LITERATURE REVIEWS

An overview of music therapy research

D. Aldridge

Institutefor Music Therapy, University of Witten Herdecke, Germany

SUMMARY. There is a broad literature covering the application of music therapy, but a general
absence of valid clinical research material from which substantive conclusions can be drawn.
Group creative music therapy in psychiatric hospitals reflects the acceptance of the creative arts
therapies themselves in such settings. Receptive taped music, used as an anxiolytic for individual
patients, has found favour particularly in coronary care units and in cancer pain care. Music
therapy with adults and children is seen as part of a necessary creative arts environment within
hospital settings for the management of the mentally handicapped of varying ages. Music ther-
apy is accepted as a valid therapeutic treatment for children.
Observations in the reahn of psychotherapy highlight a critical feature of music therapy
research; well intentioned, and often rigorous work, is spoiled by a lack of research methodol-
ogy. Music therapy clinical research needs to develop a common methodology such that standard
research tools and methods of clinical assessment be developed which can be replicated, which
are appropriate to music therapy itself and develop a link with other forms of clinical practice.
The research which has been produced is notably lacking in follow-up data, without which it
is diflicult to make valid statements about clinical value.

INTRODUCTION University-based teachers, are demanding that the pro-

Like other therapies complementary to medicine, music
therapy has been widely practised throughout Europe
and North America. Until recently there has been no
established research tradition, partly because the pro-
fession of music therapy is itself new, the practi-
tioners themselves have no academic background of
research training, a research qualification would bring no
advancement within the profession, and there are sev-
eral streams within the movement itself based on vary-
ing principles of practice which have led to little con-
census about practice, let alone research. Nevertheless,
a new generation of practitioners, often established as
fession receive academic and professional acknowledge-
ment within the community of professional health carers
and urging co-operation in teaching initiatives, and the
common requirements of training. They are also propos-
ing joint research doctoral study programmes.
There are two principal ways of doing music therapy:
‘active music therapy’ which requires that the patient,
or a group of patients, play musical instruments, or sing,
with the therapist; and, ‘passive music therapy’ whereby
the patient, or a group of patients, listen to the thera-
pist who plays live, or recorded music to them. In active
music therapy, the music is often improvised to suit the
individual patient. In passive music therapy the music

David Aldridge PhD, Professorof Clinical Research Methods, University of W&ten Herdecke, Faculty of Medicine, AlfmLHemnhausen-Strasse
50, D-58448, Witten, Germany.

