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Music therapy for depression: It seems to work, but how?

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Music therapy for depression: It seems to work, but how?

Abstract

Evidence is beginning to emerge that music therapy can improve the mental health of people with depression. We examine possible mechanisms of action of this complex intervention and suggest that music therapy partly is effective because active music-making within the therapeutic frame offers the patient opportunities for new aesthetic, physical and relational experiences.
According to a national poll of listeners to a popular BBC music
station in 2004, the best way to ameliorate one’s depressive
symptoms musically is to listen to ‘I Know It’s Over’ by The
Smiths.
1
Alas, the widespread availability of down-hearted rock
does not appear to have diminished the prevalence of depression.
And although listening alone to music that is personally
meaningful is what many people imagine music therapy to be,
the reality as practised in the UK and in many other parts of
Europe is quite different.
It is therefore gratifying to read the article by Erkkila
¨et al
2
in
this issue of the Journal that reports the results of a randomised
controlled trial of interactive one-to-one music therapy for adults
of working age with depression. In this study, conducted in
Finland, trained music therapists engaged participants in up to
20 sessions of co-improvisational active music-making as the basis
of a therapeutic relationship. This is a high-quality randomised
trial of music therapy specifically for depression and the results
suggest that it can improve the mood and global functioning of
people with this disorder.
Among the challenges involved in evaluating complex
interventions such as music therapy are those associated with
treatment fidelity. Erkkila
¨et al have addressed this issue by
ensuring that the music therapists who delivered treatment all
completed an extensive induction focused on ensuring fidelity,
and videotaped their sessions with participants to monitor
adherence. The attention to fidelity is borne out in results that
do not vary between therapists. This suggests that the agent of
change is not likely to be the personality of the therapist or the
nature of the particular therapist–patient alliance (as highlighted
by the common factors approach, for example Messer &
Wampold
3
) but rather may be attributable to the music or the
therapy (if they are indeed distinguishable).
So why might this be so? Aside from any explanations derived
from non-musical aspects of the therapy, the authors report that
‘active doing’ (i.e. the playing of musical instruments with the
music therapists) was important to many participants in the
active arm of the trial. They suggest that this is an important
characteristic of music therapy and a meaningful way of dealing
with issues associated with depression. We would like to suggest
that this ‘active doing’ within music therapy has at least three
interlinked dimensions: aesthetic, physical and relational.
Meaningfulness and pleasure
First, the relationship between a diagnosis of depression and an
experienced lack of pleasure and meaningfulness in life is well
established. Perhaps in response to this, there is also a well-
established recognition of the value of meaning-making via
aesthetic experience within psychotherapy (e.g. Zukowski,
4
Hagman & Press
5
). Here the conception is of the whole (verbal)
therapeutic process as essentially aesthetic: how much more of
an immediate aesthetic experience is on offer where the
therapeutic interaction is musical? In music therapy, the
therapist brings their musicianship to the musical encounter by
listening acutely and attuning to the musical components implied
in the patient’s improvised sounds. For example, the therapist
might draw out a shaky pulse or reinforce an implied tonal centre.
Or they might create suspense or an implied direction (using a
bass line or a harmonic progression underpinning an individual’s
melodic fragment) to entice a withdrawn person to engage in the
relationship. There are often moments in music therapy when
there is a ‘buzz’ between the two players, for example when they
spontaneously come together at a cadence point or somehow
know when to end or where to go next.
When a satisfying aesthetic is achieved within a co-improvised
musical relationship there is potential not just for some kind of
catharsis but for development, even if the music is not used as a
springboard to discussion and insight: the aesthetic draws in the
players to take the risk of doing things differently with others –
to behave differently towards each other and to experience
themselves differently.
6
Physicality
Second, and rather obviously, the act of playing musical
instruments requires purposeful physical movement. The role of
physical activity in averting depression and alleviating its effects
is well recognised. This is not simply a matter of getting people
92
Music therapy for depression: it seems
to work, but how?
{
Anna Maratos, Mike J. Crawford and Simon Procter
Summary
Evidence is beginning to emerge that music therapy can
improve the mental health of people with depression. We
examine possible mechanisms of action of this complex
intervention and suggest that music therapy partly is
effective because active music-making within the therapeutic
frame offers the patient opportunities for new aesthetic,
physical and relational experiences.
Declaration of interest
A.M. and M.J.C. are members of the International Centre for
Research in Arts Therapies (ICRA), a non-profit group that
aims to promote research in the arts therapies.
The British Journal of Psychiatry (2011)
199, 92–93. doi: 10.1192/bjp.bp.110.087494
Editorial
Anna Maratos (pictured) is a music therapist and Head of Arts Therapies at
Central and North West London Foundation Trust. Mike J. Crawford is a
Reader in Mental Health Services Research in the Centre for Mental Health,
Imperial College London and an Honorary Consultant Psychiatrist at Central
and North West London Foundation Trust. Simon Procter is Director of the
National Master of Music Therapy training programme run by Nordoff Robbins
in the UK.
{
See pp. 132–139, this issue.
moving, but also of enabling people to experience themselves as
