Music therapy

Receptive

Receptive music therapy involves listening to recorded or live genres of music such as classical, rock, jazz, and/or country music. ^[13] In Receptive music therapy, patients are the recipient of the music experience, meaning that they are actively listening and responding to the music rather than creating it. During music sessions, patients participate in song discussion, music relaxation, and are given the ability to listen to their preferred music genre. It can improve mood, decrease stress, decrease pain, enhance relaxation, and decrease anxiety; this can help with coping skills.^[14] There is also evidence chemistry in one's body may change, e.g. lowered cortisol levels.^[15]

Active

In active music therapy, patients engage in some form of music-making, e.g. vocalizing, rapping, chanting, singing, playing instruments, improvising, song writing, composing, conducting. Researchers at Baylor, Scott, and White Universities are studying the effect of harmonica playing on patients with COPD in order to determine if it helps improve lung function.^[16] Another example of active music therapy takes place in a nursing home in Japan: therapists teach the elderly how to play easy-to-use instruments so they can overcome physical difficulties.^[17]

The Bonny Method of Guided Imagery and Music

To be trained in this method, students are required to be healthcare professionals.^[27] Some courses are only open to music therapists and mental health professionals.^[28]

Music educator and therapist Helen Lindquist Bonny (1921–2010) developed an approach influenced by humanistic and transpersonal psychological views, known as the Bonny Method of guided imagery in music (BGIM or GIM). Guided imagery refers to a technique used in natural and alternative medicine that involves using mental imagery to help with the physiological and psychological ailments of patients.^[29]

The practitioner often suggests a relaxing and focusing image, and through the use of imagination and discussion, they aim to find constructive solutions to manage their problems. Bonny applied this psychotherapeutic method to the field of music therapy by using music as the means of guiding the patient to a higher state of consciousness where healing and constructive self-awareness can take place. Music is considered a "co-therapist" because of its importance. GIM with children can be used in one-on-one or group settings, and involves relaxation techniques, identification and sharing of personal feeling states, and improvisation to discover the self, and foster growth. The choice of music is carefully selected for the client based on their musical preferences and the goals of the session. The piece is usually classical, and it must reflect the age and attention abilities of the child in length and genre. A full explanation of the exercises must be offered at their level of understanding.^[29]

The use of guided imagery with autistic children has been found to decrease stereotypical behaviors and hyperactivity, increase attention and the ability to follow instructions, and increase self-initiated communication, both verbal and non-verbal.^[30]

Nordoff-Robbins

Paul Nordoff, a Juilliard School graduate and Professor of Music, was a pianist and composer who, upon seeing disabled children respond so positively to music, gave up his academic career to further investigate the possibility of music as a means for therapy. Clive Robbins, a special educator, partnered with Nordoff for over 17 years in the exploration and research of music's effects on disabled children—first in the UK, and then in the US in the 1950s and 60s. Their pilot projects included placements at care units for autistic children and child psychiatry departments, where they put programs in place for children with mental disorders, emotional disturbances, developmental delays, and other handicaps. Their success at establishing a means of communication and relationship with children with cognitive impairments at the University of Pennsylvania gave rise to the National Institutes of Health's first grant given of this nature, and the 5-year study "Music therapy project for psychotic children under seven at the day care unit" involved research, publication, training and treatment.^[32] Several publications, including Therapy in Music for Handicapped Children, Creative Music Therapy, Music Therapy in Special Education, as well as instrumental and song books for children, were released during this time. Nordoff and Robbins's success became known globally in the mental health community, and they were invited to share their findings and offer training on an international tour that lasted several years. Funds were granted to support the founding of the Nordoff Robbins Music Therapy Centre^[33] in Great Britain in 1974, where a one-year graduate program for students was implemented. In the early eighties, a center was opened in Australia, and various programs and institutes for music therapy were founded in Germany and other countries. In the United States, the Nordoff-Robbins Center for Music Therapy was established at New York University in 1989^[34]