204

is often chosen to suit particular patients. Within each
of these two main approaches, there are varying schools
throughout the Western world, some based on the work
of particular teachers, and some more eclectic and based
on psychotherapeutic approaches.
Earlier papers have suggested that a common language
should be negotiated between those involved in the cre-
ative arts therapies12 so that common experiences can be
united into a single stronger voice. One step forward in
negotiating that language is to establish procedures and
methods of research.%5An aspect of any such research is
to find out what has gone before and this paper presents
a general overview of music therapy research as it has
been published in medical journals.
MUSIC THERAPY IN THE HOSPITAL
Music therapy has been reviewed in the medical and
nursing press; the principle emphasis is on the soothing
ability of music and the necessity of music as an antidote
to an overly technological medical approach. Most of
these articles are concerned with passive music therapy
and the playing of prerecorded music to patients empha-
sising the necessity of healthy pleasures like music, fra-
grance, and beautiful sights for the reduction of stress
and the enhancement of well-being. The overall expec-
tation is that the recreational, emotional and physical
health of the patient is improved.6
After the Second World War music therapy was inten-
sively developed in American hospitals.7 Since then
some hospitals, particularly in mainland Europe, have
incorporated music therapy carrying on a tradition of
European hospital-based research and practice.113
Psychiatry and psychotherapy
Continental Europe has encouraged the use of music par-
ticularly in terms of individual and group psychother-
apy to encourage awakening of the patients’ emotions,
and in helping them cope with unconscious intrapsy-
chic conflicts.a-16 It is difficult to assess the value of
this work as the variables measured and the outcomes
described often bear little relationship to each other.
Schizophrenia
Schizophrenia has been the subject of varying studies in
applied music therapy.l5J7-20
A little over 40 years ago psychotic patients were
being treated with cold wet sheet packs in tubs of water,
as well as listening to music. The conclusion was that
overall the presence of music in the hydrotherapy room
was beneficial!21 While modem music therapy tech-
niques may seem less drastic in application, the difficulty
of researching into the treatment of schizophrenic and
psychotic patients remains. Pfeiffer’s study 15highlights
An overviewof music therapy research 205
such difficulties. First, it was difficult to find match-
ing groups of acute psychotic patients using the param-
eters of age, syndrome, and diagnosis which were not
complicated by other problems (e.g. alcohol or drug
related). Secondly, these patients were also being han-
dled using particular psycho-medication which itself
introduced variability. Thirdly, the patients themselves
were prone to crises which necessitated a change in
their handling, which could also mean a change in
medication. As the patients were being treated over a
period of 27 weeks, it might have been foreseen that
by the very nature of acute psychosis there would be
predictable crises. Fourthly, all the patients improved,
including those on the control waiting list, as the psy-
chotherapeutic support services in the area of Munich
were favourable for helping such patients. With only
14 patients it was difficult to reach a conclusion about
the value of the music therapy, as the treated patients
on follow-up had gradually deteriorated in functioning
towards their original scores. It is clear that with psy-
chotic patients, no matter how apparently effective the
music therapy, their health does not survive the test of
daily living and the temptations of normal life. One of
the subjects who appeared to be improving received a
letter from her divorced husband thus precipitating a cri-
sis. Another patient went on a weekend drinking spree.
Within recent years researchers have attempted to
understand the musical production of schizophrenic
patients in terms of emotional response.22 The underly-
ing reasoning in this work is (i) that to produce music
depends upon the mastery of underlying feelings, and
(ii) in psychiatric patients musical expression is neg-
atively influenced by the disease. Steinberg and col-
leagues found that in the musical playing of endogenous-
depressive patients there were weakened motoric qual-
ities influencing stability and rhythmicity, while manic
patients also exhibited difficulties in ending a phrase
with falling intensity. Tempo appeared uninfluenced by
depression, but was susceptible to the influence of med-
ication. Schizophrenic patients exhibited changes in the
dimensions of musical logic and order.
More recently Pavlicevic and Trevarthenta have com-
pared the musical playing of 15 schizophrenic patients,
15 depressed patients, and 15 clinically normal controls.
Significant differences in musical interaction between
therapist and patient were found between the groups
on a self-developed scale to test musical interaction.
Schizophrenic patients appeared musically unresponsive
and idiosyncratic in their playing. Depressed patients
appeared to make fewer initiatives in the music although
it was possible for the therapist to make contact with
them. Controls were able to enter into a musical part-
nership with the therapist and take musical intitiatives.
The lack of reciprocity from the schizophrenic patients
seemed to be the factor which prevented contact and
thereby disturbed communication.
206 ComplementaryTherapies in Medicine: Literaturereviews
Adolescent psychiatry
Group music therapy is the principle music therapy
approach to the treatment of adolescent problems27 as
it encourages spontaneous activity, motivates the client’s
response and fosters a culture of free expression,28 moti-
vates deviant adolescents to take part in the necessary
psychotherapy which they need to resolve their crises of
identity.29 or acts as a bridge to reach ‘highly resistant’
adolescents enabling them to communicate their feelings
about their roles in society, to express their opinions non-
aggressively and to listen to others.29-31 In this sense
music is an aid to articulacy, self expression and com-
munication in a context of psychotherapy for adolescents
who are too old for play therapy.33
Culture
Most of the references to the use of music therapy in
medicine are predominantly Western, although the use of
music as a therapeutic medium is found in most cultures.
‘Iwo papers33134describe the use of music in African
hospitals, both locating the use of music within a cul-
tural context, and combining this music with drama and
dance. As in other group therapy methods, music is used
as a vehicle to reach those who are isolated and with-
drawn and reintegrate them into social relationships.
In South Africa33 the group consists of about 100
female patients sitting in a circle directed by a doctor.
Music, though increasing tempo in singing and dancing,
is used as an activator for the psychodrama techniques
of Moreno.
A Tunisian approach is far more radical in terms
of psychiatry. Through ‘art group therapy’34 utilis-
ing dance, painting, therapy using clay, role play and
singing, patients are encouraged to integrate personal
experiences and emotions within a social context of rela-
tionships. The explanatory principle behind this work is
that of ‘the door’, whereby fixed barriers between expe-
riences are broken down, but the concept of threshold
between experiences remains and attempts to establish a
meaningful relationship between the inner rhythms of the
body, outer rhythms of personal interaction, and broader
patterns of cultural activity.
Rehabilitation
Strategies for rehabilitating psychiatric patients using
group and family approaches are not solely confined
to African traditionsleJ6-39 and music therapy has a
broad base within the tradition of psychiatric and gen-
eral rehabilitation.10,13,15.40-43
Haag”945 discusses theories including psychological
factors involved in the development of, and coping with,
disability. Psychological intervention approaches are set
out, focusing on their particular relevance to rehabilita-
tion. Music therapy is also recommended for the rehabil-
itation of patients who have difficulty in expressing their
feelings and communicating with others.
Psychosomatics
Where both physical and mental processes overlap
within medicine, i.e., the field of psychosomatics, then
individual and group music therapy appears to play an
important role.
Multiple sclerosis is a chronic neurological disease
of unknown origin which can result in severe neuro-
psychological symptoms. Difficulties of anxiety, resig-
nation, isolation and failing self-esteem seen in this dis-
ease are not easily relieved by symptom orientated med-
ication or physiotherapy. Lengdobler and KiesslinglJ set
out to treat 225 patients with multiple sclerosis with
group music therapy over a 2-year period. Each treat-
ment period lasted for 4-6 weeks. A further part of
their work was to discover the musical parameters of
the playing of such patients using methods which were
based on active improvisation: group instrumental play-
ing, singing, listening and free-painting to music, Unfor-
tunately, the size of the groups is not recorded, patient
attendance at the groups was uncontrolled and the reports
made by the patients were unstructured. Those reports
which are published are vague and general, highlighting
the need for rigorous research design with an underly-
ing structure to display what may be valuable work at
its best.
Music therapy has been used in the reduction of
rheumatic pain in antiquity,& and latterly with the
emphasis on emotional relief and rehabilitation.
ELDERLY
Music therapy has been suggested as a valuable part
of a combined treatment policy for the elderly.47 Cer-
tainly the anecdotal evidence suggests that quality of life
of Alzheimer’s patients is significantly improved with
music therapy4*, accompanied by the overall social ben-
efits of acceptance and sense of belonging gained by
communicating with others@. PrinsleySn recommends
music therapy for geriatric care in that it reduces the indi-
vidual prescription of tranquilising medication, reduces
the use of hypnotics on the hospital ward, and helps over-
all rehabilitation. He recommends that music therapy be
based on treatment objectives; the social goals of interac-
tion cooperation; psychological goals of mood improve-
ment and self-expression; intellectual goals of the stim-
ulation of speech and organisation of mental processes;
and the physical goals of sensory stimulation and motor
integration. Such approaches also emphasise the bene-
fit of music programs for the professional carers51 and

