Music Therapy and the Hearing Impaired

Deficits in auditory perception and hearing loss affect all individuals regardless of age, race, gender, socioeconomic class, and more. According to the National Institute of Deafness and Other Communication Disorders, “2 to 3 out of every 1,000 children in the United States are born with a detectable level of hearing loss in one or both ears” (2021, line 1). Traditional verbally expressed and auditorily processed communication may not be easily accessible to individuals with auditory deficits or an extreme degree of hearing loss. Therefore it is important to use alternate forms of communication such as sign language, visual supports, augmentative and alternative communication devices, vibrations, and other elements of music. Music therapy (MT) provides those who live with impaired hearing and deficits in auditory perception the opportunity to build a positive self-image, improve self-esteem, improve communication, and more through uniquely designed music-based interventions. MT is an effective mode of treatment because trained and board certified music therapists (MT-BCs) provide music-based stimulation through tactile touch, vestibular stimulation, and visuals. All of which are unique to each individual and their degree of hearing loss. 

In order to provide individualized MT interventions to children and adolescents, MTs strive to understand human auditory processing and how best to provide additional stimulation for those who are hard of hearing. Music reaches these individuals in many creative and effective ways. Research suggests that in order for MT-BCs to communicate effectively with other professionals and parents, they must have technical knowledge in regards to hearing aids and cochlear implants (CIs), how young children develop auditory perception, and typical communication goals established by speech-language pathologists and audiologists (Gfeller et. al, p.39). The human experience of music does not simply occur through aural vibrations and auditory perception. Humans experience music through other senses, such as tactile touch, vestibular stimulation, and sight. In order to treat clients with a wide range of hearing deficits, MT-BCs must understand equipment, how sound is processed for individuals with hearing impairments, and assess how this affects their presentation during MT treatment. 

While discussing the mechanics of hearing aids and CIs, which have helped those with hearing loss significantly, it is important to understand how music is perceived through these devices and by the individuals using them. It is important to note that hearing aids and CIs were originally developed to assist those who had difficulty identifying speech, not music. Kirchberger (2016, p.1) defines dynamic range and compression in music as “the level difference between the highest and lowest-level passages of an audio signal. Dynamic range compression (or dynamic compression) is a method to reduce the dynamic range by amplifying passages that are low in intensity more than passages that are high in intensity.” This informs the MT-BC which musical passages are effective for clients with varying levels of hearing loss. Dynamic compression is controlled primarily by recorded musical passages, however, with this knowledge, an MT-BC can select and adjust specific musical elements if presenting live musical interventions. If using recorded music, hearing aid listeners will receive a dual dose of compression which is not always beneficial or aesthetically pleasing. As an MT-BC, it is important to understand how hearing aids work, and to anticipate how recorded music may be experienced by young clients. MT-BCs should adjust session plans and interventions to meet the preference of the client and find the appropriately compressed music that is aesthetically comfortable for them, if not performing and accommodating while presenting live. 

The experience of hearing impaired and CI users varies considerably. Each individual’s experience needs to be considered carefully by the treating MT-BC. This information would be gathered during the assessment phase and clinically influences the techniques and interventions presented to the client. In an MT session, hard-of-hearing children may rely on visual cueing from the therapist demonstrating different rhythmic patterns, tempo, dynamics, and other musical elements for a full musical experience. Each child with hearing impairments has varying degrees of ability to perceive pitches, varying ways of hearing music, and varying degrees of perception of music. Again, hearing aids and CIs are formatted for speech sounds, not musical pitches. Therefore, an MT-BC should be aware of each child’s preference for timbres and choose instruments accordingly. MT-BCs provide interventions using a variety of instruments, sounds, and rhythms during all stages of the therapy process. MT-BCs provide tactile rhythmic stimulation, tonal interventions, and instrumental variety. 

Early intervention, especially through MT, can improve the quality of life for both the hearing-impaired child and the family as a whole. According to research, MT “is an attractive method through which children’s attention is enhanced, abolishes the shyness and social withdrawal of children, enhances children’s expressive abilities towards the uncommon vocabularies, and it doesn’t only enhance the segmental aspect of phonological development, but also the supra-segmental level of development; as it helps in recognition and discrimination of different pitch direction, proper timing of utterance and tonicity” (Bassiouny, et. al, p.109-110). This means that any child or adolescent with hearing impairments, speech and language deficits, or in need of additional support, speech-specific elements of music can provide opportunity for support. Pitch direction, timing, and melodic flow can be used to teach clients how to ask, “how are you?” to say, “my name is ___,” and more. Not only do music-based interventions address many logistical aspects of speech, as stated above, but music can also encourage and improve other forms of communication for the child. MT is indicated for children with hearing impairments provided the MT-BC appropriately assesses how the client is processing music through assistive devices, and chooses music stimuli accordingly. 

