Abstract
How can we document and explain changes in, and outcomes of, music therapeutic work? In therapy, change is connected to a timeline of meaningful moments of insight and communication between therapist and client, which need to be understood through a situationist stance on musical experience. Social neuroscience research that describes time processes of musical communication and physiological change creates frameworks for researching such processes. What accounts for change in music therapy can be elucidated by recent research into music therapy praxis of improvising and verbal reflection and research on music’s effects on neural processing, particularly in fronto-temporal and right-hemisphere regions that are implicated in music, language and emotion processing.
Keywords
When and how something is happening in the music along a timeline of therapeutic events is essential in music therapy, as F. North (2014) has demonstrated in her three graphic representations of important vocalization passages in music therapy work. Although music therapists, alert to the implications of doing music therapy with particular clients, do not necessarily aim to isolate a particular musical element from its context of occurrence, understanding musical experience requires understanding how event sequences are differentiated and contextualized within the continuous flow of music.
North’s examples show us how a music therapist makes sense of certain passages, episodes and events in a series of sessions. They demonstrate how a therapeutic narrative of how the clients and the therapist experienced the music and the development of the sessions can be created, based on these events. She describes music therapy as an invitation to change, and notes that “changes provide opportunities for communication.” Broadly speaking, North’s approach fits within the kind of music therapy that Bruscia (1987) characterizes as “music as therapy,” distinct from “music in therapy” – that is, where music is the main agent of change, as opposed to a psychotherapy-centred approach which uses music in a process of psychotherapy.
In this response I would like to take these thoughts further and discuss firstly how change is connected to a timeline of events signified as meaningful moments of insight and communication between therapist and client, and secondly how music therapy processes can change physiological processing. To do this, I argue that a situationist stance on musical experience is useful for understanding how the specific context of music therapy gives meaning to musical elements and time processes. Social neuroscience research that describes time processes of musical communication and physiological change creates frameworks for researching such processes. What accounts for change in the cases North presents, and in music therapy more generally, can be elucidated by recent research into music therapy praxis of improvising and verbal reflection and research on music’s effects on neural processing, including in Randomized Controlled Trials.
A situationist stance on musical experience
North’s characterizations of events in music therapy represent a view of musical processing that is in line with music therapists’ endeavours to identify the narrative of change in music therapy processes, related to the musical material produced (Aldridge & Aldridge, 2002; Wosch & Wigram, 2007). It is also in line with music psychological research approaches that are sensitive to the dynamics and contextual factors of participants’ experiences (Toiviainen & Krumhansl, 2003). Rather than investigating responses to preselected short music stimuli, this approach investigates continuous music listening in naturalistic listening environments (Alluri et al., 2012; Schubert, 2010).
This alternative approach requires relating the experience of time in music to events, and personal meanings and experience of events, in the music, rather than the music’s inherent logic. Rather than looking at a chronological order of parts in the music, as successive elements of the piece as a whole, the focus is on participants’ situational relationship to the music; in therapy this translates into how the perceived musical elements interact with the client’s experience of the music in this interactive setting. To use Aldridge’s terms (1997; see also Petersen, 2011) the kairos concept of personal time – the “right moment,” the ability to seize the moment, to recognize to act and decide on something, based on the individual experiences in the “here and now” – is more appropriate for music therapy than objective time as chronos. What leads to change in music therapy sessions may be characterized as kairological interdependencies.
Communication in music therapy needs to be seen through the lens of “situated cognition,” in which meaning, knowing and learning are generated in the situation of doing something bound to a social, cultural and physical context (Smith & Semin, 2004). Communication in music therapy is thus dependent on contextual developments and not on a plan made like a scene-play; the music is temporal and emotions signifying meaning are evoked through the interplay of music and the people who do the music. Furthermore, the client(s) and therapist(s) share knowledge in a way captured by the Thomas-Theorem (Thomas & Thomas, 1928) that “knowing with others” is an active process; and that those sharing the same experiences and knowledge generated in same situations and context can define rules of performance. The point is not whether the rules are right but that they are shared with others.