families of elderly patients.
MUSIC THERAPY, HEART RATE AND
RESPIRATION
The effect of music on the heart and blood pressure
has been a favourite theme throughout history. In an
early edition of the medical journal L.uncet~2an attempt
was made to discover the influence on blood pressure
of listening to music on the gramophone and radio.
The effects of music were influenced by how much the
subjects appreciated music. Differing groups of musical
competence responded in relation to volume, melody,
rhythm, pitch and type of music. Interest in the music
was an important factor influencing response. Melody
produced the most marked effect in the musical group.
Volume produced the most apparent effect in the mod-
erately musical group.
Basons3 found that the human heart rate could be. var-
ied over a certain range (an increase or decrease of up to
12% over a period of up to 3 min) by playing an audi-
ble click to the subject at a precise time in the cardiac
cycle. Fluctuations caused by breathing remained, but
these tended to be less when the heart was entrained with
the audible stimulus. When the click was not within the
time range of the cardiac cycle then no influence could
be made.
Haas and her colleagues54 also investigated the effects
of perceived rhythm on respiratory pattern, hypothesiz-
ing that listening to taped music would have an influence
on respiratory pattern. 20 subjects were randomly pre-
sented with 4 musical excerpts, and a period of silence,
to which they tapped along. There were no appreciable
changes in heart rate during the experiment, but there
was an appreciable change in respiratory frequency and
a significant decrease in the coefficient of variation for
all respiratory parameters during the finger tapping.
Auditory cues, then, appear to be important in the
synchronization of respiration and other motor activity.
This finding supports other evidence linking a decrease
in muscle activity while performing a motor task accom-
panied by a musical rhythm; 55 that respiratory rhythm
follows that of music within certain limits of variability;
and that there is a relationship between disturbed func-
tional cardiac arrythmias and musical rhythmic ability.
Richter and Kay&6 hypothesised that patients with
cardiac arrhythmias perform worse in rhythm percep
tion and production than healthy controls. 31 patients
with functional cardiac arrythmias were compared with
31 control subjects. Subjects were required to mark on
a sheet of paper rhythmic patterns which were played to
* BeethovenSymphony Nr.6 (first movement); Mozart, Eine kieine Nachtmusik (first and fourth movements) and Snwana, ‘Ihe. Moldau.
“Bach, brgo; Beethoven, Large; Debussy, Prelude to the Afternoon of a Faun.
An overviewof music thempy research 207
them by a taperecorder, and to tap synchronously with
repeating patterns from a taperecorder. Patients with dys-
rhythm& have significantly poorer abilities in musical
perception and rhythmic anticipation than healthy con-
trols. Patients with tachycardia show a particularly poor
sense of rhythm perception and synchronisation.
Coronary care
A hospital situation which is fraught with anxiety for
the patient is the intensive care unit. For patients after
a heart attack, where heart rhythms are potentially
unstable, the setting of coronary care is itself anxiety-
provoking, which recursively influences the physiologi-
cal and psychological reactions of the patient. In these
situations several authors, in varying hospital intensive
care or coronary care clinics, have assessed the use of
tape recorded music delivered through headphones as
an anxiolytic with the intention of reducing stress.43~57
Bonny58-60 has suggested a series of musical selections
for tape recordings which can be chosen for their seda-
tive effects and according to other mood criteria, asso-
ciative imagery and relaxation potential;61 none of which
has been empirically confirmed although Updike, in
an observational study, confirms Bonny’s impression that
there is a decreased systolic blood pressure, and a ben-
eficial mood change from anxiety to relaxed calm when
sedative music is played.
Davis-Rollan@ describes the use of a 37-min tape
recording of selected classical music* on the heart rate
and rhythm of coronary care unit patients. 12 of the
patients had experienced heart attacks and another 12
had a chronic heart condition. Patients were exposed to
2 randomly varied 42-min periods of continuous mon-
itoring: 1 period with music delivered through head-
phones, the other control period was without music
and contained background noise of the unit as heard
through silent headphones. 8 patients reported a signif-
icant change to a happier emotional state after listening
to the music although there were no significant changes
in specific physiological variables during the music peri-
ods. A change in mood, however, which relieves depres-
sion is believed to be beneficial to the overall status of
coronary care patients.63
Bolwerku set out relieve the anxiety state of patients
in a myocardial infarction ward using recorded classical
music.** 40 adults were randomly assigned to 2 equal
groups; 1 of which listened to relaxing music during
the first 4 days of hospitalisation, the other received no
music. There was no controlled ‘silent condition’. While
there was a significant reduction in anxiety state in the
208 Complementary Therapies in Medicine: Literature reviews
treatment group, this was also reduced in the control
group. The reasons for this overall reduction in anxiety
may have been that after 4 days the situation had become
less acute, and not so strange for the patient, and by then
a diagnosis had been confirmed.
The purpose of a study by Guzzetta65 was to deter-
mine whether relaxation and music therapy were effec-
tive in reducing stress in patients admitted to a coro-
nary care unit with the presumptive diagnosis of acute
myocardial infarction. In this experimental study, 80
patients were randomly assigned to a relaxation, music
therapy, or control group. Music therapy consisted of
a relaxation induction and listening to a 20-min musi-
cal cassette tape selected from 3 alternative musical
styles; soothing classical music, soothing popular music,
and non-traditional music.65 Stress was evaluated by
heart rates, peripheral temperatures, cardiac complica-
tions, and qualitative patient evaluative data. The inci-
dence of cardiac complications was found to be lower in
the intervention groups, and most intervention subjects
believed that such therapy was helpful. Both relaxation
and music therapy were found to be effective modalities
of reducing stress in these patients, and music listening
was more effective than relaxation alone. Furthermore,
apical heart rates were lowered in response to music over
a series of sessions thus supporting the argument that the
assessment of music therapy on physiological parameters
is dependent upon adaptation over time.
This positive finding above was in contrast to
Zimmerman66 who failed to find an influence of music
on heart rate, peripheral temperature, blood pressure, or
anxiety score.
Given that Bason’s study53 could influence heart rate
by matching the heart rate of the patient, we must con-
clude that studies of the influence of music on heart rate
must match the music to the individual patient. This also
makes psychological sense as different people have var-
ied reactions to the same music. Furthermore, impro-
vised music playing which takes meeting the tempo of
the patient as one of its main principles, may have an
impact other than the passive listening to music. In addi-
tion, the work of Haas mentioned above showed that
listening, coupled with tapping, synchronizes respiration
pattern with musical rhythm, further emphasising that
active music playing can be used to influence physio-
logical parameters and that this synchronization can be
learned.
Breathing
The relationship between listening to music and changes
in respiration has also been investigated in situations
other than coronary care.9$6749
Fried7n presents a general overview of music as it is
integrated in breathing training and relaxation. Breath-
ing training itself is believed to have a physical benefit
in increasing tidal volume without excessive loss of CO2
(hypocapnia). Typically anxious patients have relatively
rapid shallow chest breathing and may hyperventilate.
However, music appears to have a paradoxical effect:
while subjects report music to be highly relaxing, sooth-
ing and sedative, their physiological reactions indicate
otherwise.
Music and breathing have been used to induce alterna-
tive states of consciousness and Fried’s paper correlates
the characteristics of consciousness and the role of music
in altering those states, and the qualities of music which
can be used to invoke calm and inner peace.71 Nurs-
ing approaches have also utilised the anxiolytic effect of
music in combination with massage and breathing exer-
cises to relax patients.72173
The ability of music to induce calm and well-being has
been used in general anaesthesia.74 Patients express their
pleasure at awakening to music in the operating suite60
where music is played openly at first, and then through
earphones during the operation.
CANCER THERAPY, PAIN MANAGEMENT
AND HOSPICE CARE
In the Supportive Care Program of the Pain Ser-
vice to the Neurology Department of Sloan-Kettering
Cancer Center, New York, a music therapist is part
of the supportive team along with a psychiatrist,
nurse-clinician, neuro-oncologist, chaplain, and social
worker.75976Music therapy is used to promote relax-
ation, to reduce anxiety, to supplement other pain con-
trol methods and to enhance communication between
patient and family. 77178As depression is a common fea-
ture of the patients dealt with in this programme, music
therapy is hypothetically an influence on this parame-
ter and in enhancing the quality of life, Although qual-
ity of life has assumed a position of importance in can-
cer care in recent yearslQ79-81 and music therapy, along
with other art therapies, is thought to be important, the
evidence for this belief is largely anecdotal and unstruc-
tured. Bailey75 discovered a significant improvement in
mood for the better when playing live music to cancer
patients as opposed to playing taped music which she
attributes to the human element being involved.
A better researched phenomenon is the use of music
in the control of chronic cancer pain, although such
studies abdicate the human element of live perfor-
mance in favour of tape recorded interventions. Com-
binations of pharmacological and non-pharmacological
pain management are acceptable in modern medicine
with non-pharmacological interventions offering a form
of distraction.82
Such diversion from attention to pain was the sub-
ject of a study by Zimmerman83 who investigated the
influence of playing preferred taped music, combined
with suggestion, on a controlled sample of patients suf-
fering with chronic pain. The objective of the study
was to determine the self-reported relief obtained by

