Publication: Nurses World Magazine

Author / Writer: Kathleen A. Wildasin

“He could move his eyes, fingers, and toes when I met him, but could no longer speak,” says Barbara Reuer, PhD, MT-BC. “I had to find a way to connect with a teenager whose world was lying in a bed in a long-term care unit.”

Suffering from amyotrophic lateral sclerosis, Reuer’s patient liked to roll his toes on a rattle like instrument called a cabasa. Once he lost use of his toes, she held an electronic instrument called a QChord over his hands to he could feel vibrations.

After two years of weekly visits with her young patient, Reuer learned that he and his family had decided to discontinue life support. She also learned that they specifically asked that she be in the room, doing what she had done for so many months.

As a certified music therapist, Reuer belongs to a growing family of professionals around the country. Its practitioners use a complex and often subtle combination of skills and techniques in a wide range of clinical settings.

Music therapy is defined as an intervention applied by a qualified professional to produce positive changes in cognitive, physical psychological, or social functioning. The development and application of this practice took place during the twentieth century, although a relationship between music and health and healing has been presumed in many cultures for centuries.

Michigan State University was first to offer a degree program in 1944. The undergraduate curriculum, now standardized, includes coursework in the biological, behavioral, and social sciences. Today, the discipline has 70 approved baccalaureate programs and about 170 intern training sites, as well as graduate programs. The American Music Therapy Association Inc., with approximately 4,000 members, and the World Federation of Music Therapy promote the use of music therapy globally.

After completing an undergraduate degree and a six-month clinical training program, music therapy candidates must pass a national board exam to receive certification (MT-BC). Music therapists can then design programs in medical and corporate settings to address the physical, emotional, and spiritual issues of individual clients. Music therapy programs, monitored for quality assurance at the institutional level, are governed by Code of Ethics and Standards of Clinical Practice regulations.

Structuring a music therapy intervention

According to Reuer, music interventions typically include patient assessment, individualized program design and implementation, and appropriate follow-up and monitoring.

“After assessment, I let the patient leaf through our top 30 songbook, a list of frequently up-dated patient requests,” Reuer says. “Songs like You Are My Sunshine, Country Roads, and Let It Be are familiar to most people and serve as ice breakers.”

Reuer’s sessions, which average 30-45 minutes, include listening to live or recorded music, playing instruments, improvising, creating lyrics, and/or vibrotactile experiences.

While selected music should be non-threatening and patient centered, no genre or style is ruled out. “Goals can vary from managing pain and discomfort, to reducing anxiety, to resolving past conflict,” Reuer observes.

The results of Reuer’s interventions are documented in the patient chart. She routinely confers with the treatment team when reviewing patient care management issues.

In the mental health arena

Lisa Jackert, MA, MT-BC, rehabilitation therapy supervisor at Community Hospital-Long Beach, says patients in the behavioral unit receive almost daily group music therapy intervention. Recreation, pet, and group therapy activities supplement the music, as part of the multidisciplinary rehabilitation program.

Adults with a variety of thought disorders, many with substance abuse problems, are housed in the 28-bed acute-care mental health facility. A range of experiences in this setting—percussion improvisation, group singing with lyric analysis, and songwriting—provide insight into patient emotion and behavior.

“I might ask a patient to select a percussion instrument that reflects how he feels and then prompt him to play that feeling, while the group follows and reflects the same musical expression.” Jackert explains. “Increased self expression and self awareness are observed as patients are given this non-verbal opportunity to express themselves, which is less threatening than a verbal interaction.”

Jackert says that many patients feel that music helps to decrease auditory/visual hallucination. “For patients with thought disorders, the music therapy experience provides a reality-based form of self expression and social interaction.”

Sherry Raley, MS, MT-BC, incorporates listening and performing elements in her music therapy programs at the Langley Porter Psychiatric Institute (San Francisco) and Gladman Mental Health Rehabilitation Center (Oakland).

Some of her patients have used songwriting to build frustration tolerance and problem solving skills. Ten patients in a sub-acute setting have prepared to transition into community living by composing songs with very personal lyrics.

“Important life skills—compromise/negotiation, management of feelings, and how to resolve disagreement—were learned though this songwriting experience,” Raley asserts.

Efficacy in senior care

“While developing a palliative care program, I read an article about using music to help dying patients,” says nurse-turned-music-therapist Mary Claire Mahoney. “The chaplain in our program liked the idea, so we got a boombox and a few tapes and offered music to patients in intensive care units.”

