MUSIC THERAPY IN

PSYCHIATRY

Dr. Ulaş M. Çamsarı

Department of Psychiatry, Cleveland Clinic
June 17, 2009
 What is music therapy?
• Music therapy is a special type of therapy
where forms of musical interaction and
communication are used alongside verbal
communication. (Gold et al, 2009)
• Systematic process of intervention wherein
the therapist helps the client to promote
health, using music experiences and the
relationships developing through them as
dynamic forces of change. (Bruscia, 1998)
 What is music therapy?
• Music Therapy is an established healthcare
profession that uses music to address physical,
emotional, cognitive, and social needs of
individuals of all ages.
• Music therapy interventions can be designed to
promote wellness, manage stress, alleviate pain,
express feelings, enhance memory, improve
communication, promote physical rehabilitation.
(American Musical Therapy Association, 2009)
 What music therapy is NOT?
• Treatments rely solely on the direct effects of
music alone, which do not involve or depend
upon a process of intervention and change
within a client-therapist relationship are not
music therapy.
• The term “music medicine” is sometimes used
to distinguish such treatments form music
therapy.
(Bruscia, 1998 ; Gold et al, 2009)
 History of Music Therapy
• Using music as a healing medium
dates back to ancient times which is
evident in biblical scriptures and
historical writings of ancient
civilizations such as Egypt, China,
India, Greece, and Rome.
• The oldest known documentation of
medical practices, the Kahum
papyrus, refers to the use of
incantations for healing the sick.
• Greek philosopher Pythagoras is
considered the founder of music
therapy in the 6th century.
(Prickett, C & Standley, J, 1994 ;
Nillson, 2008)
 History of Music Therapy
• The first documented music medicine in a
general hospital began in 1484 in the Beyazid
Hospital (“Beyazit Kulliyesi”), in the city of
Edirne, during Ottoman Empire.
• Mental Disorders were treated with music and
each key (“makam”) of classical Turkish Music
were used to treat a different disease.
(Poch, 1970)
“Beyazıd Kulliyesi”, Edirne, Turkey
 History of Music Therapy

• In 1744 A. J. Rodríguez in
Spain, established the basis of
a scientific theory of Music
Therapy in his work :
“Palestra Crítico Médica”
(Medical Critical Arena)
• In 1800, Florence Nightingale
in France recognized the
power of music in hospital
wards during Crimean War
and used it to aid in the
healing process for soldiers.
(Poch, 1970 ; Nilsson, 2008)
 History of Music Therapy in US
• Music therapy in the United States of
America began in the late 18th
century.
• The profession of music therapy in the
United States began to develop during
W.W.I when music was used in
Veterans Administration Hospitals as
an intervention to address traumatic
war injuries.
• Veterans actively and passively
engaged in music activities that
focused on relieving pain perception.
(Music as Medicine,
www.musicasmedicine.com,
University Hospitals, CWRU, 2009)
 History of Music Therapy in US
• In 1950 a professional organization was formed
by a collaboration of music therapists that
worked with veterans, mentally retarded,
hearing/visually impaired, and psychiatric
populations.
• This was the birth of the National Association for
Music Therapy (NAMT)
(Music as Medicine, www.musicasmedicine.com,
University Hospitals, CWRU, 2009)
 History of Music Therapy in US

• In 1998, NAMT joined forces with

another music therapy
organization to become what is
now known as the American Music
Therapy Association (AMTA).

(Music as Medicine,
www.musicasmedicine.com,
University Hospitals, CWRU, 2009)
 History of Music Therapy in US
• U.S. Army’s Reconditioning Program, which uses music
for physical reconditioning, educational reconditioning,
and occupational reconditioning program became the
first official recognition of music as a therapeutic
means to be used in military hospitals in assisting the
sick and injured during recovery.
• Toward the end of World War II, musicians were
assigned to military hospitals to work directly with
patients and it was during this time period that led to
the establishment of the music therapy profession.
(Tyson, F. 1981)
Music Therapy in US - Current Practice
• The first undergraduate degree program in the US and the
world was founded at Michigan State University and the
first graduate degree program at the University of Kansas.
More recently Temple University and Lesley University have
founded a music therapy Ph.D. program.
• Currently there are 68 undergraduate and 25 graduate
programs approved by the association across the nation.
• Music therapist is most commonly designated by MT-BC
(Music Therapist-Board Certified), this is given by the
Certification Board of Music Therapists.
(American Musical Therapy Association, 2009 ; CWRU
www.musicasmedicine.com , 2009)
Music Therapy in US - Current Practice
• A degree in music therapy
requires proficiency in
guitar, piano, voice, music
theory, music history,
reading music,
improvisation, as well as
varying levels of skill in
assessment, documentation,
and other counseling and
health care skills depending
on the focus of the
particular university's
program.

