Can Music Fight Disease? Can Cultural Sociology Help? Norwegian Vistas

Abstract

A cartoon-doctor attending a hospital bedside. A patient, quizzically examining a row of stitches. The patient speaks: “It looks like I’ve had an operation.” The doctor replies, “That’s the main thing.” A second cartoon. A doctor reaches across a large desk to hand the patient a prescription. The caption reads, “If this placebo doesn’t work, I can prescribe a stronger one.”

In recent years, placebo research has burgeoned. There is a dedicated interdisciplinary center (PIPS) at Harvard. There is a raft of randomized controlled trials and other publications about placebos, many in mainstream medical journals, addressing a wide range of topics including placebos for depression (Kirsch 2010), placebo surgery for knee pain (Wartolowska et al. 2014), and placebos for cancer-related fatigue (Zhou 2018). A sign that the research has reached a watershed is its tendency nowadays to focus less on the question of whether placebos work (it seems they do) and more on the question of how and why placebos are effective (and effective even when, as in the case of “open placebos,” people are informed that they are being treated “with a placebo”).

It has become increasingly clear that answers to these questions involve something more complex than talk about “mind” over “matter.” “Belief, expectation, and desire,” says one eminent physician-researcher, “activate brain circuits that cause the release of endorphins” (endogenous analgesic substances) (Groopman 2005:174). In this passage, Groopman is describing an experiment in which a placebo effect is prevented from happening because a drug (Naxolone) is injected to block the subject’s endorphin receptors (p. 173). Endorphins are triggered (by the expectancy effect) and released, but they are unable to establish contact with nerve cells because of the Naxolene barrier. The procedure highlights how the placebo effect is by no means “all in the mind”: rather, placebos are part of an intricate chain reaction—from the initial social set-up and ritual of giving “the treatment,” to the expectation of relief, to complicated neurotransmissions and brain circuitry, to the release of endorphins, to contact between endorphins and nerve cells, to the alleviation of pain, to the attribution of effectiveness to the treatment, to, via learning, further enhancement of the power of the set-up and ritual next time around.

While, clearly, the brain is highly involved in this process, it is by no means the only actor. Rather, the placebo effect arises due to a concatenation of endogenous and exogenous factors with which any student of Actor-Network Theory (Mol 2003) would feel immediately at home: nerve cells, neurons, conversation, rooms, furniture, costumes, props and gestures, chemical substances, instruments, hopes, pedagogical techniques, meanings, expectations, and ritual practices. These factors coalesce as sequences and partnerships and are bundled temporally (Polich et al. 2018). They have an “up-stream” (contexts, cues, frames, meanings, expectations). That up-stream triggers mid-stream reactions (“reward pathways” in the brain are triggered). The mid-stream in its turn triggers down-stream physiological effects (the release of endorphins and their uptake by nerve cells; associated changes in respiratory, cardiovascular, and gastrointestinal systems; muscle tonicity; social orientation and affect). The boundaries between these multiple features of “mind” and “body” in this perspective are, of course, severely blurred (in ways that recall Becker’s classic study of the social framing and learning required in the marijuana experience [Becker 1953]).

“Within a paradigm that is not based on the Cartesian dualism of body and mind,” says Norwegian social psychologist Tor-Johan Ekeland, “there would not be any placebo effect to explain” (Ekeland 1997:77). His words, published in 1997, point to what has more recently emerged as a new (but also in many ways ancient) metafield, psychoneuroimmunology (PNI) (Fancourt et al. 2014). This transdisciplinary area tilts thinking about things such as disease, mental health, pathogens, and painful stimuli. PNI offers a novel ontology and etiology of contagion focused not only on the agents that infect, invade, and irritate, but on the agentic properties of the hosts to whom they become attached (Pedersen et al. 2011). Thus, as with placebo research, PNI studies the things that are capable of kick-starting the immune system, inducing the release of endogenous opioids and endorphins and suppressing substances linked to stress and inflammation.