Today, Nordoff-Robbins is a music therapy Theoretical Model / Approach.^[31] The Nordoff-Robbins approach, based on the belief that everyone is capable of finding meaning in and benefiting from musical experience, is now practiced by hundreds of therapists internationally. This approach focuses on treatment through the creation of music by both therapist and client together. The therapist uses various techniques so that even the most low functioning individuals can actively participate.^[35]

Orff

Gertrude Orff developed Orff Music Therapy at the Kinderzentrum München. Both the clinical setting of social pediatrics and the Orff Schulwerk (schoolwork) approach in music education (developed by German composer Carl Orff) influence this method, which is used with children with developmental problems, delays, and disabilities.^[36] Theodor Hellbrügge developed the area of social pediatrics after the Second World War in Germany. He understood that medicine alone could not meet the complex needs of developmentally disabled children. Hellbrügge consulted psychologists, occupational therapists and other mental healthcare professionals whose knowledge and skills could aid in the diagnostics and treatment of children. Gertrude Orff was asked to develop a form of therapy based on the Orff Schulwerk approach to support the emotional development of patients. Elements found in both the music therapy and education approaches include the understanding of holistic music presentation as involving word, sound and movement, the use of both music and play improvisation as providing a creative stimulus for the child to investigate and explore, Orff instrumentation, including keyboard instruments and percussion instruments as a means of participation and interaction in a therapeutic setting, and the multisensory aspects of music used by the therapist to meet the particular needs of the child, such as both feeling and hearing sound.^[36]

Corresponding with the attitudes of humanistic psychology, the developmental potential of the child, as in the acknowledgement of their strengths as well as their handicaps, and the importance of the therapist-child relationship, are central factors in Orff music therapy. The strong emphasis on social integration and the involvement of parents in the therapeutic process found in social pediatrics also influence theoretical foundations. Knowledge of developmental psychology puts into perspective how developmental disabilities influence the child, as do their social and familial environments. The basis for interaction in this method is known as responsive interaction, in which the therapist meets the child at their level and responds according to their initiatives, combining both humanistic and developmental psychology philosophies. Involving the parents in this type of interaction by having them participate directly or observe the therapist's techniques equips the parents with ideas of how to interact appropriately with their child, thus fostering a positive parent-child relationship.^[36]

Methods

Among adolescents, group meetings and individual sessions are the main methods for music therapy. Both methods may include listening to music, discussing concerning moods and emotions in or toward music, analyzing the meanings of specific songs, writing lyrics, composing or performing music, and musical improvisation.^[38]

Private individual sessions can provide personal attention and are most effective when using music preferred by the patient. Using music that adolescents can relate to or connect with can help adolescent patients view the therapist as safe and trustworthy, and to engage in therapy with less resistance.^[38] Music therapy conducted in groups allows adolescent individuals to feel a sense of belonging, express their opinions, learn how to socialize and verbalize appropriately with peers, improve compromising skills, and develop tolerance and empathy.^[37] Group sessions that emphasize cooperation and cohesion can be effective in working with adolescents.^[40]

Assessment

Assessment includes obtaining a full medical history, musical (ability to duplicate a melody or identify changes in rhythm, etc.) and non-musical functioning (social, physical/motor, emotional, etc.).^[41][42]

Autism

Music has played an important role in the research of dealing with autism, mainly in diagnosis, therapy, and behavioral abilities according to a scientific article written by Thenille Braun Janzen and Michael H. Thaut. This article concluded that music can help autistic patients hone their motor and attention skills as well as healthy neurodevelopment of socio-communication and interaction skills. Music therapy also resulted in positive improvement in selective attention, speech production, and language processing and acquisition in autistic patients^[54]

Heart disease

According to a 2013 Cochrane review, listening to music may improve heart rate, respiratory rate, and blood pressure in those with coronary heart disease (CHD).^[55]

Stroke

Music is useful in the recovery of motor skills.^[56] In a study on stroke patients in the recovery phase, music therapy was used in addition to other types of therapy in one group of patients and was not used in the other group. While both groups showed an increase in their standard of living, the group that used the music therapy showed more of an increase than the group that didn't. The group that used music therapy also showed less anxiousness and depression after the therapy. While both groups showed an increase in the strength of their non-dominant hands, the group with music therapy showed a much larger increase. Also, patients that underwent music therapy were able to regulate their emotions better and showed increased communication as a whole.^[57]