patients receiving pain-medication where the blood level
of analgesic was controlled. Music was found to decrease
the overall level of the pain experience as reported by
patients randomly assigned to the music treatment group.
Furthermore, the sensory component, as well as the
affective component, of the pain as measured by the
McGill Pain Questionnaires4 was significantly reduced
for patients who listened to music. Not only was suffer-
ing as an emotional experience reduced, the actual sen-
sation of pain was experienced as reduced. This would
appear to confound the common belief that music ther-
apy is primarily an intervention based upon qualitative
emotional experiences, and support the contention that
music therapy also has a direct influence upon sensory
parameters.
In addition to reducing pain, particularly in pain clin-
ics, 85-88 music as relaxation and distraction has been
tried during chemotherapys9, to bring overall reliePu
and to reduce nausea and vomiting.91 Using taped music
and guided imagery in combination with pharmacolog-
ical anti-emetics, Frank91 found that the anxiety state
was significantly reduced resulting in a perceived degree
of reduced vomiting, although the experienced nausea
remained the same.
NEUROLOGICAL PROBLEMS
In many cases neurological diseases become traumatic
because of their abrupt appearance resulting in physi-
cal and/or mental impairment.37 Music appears to be a
key in the recovery of former capabilities in the light
of what at first can seem like hopeless neurological
devastation.92-94
For some patients with brain damage following head
trauma, the problem may be temporary resulting in the
loss of speech (aphasia). Music therapy can play a valu-
able role in the aphasia rehabilitation.95 Melodic Into-
nation Therapy%*97 has been developed to fulfil such a
rehabilitative role and involves embedding short propo-
sitional phrases into simple, often repeated melody pat-
terns accompanied by finger tapping. The inflection pat-
terns, of pitch changes and rhythms of speech, are
selected to parallel the natural speech prosody of the
sentence. The singing of previously familiar songs is
also encouraged as it encourages articulation, fluency
and the shaping procedures of language which are akin to
musical phrasing. In addition, the stimulation of singing
within a context of communication motivates the patient
to communicate and, it is hypothesized, promotes the
activation of intentional verbal behaviour.
Jacomegs tells of a stroke patient who was dysflu-
ent and had difficulty finding words. Yet, ‘. . . he fre-
quently whistled instead of attempting to answer with
phonemes . . . he spontaneously sang Spanish songs with-
out prompting with excellent pitch, melody, rhythm,
lyrics and emotional intonation, he could tap, hum, whis-
tle and sing along . . . Emotional intonation of speech
An overview of music therapy research 209
(prosody), spontaneous facial emotional expression, ges-
turing and pantomimia were exaggerated’ (~309). From
this case study Jacome goes on to recommend that
singing and musicality in aphasics be tested by clini-
cians, a point also recommended by Morgan9 in terms
of aphasia following stroke.
Evidence of the global strategy of music processing in
the brain is found in the clinical literature. In 2 cases of
aphasia99 singing was seen as a welcome release from
the helplessness of being a patient. The author hypothe-
sized that singing was a means to communicate thoughts
externally. Although the ‘newer aspect’ of speech was
lost, the older function of music was retained possi-
bly because music is a function distributed over both
hemispheres. BermantOO suggests that recovery from
aphasia is not a matter of new learning by the non-
dominant hemisphere, but a taking-over of responsibil-
ity for language by that hemisphere. The non-dominant
hemisphere may be a reserve of functions in case of
regional failure indicating an overall brain plasticity,97
and language functions may shift with multilinguals as
compared with monolinguals,lul, or as a result of learn-
ing and cultural exposure where music and language
share common properties.102
That singing is an activity correlated with certain cre-
ative productive aspects of language is shown in the
case of a 2-year-old boy of above-average intelligence
who experienced seizures, manifested by tic-like turning
movements of the head, which were induced consistently
by his own singing, but not by listening to or imagining
music. His seizures were also induced by his recitation
and by his use of silly or witty language such as pun-
ning. Seizure activity on an EEG was present in both
temporocentral regions, especially on the right side, and
was correlated with clinical attackstO
Aphasia is also found in elderly stroke patients and
music therapy, as reported in case studies, has been used
effectively in combination with speech therapy.104
Gustorfflu5 has successfully applied creative music
therapy to coma patients who were otherwise unrespon-
sive. Matching her singing with the breathing patterns of
the patient she has stimulated changes in consciousness
which are both measurable on a coma rating scale and
apparent to the eye of the clinician.
MENTAL HANDICAPPED ADULTS AND
CHILDREN
Music appears to be an effective way of engaging pro-
foundly mentally handicapped adults in activity.*wt@i
The functional properties of music have implications
for the treatment of the mentally handicapped in that:
(i) Exposure to sound arouses sensory processes.
(ii) A musical event is an organized temporal auditory
structure with a beginning and an end.
 210 Complementary Therapies in Medicine: Literature reviews
(iii)Music facilitates memory recall and expectation (the
signature tune effect).