Tragically, as we have seen with the COVID-19 pandemic, not all “hosts” are equally inhospitable to pathogens. There are, it seems, connections between endogenous factors (immune resistance), exogenous factors (such as occupation, education, and access to safe circumstances of living), and the things produced between them (such as stress or loss of self-esteem, agency, validation). This social variation calls for what might be termed a sociology of susceptibility (Larazzi, Bottaccioli, and Bottaccioli 2020). That perspective shines a light on the complex dance of dis/infection in which pathogens and demography, affect and aspiration, habits, life experiences and opportunities, social relations, roles, situations, gestures, aesthetic materials, meanings, affect, and rituals are closely intertwined. And the study of what is effective, medicinally speaking, is opened up to a set of new questions drawn from the placebo and PNI research platforms. That study is directed to how healing rituals are ceremonially crafted and how participants in such rituals themselves contribute (if at times unwittingly) to the effectiveness of treatments. But that lens is also directed, critically, toward the question of who benefits, how, when, where, and from what. In other words, the stage is now prepared for sociology and cultural sociology’s fullest participation in the study of immunity and the promotion of health.

Enter Toward a Sociology of Music Therapy: Musicking as a Cultural Immunogen, a new book on cultural immunogens by Even Ruud. One of Scandinavia’s most distinguished socio-musical scholars (he has received Norway’s King’s Medal of Merit in honor of his contributions to knowledge), Ruud is emeritus Chair of Musicology at the University of Oslo and also Chair of Music Therapy at the Norwegian Academy of Music. His numerous publications reveal him as polymath and as pioneer. He has directed projects and published on sound studies, soundscape and sound walking (well before work in these areas became established), improvisation in music therapy (Ruud 1998), guided imagery and music, community music therapy, relational musicology, the sociology of musical identities, agency (Ruud 2008), careers, music and grief (Ruud 2013), music and refugees (Storsve, Westbye, and Ruud 2010), music education, music and mental health, multiculturalism, the health benefits of singing, humanistic music therapy (Ruud 2010), and music and conflict resolution.

In Toward a Sociology of Music Therapy, Ruud develops and consolidates topics first broached in some of his earlier research on music and salutogenics. Originally coined by Israeli sociologist Aaron Antonovsky (1987), the term “salutogenics” indicates the study of factors that produce and sustain health and well-being. Antonovsky suggests that being able to enjoy a sense of coherence (ontological security) is crucial to staying well and to resisting disease, dis-ease (the more general and inclusive feeling of being unwell mentally, physically, socially, or spiritually), and pain.

Conceptually, Ruud develops this theme by taking his cue from the post-humanist perspectives of Deleuze and Guitarri ([1987] 2013). Ruud depicts human being, and human health, as the product of assembly, a “rhizome” or non-hierarchical network of heterogeneous materials that can develop in multiple directions. That rhizome develops in relation to materials and practices that are afforded within a given environment. So, for Ruud, the ontology and etiology of health is emergent; the potential “host” to disease, the perceiver of (and body in) pain, the psyche, and indeed the person or self is never a given but takes shape relationally, and in actual space and time. There is, in other words, a great deal of plasticity to the human social organism.

In ways that complement the placebo research discussed above, Ruud gives the example of pain perception as a case in point (p. 236). The sense of pain takes shape, temporally and situationally, in relation to the staging and framing of the painful situation (think of the difference between hearing one of the following at the key moment of administering an injection: “Are you planning to go somewhere for a holiday this year?” versus “This is going to hurt”; now think of the quality of the social relation between health practitioner and patient that might steer the course of this mini-ritual). Ruud describes the factors capable of mitigating pain: distraction, expectation, relaxation, and, importantly, the sense of being in control and feeling empowered, plus a vision of a temporal arc in which, down the line, pain might be vanquished. When we consider music’s role in configuring and shifting mood and atmosphere and in recalibrating consciousness (Clarke and Clarke 2011; Herbert, Clarke, and Clarke 2019) it becomes fairly easy to imagine music’s affordances for redefining situations of pain (“up-stream”) in ways that trigger responses in time (“mid-stream” and “down-stream”); and there is a strong tradition of research and practice on music and pain management (Hanser 2010; Mitchell and MacDonald 2012).

With a nod to Christopher Small (1998), who conceptualized musical activity as much more than making or listening to sounds, musicking is a cultural “immunogen.” Humorously, Ruud describes how, after first publishing an article entitled “Can Music Serve as a Cultural Immunogen?” in 2013, his email inbox was inundated with invitations to attend biomedical conferences and purchase the services of laboratories for testing hypotheses associated with this new immunogen. Musing on the wisdom of having employed a biomedical metaphor, Ruud adopts a bullish line, pursuing, as he puts it (and in dialogue with some of my own work [DeNora 2014]), a “sociology of the possible” (p. x): “Why not stretch the natural science or biomedical metaphor a bit? What kinds of cultural or social antigens or ‘substances’ can musicking offer to protect ourselves from ill health?” (p. 2).