Dementia

Like many of the other disorders mentioned, some of the most common significant effects of the disorder can be seen in social behaviors, leading to improvements in interaction, conversation, and other such skills. A study of over 330 subjects showed that music therapy produces highly significant improvements in social behaviors, overt behaviors like wandering and restlessness, reductions in agitated behaviors, and improvements to cognitive defects, measured with reality orientation and face recognition tests. The effectiveness of the treatment seems to be strongly dependent on the patient and the quality and length of treatment.^[58]

A group of adults suffering with dementia participated in group music therapy.^[58] In the group, these adults engaged in singing, drumming, improvisation, and movement. Each of these activities engaged the adults in different ways. The singing aided with memory, as these adults improved memorization skills in by taking out specific words in the chorus of a song and by repeating phrases back to the music therapist when the therapist sang a phrase of a song to them. Drumming led to increased socialization of the group, as it allowed the patients collaborate in order to create particular rhythms. Improvisation allowed the patients to get out of their comfort zone and taught them how to better deal with anxiety. Lastly, movement with either one arm or two increased social interaction between the patients.^[58]

Another meta-study examined the proposed neurological mechanisms behind music therapy's effects on these patients. Many authors suspect that music has a soothing effect on the patient by affecting how noise is perceived: music renders noise familiar, or buffers the patient from overwhelming or extraneous noise in their environment. Others suggest that music serves as a sort of mediator for social interactions, providing a vessel through which to interact with others without requiring much cognitive load.^[58]

Aphasia

Broca's aphasia, or non-fluent aphasia, is a language disorder caused by damage to Broca's area and surrounding regions in the left frontal lobe.^[59] Those with non-fluent aphasia are able to understand language fairly well, but they struggle with language production and syntax.^[60]

Neurologist Oliver Sacks, author of Musicophilia: Tales of music and the Brain, studied neurological oddities in people, trying to understand how the brain works. He concluded that people with some type of frontal lobe damage often “produced not only severe difficulties with expressive language (aphasia) but a strange access of musicality with incessant whistling, singing and a passionate interest in music. For him, this was an example of normally suppressed brain functions being released by damage to others”.^[61] Sacks had a genuine interest in trying to help people affected with neurological disorders and other phenomena associated with music, and how it can provide access to otherwise unreachable emotional states, revivify neurological avenues that have been frozen, evoke memories of earlier, lost events or states of being and attempts to bring those with neurological disorders back to a time when the world was much richer for them. He was a firm believer that music has the power to heal.

Melodic intonation therapy (MIT), developed in 1973 by neurological researchers Sparks, Helm, and Albert, is a method used by music therapists and speech–language pathologists to help people with communication disorders caused by damage to the left hemisphere of the brain by engaging the singing abilities and possibly engaging language-capable regions in the undamaged right hemisphere.^[62][63]

While unable to speak fluently, patients with non-fluent aphasia are often able to sing words, phrases, and even sentences they cannot express otherwise.^[64] MIT harnesses the singing ability of patients with non-fluent aphasia as a means to improve their communication. Although its exact nature depends on the therapist, in general MIT relies on the use of intonation (the rising and falling of the voice) and rhythm (beat/speed) to train patients to produce phrases verbally.^[63] In MIT, common words and phrases are turned into melodic phrases, generally starting with two step sing-song patterns and eventually emulating typical speech intonation and rhythmic patterns.^[62] A therapist will usually begin by introducing an intonation to their patient through humming.^[63] They will accompany this humming with a rhythm produced by the tapping of the left hand.^[63] At the same time, the therapist will introduce a visual stimuli of the written phrase to be learned.^[63] The therapist then sings the phrase with the patient, and ideally the patient is eventually able to sing the phrase on their own.^[63] With much repetition and through a process of “inner-rehearsal” (practicing internally hearing one's voice singing), a patient may eventually be able to produce the phrase verbally without singing.^[63] As the patient advances in therapy, the procedure can be adapted to give them more autonomy and to teach them more complex phrases.^[63] Through the use of MIT, a non-fluent aphasic patient can be taught numerous phrases which aid them to communicate and function during daily life.