(iv) A sequence of musical themes can enhance memory
recall and the organization of a sequence of cognitive
activities.1 lrJ
Much of modem music therapy was developed in
working with handicapped children,l*lJ12 and the diver-
sity and richness of this work is reflected in several
papers.tlJ-116
Stem117 emphasises the importance of the creative
arts in general to child development as they involve the
child’s natural curiosity. However, she also proposes that
in terms of child development therapies must involve
the family of the child, particularly in the case of child
disability. For children with multiple disabilities there
is need for stimulation, and this can be achieved using
music which also provides a sense of fun and enjoyment.
Songs, both composed and improvised, provide the
vehicle for working with hospitalized children, in the
pre-operative preparation of children in an attempt to
relieve fear and anxiety by transmitting surgery-related
information,lt4 and in working with terminally ill hos-
pitalized children.l*a
In a general study of music therapy as applied to new-
borns and infants in hospital,*15 music appeared benefi-
cial as a calming effect inducing sleep and relaxation.
The methods ranged from simple tapping on the back to
simulate a heartbeat, through rocking of children in time
to played music, to receptive music therapy.
Creative expression is generally accepted as a means
of coping whereby pain and anxiety are channelled into
activities.119 In an attempt to encourage children to cope
with the trauma of hospitalization by verbalizing their
experiences, Froehlich*ts compared the use of play ther-
apy and music therapy as facilitators of verbalization.
When specifically structured questions about hospitaliza-
tion were asked of the children after sessions of music
therapy or play therapy, music therapy elicited more
‘answers’ than ‘no answers’, and a more involved type
of verbalization involving elaborated answers, than play
therapy.
Autism
Music therapy allows children without language to
communicatet20 and has developed a significant place
in the treatment of mental handicap in children.121~124
Children exhibiting autistic behaviour appeared to pre-
fer a musical stimulus rather than a visual stimulus when
compared with normal children and appear to listen to
music longer than their normal peers who prefer visual
displays.12sJ26 Thaut*27 also found that children with
gross motor dysfunction performed significantly better
motor rhythm accuracy when aided by auditory rhythm
and rhythmic speech.
CONCLUSION
While there is a broad literature covering the application
of music therapy as reported in the medical press, there
is a general absence of valid clinical research material
from which substantive conclusions can be drawn. How-
ever, some studies of applied music therapy are appear-
ing in the medical literature. Group creative music ther-
apy in psychiatric hospitals (Table 1) appears to reflect
the acceptance of the creative arts therapies themselves
in such hospital settings. Receptive taped music, used as
an anxiolytic for individual patients, has found favour
particularly in coronary care units (Table 2) and in can-
cer pain care (Table 3). Surprisingly music therapy with
handicapped adults and children is not extensively repre-
sented in the medical literature, although general reports
emphasise the necessity of a creative arts environment
within general hospital settings for the management of
the mentally handicapped of varying ages. It could well
be that music therapy is accepted as a valid therapeu-
tic treatment for children and requires no further scien-
tific investigation to support its incorporation as part of
a treatment plan. However, there are grounds for devel-
oping validated studies to investigate the stages of chil-
dren’s musical development as it is correlated with their
social, emotional and physical development.128
The obscure observations in the realm of psychother-
apy highlight a critical feature of music therapy research;
well intentioned, and often rigorous work, is spoiled by
a lack of research methodology. This is not to say that
all music therapy clinical research should conform to a
common methodology, or that it be medical research;
rather that standard research tools and methods of clin-
ical assessment be developed which can be replicated,
which are appropriate to music therapy,129 and develop
a link with other forms of clinical practice. The research
which has been produced is notably lacking in follow-up
data, without which it is impossible to make any valid
statements about clinical value. The assessment instru-
ments are generally lacking by which internal or external
validity can be conferred.
Much of the research work has been developed within
the field of nursing where the use of music is accepted as
a useful therapeutic adjunct. Not surprisingly, the work
from this field has concentrated on medical scientific per-
spectives. There is almost a complete absence of cross-
cultural studies, or the use of anthropological methods
which would bring other insights into music therapy.
That music has been used therapeutically in other cul-
tures cannot be denied, and other perspectives regarding
the application of music therapeutically would highlight
the limitations of modern Western scientific approaches
when used as the sole source of research methodology.
While the influence of music on physiological param-
eters (i.e., heart rate and breathing) is evident, it is diffi-
cult to find any work referring to the influence of music
therapy on immunological parameters. Apart from the
Table I. Research studies using music therapy in psychiatry and psychotherapy as reported in the medical literature