For Ruud, the concept of the cultural immunogen builds on the related concept of the more general “behavioral immunogen,” or “actions we undertake to protect ourselves from harmful behavior, such as using a seat belt when driving or refraining from smoking” (p. 1). Cultural immunogens are also behavioral, but they add meaning. They create “dialogic and mutual relationships with the world” (p. 3) through the ways they promote vitality and emotional regulation, agency, connectivity, and meaning-making (p. 3). Ruud then sets out the research agenda: “How do people actually use music in their daily life . . . . What characterizes their idiosyncratic use of music as a cultural immunogen? How does this all relate to the larger field of music therapy? And, not least, how do societal, technological, economic and ideological conditions influence health musicking practices?” (p. 3).

The focus on societal, technological, economic, and ideological conditions is one of the features that distinguishes Ruud’s work from the individualistic and overly positive approach associated with some forms of positive psychology. For Ruud, the salutogenic paradigm, devoted to the promotion of coherence, hope, and belief, needs also to attend to the conditions under which positivity is fostered and deterred, and that includes equality of access to salutogenic activities and lifestyle practices. In this sense, Ruud’s advocacy of health-musicking is related to a particularly Norwegian approach to cultural engagement and public health: in 2013 the Norwegian government issued national guidelines for the treatment of people living with psychotic disorders, within which was a strong recommendation of music therapy (Helsedirektoratet 2013, as discussed in Stige 2018:117); and in 2015 all health trusts, acting on long-standing demands from user groups, were instructed by the Health Directorate to allow mental health patients to opt for medication-free services (such as cultural activities). Moreover, health trusts were instructed to develop “high-quality psychosocial alternatives” (Stige 2018:217). In 2017, Bergen became the first health trust in Norway to develop a health-promotion strategy that stipulated all clinics must include one or more music therapists (Stige 2018:118). Subsequent programs developed in Bergen aim for sustainable programs of health musicking, integrating bespoke music therapy with musical engagement in everyday life. The shift is one away from clinical provision and toward an overt focus instead on health promotion, public health, and, critically, empowerment through health-promoting activity. As Stige observes:

The math that the health authorities usually ask for is performed in the Cochrane Reviews and meta-analyses that inform the treatment guidelines where music therapy is recommended (e.g., Mössler et al. 2011; Gold et al. 2009). Increasingly also, we could expect the request for studies that calculate the health economics involved, as indicated in the participant quote above. In addition to the math, we need to bring forward the narratives of the people who use and experience the services, however. There are good reasons to suggest that the processes and effects of music therapy depend upon participants’ use of music in context (Stige et al. 2010; Ansdell 2014), and studies of participant contributions will be key (Rolvsjord 2015). (Stige 2018:125)

Ruud is very much a part of, and instigator of, this movement. Too much of music therapy, Ruud argues in ways that are in dialogue with critical work in the sociology of health and illness, is informed by psychotherapy and its pathologizing of health-related conditions; and yet, Ruud argues, “From the perspective of public health, the most important challenges to a healthy life come from issues like loneliness, unemployment, poverty and unequal access to health services” (p. 55).

Ruud’s aim is to widen the field of music therapy with, as he puts it, “greater social and political awareness” (p. xi), and he finds inspiration in Hartmut Rosa’s (2019) critique of modern social relations and Rosa’s (arguably romantic) yearning (Mühlhoff 2019:197) for a better way of life. In common with Rosa, Ruud sees modern life as characterized by a precarious socioeconomic situation that produces disturbances in our relationship with the environment, with each other, and psychologically, with ourselves. These disturbances in turn promote insecurity—ontological and otherwise—that in turn weaken our endogenous health-promoting mechanisms and can trigger the release of stress hormones and inflammation (which in turn affect mental health and sense of well-being). For Ruud, health and well-being come when we have access to what Rosa calls “resonance,” an affective, emotive mode of relation between beings and environments that is characterized by mutual transformation (Rosa 2019:174). Resonant relations open up opportunities to experience moments in which things feel whole, connected, pleasurable, confident, fulfilled, empowered. A cultural immunogen, then, is a material with which to “provide resources and give access to sites of resonance, to establish opportunities for sustainable axes of resonance both in the community and for the individual” (p. 35). Thus Ruud describes Rosa as wanting to promote “a vibrant relation to the world. This, he contends, may involve intense moments of subjective happiness understood as forms of resonant experiences in contrast to a feeling of unhappiness that may rise particularly when and where we find the world unexpectedly indifferent or even repulsive” (p. 59).