The mechanisms of this success are yet to be fully understood. It is commonly agreed that while speech is lateralized mostly to the left hemisphere (for right-handed and most left-handed individuals), some speech functionality is also distributed in the right hemisphere.^[65] MIT is thought to stimulate these right language areas through the activation of music processing areas also in the right hemisphere^[66] Similarly, the rhythmic tapping of the left hand stimulates the right sensorimotor cortex in order to further engage the right hemisphere in language production.^[66] Overall, by stimulating the right hemisphere during language tasks, therapists hope to decrease dependence on the left hemisphere for language production.^[63]

While results are somewhat contradictory, studies have in fact found increased right hemispheric activation in non-fluent aphasic patients after MIT.^[66] This change in activation has been interpreted as evidence of decreased dependence on the left hemisphere.^[66] There is debate, however, as to whether changes in right hemispheric activation are part of the therapeutic process during/after MIT, or are simply a side effect of non-fluent aphasia.^[67] In hopes of making MIT more effective, researchers are continually studying the mechanisms of MIT and non-fluent aphasia.

Cancer

There is tentative evidence that music interventions led by a trained music therapist may have positive effects on psychological and physical outcomes in adults with cancer. The effectiveness of music therapy for children with cancer is not known.^[68]

Adults

There is weak evidence to suggest that people with schizophrenia may benefit from the addition of music therapy along with their other standard treatment regieme.^[69][70] Potential improvements include decreased aggression, less hallucinations and delusions, social functioning, and quality of life of people with schizophrenia or schizophrenia-like disorders.^[69][70] In addition, moderate-to-low-quality evidence suggests that music therapy as an addition to standard care improves the global state, mental state (including negative and general symptoms). Further research using standardized music therapy programs and consistent monitoring protocols are necessary to understand the effectiveness of this approach for adults with schizophrenia.^[70] Music therapy may be a useful tool for helping treat people with post-traumatic stress disorder however more rigorous empirical study is required.^[71]

For adults with depressive symptoms, there is some weak evidence to suggest that music therapy may help reduce symptoms and recreative music therapy and guided imagery and music being superior to other methods in reducing depressive symptoms.^[72]

In the use of music therapy for adults, there is "music medicine" which is called for listening to prerecorded music as treated like a medicine. Music Therapy also uses "Receptive music therapy" using "music-assisted relaxation" and using images connecting to the music.^[73]

Children

For children and adolescents with major depressive or anxiety disorders, there is moderate to low quality evidence that music therapy added to the standard treatment may reduce internalizing symptoms and may be more effective than treatment as usual (without music therapy).^[74][75]

Practice

Music therapy practice is working together with clients, through music, to promote healthy change (Bruscia, 1998; Abrams, 2010). The American Music Therapy Association (AMTA) has defined the practice of music therapy as "a behavioral science concerned with changing unhealthy behaviors and replacing them with more adaptive ones through the use of musical stimuli" (Davis, Gfeller & Thaut, 2008).

Diagnosing bereavement

As of 2017, bereavement is listed as its own diagnosis in the DSM-IV TR, but proposed changes in the DSM-V may impact the way bereavement is diagnosed. The DSM-IV TR states the following about bereavement:

This category can be used when the focus of clinical attention is a reaction to the death of a loved one. As part of their reaction to the loss, some grieving individuals present with symptoms characteristic of a Major Depressive Episode (e.g., feelings of sadness and associated symptoms such as insomnia, poor appetite, and weight loss). The bereaved individual typically regards the depressed mood as "normal," although the person may seek professional help for relief of associated symptoms such as insomnia or anorexia. The duration and expression of "normal" bereavement vary considerably among different cultural groups. The diagnosis of Major Depressive Disorder is generally not given unless the symptoms are still present 2 months after the loss. However, the presence of certain symptoms that are not characteristic of a "normal" grief reaction may be helpful in differentiating bereavement from a Major Depressive Episode. These include 1) guilt about things other than actions taken or not taken by the survivor at the time of the death; 2) thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person; 3) morbid preoccupation with worthlessness; 4) marked psychomotor retardation; 5) prolonged and marked functional impairment; and 6) hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person.