Author and date Typeofpatientand Ageaud Typeof~- Independent Dependent variables Type and function of music Results
reaearcll lecanon gender search design variables

Courtright, Johnson, Chronic psychiatric Mean age 55, ABAB with 2 Music/no music Observed behavioural targets; Group receptive; composed Incidents of disruptive
Baumgartner, Jordan inpatients in the all male groups disruption, swearing and taped music for listening, to behaviour reduced with the
& Webster(1990)’ cafeteria of a pushing facilitate relaxation introduction of music, and
psychiatric hospital increased when music was
N=109 withdrawn
Mescbede, Bender & Chronic schizo- Mean age 35; Observational Active music making Behavioural observations Group active; to promote Patients report improved
Pfeiffer (1983)a phrenic patients in a 5 male, 4 female study using a scored questionnaire; communication and stimulate motivation, elevated mood
psychic hospital self-report using a scored mood and positive feeling of joint
N=9 questionnaire responsibility
Schmuttermayer Chronic schizo- 10 adults: female Observational Instrumental music/ ‘Anxiety’ and activity’ Group active and passive: to Art therapies have differing
(1983)’ phrenic patients in a study dancing/ singing/ behaviourai observations stimulate, promote effects; communication is
psychiatric hospital listening using a scored questionnaire; communication and as an improved, instrumental
N= 10 self-report using an adjective anxiolytic playing enhances activity,
list singing reduces anxiety
Reinhardt, Ficker Depressed patients Observational Receptive music Behaviouml observations ‘Regulative’ music therapy Patient gains a conscious
(1983)‘) in a psychiatric study for the stimulus of mood perception of emotions
hospital leadiig to a rational
confrontation with self
Pfeiffer, Wunderlich, Psychotic and Mean age 30 Matched Therapy proup/ Behavioural observations Improvised group therapy to Inconclusive study, all
Bender, Elz & Horn schizophmnic (21-42) years; controwwaiting waiting group using a scored questionnaire; stimulate communication patients benefited but no
( 1987)e outpatients in a 8maleand list; 2 groups self-report using a scored improvement in social and
psychiatric hospital 8 female questionnaire recreational behaviour
N=16
Paviicevic & Trevarthen Depressed and 24maleand21 Controlled Schizophrenia, Behavioural observations; Individual, improvised music Significant difference
(1989f schizophrenic female patients depression or normal index of musical playing and between the playing of
patients in a aged 17-55 years 3 groups control contact between patient and and emotional expression schizophrenic and depressed
psychic hospital therapist in the musical patients and controls
N=45 playing
Lengdobler & Kiessling Multiple sclerosis 62 male and 163 Observational Music Self-report, UllStNCtUEd Active group improvisation Music therapy provides
(1989)s patients in a hospital female adults study interview of communication, using mixed medii to general psychological support
setting N = 225 aged 1-8 years mood and anxiety stimulate cormnunication and and possibly a useful coping
using music as an anxiolytic strategy