physical beings. Music has its own internal sense of meaning
founded on structure and cultural norms: this engages us and
draws us into it whether or not we are aware of it on a technical
level. Hence we find ourselves tapping our foot along to a song on
the radio or being dissatisfied by a piece that does not finish as we
expect. We are therefore entrained into musical participation:
music itself offers us ways in – even in circumstances where we
may feel distinctly unmotivated. Where we find ourselves
musically entrained into physical participation with others we
can have a physical experience of ourselves with others. This
mirrors the experiences of musicians when playing in groups as
can be seen in the coordinated movements of the players in a
string quartet.
7
Our participation in turn enables us to hear
(and feel) ourselves in the context of the aesthetic experiences
outlined earlier, and this lends a potent sense of being part of
something meaningful in the here-and-now:
. . . music heard so deeply
That it is not heard at all, but you are the music
While the music lasts.
(T. S. Eliot: p. 48)
8
Relating
This leads to a third category of ‘active doing’: the relational. Our
first experiences of relating (with our primary caregiver) are
fundamentally musical. Developmental psychologists use musical
vocabulary to describe the finely attuned interplay of gesture
and sound between parent and newborn baby (e.g. Hobson
9
): it
is in this pre-verbal interaction that we first learn who we are,
how to think and to take pleasure in the possibilities that the
world around us has to offer. Where mothers of infants are
depressed, the musicality of infant-directed speech and
conversational engagement is demonstrably affected with
significant developmental implications for the child.
10
These early
experiences of musicality are frequently offered as a rationale for
music therapy as a whole (e.g. Trevarthen & Malloch
11
) and
from this perspective the role of the therapist can be seen as
neo-parental: musically nurturing the patient in order to
facilitate a similar process of discovery of self and self in relation
to others, including the capacity for experiencing meaning and
pleasure. Once again, it is music itself that facilitates this: a
melodic riff, a harmonic progression, a rhythmic catch – these
all naturally engage people in active participation (and hence
meaning-making) in ways that words may simply not be able to.
It has been argued that music therapy builds on people’s capacity
for communicative musicality, that we are hard-wired for this
kind of engagement and interaction, and that through music-
making we experience a kind of relating that is very different from
that which talking has to offer.
12
Music – therapy?
In these respects, then, music cannot be treated simply as a
stimulus intended to provoke a predetermined behavioural
response. Rather, music-making offers what DeNora
13
terms
affordances – physical, relational and aesthetic. Above all,
music-making is social (and hence interpersonal), pleasurable
and meaningful: this may also be why randomised trials of music
therapy have shown high levels of engagement with patient groups
who are traditionally difficult to engage (e.g. Talwar et al
14
).
Clinical trials inevitably focus on the outcomes of inter-
ventions rather than the process through which these outcomes
may be achieved. Further research using mixed methods is needed
if a better understanding of the active ingredients of music therapy
that enhance patient outcomes is to be reached.
Nevertheless, Erkkila
¨et al
2
lay down a clear marker for the
value of music therapy as part of the range of interventions
available for the treatment of people with depression.
Anna Maratos, MSc, Central and North West London Foundation Trust;
Mike J. Crawford, MD, Centre for Mental Health, Imperial College London and
Central and North West London Foundation Trust; Simon Procter, MMT(NR), National
Music Therapy training programme, Nordoff Robbins, UK
Correspondence: Anna Maratos, Head of Arts Therapies, CNWL Foundation
Trust, c/o 7a Woodfield Road, London W9 2NW. Email: anna.maratos@nhs.net
First received 16 Dec 2010, accepted 27 Apr 2011
References
1BBC. The Songs That Saved Your Life. Poll for BBC 6 Music. BBC, 2004 (http://
news.bbc.co.uk/2/hi/entertainment/3547347.stm).
2Erkkila
¨J, Punkanen M, Fachner J, Ala-Ruona E, Po
¨ntio
¨I, Tervaniemi M,
et al. Individual music therapy for depression: randomised controlled trial.
Br J Psychiatry 2011; 199: 132–9.
3Messer SB, Wampold BE. Let’s face facts: common factors are more potent
than specific therapy ingredients. Clin Psychol Sci Pract 2000; 9: 21–5.
4Zukowski EM. The aesthetic experience of the client in psychotherapy.
J Humanistic Psychol 1995; 35: 42–56.
5Hagman G, Press CM. Between aesthetics, the co-construction of empathy
and the clinical. Psychoanal Inq 2010; 30: 207–21.
6Ansdell G. Music for Life. Jessica Kingsley Publishers, 1995.
7Davidson JW, Good JMM. Social and musical co-ordination between members
of a string quartet: an exploratory study. Psychol Music 2002; 30: 186–201.
8Eliot TS. The dry salvages. In On the Four Quartets of TS Eliot
(ed C De Masirevich): 48. Barnes and Noble, 1965.
9Hobson P. The Cradle of Thought. Exploring the Origins of Thinking.
Pan, 2002.
10 Marwick H, Murray L. The effects of maternal depression on the
‘musicality’ of infant-directed speech and conversational engagement.
In Communicative Musicality: Exploring The Basis of Human Companionship
(eds S Malloch, C Trevarthen): 281–300. Oxford University Press, 2009.
11 Trevarthen C, Malloch S. The dance of well-being: defining the music-
therapeutic effect’. Nord J Music Ther 2000; 9: 3–17.
12 Ansdell G, Pavlicevic M. Musical companionship, musical community:
music therapy and the process and values of musical communication.
In Musical Communication (eds D Miell, R MacDonald, DJ Hargreaves):
192–213. Oxford University Press, 2005.
13 DeNora T. Beyond Adorno: Rethinking Music Sociology. Cambridge University
Press, 2003.
14 Talwar N, Crawford MJ, Maratos A, Nur U, McDermott O, Procter S.
Music therapy for in-patients with schizophrenia. Exploratory randomised
controlled trial. Br J Psychiatry 2006; 189: 405–9.
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