In many countries, including the United States, music therapists do not diagnose, therefore diagnosing a bereavement-related disorder would not be within their scope of practice.

Empirical evidence

Since 2017, providing evidence-based practice is becoming more and more important and music therapy has been continuously critiqued and regulated in order to provide that desired evidence-based practice. A number of research studies and meta-analyses have been conducted on, or included, music therapy and all have found that music therapy has at least some promising effects, especially when used for the treatment of grief and bereavement. The AMTA has largely supported the advancement of music therapy through research that would promote evidenced-based practice. With the definition of evidence-based health care as "the conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services, current best evidence is up-to-date information from relevant, valid research about the effects of different forms of health care, the potential for harm from exposure to particular agents, the accuracy of diagnostic tests, and the predictive power of prognostic factors" (Cochrane, 1972).

Both qualitative and quantitative studies have been completed and both have provided evidence to support music therapy in the use of bereavement treatment. One study that evaluated a number of treatment approaches found that only music therapy had significant positive outcomes where the others showed little improvement in participants (Rosner, Kruse & Hagl, 2010). Furthermore, a pilot study, which consisted of an experimental and control group, examined the effects of music therapy on mood and behaviors in the home and school communities. It was found that there was a significant change in grief symptoms and behaviors with the experimental group in the home, but conversely found that there was no significant change in the experimental group in the school community, despite the fact that mean scores on the Depression Self-Rating Index and the Behavior Rating Index decreased (Hilliard, 2001). Yet another study completed by Russel Hilliard (2007), looked at the effects of Orff-based music therapy and social work groups on childhood grief symptoms and behaviors. Using a control group that consisted of wait-listed clients, and employing the Behavior Rating Index for Children and the bereavement Group Questionnaire for Parents and Guardians as measurement tools, it was found that children who were in the music therapy group showed significant improvement in grief symptoms and also showed some improvement in behaviors compared to the control group, whereas the social work group also showed significant improvement in both grief and behaviors compared to the control group. The study concludes with support for music therapy as a medium from bereavement groups for children (Hilliard, 2007).

Though there has been research done on music therapy, and though the use of it has been evaluated, there remain a number of limitations in these studies and further research should be completed before absolute conclusions are made, though the results of using music therapy in the treatment have consistently shown to be positive.

Cultural considerations in music therapy services, education, and research

The 21st century is a culturally pluralistic world. In some countries, such as the United States, an individual may have multiple cultural identities that are quite different from the music therapist's. These include race; ethnicity, culture, and/or heritage; religion; sex; ability/disability; education; or socioeconomic status.^[77][78][79] Music therapists strive to achieve multicultural competence through a lifelong journey of formal and informal education and self-reflection. Multicultural therapy "uses modalities and defines goals consistent with the life experiences and cultural values of clients” ^[80]: 6 rather than basing therapy on the therapist's worldview or the dominant culture's norms.

Empathy in general is an important aspect of any mental health practitioner and the same is true for music therapists, as is multicultural awareness. It is the added complexity to cultural empathy that comes from adding music that provides both the greater risk and potential to provide exceptional culturally sensitive therapy (Valentino, 2006). An extensive knowledge of a culture is really needed to provide this effective treatment as providing culturally sensitive music therapy goes beyond knowing the language of speech, the country, or even some background about the culture. Simply choosing music that is from the same country of origin or that has the same spoken language is not effective for providing music therapy as music genres vary as do the messages each piece of music sends. Also, different cultures view and use music in various ways and may not always be the same as how the therapist views and uses music. Melody Schwantes and her colleagues wrote an article that describes the effective use of the Mexican "corrido" in a bereavement group of Mexican migrant farm workers (Schwantes, Wigram, Lipscomb & Richards, 2011). This support group was dealing with the loss of two of their coworkers after an accident they were in and so the corrido, a song form traditionally used for telling stories of the deceased. An important element that was also mentioned was that songwriting has shown to be a large cultural artifact in many cultures, and that there are many subtle messages and thoughts provided in songs that would otherwise be hard to identify. Lastly, the authors of this study stated that "Given the position and importance of songs in all cultures, the example in this therapeutic process demonstrates the powerful nature of lyrics and music to contain and express difficult and often unspoken feelings" (Schwantes et al., 2011).