-Kathryn Trujillo

References

Quick statistics about hearing. (2021, March 25th). National Institute of Deafness and Other Communication Disorders. https://www.nidcd.nih.gov/health/statistics/quick-statistics-hearing

Adamek, M., Darrow, A. (2018). Music in special education. The American Music Therapy Association. (3rd ed., pp. 319-351). The American Music Therapy Association.  

Bassiouny, S., Saleh, M., Elrefaie, D., & Girgis, M. (2017). Using music therapy in (Re)habilitation of prelingual cochlear implant children. Journal of Scientific and Technical Research, p.1-6. DOI: 10.26717/BJSTR.2017.01.000127

Du, M., Jun, J., Li, Z., Man, D., & Jiang, C. (2020). The effects of background music on neural responses during reading comprehension. Scientific Reports, 10, p. 1-11.

Gfeller, K., Driscoll, V., Kenworthy, M., & Voorst, T. (2011). Music therapy for preschool cochlear implant recipients. Music Therapy Perspectives, 29, p.1-11.

Kirchberger, M. & Russo, F. (2016). Dynamic range across music genres and the perception of dynamic compression in hearing-impaired listeners. Sage, 20, p.1-16. 10.1177/2331216516630549

Improvisational Music Therapy for Young Adults

The United States of America is experiencing a mental health crisis. There have been many mass shootings and acts of violence in the country. According to Everytown Research & Policy, “between 2009 and 2020, 1,363 people in the United States were killed and 947 more were wounded in 240 mass shootings, an average of 20 shootings each year. Among the casualties were at least 362 children and teens killed as well as 21 law enforcement officers killed and 35 wounded” (paragraph 5). Because mental health disorders are so often present by the time someone is in their mid-20s, it is important for a person to receive appropriate intervention as soon as possible. In addition to other therapies, Music Therapy (MT) is indicated in the treatment of mental health disorders. Researchers Clements-Cortes and Yu (2021) conducted a literature review concerning the benefits of improvisational music therapy with university and college age students experiencing mental health issues. The body of literature suggests that improvisation plays an integral role when it is difficult for clients to verbally express their emotions ( Clements-Cortes et al., p1). Hans Christian Anderson is well known for once saying, “where words fail, music speaks.” 

Clements-Cortes and Yu explore clinical improvisation and improvisational MT research outcomes. First a general explanation of mental health issues and MT is offered. The purpose of Clements-Cortes and Yu’s article is to explore the mental health benefits of improvisational music therapy for young adults through literature review of fourteen articles and research studies. The literature review provides hope for those living with mental health issues and provides evidence for the use of MT as a non-invasive treatment of mental health concerns. Musical improvisation in MT sessions, as studied by Erkkilia, et al. (p. 32 as cited by Clements-Cortes and Yu) resulted in positive outcomes for those with depression and increased their personal well-being compared to the control group. Maraos’ study found that active music making provided clients with novel aesthetic, relational, and physical experiences thus ameliorating mental health challenges (p. 32 as cited by Clements-Cortes and Yu). General findings confirm that MT benefits those with mental health disorders such as depression, anxiety, autism, trauma, and schizophrenia.

Musical improvisation can be active playing or receptive listening. According to Bruscia, “active improvisation involves spontaneous exploration of one's own character, while receptive improvisation involves listening to improvisations to build support, openness, and provoke physical responses from those who might otherwise be reluctant to participate” (p. 31, as cited by Clements-Cortes and Yu). It is not the therapist, or other group members, but the music that is the medium for regulating and processing client emotions and mood states. MTs facilitate structured or free-flowing sessions in which they provide prescriptive support, such as written prompts for the clients, or in which they support the direction set by the client(s). Improvisation of voice, instruments, and body is important because musical improvisation becomes an emotional coping mechanism for clients. 

Below is a case study for how MTs use improvisational music to address mental health concerns: 

Client A: 16-year old female with depression and anxiety 

Therapy Goals: to grow in self-confidence, self-esteem, create a positive sense of self, and gain more creative coping skills

Procedure: Treating MT first provides instrument choice for Client A to manipulate during improvisation intervention. MT then offers pre-determined prompts for Client A to choose from. For example “relaxing on the sand sounds like…” or “crying while it rains sounds like…” If appropriate, after improvisation finds a natural end, both Client A and MT discuss the experience.   

