Music Therapy in the Neonatal Intensive Care Unit

Music therapy is a profession that uses clinical and evidence-based music interventions to address specific therapeutic goals to improve the health and well-being of a patient within a therapeutic relationship. Neonatal Intensive Care-Music therapy is defined by Standley and Gutierrez (2020) as “an evidence-based, specialized training in music therapy, neurodevelopmental, and family care intervention for premature infants.” NICU-MTs are equipped with counseling skills, experience working in a NICU interdisciplinary team, and providing assistance to parents who may become overwhelmed by the stress of the NICU. For premature infants, the NICU is a stressful environment that includes loud noises, bright lights, separation from their parents, and invasive treatments that are necessary to save the infant’s life. Music therapy is employed to assist in improving the health of infants, resulting in shorter hospital stays, increased resting energy preservation, and increased growth (Allen, 2013).

The purpose of studying music therapy on infants in the NICU is to find interventions that improve infant health, decrease infant and family anxiety, and get the infants home faster. The NICU is a stressful environment for preterm infants with bright lights, loud noises, and increased physical touch from nonmaternal figures on a regular basis. Preterm infants are “touched, positioned, examined, and manipulated more than 8 to 12 times over a 4-hour period to assess and evaluate their clinical status. Each of these stimuli can be viewed as a stressor by the immature system of a premature infant, which can lead to impaired oxygenation, blood flow, heart rate, and behavioral responses” (Allen, 2013). When introduced at an appropriate decibel level, music can counteract the negative effects of physical discomfort.

In this photo, the music therapist is using a music therapy technique called multimodal sensory stimulation.

Caine (1991) did a study that showed “that listening to continuous music for up to four hours a day… has a number of physiological benefits such as: reduced infant stress, increased weight gain, stabilized heart and respiratory rates, increased oxygen saturation, and reductions in apnea and bradycardia.” Kraft (2021) also found that music interventions improve premature infants’ vital signs, movement patterns, and positive neurodevelopment. Maternal singing is especially beneficial because it reduces the mother’s stress, increases her attachment to her infant, and trains her to combat overstimulation with her child. Maternal singing “is particularly responsible for sustaining infant’s attention, modulating arousal and enabling mother-infant protocol versatile self in at term infants” (Trehub, 2017). Live singing is important to continue in the home because it promotes “social development as evidenced by the infant giving positive responses to eye contact, watching or focusing attention on the caregiver, orienting the head and eyes to visual and auditory stimuli, mimicking care-giver facial expressions, and beginning to self-regulate” (as cited in Standley, 2019).

-Janelle Lockney, Music Therapy Intern

References:

Kraft, K. (2021). Maternal anxiety, infant stress, and the role of live performed music therapy during nicu stay in the netherlands. International Journal of Environmental Research and Public Health, Vol. 18(No. 13), p.7077.

Caine, J. (1991). The effects of music on the selected stress behaviors, weight, caloric and formula intake, and length of hospital stay of premature and low birth weight neonates in a newborn intensive care unit. The Journal of Music Therapy

Trehub, S. (2017). The Maternal Voice as a Special Signal for Infants. 10.1007/978-3-319-65077-7_3. 

Standley, J. (2020). Benefits of a comprehensive evidenced-based NICU-MT program: Family-centered, neurodevelopmental music therapy for premature infants. Pediatric Nursing, Vol. 46(No. 1), p.40-46.

Allen, K. (2013). Music therapy in the nicu: Is there evidence to support integration for procedural support? Advances in Neonatal Care, Vol. 13(No. 5), p.349-352.

Music Therapy and Language Barriers

Any form of therapy utilizes communication to assist in the flow of the sessions and help the clients reach their goals. Music therapy is unique because it can use music as communication, but can it still be effective through a language barrier? Language barrier refers to “music therapists who conduct music therapy sessions in a language that is not their native tongue” (Mori, 2021).

There are two main ways to facilitate music in music therapy: music in therapy and music as therapy. Music in therapy refers to when music is used as a tool to enhance existing treatment. Music as therapy refers to when the music has a direct impact on the client and is the primary tool for growth (Zanders, 2018). When a music therapist uses music as therapy, “music is the essential medium of communication and interaction to build a therapeutic relationship” (Mori, 2021). Four other methods of facilitating music therapy have been presented by Bruscia (2013). His methods are the receptive method, the re-creative method, the improvising method, and the compositional method. Mori (2021) describes these methods precisely as:

In the receptive method, clients listen to music and respond to it verbally or in different modalities. In the re-creative method, clients sing and play instruments through precomposed music or reproduce music forms. In the improvisational method, clients create a melody, rhythm, and instrumental piece with the therapists’ support. In the compositional method, the therapists assist clients in writing music and lyrics.