Western cultures

African continent

In 1999, the first program for music therapy in Africa opened in Pretoria, South Africa. Research has shown that in Tanzania patients can receive palliative care for life-threatening illnesses directly after the diagnosis of these illnesses. This is different from many Western countries, because they reserve palliative care for patients who have an incurable illness. Music is also viewed differently between Africa and Western countries. In Western countries and a majority of other countries throughout the world, music is traditionally seen as entertainment whereas in many African cultures, music is used in recounting stories, celebrating life events, or sending messages.^[96]

Australia

Canada

Germany

The Germany Music Therapy Society defines music therapy as the "targeted use of music as part of a therapeutic relationship to restore, maintain and promote mental, physical and cognitive health [Musiktherapie ist der gezielte Einsatz von Musik im Rahmen der therapeutischen Beziehung zur Wiederherstellung, Erhaltung und Förderung seelischer, körperlicher und geistiger Gesundheit]."^[105]

India

The roots of musical therapy in India can be traced back to ancient Hindu mythology, Vedic texts, and local folk traditions.^[106] It is very possible that music therapy has been used for hundreds of years in Indian culture. In the 1990s, another dimension to this, known as Musopathy, was postulated by Indian musician Chitravina Ravikiran based on fundamental criteria derived from acoustic physics.

The Indian Association of Music Therapy was established in 2010 by Dr. Dinesh C. Sharma with a motto "to use pleasant sounds in a specific manner like drug in due course of time as green medicine".^[107] He also published the International Journal of Music Therapy (ISSN 2249-8664) to popularize and promote music therapy research on an international platform.^[108]

Suvarna Nalapat has studied music therapy in the Indian context. Her books Nadalayasindhu-Ragachikitsamrutam (2008), Music Therapy in Management Education and Administration (2008) and Ragachikitsa (2008) are accepted textbooks on music therapy and Indian arts.^{[109][110][111][112][113]}

The Music Therapy Trust of India is another venture in the country. It was started by Margaret Lobo.^[114] She is the founder and director of the Otakar Kraus Music Trust and her work began in 2004.^[115]

Lebanon

In 2006, Hamda Farhat introduced music therapy to Lebanon, developing and inventing therapeutic methods such as the triple method to treat hyperactivity, depression, anxiety, addiction, and post traumatic stress disorder. She has met with great success in working with many international organizations, and in the training of therapists, educators, and doctors.

Norway

Norway is recognized as an important country for music therapy research. Its two major research centers are the Center for Music and Health^[116] with the Norwegian Academy of Music in Oslo, and the Grieg Academy Centre for Music Therapy (GAMUT),^[117] at University of Bergen. The former was mostly developed by professor Even Ruud, while professor Brynjulf Stige is largely responsible for cultivating the latter. The center in Bergen has 18 staff, including 2 professors and 4 associate professors, as well as lecturers and PhD students. Two of the field's major international research journals are based in Bergen: Nordic Journal for Music Therapy^[118] and Voices: A World Forum for Music Therapy.^[119] Norway's main contribution to the field is mostly in the area of "community music therapy", which tends to be as much oriented toward social work as individual psychotherapy, and music therapy research from this country uses a wide variety of methods to examine diverse methods across an array of social contexts, including community centers, medical clinics, retirement homes, and prisons.