‘Courtright P, Johnson S, Baumgartner M, Jordan M, Webster J. Dinner music: does it affect the behavior of psychiatric inpatients? J Psychosoc Nurs Ment Health Serv 1990; 28 (3): 37-40.
?vleschede H, Bender W, Pfeiffer H. Music therapy with psychiatric problem patients. Psychother Psychosom Med Psycho1 1983: 33 (3): 101-l 16.
cSchmuttermayer R. Possibilities for inclusion of group music therapeutic methods in the tmatment of psychotic patients. Psych&r Neuroi Med Psycho1 Lcipz 1983; 35 (1): 49-53.
dReinhardt A, Ficker F. Initial experiences with regulative music therapy in psychiatric patients. Psych&r Neuml Med Psycho1 L.eipz 1983; 35 (10): 604-610.
?feiffer H, Wunderlich S, Bender W, E3z U, Horn B. Music improvisation with schizophrenic patients - a controlled study in the assessment of therapeutic effects. Rehabilitation Stuttg 1987; 26 (4): 184-192.
‘Pavlicevic M. Trevarthen C. A musical assessment of psychiatric states in adults. Psychopathology 1989; 22 (6): 325-334.
%ngdobler H, Kiesshng W. Group music therapy in multiple sclerosis: initial report of experience. Psychotbsr Psychosom Med Psycho1 1989; 39 (9-10): 369-373.
Table 2. Research studies using music therapy in coronary care as reported in the medical literature

