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Music Therapy: A Noninvasive Treatment?

January 27, 2009, Suzanne Hanser, Ed.D, MT-BC, Chair, Music Therapy Department, Berklee College of Music (shanser@berklee.edu)

Music Therapy as Noninvasive Treatment

Thank you for your recent essay in the Nordic Journal of Music Therapy on music therapy as noninvasive treatment (Abstract). I appreciate your arguments, particularly regarding the power of music to psychologically penetrate during therapeutic interventions. Your well-written article provides excellent examples of how music therapy has been invasive to yourself and other clients. You challenge readers to consider its strong influences, both positive and negative, and ask us to be specific when using the term.

While I agree in principle with most of your contentions, what is lacking in your paper is the rationale for labeling music therapy as noninvasive. As you have quoted my own writing, I would like to substantiate my reason for using the adjective “noninvasive,” when referring to music therapy in general.

Much of my career has been devoted to advocating for music therapy services, particularly in the medical, psychiatric and geriatric settings. Although medical science and treatment methodologies have been evolving into more integrative and holistic approaches to care, the medical model has provided standards for our practice, ethics, reimbursement guidelines and research protocols In this context, it is, indeed, the medical definition of noninvasive that I refer to when I use the term. As my clinical practice has focused primarily on medical specialties, and my postdoctoral training was based at a school of medicine (Stanford U.), I incorporate the language of medical practitioners and researchers in my work, whenever appropriate. In clinical settings, I am told repeatedly that referral to any treatment is based on safety and effectiveness. In the case of music therapy, the efficacy and effectiveness of our interventions are still questioned by decision makers who fund research or implement new clinical programs. In a recent research paper I submitted to a medical journal, I described the results of a randomized controlled trial of music therapy with women who have metastatic breast cancer. I dared to define music therapy as an evidence-based practice, citing the American Music Therapy Association definition (and by the way, I never used the term noninvasive). The reviewers only accepted the article on the condition that I remove the reference to music therapy as an evidence-based practice. They contended that there is insufficient evidence of the effectiveness of music therapy.

That takes us back to the arguments we make in favor of the safety of music therapy. Is music therapy safe? Noninvasive treatments are considered in a different class than invasive treatments. Noninvasive treatments do not require the pilot testing and experimentation prior to implementation that invasive treatments do. Consent forms for invasive therapies must cite and explicate potential harmful events or consequences. That said, it is true that my most recent patient consent forms include possible side effects of emotional sequelae and sources of psychological referral, if necessary. But, when we acknowledge the potential negative impact of music therapy, we raise questions about the safety of our interventions.

As a profession, we must come to terms with the arguments that you pose because we cannot have it both ways. Are we ready to proclaim that music therapy is not completely benign, that it carries risks that we can document and define? If we are at this stage of sophistication in our treatment, then it is right for us to discontinue use of the term, “noninvasive,” and describe precisely the potential negative impact of music therapy. Of course, we are still in the process of defining the specific positive outcomes that can be expected as a result of our diverse techniques and approaches.

I thank you for initiating dialogue that will stimulate thinking about our claims regarding the potential positive and negative results of music therapy. As we grow and develop new methodologies and applications, it is even more important that we define what we do and what patients can expect from music therapy.

February 23, 2009, Jane Edwards, PhD, Director, MA in Music Therapy, Irish World Academy of Music and Dance, University of Limerick, Ireland. (jane.edwards@ul.ie)

Response to Music Therapy as Noninvasive Treatment

I appreciate Professor Hanser’s response to this article which queries the claims for music therapy as a non-invasive treatment. Like Professor Hanser, I have worked and researched mainly in medical contexts. Consequently I wonder if this is a cultural issue to some degree, with those of us from the medical side of the house being much more likely to engage in this languaging about music therapy. Similarly to Professor Hanser, I am open to the suggestion that if we claim music is a powerful medium we must also temper claims that it will not intrude on patient’s equilibrium. In the same way Professor Hanser has described, I have made the claim that music therapy is an “evidence based profession”, in order to engage with the dominant contemporary discourse. As yet no-one has challenged this claim but I appreciate the dilemma she has described so clearly.

I have sometimes used the term non-intrusive in my writing, and I note that some of my former students adopt this terminology in their writing also; for example http://www.imt.ie/lifestyle/2006/12/music_therapy_hits_right_note.html

Based on my work in a children’s hospital for seven years, I believe that any therapies that do not require a child to be touched or physically manipulated in any way have a distinct role. It is possible then for the therapist to be part of a helpful “split” for the child and acquire a non-medicalised role (exemplified for me when a surgeon came in to check a graft on a 4 year old boy during a music therapy session. When the bandages were taken back I exclaimed ‘wow that looks much better’ and the boy asked ‘how would you know?’). This is potentially a powerful advocacy position, both in terms of the trust of the child and family but also as a conduit between the child’s experiences of hospitalisation and the team’s responsibility to provide optimal medical care.