Nigeria

The origins of Musical therapy practices in Nigeria is unknown, however the country is identified to have a lengthy lineage and history of musical therapy being utilized throughout the culture. The most common people associated with music therapy are herbalists, Witch doctors, and faith healers according to Professor Charles O. Aluede of Ambrose Alli University (Ekpoma, Edo State, Nigeria).^[120] Applying music and thematic sounds to the healing process is believed to help the patient overcome true sickness in his/her mind which then will seemingly cure the disease. Another practice involving music is called "Igbeuku", a religious practice performed by faith healers. In the practice of Igbeuku, patients are persuaded to confess their sins which cause themselves serve discomfort. Following a confession, patients feel emotionally relieved because the priest has announced them clean and subjected them to a rigorous dancing exercise. The dancing exercise is a "thank you" for the healing and tribute to the spiritual greater beings. The dance is accompanied by music and can be included among the unorthodox medical practices of Nigerian culture. While most of the music therapy practices come in the medical field, musical therapy is often utilized in the passing of a loved one. The use of song and dance in a funeral setting is very common across the continent but especially in Nigeria. Songs allude to the idea the finally resting place is Hades (hell). The music helps alleviate the sorrows felt by the family members and friends of the lost loved one. Along with music therapy being a practice for funeral events, it is also implemented to those dying as a last resort tactic of healing. The Esan of Edo State of Nigeria, in particular, herbalists perform practices with an Oko – a small aerophone made of elephant tusk which is blown into dying patients’ ears to resuscitate them. Nigeria is full of interesting cultural practices in which contribute a lot to the music therapy world.^[121]

South Africa

There are longstanding traditions of music healing, which in some ways may be very different than music therapy.^[122]

Mercédès Pavlicevic (1955-2018),^[123][124] an international music therapist, along with Kobie Temmingh, pioneered the music therapy program at the University of Pretoria, which debuted with a master's degree program in 1999. She noted the differences in longstanding traditions and other ways of viewing healing or music. A Nigerian colleague felt "that music in Africa is healing, and what is music therapy other than some colonial import?"^[122] Pavlicevic noted that "in Africa there is a long tradition of music healing" and asked "Can there be a synthesis of these two music-based practices towards something new?... I am not altogether convinced that African music healing and music therapy are especially closely related [emphasis added]. But I am utterly convinced that music therapy can learn an enormous amount from the African worldview and from music-making in Africa - rather than from African music-healing as such."^[122]

The South African Music Therapy Association can provide information to the public about music therapy or educational programs in South Africa.^[125]

South Africa was selected to host the 16th World Congress of Music Therapy in July 2020, a triennial World Federation of Music Therapy event. Due to the coronavirus pandemic (SARS-CoV-2) the congress was moved to an online event.^[126]

United States

United Kingdom

Live music was used in hospitals after both World Wars as part of the treatment program for recovering soldiers. Clinical music therapy in Britain as it is understood today was pioneered in the 1960s and 1970s by French cellist Juliette Alvin whose influence on the current generation of British music therapy lecturers remains strong. Mary Priestley, one of Juliette Alvin's students, created "analytical music therapy". The Nordoff-Robbins approach to music therapy developed from the work of Paul Nordoff and Clive Robbins in the 1950/60s.

Practitioners are registered with the Health Professions Council and, starting from 2007, new registrants must normally hold a master's degree in music therapy. There are master's level programs in music therapy in Manchester, Bristol, Cambridge, South Wales, Edinburgh and London, and there are therapists throughout the UK. The professional body in the UK is the British Association for Music Therapy^[139] In 2002, the World Congress of Music Therapy, coordinated and promoted by the World Federation of Music Therapy, was held in Oxford on the theme of Dialogue and Debate.^[140] In November 2006, Dr. Michael J. Crawford and his colleagues again found that music therapy helped the outcomes of schizophrenic patients.^[141][142]

History

Music therapy finds its roots in the military. The United States Department of War issued Technical Bulletin 187 in 1945, which described the use of music in the recovery of military service members in Army hospitals.^[143] The use of music therapy in military settings started to flourish and develop following World War II and research and endorsements from both the United States Army and the Surgeon General of the United States. Although these endorsements helped music therapy develop, there was still a recognized need to assess the true viability and value of music as a medically-based therapy. Walter Reed Army Medical Center and the Office of the Surgeon General worked together to lead one of the earliest assessments of a music therapy program. The goal of the study was to understand whether “music presented according to a specific plan” influenced recovery among service members with mental and emotional disorders.^[144] Eventually, case reports in reference to this study relayed not only the importance but also the impact of music therapy services in the recovery of military service personnel.