Here are two visual examples of how music improvisation can be used with adults participating in MT sessions: can this be listed after the case study as more examples? It belongs there, not as a conclusion. And then maybe just conclude by listing where people can get MT services for mental health--I’m sure this in the AMTa website 

Music Improvisation - Loneliness https://youtu.be/5ALShMMbJ-k (Nordoff-Robbins Music Therapy Australia, 2011)

Music Improvisation - Anger https://youtu.be/GS5EX1EhPHc (Nordoff-Robbins Music Therapy Australia, 2011). 

It is important that professionals invest their time and resources in mental health research, treatment planning, and advocacy efforts in order to reduce the stigma around mental health. MT has been recognized as a non-invasive treatment for mental health diagnoses and many MTs continue to advocate for continuing MT services in settings such as hospitals, psychiatric facilities, hospices, assisted living homes, schools, private practices, and more. If you, or someone you know, is experiencing mental health issues, contact your healthcare provider or seek referrals for a MT assessment. 

-Kathryn Trujillo, Music Therapy Intern

Reference(s):

Mass shootings in America 2009-2020. 2021, June 4th. Everytown for Gun Safety. https://everytownresearch.org/maps/mass-shootings-in-america-2009-2019/

Clements-Cortes, A., & Yu, M. T. (2021). The mental health benefits of improvisational music therapy for young adults. Canadian Music Educator, 62 (3), 30-33. http://0-search.ebscohost.com.pacificatclassic.pacific.edu/login.aspx?direct=true&db=ehh&AN=149346483&site=eds-live&scope=site&CUSTID=s8968023

Nordoff-Robbins Music Therapy Australia. (2011, July 5th). Music improvisation - loneliness [Video]. Youtube. https://youtu.be/5ALShMMbJ-k

Nordoff-Robbins Music Therapy Australia. (2011, July 5th). Music improvisation - anger [Video]. Youtube. https://youtu.be/GS5EX1EhPHc

Music Therapy Improves Social Skills in Children and Adolescents with Autism Spectrum Disorder

Music therapy (MT) professionals are often searching for new, music-based, creative interventions and approaches to support children and adolescents with a myriad of diagnoses. Those who conduct research in the MT field have provided many approaches, interventions, and case studies which demonstrate the success of MT to improve social skills of children and adolescents with Neurological Developmental Disorders (NDDs) such as Autism Spectrum Disorder (ASD). Below is further support as to why MT services for children and adolescents with NDD is important and often successful in improving social competence. 

Music, a multi-modal approach, facilitates many developmental skills. When children experience joy and play, they are more willing to participate in activities. Music is motivating and uplifting, but can also calm and relax clients. MT interventions are designed to set clients up for success and therefore help children feel better about themselves and others. Music often encourages socialization, self-expression, communication and motor development. Through music, those with NDD or ASD are able to self-manage pain and stressful situations. Elements of music are malleable, making it an appropriate therapeutic tool for many diagnoses as it can be tailored to each individual. 

According to the American Music Therapy Association (AMTA), those with ASD have a heightened interest in music and often display positive responses to music, making it an integral therapeutic tool while working with them (2012, p. 1). Social skill deficits are addressed through music performance, movement to music, and improvisation. According to Gooding, MT interventions “improve social skills and specific deficits within the social skills areas of peer relations and self-management skills” (2011, p. 440). MT interventions with children often address cooperation, communication, positive peer interactions, focus of attention, impulse control, delayed gratification and accepting consequences. 

As a result of MT intervention, children and adolescents with NDDs may have less outbursts at school, less behavioral reports from school, and improved social interactions. Below is a case study: 

Client: Client A  is a teenage male who is a sophomore in high school. Client A struggles with impulse control and often throws items for attention. This occurs within his home and while at school. 