Nordoff-Robbins Music Therapy (NR-MT) is a prime example of music therapy that is effective in a language barrier due to its techniques of improvisational music making as the primary form of communication. An interview conducted by D. M. Kim (2010) revealed that therapists who worked through a language barrier preferred NR-MT over other music therapy methods. They appreciated NR-MT because it enabled both them and their clients to express themselves fully through music without the need for verbal communication (Towards musical individuation).

When practicing music therapy with a present language barrier, it is important to maintain a music as therapy model and rely on the music to communicate with the client. Research shows that the most important factors in building rapport in a second language include being honest, understanding facial expressions and body language, authenticity, and empathy (Mori, 2021). Mori’s (2021) study resulted in three significant findings: “English [for non-native English speakers] is not necessarily a language barrier; the respondents use music interventions depending on the clients’ goals; and the respondents are sensitive to the clients’ cues (e.g., body language, facial expressions), rather than depending only on verbal cues to facilitate the therapeutic process.”

-Janelle Lockney, Music Therapy Intern

References:

Kim, D. (2010). Towards musical individuation: Korean female music therapists’ experiences in the nordoff-robbins music therapy certification training. The Arts in Psychotherapy, 37, 353-362.

Mori, K. (2021). The influence of language barriers in music therapy (Publication No. 107) [Master’s thesis, Molloy College]. Lila D. Bunch Library.

Zanders, M. (2018). Music as therapy versus music in therapy. Journal of Neuroscience Nursing, 50(4), 218-219.

Humanism in Music Therapy

Humanistic music therapy is rooted in the belief that everybody can actualize their desires for their health and well-being and that conditions and states present opportunities for change. A humanistic music therapist does not need to limit themselves to only utilizing humanism in their practice. Humanistic music therapists can learn and practice techniques from other therapeutic approaches as long as they keep the core principles of humanism.

Bugental (1964) published five core principles of humanism in psychology. 

1. Humans are more than the sum of their parts and cannot be reduced to individual components.

2. Humans exist in a uniquely human context

3. Humans are conscious and aware of being conscious in the context of themselves and others

4. Humans have both choice and responsibility

5. Humans are intentional beings with goals, aware of how they play a role in future events and seek meaning, value, and creativity

These principles laid the foundation for humanism’s use in therapy. There are four foundations of humanistic music therapy and four humanistic constructs that exist outside of Bugental’s five principles. The four foundations of humanistic music therapy include clients, music, therapy goals, and the therapeutic process. The four core humanistic constructs include being, holism, agency, and relationship.

Humanistic music therapy is relational. It does not focus on the client’s response to interventions, but on how the treatment helps the client feel empowerment, meaning, and dignity. Relationships in humanistic music therapy are not just an aspect of the treatment but the therapy itself. Clients are regarded as beings. Being (in the context of humanism) is a way of existence centered on humanity and distinguishes each individual with a unique identity. This is typically contextualized most clearly as somebody’s name. Being is more concerned about the who rather than the what of the client's needs.

Humanism is practiced in music therapy through musicing. Musicing is the expression of a person’s aesthetic agency in action. Aesthetic agency is the capacity for an individual to control their musical experience. Goals in humanistic music therapy center around the “ongoing, evolving pursuit of self-actualization, or the maximal expression of human potential” (Wheeler et al., 2017). In the Humanistic music therapy intervention process, interventions are not isolated techniques accomplishing isolated goals but are understood by how they play a role within the context of the whole person.

-Janelle Lockney, Music Therapy Intern

References:

Wheeler, B. (2017). Music therapy handbook. The Guilford Press.

Music Therapy and Adults with Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a lifelong neurodevelopmental condition (Bergmann, 2016) defined by deficits in social communication and interactions paired with restricted, repetitive behaviors, activities, and interests (Velikonja, 2019; Andersson, 2020). Goals and objectives for adults with ASD seeking treatment can be addressed during music therapy sessions. Music therapy positively impacts adults with autism spectrum disorder by assisting in activities of daily living, social interaction, and cognitive function. Music therapy interacts with adults with ASD through improvisation, group music-making activities, and various other interventions to improve their quality of life. Symptoms and severity range in every person diagnosed with ASD, and how the condition progresses into adulthood is also unique to the individual and their level of care.

Activities of Daily Living [ADLs] are the everyday tasks (such as cooking, cleaning, and sustainability) that can be impacted by an individual’s diagnosis. Within ASD specifically, “Clinical characteristics… influence the relationship to the self, to other people, and to objects and thus include all areas of life” (Bergmann, 2016). Andersson (2021) released an article that studied positron emission and serotonin availability in adults with ASD and how this affects performance in cognition and functioning compared to neurotypical adults. They found that adults with ASD perform lower in social cognition, executive function, and central coherence (Andersson, 2021). The two most common goals for adults with ASD are understanding behavior and how it affects their lives and developing executive functioning skills.