The first university sponsored music therapy course was taught by Margaret Anderton in 1919 at Columbia University.^[145] Anderton's clinical specialty was working with wounded Canadian soldiers during World War II, using music-based services to aid in their recovery process.

Today, Operation Enduring Freedom and Operation Iraqi Freedom have both presented an array of injuries; however, the two signature injuries are posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI). These two signature injuries are increasingly common among millennial military service members and in music therapy programs.

A person diagnosed with PTSD can associate a memory or experience with a song they have heard. This can result in either good or bad experiences. If it is a bad experience, the song's rhythm or lyrics can bring out the person's anxiety or fear response. If it is a good experience, the song can bring feelings of happiness or peace which could bring back positive emotions. Either way, music can be used as a tool to bring emotions forward and help the person cope with them.

Methods

Music therapists work with active duty military personnel, veterans, service members in transition, and their families. Music therapists strive to engage clients in music experiences that foster trust and complete participation over the course of their treatment process. Music therapists use an array of music-centered tools, techniques, and activities when working with military-associated clients, many of which are similar to the techniques used in other music therapy settings. These methods include, but are not limited to: group drumming, listening, singing, and songwriting. Songwriting is a particularly effective tool with military veterans struggling with PTSD and TBI as it creates a safe space to, "... work through traumatic experiences, and transform traumatic memories into healthier associations".^[146]

Programs

Music therapy in the military is seen in programs on military bases, VA healthcare facilities, military treatment facilities, and military communities. Music therapy programs have a large outreach because they exist for all phases of military life: pre-mobilization, deployment, post-deployment, recovery (in the case of injury), and among families of fallen military service personnel.^[147]

Resounding Joy, Inc., a San Diego, California-based music therapy program, is a pioneer for the use of music therapy in the military. Its Semper Sound program specializes in providing music therapy services to active duty military service members and veterans diagnosed with PTSD, TBI, substance abuse, and other trauma-related diagnoses. It features different programs such as The Semper Sound Band, based in San Diego, California, and the GI Jams Band, based in Chelsea, Massachusetts.^[148]

Walter Reed Army Medical Center located in Bethesda, Maryland, is another pioneer for the use of music therapy in the military. All patients at the medical center are eligible to receive music therapy services; therefore, the range of clients is wide: TBI, stroke, psychological diagnoses (anxiety, depression, PTSD), autism spectrum disorder, and more.^[147]

The Exceptional Family Member Program (EFMP) also exists to provide music therapy services to active duty military families who have a family member with a developmental, physical, emotional, or intellectual disorder. Currently, programs at the Davis-Monthan Air Force Base, Resounding Joy, Inc., and the Music Institute of Chicago partner with EFMP services to provide music therapy services to eligible military family members.^[147]

Music therapy programs primarily target active duty military members and their treatment facility in order to provide reconditioning among members convalescing in Army hospitals.^[149] Although, music therapy programs not only benefit the military but rather a wide range of clients including the U.S. Air Force, American Navy, and U.S. Marines Corp. Individuals exposed to trauma benefit from their essential rehabilitative tools in order to follow the course of recovery from stress disorders. Music therapists are certified professionals who possess the abilities to determine appropriate interventions to support one recovering from a physically, emotionally, or mentally traumatic experience.^[150] In addition to their skills, they play an integral part throughout the treatment process of service members diagnosed with post-traumatic stress or brain injuries. In many cases, self-expression through songwriting or utilizing instruments help restore emotions that can be lost after suffering trauma.^[150] Music has a significant effect on troops traveling overseas or between bases because many soldiers view music to be an escape from war, a connection to their homeland and families, or as motivation. By working with a certified music therapist, marines undergo sessions re-instituting concepts of cognition, memory attention, and emotional processing.^[151] Although programs primarily focus on phases of military life, other service members such as the U.S. Air Force are eligible for treatment as well. For instance, during a music therapy session, a man begins to play a song to a wounded Airmen. The Airmen says “ [music] allows me to talk about something that happened without talking about it”.^[152] Music allows the active duty airmen to open up about previous experiences while reducing his anxiety level.