It is worth pausing for a moment to consider Ruud’s concern with Rosa and “intense moments.” The focus on pleasurable or meaningful moments illuminates the temporal production of health and well-being. And it helps to elaborate Rosa’s notion of “resonance,” empirically construed, setting that notion in the context of interactional events and showing us how music is good to think with. As music therapist Gro Trondalen once observed, with deceptive simplicity, “important moments are often unspoken and relational, and they happen in a moment” (2016:17).

Music therapists have explored the importance of momentary respite. Their explorations have included the occasionally electrifying, split-second moments of collective effervescence in which two or more people seem to “meet” in musical time and space (Pavlicevic 2010). They include moments in which a person, or group, may experience recognition or validation through the medium of music—and songwriting can be a tremendous resource for advancing this type of project (Rolvsjord 2005; Lewis 2017; Aasgaard 2004). They include epiphanous moments of profound pleasure and beauty (Ansdell 2014), moments in which hope is supported and enhanced (DeNora forthcoming), and moments that, through mutual, creative crafting, and often with terrific uncertainty, can be stretched, one into the next, such that, for all practical purposes, well-being is established (MacDonald and Wilson 2020). These moments can be catalytic and enlivening, even in the face of grave injury and imminent demise (Schmid 2017). More mundanely, many of us will have experienced how, within a moment of musical engagement, we may find refuge or respite (DeNora 2013) and shift away from exhaustion or mild depression and into energy or even joy (Skånland 2011). Such moments can be multiplied, facilitated, and developed into pathways away from dis-ease and dis-ability toward—in the broadest sense of the term—recovery (Stige et al. 2010; Ansdell and DeNora 2016).

Significantly, Ruud’s focus on health and illness and his concern with public health in the face of social disturbances draw together a concern with individual health and illness and a concern with community resilience. As such, Ruud’s perspective outlines an understanding of cultural immunogen that resonates with the study of cultural trauma, social movement, and social protest activity, and with endurance under oppressive social, political, and economic conditions. In this respect, Ruud’s work has been influential within music-sociological studies of resistance and underlines the importance of cultural engagement to collective health.

For example, in a study of underground culture in the former Czechoslovakia from 1968 and into the twenty-first century, Trever Hagen describes how shared cultural, and specifically musical, furnishing of scenes made it possible, as Hagen puts it, to “connect people together in action and consciousness” (2019:xii) in ways that could then be converted into, that generated, collective power for activism and “immunity.” Specifically influenced by Ruud’s notion of immunogen, Hagen goes on to describe how “immunizing” a collective was for the members of the Underground movement “a form of aesthetic resistance to the ‘sea of mental poverty’ and the ‘unhealthiness’ of normalization conditions linked to ‘official culture’ . . . [it] occurred in secure spaces that were furnished for habitation wherein one could feel certain emotions and adopt subject positions” (Hagen 2019:92).

Hagen speaks of a three-step process involved in connecting people, action, and consciousness: locating, opening up, and crafting. In the context of underground culture, that three-step process produced an alternative, resistant (“habitable”) cultural ecology, or way of life, that took shape through the ways that a “collective feedback loop” expanded hopeful visions and tapped resources for the growth of collective hope. As Hagen understands it, communities, depending on how they are created and sustained, can promote public well-being and resistance to what we might think of as social pathogens—oppressive regimes, prejudice, exploitation, confinement.

The concern with cultural immunogens clearly enriches cultural sociology, and socio-musical studies enrich the concern with cultural immunogens. Together, these areas highlight health and embodiment as shaped by a greater social whole, and they highlight the “active ingredients” of healing as involving more than a small dose of hope and faith (Goodhead and Hartley 2018; Tsiris and Ansdell 2019). Of course, musicking may not be health-promoting to all and under every set of circumstances, no more than a particular form of medicine or medical procedure might (DeNora and Ansdell 2014). But thinking about music in relation to health and thinking with music, as Ruud has done, reconfigures our notions of health, public health, and access to health promotion in ways that render them holistic and set them in a context of human rights. As such this book by Even Ruud underlines one of sociology’s most fundamental lessons, namely, the power of social, or supra-individual, phenomena—including belief, anticipation, faith, and form—and their role in effecting changes in what pass for psyche and for soma.

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