Author and date Type of patient and Age and gender Type of re- Independent Dependent variables Type and function of music Results
reaearcb location search design variables

Bolwerk ( 1990)’ Myocardiai Mean age 59 Random&d Music/no music Psychological; state anxiety Receptive taped music as Anxiety reduced in both
infarction patients in (33-79); 27 male control; 2 groups measured by validated anxiolytic groups but significantly
intensive care and 8 female questionnaire and structured lower in the music treatment
N=35 self-report group post-test
Davis-Rollans & Coronary care Mean age 62 Controlled Music/silence Physiological measures and Receptive taped music as No significant change in
Cunningham ( 1987)b patients in coronary (45-7.5); 19 male comparison; psychological observations anxiolytic heart rate; a significant
cm unit and 5 female 2 groups including structured change in mood to a
N=24 self-report ‘happier’ state and relief of
depression
Acute myocardial Mean age 57 Random&d Music, relaxation Physiological measures and Receptive taped music as Music therapy effective for
infarction in (36-71); all male control; 3 groups and control psychological observations relaxation lowering apical heart rate;
coronary care unit including structured significant difference
N=80 self-report compared with control
Updike ( 1990)d Intensive care Aged 25-60 Pm-test; post- Music Physiological measures and Receptive taped music as Reduces anxiety, promotes
patients in an years; all male test observation psychological observations anxiolytic calm, diminishes pain
intensive care unit including structured
N=20 self-repolt
Zimmerman, Pierson & Myocardial Mean age 65 Randomised Listening to music/ Physiological and psycho- Receptive taped music as No significant difference
Marker (1988)’ infarction in (34-92); 41 male control; 3 groups listening to ‘white logical; state anxiety anxiolytic between groups; (music was
coronary care unit and 26 female noise’/ control measured by validated a ‘one shot’ intervention)
N=75 questionnaire and structured
self-report

‘Bolwerk C. Effects of relaxing music on state anxiety in myocardial infarction patients. Crit Care Nurs Q 1990; 13 (2): 63-72.
hDavis-Rollans C, Cunningham S. Physiologic responses of coronary care patients to selected music. Heart Lung 1987; I6 (4): 370-378.
‘Guzzetta C. Effects of relaxation and music therapy on patients in a coronary care unit with presumptive acute myocardial infarction. Heart Lung 1989; 18 (6): 609-616.
‘Updike P. Music therapy results for ICU patients. Dimens Crit Care Nurs 1990; 9 (1): 39-45.
eZimmerman L, Pierson M, Marker J. Effects of music on patient anxiety in coronary care units. Heart Lung 1988; 17 (5): 56&566.
Table 3. Research with cancer pain using music therapy

Author and date Type of patient and Age and gender Type of re- Independent Dependent variables Type and function of music ReSUlt.3
research location search design variables

Frank (1985)’ Cancer patients in 20-71 years; Observational Music Behavioural observations of Receptive taped music as Significant reduction in
hospital 13 female, 2 male pre-test/post-test; nausea and vomiting using anxiolytic + guided imagery vomiting; non-significant
N= 15 1group questionnaire and self-report reduction in experience of
nausea
Zimmerman, Pozehl. Cancer patients with 34-79 years; Random&d con- Music + suggestion/ Behaviourai observations of Receptive taped music as Music decreases the overall
Duncan & Schmitz chronic pain in 24 female, trolled trial; relaxation + pain relief and self-report anxiolytic and relaxant intensity of the pain
(1989)b hospital 16 male pm-test/post-test; suggestion questionnaire using visual experience: sensory and
N=40 2 groups analogue scale affective components
influenced
Bailey (1983)” Cancer patients in 17-69 years; Random&d con- Taped music/ Self-report questionnaire of Receptive taped music/live Significant changes in
hospital 30 female, trolled trial; live music mood music as anxiolytic physical discomfort and mood
N=50 20 mate pretest/post-test; with live music
2 groups

“Frank J. The effects of music therapy and guided visual imagery on chemotherapy induced nausea and vomiting. Oncol Nuts Forum 1985; 12 (5): 47-52.
%hnmerman L, Pozehl B. Duncan K, Schmitz R. Effects of music in patients who had chronic cancer pain. West J Nuts Res 1989; 11 (3): 298-309.
‘Bailey L M. The effects of live music versus tape-recorded music on hospital&d cancer patients. Music Ther 1983; 3 (1): 17-28.
*although not a medical journal has a relevance to the other studies.
 2 14 Complementary Therapies in Medicine:Literaturereviews
significance of quality of life measures which could be
used as criteria for such research, there remains the pos-
sibility that immunological parameters may also be influ-
enced by creatively improvising music.128 Such research
would bring a parallel realm of clinical information to
complement musical analyses such that therapeutic cor-
relations can be attemptedl-3J317132 and would provide
a link with the current initiatives being made in psych-
neuroimmunology.
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