Mahoney, RN, MS, MT-BC, conducts weekly group sessions with senior citizens in nursing homes and assisted-living facilities in California. She uses the power of reminiscence to open a dialogue with her patients and encourage participation with her performances on guitar and dulcimer. Patients use egg shakers and percussive instruments to promote sensory stimulation and gross motor movement through mild exercise. They also experience heightened socialization and memory recall.

At San Diego Hospice and Palliative Care, Sharon O’Mary, RN, MN, says that music interaction with patients referred to the music therapy program is built right into the plan of care. It’s been very effective for patients experiencing deep emotional conflict or agitation. “Goals are very individualized,” says O’Mary; “life review, relaxation, stimulation, symptom management, a connection for [those who feel] isolated.”

Use with pediatric and short-term patients

Laurel Terreri, MT-BC, works at Orthopaedic Hospital in Los Angeles. Her challenge is to design a music therapy program for patients who are in the facility for brief periods. “When I meet patients for the first time, I must immediately decide if they are a candidate for an individualized music program—songwriting or beginning piano and guitar lessons or group music therapy—or if they just need supportive music like singing or listening,” she says.

Although most of Terreri’s patients are short term, she works with five toddlers on a weekly basis. These patients were initially treated for cleft palate and now receive ongoing speech-based music sessions designed to increase verbal skills and communication.

The children’s mothers have noted significant improvement at home. One of Terreri’s young patients, previously non-verbal, now imitates excerpts from his favorite songs at home. “I view these small steps as major accomplishments,” Terreri says proudly.

Music programs without MT-BC professionals

Marion Silverbear, music program coordinator at Stanford Hospital feels no competition toward music therapists.

“I have no formal background in music, but [I have] a great love and appreciation for many different kinds of music and the profound effect it has on human beings, particularly in healthcare settings,” Silverbear says.

For the past four years, she has coordinated ongoing musical programs throughout the facility. “Music allows relaxation into a deeper, calmer place—a smile or tears transforming a patient’s face when they hear a beloved song, a sigh or relief when hearing an adagio,” she says.

With the help of a few volunteers, Maureen Draper, pianist, teacher, and author of the book The Nature of Music: Beauty, Sound, and Healing (Riverhead Books, 2001), administers Stanford Hospital’s “CDs on the Units” program. Armed with recordings and portable CD players, Draper and team make daily hospital rounds.

“I try to match the music with the patient’s needs by asking what type of music they associate with happy times or if they need soothing or stimulating energy,” Draper explains. “Even when patients don’t want music, they feel grateful and cared-for when we offer it.”

Structured music therapy versus passive listening

Articles in the Journal or Music Therapy, Music Therapy Perspectives, and other scholarly journals report positive physiological and psychological changes in patients after music therapy intervention. An equal number of studies can be found in the literature that point to positive patient results after unstructured, passive listening. To date, there appears to be little effort to differentiate the effectiveness of the two activities.

Michael Silverman, MM, MT-BC, Austin State Hospital, Texas, was dissatisfied with the findings of his recent research, reported in the Spring 2003 issue of the Journal of Music Therapy. Silverman found that music was effective in suppressing the symptoms of psychosis, but that there was no statistically significant difference in patients using passive listening versus structured music therapy.

“Anyone can hit ‘play’ on a CD player, but not everyone can sing and play an instrument in a structured therapy session,” he told Nurses World Magazine. “Many times my psychiatric clients view me as musician first, and therapist second, which enables me to instantly establish a positive rapport, thus opening the door for the therapeutic process to begin.”

“If listening to music were just as effective as music therapy interventions, music therapists would become obsolete,” Silverman notes. “Since music is effectively used by many professionals, music therapists need to further define their unique contributions.”

MT and the future

“Music offered informally is wonderful, but it is not music therapy,” insists Sherry Raley. “In a therapeutic setting, the music therapist synthesizes and uses knowledge about patient population, psychology, music, and psychology of music to facilitate the patient’s psychological process through music.”

Without incontrovertible proof of the therapy’s effectiveness, Raley’s argument may be difficult to make to budget directors in California’s fiscally constrained healthcare system. Still, Barbara Reuer says music therapists provide benefits that music performers or passive listening activities cannot emulate. “I would go so far as to say that hospitals shouldn’t hire musicians to provide music therapy as treatment unless they are board certified or supervised by a board-certified music therapists.”

Whether the results of future research will strengthen the role of music therapists in the clinical setting is unknown. For the moment, it is reasonable to speculate that the contributions theses practitioners make to the patient experience would, if withdrawn, be sorely missed.   [ end ]