North’s characterization of the four excerpts clearly reflects a situationist stance, a context-driven deciphering of what is “beyond words.” In therapy, therapists and clients are immersed through the senses, interaction, embodiment and narrative experience in real-time contextually performed interpersonal action (Fachner & Gilbertson, 2012). In North’s Example 2, the girls knew distinctly about Helen’s vocalization and about her hard day; North sensed it as well from being in the contingency of this particular context and constellation in time. To share this in a joyful musical play illustrates how the meaning of musical elements that we use for communicative purposes in therapy is governed by context.
North’s excerpts focus on specific meaningful “pivotal” moments in the sessions, which are distinct within the time-course of therapy (Amir, 1992; Grocke, 1999), and which are related to the change that occurs. However, her characterizations also embody awareness that to understand the process of music therapy properly one has to follow it through an extended and sometimes gradual series of changes. To focus only on highlights or significant moments will not suffice in characterizing the process and its development (Nordoff & Robbins, 2007, pp. xxii–xxiv); understanding communication in music over time is essential.
Physiological and neurological observations
Micro-analysis, as employed in North’s excerpts, is a detailed analysis of moments, events and episodes within a session to document the “moment-by moment experienced change” (Wosch & Wigram, 2007, p. 22). Music therapists usually document important moments by doing AV recordings of their sessions and using a range of methods to analyse them. An important methodological challenge for the analysis of events in the timeline of a therapy session is to analyse the co-ordination of co-created events in improvisation (Aldridge, 1991) or in continuous self-report methods to monitor experiences (Schubert, 2010). Micro-analytic techniques, such as the pioneering frame-by-frame analysis introduced by Condon to show the interactive nature of bodies synchronizing to speech (Condon & Sander, 1974), have been applied in music therapy research to analyse processes and development of change (Wosch & Wigram, 2007) and the relations between musical features and clinical outcomes.
A complementary type of analysis that has the potential to provide additional insight into what happens when we create music together is electrophysiological: analysing the synchronization patterns of brain waves and heart beat during interactive music-making. There are significant challenges in contextualising brain activity during important moments in musical interaction in general, and music therapy sessions in particular, as attempts to locate musical interaction in a laboratory setting can impair the authenticity of the situation. The documentation of significant moments in therapy on recording appliances in particular demands a sensitive approach, that is, the measuring instruments must be adjusted as close as possible to every-day practice (Fachner, 2006), in order to generate context sensitive data. The good news is that recent developments in telemetric EEG hardware applications have made it possible to use bigger (Lindenberger, Müller, & Sänger, 2011) or smaller portable EEG units (Debener, Minow, Emkes, Gandras, & de Vos, 2012) that allow recording of data during music performance, music therapy, and other non-laboratory music settings in which participants can move freely. This is a big advance, as most stationary recording systems require quiet sitting.
Such new devices allow new exploration of the kinds of dialogical elements in the improvisations described in North’s examples, and new evidence on how “communication in music can emulate verbal communication.” In a pioneering study (Neugebauer & Aldridge, 1998), an analysis of musical dialogue in music therapy recorded physiological data of two musicians improvising: two synchronous electrocardiograms (ECG). Following Nordoff-Robbins music therapy practice, an index of therapeutic events was created that catalogued “communicative interaction and/or musical events such as moments of musical interrelation, initiatives for musical change, mutual changes in the playing, changes of tempo, dynamic and mood” (Neugebauer & Aldridge, 1998, p. 47). Such indices of the therapeutic events were then compared to the events identified on the timeline of the ECG. Analysing patterns of heart rates revealed a convergence of activity within dialogical events; that is, parallel or opposite heart rates and simultaneous or alternating peaks indicating action specific synchrony patterns of co-ordinated activity (Neugebauer & Aldridge, 1998, p. 48).
In non-therapeutic settings, electrophysiological music performance research has examined two people playing guitar (Lindenberger, Li, Gruber, & Müller, 2009) or four people playing saxophone (Babiloni et al., 2011). This showed how physiological functions synchronize in a coherent manner, for the guitarists especially “during the periods of (i) preparatory metronome tempo setting and (ii) coordinated play onset” (Lindenberger, et al., 2009), in order to produce a social product, a piece of music performed together. Such analysis of synchronous brain activity can be carried out with two or more synchronized MEG/EEG machines or sources. Playing a piece together leads to synchronous activity in frontal and central brain areas (Sänger, Müller, & Lindenberger, 2012), which points to time-locked synchronization of fine-grained planning and executing of shared activity. Neuroimaging technology can be used reliably to capture data from multiple participants engaged in simultaneous, improvised music-making (Donnay, Rankin, Lopez-Gonzalez, Jiradejvong, & Limb, 2014; Müller, Sänger, & Lindenberger, 2013).