My citation in the NJMT paper is from a promotional web page intended for potential students of the MA programme I teach. I was surprised to see this non-refereed source included in a scholarly journal. Although I did not write everything on the page cited, I do believe I must have worded the particular section that is referenced. However, I consider that the comments about the statement I made are taken out of context and need clarification.

My claim in the promotional web based materials is not that music therapy is non-invasive per se, but rather the statement including the term “non-intrusive” is

“Music Therapists are experts in using the gentle, non-intrusive, non-verbal qualities of music making in conjunction with their insight and training in therapeutic relationships to develop programmes that help identify and address client’s needs.”

I actually suggested that music therapists have the expert skills to use music in ways that are non-invasive and non-intrusive. This is not to say that I understand that music itself is not in some way penetrating the client or patients auditory or intra-psychic system, or has no potential for harm. Indeed I have written about my disturbance at the finding that music is used for torture of prisoners by the US military http://www.voices.no/columnist/coledwards200605.html

I do feel somewhat confused by the unremarked assumption in the paper that experiences reported in the Bonny Method of GIM are equitable with other music therapy provision. I am not sure it is possible to claim that the way music is conceptualised in BMGIM is equitable with the way music therapy clinicians, myself included, use music in music therapy. I am not trying to evoke an altered state in the patient, and I do not work with any understanding that particular pieces of music can evoke certain moods or imagery. While I am interested in the evocative potentials of music making, and the expressive intent of some patients’ use of musical instruments, or particular combinations of notes or timbres, I am using this experience to encourage relating between myself and the patient. It is this relating that is the focus of my work. Relating requires sensitivity and empathy to the experience of the other. Therefore, it would be my expectation that if a patient was experiencing music we created together as intrusive in some way, there would be an expectation that we could explore that with the goal of working collaboratively towards better understanding.

However, I do appreciate the author’s dilemma that the way music therapy is described could be potentially misleading for clients and for our co-workers. In particular that we may engage in a kind of self-deception about what it is we are doing. The opportunity for this discussion is therefore welcome.

April 28, 2009, Joanne Loewy DA, LCAT, MT-BC Director, The Louis Armstrong Center for Music & Medicine, Beth Israel Medical Center, NYC. (LoewyJoey@aol.com)

Response to Music Therapy as Noninvasive Treatment

I appreciate Susan Gardstrom’s article and Dr. Hanser and Dr. Edwards’ discussion and the points they have raised thus far. I work in a medical context and research the “effectiveness” and/or “impact” of “music” and/or “music therapy.” I distinguish these to bring forth the realization that conducting research that can be all-encompassing in its design is important. A design that can have sections which both quantify and qualify outcomes seems to have far-reaching capacity for those interested in musicmedicine, music therapy and music and medicine. Submissions for IRBs require our consideration of the term “invasive” or “non-invasive”-and in reality, this may mean the difference between a 20 page IRB or a shorter “expedited review.” But all review work aside, Dr Hanser’s experience with the reviewers requesting that we not call ourselves “evidence-based” rings true. Our work needs greater “proof” – and we need to reflect that we are “safe” – There is insufficient evidence of the effectiveness of music therapy.

Until we have more numbers, and clinical trials involving our peers (MDs, RNs), we will be seen as potentially harmful. Therefore, let’s research and review our clinical work. We are conducting sessions anyway. It is quite enriching to discover the impact of our interventions (or lack thereof!) and to learn about our outcomes.

To the question – “are we invasive” or “are we safe” – I do believe that music therapy training (hopefully) has informed us that we have the expertise to assess how the music is affecting others and in doing so, we (and our music) can bring others to a point of resource and safety. This is particularly important when working with someone in pain, or a person who is in a state of trauma or heightened vulnerability, particularly when he/she is exposed to a potent piece of music. I would not red-flag music therapy as invasive in an IRB. If it was questioned, I would acknowledge that the impact of music, and say that music therapy is safe, particularly because the therapist is trained to work with the issues as they come into the moment and therefore questions of potential risk would not be in question. This is not the case in music intervention studies, where music used as the sole intervention, could have potentially damaging effects as no one is with the patient to monitor emotional issues or reflect upon significant material. The music therapist’s training in addressing cultural issues is another area where ‘orienting’ is appreciated-and this is often unobtainable by other healthcare professionals. Learning about the rituals and practices of patients from other countries though music can afford us experiences of trust and familiarity which could lesson ‘invasive’ perception.

Music therapy is not completely benign because music itself is potent. To have music be the sole intervention could carry more risk in its invasive capacity than in having a trained music therapist involved, who can assist the patient in processing and contextualizing. “Noninvasive” in the medical world implies a physically intrusive experience with associated risk. I think we diminish such risk factors, especially if we assess fully, with all of our team members on board, with their input, and with the patients’ desires and requests in check.


© 2009. Nordic Journal of Music Therapy. All right reserved. This page was last updated by Rune Rolvsjord April 28, 2009.