Music therapy, as a treatment for ASD, can be rewarding and exciting for patients. Adults benefit from music therapy in the areas of “regulation/behavioral variability, imitation, disorders pertaining to different areas related with instinct, emotional disorders and interaction disorders” (Mateos-Moreno, 2013). The structure of music therapy can be comforting for adults with ASD because it can be uniquely tailored to their needs and wishes. A commonality amongst people with ASD is the comfort they receive in predictability and structure, and music therapy can provide that for its patients. Tony Wigram developed many improvisation techniques in music therapy that can be applied when working with adults with ASD. Improvisation is particularly effective in understanding emotions and emotional regulation. Portraying different emotions through piano or drumming can help a client connect with that particular emotion and how they can express it when it arises in their daily life. Group music-making allows adults with ASD to create joyful experiences and connections with their peers (Mateos-Moreno, 2013). An example of music therapy being used for adults with ASD was in 2013 when The Arts in Psychotherapy released an article discussing music and dance/movement therapy’s impact on adults with ASD. Their session started with everybody entering the room with soothing music and forming a circle. They then stated their names using a drum since the rhythm enhances the memory process. They continued the exercise by expressing their feelings by using the drum. After each client said their name and how they felt, the rest of the group chanted it back to them. This encouraged the participants to remember the details of their fellow peers and validate what the individual stated. Music therapy is a beneficial treatment option for adults with ASD because it is fun, safe, and inclusive and reaps real benefits for adults in the ASD community.

-Janelle Lockney, Music Therapy Intern

References:

American Music Therapy Association. (2005). What is Music Therapy? American Music Therapy Association. Retrieved 2022, from https://www.musictherapy.org/about/musictherapy/

Anderson, M. (2021). Serotonin transporter availability in adults with autism - a positron emission tomography study. Molecular Psychiatry. Vol.26(5), pp. 1647-1658

Bergmann, T. (2016) Music in diagnostics: Using musical interactional settings for diagnosing autism in adults with intellectual developmental disabilities. Nordic Journal of Music Therapy. Vol.25(4), pp.319-351

Buijsman, R. (2022). ‘Autistic man’ or ‘person with autism’?: Person-first language preference in Dutch adults with autism and parents. Autism: The International Journal of Research and Practice. Pp. 13623613221117914-13623613221117914

Mateos-Moreno, D. (2013). Effect of a combined dance/movement and music therapy on young adults diagnosed with severe autism. The Arts in Psychotherapy. Vol.40(5), pp. 465-472

Roberson, K. (2019). Goals of therapy for adults with autism spectrum disorder. Kenneth Roberson PhD. Retrieved July 2022, from https://kennethrobersonphd.com/goals-of-therapy-for-adults-with-aspergers/

Velikonja, T. (2019). Patterns of nonsocial and social cognitive functioning in adults with autism spectrum disorder: A systematic review and meta-analysis. JAMA Psychiatry, Vol.76 (2), p.135-151.

Final Farewells

Reflecting on my time here at Therabeat Inc., I have grown so much from when I first started. With the support of my supervisors, I created new music games, helped clients reach their goals, and built a library of materials. I learned how to go with the flow during co-treats and address the client’s needs such as needing a break or moving around.

I have learned many valuable lessons. For instance, I learned how to play the ukulele. Before this internship, I had never played the ukulele. Now, I can play and teach clients how to play the ukulele in sessions. I have learned how to think on my feet and think outside of the box. For instance, when a client requested more of the gong during her physical therapy session. I used the gong and her preferred music to cue her to cross midline to play it.

Other skills I have learned include how to look at a chord sheet and keep eye contact with the client and the importance of small talk during a session. I found that talking with the clients during the session created a positive client therapist bond and I learned more about the client. It helped to inform the way I plan to create more opportunities for clients to reach their goals. For instance, using their preferred music to write a song to work on goals such as answering questions and creating original ideas.   

One of the memories I look fondly on is seeing how well all my clients did at the recital. They all worked so hard to perform for their family and friends. For instance, one client successfully played and sang his song. The joy and pride he felt for his performance reminded me why I am a music therapist in the first place. Another fond memory I have with a client is a client diagnosed with autism. She was working on spelling and pronunciation words, so I brought visuals, a letter puzzle, and a song with an easy melody to remember. Within 2 weeks, she could spell and pronounce 3 words of the song. Not only did I help her develop her speech and academic skills, but it made me feel accomplished as a music therapist.

Thank you to Therabeat Inc. for giving me the confidence and skills that you have taught me. I will carry all the memories and lessons to my next adventure. I am not sure where I will be, but wherever I go I know I will be ready thanks to this internship. Farwell Therabeat Inc. You will always have a special place in my heart.

-Teresa Dominguez, Music Therapy Intern