients belong to a much less observed strategy.—I think the paradox of logical structure and a somewhat confusing reading experience is due to the fact that many authors with different background have written separate contributions to the book, and that it has not been possible for the editor to reedit the text in clear sections of background, research questions and methodology, results, and discussion. As mentioned, this gives the reader some extra work and causes some confusion, but it is worth while:
The book offers very important and highly controversial research results, especially concerning the gender question. The study documents that male cancer patients, in a German context, benefit just as much from music therapy as female patients. However (unfortunately), male patients do not get the same access to music therapy, partly because of the more or less conscious expectations and recruitment strategies of the—predominantly female—music therapists in German oncology.
Do we have substantial evidence to believe that the situation is different in other countries? I am afraid not.
References
Gaertner, B. and A. Seidel (2003). Music Therapy in Psycho-oncology – A Gender Comparison Research Project. [online] Music Therapy Today 4(4). Retrieved November 5, 2005, from http://www.musictherapyworld.net
Körlin, D. and B. Wrangsjö (2001). Gender Differences in Outcome of Guided Imagery and Music (GIM) Therapy. Nordic Journal of Music Therapy 10(2) 132-143.