As I have argued elsewhere (Fachner & Stegemann, 2013), research in the field of social neuroscience is of vital interest for the field of music therapy: research on how brain-to-brain coupling functions in social interaction (Hasson, Ghazanfar, Galantucci, Garrod, & Keysers, 2012), how this aligns with body posture and movement (Hari, Himberg, Nummenmaa, Hämäläinen, & Parkkonen, 2013) and how brain processes between music listeners synchronize when they listen to longer pieces of music (Abrams et al., 2013). How much of the brain coupling identified so far is applicable to clinical improvisation awaits further experimental studies. Nevertheless, as Neugebauer’s study demonstrates, it is feasible to carry out social neuroscientific research on clinical scenarios as they happen in the everyday life of clinical practice.
Randomized Controlled Trial (RCT) approach
Music therapy research is rich in phenomenological methods of inquiry that systematically document, reflect and discuss our observations of change (Aldridge, 1996; Bruscia, 1998; Wheeler, 2005). Experiments in laboratory settings offer one complementary approach to modelling what is happening in “real life,” while aiming to reduce and control the variables of influence. This allows for systematic control over the context but can be criticized for being limited in its representation of real life.
Another approach, which reflects an epistemology informed by pharmaceutical practices, tests whether a particular treatment is effective. This requires defining outcome measures to follow change, in the process identifying key features which contribute to change. Applying this approach to music therapy research in a way that is informed by music therapy’s blend of significant moments, uniqueness, situated cognition and embodied interaction requires standardizing our “soft ingredients.” RCT methods, I would argue, can be usefully applied to music therapy if we create a framework of an appropriate model informed by insight into music therapy practice.
As an example of a music therapy RCT that takes this approach, we (Erkkilä et al., 2008) were interested in whether music therapy added to standard care of depression treatment produced different outcomes from standard care only. Our challenge was to develop a balance between a flexible and spontaneous practice of responding to clients and a standardization of a treatment practice. Standardization meant, for example, using the same musical instruments and a shared reference system created by all therapists taking part in the study, in terms of understanding depression, research and treatment practice and its philosophy (Erkkilä, Ala-Ruona, Punkanen, & Fachner, 2012). Consensus was reached among the researchers and therapists that music therapy here would have common aims and techniques that would be more constrained than usual, that is, that this would be a model of a normal treatment and not a normal treatment as such. This allowed a baseline to start from, to be developed and supervised on the way (Fachner & Erkkilä, 2013).
The results indicated a significant effect of music therapy added to standard care compared to standard care only (Erkkilä et al., 2011). Three of the outcome measures indicated a substantial improvement: a reduction of depression and anxiety scores and an increase of overall global function, and most clients reported not being happy that the treatment ended after 20 sessions.
Within this RCT approach we could also explore new hypotheses about music therapy’s effects on the brain. Our focus was on clients with depression, who have difficulties in expressing and processing emotion (Punkanen, Eerola, & Erkkilä, 2011), and, given the frequent comorbidity with anxiety (Aina & Susman, 2006), are more likely to act in a withdrawn and anxious manner in social interaction (Davidson, Marshall, Tomarken, & Henriques, 2000). Depressed clients tend to use rumination and expressive suppression as strategies to regulate their emotions instead of actively approaching them (Joormann & Gotlib, 2010). The withdrawal behaviour of depressed clients has been linked with increased right frontal activity; that is, pathological asymmetric frontal processing of emotion (Henriques & Davidson, 1991).