(American Musical Therapy

Association, 2009)
Music Therapy in US - Current Practice
• To become board-certified in the United States, a
music therapist must complete course work at an
accredited AMTA program at a college or
university, successfully complete a 1040 hour
Music Therapy internship, and pass the Certifying
Board examination.
• Music therapy services have been identified as
reimbursable under Medicaid, Medicare.
(American Musical Therapy Association, 2009)
 Music Therapy in Mental Health :
Indications
• Usually tailored to an individual patient and
patient’s specific needs more than to a specific
clinical diagnosis.
• Contents of therapy are negotiated with the
patient within the process of therapy, based on a
variety of individual traits.
• No direct link between a patient’s clinical
diagnosis and the specific techniques used in
therapy.
(Gold et al, 2009)
 Music Therapy in Mental Health:
Indications
Psychotic Disorders
• Schizophrenia
• Schizoaffective Disorder
• Drug induced psychosis
Mood Disorders
• Major Depressive Disorder
• Bipolar Disorder
• Adjustment Disorder
• Bereavement
(Pubmed Search, accessed June15, 2009)
 Music Therapy in Mental Health:
Indications

Anxiety disorders
Developmental Disorders
• Autism, Mental Retardation
Neurological Disorders
• Dementia
• Parkinson’s Disease

(Pubmed Search, accessed June15, 2009)

 Music Therapy in Mental Health:
Types
Background Music Therapy
• Background music therapy is a form of therapy in
which music is heard for an average of 8 to 12
hours per day as part of a hospital routine.
• It is transmitted via audiotapes and radio.
• The aim of this therapy is to create a calm
environment in the hospital.
(De Sausa, 2005, The role of music therapy in
psychiatry)
 Music Therapy in Mental Health:
Types
Contemplative Music Therapy
• Contemplative music therapy helps patients
appreciate the significance of music and art in
general.
• Before music is played for patients, they are
given a biography of the composer and other
details about the music. This may be
administered in a group setting or individually.
 Music Therapy in Mental Health:
Types
Contemplative Music Therapy
• This facilitates the uncovering of morbid
experiences, termed communicative music
therapy, and causes emotional enlivenment.
• Also termed reactive musical therapy.
• In contemplative therapy, both the music that
soothes as well as the group setting and the
group therapy used bring out morbid experiences
of the patients. This therapy also aims to soothe
agitation and alleviate sadness. (De Sousa,
2005, The role of music therapy in psychiatry)
 Music Therapy in Mental Health:
Types
Combined Music Therapy
• In combined music therapy, music therapy is used in
conjunction with other therapeutic procedures.
• Unlike background music therapy, it calls for the
patient to select musical compositions that enhance
therapeutic outcome and suit the patient.
• Sometimes in this form of music therapy, hypnosis is
conducted while the subject listens to the music. This
music is often accompanied by suggestion under
hypnosis that improves the therapeutic outcome.
 Music Therapy in Mental Health:
Types
Combined Music Therapy
• The patient is asked to select music he likes as it
will soothe him better, and here music is used as
an adjuvant to various other therapies.
• This form of music therapy has been used in
combination with cerebral electro sleep therapy
and behavior therapy methods such as autogenic
training. (De Sousa, 2005, The role of music
therapy in psychiatry)
 Music Therapy in Mental Health:
Types
Executive Music Therapy
• Executive music therapy consists of individual or
group singing and playing musical instruments.
• Patients with long hospital stays are the best
candidates for this form of therapy.
• It was suggested that executive music therapy be
incorporated into the occupational therapy
routine. (De Sousa, 2005, The role of music
therapy in psychiatry)
 Music Therapy in Mental Health:
Types
Executive Iatromusic Therapy
• In executive iatromusic therapy, a musician
performs in children’s psychiatric units.