The evidence to date has indicated an immediate effect of pleasurable music listening on frontal processing in depression. For example, during and after music listening the relatively right-sided frontal activity of depressed adolescents (Field et al., 1998; Jones & Field, 1999) and depressed mothers (Tornek, Field, Hernandez-Reif, Diego, & Jones, 2003) shifted towards relatively left-sided activity. Our aim, within the RCT study, was to find out whether these effects last beyond immediate music listening, and can be observed in an additional resting EEG recording after a course of active music therapy (Fachner, Gold, & Erkkilä, 2013). (This differs from Field et al.’s (1998) study with depressed mothers, where measurements were taken during or directly after listening). To measure EEG resting state, we used a simple and easy-to-apply indicator of neuroplasticity, as utilized in Pharmaco-EEG studies (Saletu, Anderer, & Saletu-Zyhlarz, 2010). To test our hypotheses about how frontal activity is affected by music therapy, we explored correlations between anterior EEG, the Montgomery–Åsberg Depression Rating Scale (MADRS) and the Hospital Anxiety and Depression Scale – Anxiety Subscale (HADS-A), power spectral analysis (topography, means, and asymmetry) and normative EEG database comparisons. Normative EEG comparisons allowed us to distinguish excessive or abnormal EEG patterns against a database of age, gender, and condition-matched controls (Thatcher, 2010).
The EEG resting state measures pointed to fronto-temporal changes as a signature of difference between both groups and between the pre and post music therapy treatment (Fachner et al., 2013). This finding is consistent with research on the role of fronto-temporal areas in music and language processing (Koelsch, 2012) and evidence from a study on fronto-temporal lobar degeneration in 26 patients demonstrating the importance of fronto-temporal areas for the recognition and processing of emotion in music (Omar et al., 2011). It is also consistent with Koelsch’s (2009) proposal that emotional modulation of limbic structures, activation of the perception-action mediation in premotor areas, and intentional processes of social cognition in frontal and temporal areas are possible neuroscientific concomitants of music-therapeutic action.
In her musical excerpts North exemplifies how vocalization and communication link to music and language processing, and how the emotional colour of the voice can change in a musical dialogue. Our EEG evidence from a music therapeutic setting adds to the body of neuroscientific work that is clarifying how emotion, music and linguistic prosody are neurally represented. Some time ago, Patel et al. (1998) suggested a shared neural resource for prosody and music; more recently Panksepp and Trevarthen (2009) have theorized the importance of right hemispheric prosody in its connection to emotion processing and communicative musicality. Koelsch et al. (2004) have stressed the close connection of semantic and syntactic functions in music and speech processing. Processing of melody is connected to pre-motor speech process activation at a laryngeal level, initiating pre-motoric level movement processes, especially when meaningful and rewarding emotional processes trigger perception-action mediation (Koelsch, 2009). Results with aphasic patients undergoing melodic intonation therapy showed plasticity changes in the fibre tract connecting the superior temporal and inferior frontal lobes and the motor cortex in the right anterior hemisphere (Schlaug, 2009; Schlaug, Marchina, & Norton, 2009).
In our EEG depression study, right-hemispheric activity increased after music therapy (Fachner et al., 2013). Considering that about 70% of the therapy sessions were used for verbal reflection and 30% for improvising, fronto-temporal changes may indicate that participating in music therapy initialized neural reorganization in areas which were busy with processing music and language in manifold ways, while offering the client a context to experience and embody a playful means of emotional expression supporting reduction of anxiety among, and depressive withdrawal from, others.
The observations of fronto-lateral asymmetry changes in Fachner et al.’s study together with the various findings on prosodic processing in these regions suggest a physiological basis for the emotional processing that occurs in music therapy with depressed clients.
Conclusion
In providing examples of how music therapists invite change in their clients, North offers a solid base of detailed case-study work for generating new hypotheses. In this response, the focus was on the timelines of the events that lead to change. Change in music therapy must be seen through a situationist and context-dependent lens. Distinct moments in which important information has been mutually created provide a useful entry into understanding the continuous and longer-term change of which they are a part. Documentation of such processes in music therapy research and practice is rich, as North’s paper demonstrates.
I would argue that a broader unifying framework for understanding communicative processes is needed: a common language to describe sufficiently what we have witnessed in these cases, and what is seen in research that has documented the efficacy of music therapy approaches in several fields of mental health (Carr, Odell-Miller, & Priebe, 2013), psychiatry (Erkkilä, et al., 2011), neurological rehabilitation (O’Kelly et al., 2013), etc. I propose that new process research on, for example, physiological traces of synchronized processes of interaction, and on areas of neurophysiological interest regarding the processing of music and language (Koelsch, 2009) in music therapy (Fachner et al., 2013), will help in creating that common language.
Footnotes
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.