• This form of therapy frequently is used in

managing emotionally disturbed, mentally
retarded, and dyslexic children. (De Sousa,
2005, The role of music therapy in psychiatry)
 Music Therapy in Mental Health:
Types
Creative Music Therapy
• In creative music therapy, patients write
songs, compose music, and play instruments
as a form of catharsis.
• Grief over a deceased loved one, oppression,
and repressed feelings and fears are thought
to be well expressed in music and song.
(De Sousa, 2005, The role of music therapy in
psychiatry)
 Music Therapy in Mental Health:
Techniques
• All these different modes of ‘music experiences’
become therapeutic by being used in the context
of a therapeutic relationship.
• Verbal discussions, reflections, or interpretations
connected to the music are important to help
clients explore the potential meaning of an
experience, and relate a new experience within
therapy to situations in the client’s life.
(Gold et al, 2009)
 Music Therapy in Mental Health:
Techniques

• Music therapists are specifically trained to

intervene therapeutically, for example to
support by providing rhythmical or tonal
grounding, to clarify, to confront or to
challenge the client’s expression in the music.
(Bruscia, 1987; Wigram, 2004)
 Music Therapy in Mental Health :
Evidence to date
• Several systematic reviews and meta-analyses
have been conducted to examine effects of
music therapy in the field of mental health.

• Main focus was on articles which studied

music therapy on depression, schizophrenia,
autism, dementia, substance dependence and
anxiety.
 Music Therapy in Mental Health :
Evidence to date
• Cochrane systematic review : Music Therapy for
schizophrenia or schizophrenia-like illnesses,
Gold, Heldal et al, 2005
• Cochrane systematic review : Music therapy for
depression, Maratos et al, 2008
• Systematic review : The anxiety and pain reducing
effects of music interventions, Nillson, 2008
• Systematic review : Music therapy for the
treatment of patients with addictions, Mays et al,
2008
 Music Therapy in Mental Health :
Evidence to date
• Cochrane systematic review : Music therapy
for autistic spectrum disorder, Gold et al, 2009
• Cochrane systematic review : Music therapy
for people with dementia, Vink et al, 2009
• Systematic review and meta-analysis : Dose-
response relationship in music therapy for
people with serious mental disorders, Gold et
al, 2009)
 Music Therapy in Mental Health :
Evidence to date - Schizophrenia
• Cochrane systematic review, music therapy for
schizophrenia or schizophrenia-like illnesses, 2005
• Six randomized controlled trials from 1994 to 2004
were included that compared music therapy with
standard care or other psychosocial interventions for
schizophrenia.
• Conclusion: Music therapy as an addition to standard
care helps people with schizophrenia if a sufficient
number of music therapy sessions are provided.
• Significantly improved areas were global state, general
and negative symptoms and functioning.
(Gold and Heldal et al, 2005)
 Music Therapy in Mental Health :
Evidence to date - Depression
• Cochrane systematic review, music therapy for
depression, 2008
• Five randomized controlled trials from 1992 –
2006 were included comparing music therapy
with standard care or other interventions for
depression.
• Conclusion: Findings from individual randomized
trials suggest that music therapy, at least in short
term, is associated with improvements in mood.
(Maratos et al, 2008)
 Music Therapy in Mental Health :
Evidence to date : Autism
• Cochrane systematic review, music therapy for
autistic spectrum disorder, 2008
• Three randomized controlled trials from 1995 to
2005 were included comparing music therapy or
music therapy added to standard care to
“placebo” therapy, no treatment or standard
care.
• Conclusion: Findings indicate that music therapy
may help children with autistic spectrum disorder
to improve their communicative skills.
(Gold et al, 2009)
 Music Therapy in Mental Health :
Evidence to date : Dementia
• Cochrane systematic review, music therapy for
people with dementia, 2009
• Five randomized controlled trials from 1993 to
2005 that reported clinically relevant outcomes
associated with music therapy in treatment of
behavioural, social, cognitive and emotional
problems of older people with dementia
• Conclusion: Methodological quality and the
reporting of the included studies were too poor
to draw any useful conclusions.
(Vink et al, 2009)
 Music Therapy in Mental Health :
Evidence to date : Anxiety
• Systematic review , anxiety and pain reducing
effects of music interventions, 2008
• 42 randomized controlled trials of the effects
of music interventions in peri-operative
settings.
• Conclusion: Music intervention had positive
effects on reducing anxiety and pain in half of
the reviewed studies.
 Music Therapy in Mental Health :
Evidence to date : Addiction
• Systematic review, music therapy for the
treatment of patients with addictions, 2008
• Few studies were included which assessed the
use of music therapy in the treatment of
patients with addictions.
• Conclusion: No consensus exists regarding of
the efficacy of music therapy as treatment for
patients with addictions.
(Mays et al, 2008)
 Music Therapy in Mental Health :
Evidence to date : Dose-response
• Systematic review and meta analysis, dose-
response relationship in music therapy for people
with serious mental disorders, 2009
• The most comprehensive systematic review and
meta-analysis of the effects of music therapy in
adult mental health to date.
• All existing prospective studies from 1989 to 2007
were included and combined using mixed-effects
meta-analysis models.
(Gold et al, 2009)
 Music Therapy in Mental Health :
Evidence to date : Dose-response
• Nine countries and three continents are
represented in this analysis. (N=691)
• Psychotic disorders (N=456) , 2/3
• Non-psychotic disorders (N=235), 1/3
• MT in group settings, 2/3
• MT in combined and individual settings, 1/3
• Most used a combination of different models :
improvisation, singing and/or writing songs,
listening to music, verbal reflection around the
music experiences
 Music Therapy in Mental Health :
Evidence to date : Dose-response
• Conclusions: Music therapy, when added to
standard care, has strong and significant
effects on global state, general symptoms,
negative symptoms, depression, anxiety,
functioning and musical engagement.
Significant dose-effect relationships were
identified for general, negative and depressive
symptoms, as well as functioning.
(Gold et al, 2009)
 Music Therapy in Mental Health :
Evidence to date : Dose-response
• Conclusions: Results showed that effects do not
depend on diagnosis, which confirms music
therapy’s broad applicability.
• The results did not depend on the study design.
• Effects do depend on the number of sessions.
• “Dosage” of the MT is the best predictor of its
effects, explaining more than %70 of the
variance.
(Gold et al, 2009)
Music Therapy: Proposed mechanisms
Physiological framework

• Most of the studies on the effects of music

therapy have identified several psychological
and physiological responses to music.
• Some explanations have been proposed to
identify these responses.

(Watkins, 1997)
 Music Therapy: Proposed mechanisms
Physiological framework

Music HR, BP CT, Emo

Music CT, Emo HR, BP

CT, Emo, CT, Emo,

Music HR, BP HR, BP

Landreth and Landreth, 1974

 Music Therapy: Proposed mechanisms
Auditory Pathways
MUSIC
core region
AUDITORY
Lateral inhibition INFORMATION belt region
ONLY
CN VIII

Medulla Thalamus
• Epithelial • Inferior
hair cells • dCN colliculus • Medial
• vCN Geniculate
Body
Cochlea Midbrain

Watkins, 1997 ; Guyton Textbook of Physiology 9th Edition

 Music Therapy: Proposed mechanisms
Auditory Pathways
THALAMUS - MGB AMYGDALA
Lateral Nuclei

MEDULLA – dCV, vCV

Cardioregulatory Nuclei

AUDITORY CORTEX - TEMPORAL LOBE MIDBRAIN – Inferior Colliculus

Watkins, 1997 ; Guyton Textbook of Physiology 9th Edition

 Music Therapy: Proposed mechanisms
Auditory Pathways
• Interpretation of pitch, loudness, location and
meaning of auditory stimuli is complex.
• It involves analysis of frequency, duration,
amplitude and time interval distributions of
neural impulses and their modulations.
• Analysis of neuronal impulses produced by
auditory stimuli occurs at all levels in the
central auditory pathway.

Watkins, 1997 ; Guyton Textbook of Physiology 9th Edition

Music Therapy: Proposed mechanisms
Auditory Pathways

• Theoretically, identification of neurons in the

central auditory pathway and their projections to
brain centers that regulate BP, HR, or anxiety level
might be the first step in providing evidence for a
mechanism whereby music modifies physiological
and psychological responses.

(Watkins, 1997)
 Music Therapy: Proposed mechanisms
Endocrine system interactions

Amygdala
• CRH
• Auditory Cortex • Amygdala • ACTH
Lateral Nuclei • Cortisol
• Basolateral N.
• Centromedial N.
Temporal Lobe Hypothalamus

Watkins, 1997 ; Guyton Textbook of Physiology 9th Edition

 Music Therapy: Proposed mechanisms
Endocrine system interactions
AUDITORY STIMULI AUDITORY STIMULI

Lateral Nuclei

? ?

Centromedial Basolateral
Nuclei Nuclei

AMYGDALA NUCLEI
Watkins, 1997 ; Guyton Textbook of Physiology 9th Edition
Music Therapy: Proposed mechanisms
Physiological framework
• Music likely reduces alterations in the hypothalamic-
anterior pituitary-peripheral hormone axes that produce
cortisol and growth hormone.
• Music may also increase growth hormone levels, which can
induce decreased production of cytokines such as IL-6 by
white blood cells.
• Dopaminergic neurotransmission has also been implicated
as a means by which music can modulate the central
nervous system.
• Another commonly accepted theory is that music acts as a
distractor, focusing the patient’s attention away from
negative stimuli to something pleasant and encouraging.
(Nelson et al, 2008 ; Nillson, 2008)
Music Therapy: Proposed mechanisms
Physiological framework
• Exact neural pathways
mediating the
psychological and
physiological
responses of the
music are unknown.
• How “music” is
processed by the
human brain remains
being a mystery.
 Music Therapy in Mental Health :
Conclusions
• Indicated for a broad range
of serious mental disorders.
• Proven an effective therapy
for serious mental
disorders.
• Helps patients to improve
global state, symptoms and
functioning.
• It may be an effective
therapy for a population
which often does not
respond easily to traditional
approaches.
 Music Therapy in Mental Health :
Conclusions
• Music has no doubt plays a critical role in the
lives of human beings.
• Incorporating music therapy into regular
therapy programs for psychiatric disorders can
help speed recovery and also help make
therapy a more positive experience.
• Music therapy is valuable but relatively
unexplored asset in the field of psychiatry and
psychotherapy.
 References
• Dose-response relationship in music therapy with serious mental disorders : Systematic review and meta-analysis,
Gold et al, 2009
• Music therapy for schizophrenia or schizophrenia-like illnesses : Systematic review, Gold et al, 2005
• Music therapy for depression : Systematic review, Maratos et al, 2009
• Music therapy for autistic spectrum disorder : Systematic review, Gold et al, 2009
• Music therapy for people with dementia : Systematic review, Vink et al, 2009
• Anxiety and pain reducing effects of music interventions : Systematic review, Nilsson, 2008
• Treating addiction with tunes : Systematic review of music therapy for the treatment of patients with addictions,
Mays, 2008
• Is there a role for music therapy in the care of the severely mentally ill?, Grocke et al, 2008
• Music Therapy : Proposed physiological mechanisms and clinical implications, Watkins, 1997
• Music Therapy in the 19th Century America, Davis, 1987
• The patients can’t wait, and why should they?, Gifford, 2009
• The role of music therapy in psychiatry, De Sousa, 2005
• Guyton Textbook of Physiology, 9th Edition
• Defining music therapy, Bruscia, 1998
• Resource oriented music therapy for psychiatric patients with low therapy motivation, Gold et al, 2005
• American musical therapy association website, www.musictherapy .org
• Youtube web site , www.youtube.com
• Case Western Reserve University Music Medicine website, www.musicasmedicine.com
• Nordoff-Robbins Musical Therapy Foundation of New York University website,
http://steinhardt.nyu.edu/music/nordoff/
Glen Gould Plays Bach