Session: The treating MT, and MT intern (MTI), addressed impulse control and social-emotional development skills through turn-taking interventions, start and stop interventions, and emotional-regulation interventions. To facilitate movement to music and positive social interaction, the MTI used a Sony speaker to project the pt’s preferred song “Count on Me” by Bruno Mars. The MTI then stood in close proximity with Client A, began to dance with them, smiled, and used positive verbal affirmations to further encourage Client A’s positive social behaviors. When the MTI affirmed Client A’s positive reactions to the music, Client A made eye contact with the MTI and reached for their hand in order to dance together. This intervention used music as motivation, close proximity and bright affect to encourage social interaction, and was in the safety of the client’s own home. As the MTI and Client A sang along together, Client A experienced positive music-making AEB smiling, dancing, and vigilance to stimuli throughout intervention. After 3 weeks of treatment plan, Client A decreased frequency of throwing household items from 3 to 1x per session. The treating MT and MT intern will continue to add to Client A’s social skills toolbox as they continue his plan of care. 

In a safe therapeutic learning environment, children and adolescents with NDDs can explore, practice, and equip themselves with social skill tools for more successful experiences with their peers. As the picture above states, MT can facilitate the exploration of sharing, cooperation, listening, following directions, respecting personal space, making eye contact, and using culturally appropriate manners, among many other skills.  

-Kathryn Trujillo, Music Therapy Intern

References

Gooding, L. (2011). The effect of a music therapy social skills training program on improving social competence in children and adolescents with social skills deficits. Journal of Music Therapy, 48(4), 440-462

American Music Therapy Association. (2012, June). Music therapy as a treatment modality for Autism Spectrum Disorders. American Music Therapy Association. http://www.musictherapy.org/assets/1/7/MT_Autism_2012.pdf

The Effects of Music Therapy on Pediatrics with Preoperative Anxiety

Preoperative anxiety is a common obstacle for individuals of all ages before surgery. This causes uncomfortable and painful reactions because of the mental fears about the procedure. Preoperative anxiety is commonly experienced in children specifically. This anxiety can cause negative outcomes of an operation because of the behavioral responses it causes. These behaviors that inhibit the production of the operation are coping mechanisms children use in an attempt to control their current situation, including behaviors such as crying, screaming, avoidance, or physical resistance (Millet & Goodding, 2017, p. 462). Often, these behaviors can cause surgical complications that can spiral into further health complications. 

According to Giordano et al., pediatric patients who previously had negative surgical experiences have an increased likelihood of preoperative anxiety for future procedures (2020, p. 2). In order to eliminate the complications of preoperative anxiety, removing stress and fear behaviors, pharmacological analgesia, and sedation are often used. However, pharmacological techniques can also cause negative side effects and potential risks such as nausea and vomiting, itching, respiratory depression, constipation, etc (Giordano et al., 2020, p. 1). 

To avoid pharmacological side effects and risks, multidisciplinary and multimodal prevention techniques are becoming the preferred anxiety prevention method. Music therapy is an evidence-based multidisciplinary and multimodal prevention approach to treat preoperative anxiety (Giordano et. al, 2020, p. 3). Music therapy “involves the systematic use of musical experiences aimed at achieving therapeutic goals by a trained music therapist and implies the establishment of a relationship between patient, music and music therapist” (Giordano et al., 2020, p. 1). There are so many benefits that music therapy provides that outweigh the possible negative effects of pharmacological implementation. Music therapy eliminates pharmaceutical risk factors, is more cost effective, and treats more needs than just preoperative anxiety coping skills. Music therapy provides family support, physical and emotional benefits, and goals that enhance relaxation, self-expression, and communication (Giordano et. al, 2020, p. 1). 

Music naturally stimulates bodily sensations, feelings, emotions, and thoughts (Giordano et al., 2020, p. 2). Because this is music’s nature, music therapy is able to effectively calm the nervous system of preoperative patients. Treatment for a session in this setting may vary based on the patient’s demographic information and nature of the operation. However, music therapists use client-preferred music to stimulate the mind to distract from negative emotions that may arise and inhibit pre-procedural processes. Music therapists plan their session in close accordance with operational schedules, proactively beginning their sessions before anxious coping skills arise, instead of after. Depending on the length of the preoperational process, the session may last one intervention, or several. However, the music therapist should be prepared to treat until the patient has achieved a normal resting state and the procedure has been completed.

-Hanlee McCart, Music Therapy Intern

References

Charles, K. (2015, December 27). Daily Checkup: Music therapy shows dramatic results; patients with range of different diseases taking note. NY Daily News. https://www.nydailynews.com/life-style/health/daily-checkup-music-therapy-power-article-1.2469024

Giordano, F., Zanchi, B., De Leonardis, F., Rutigliano, C., Esposito, F., Brienza, N., & Santoro, N. (2020). The Influence of Music Therapy on Preoperative Anxiety in Pediatric Oncology Patients Undergoing Invasive Procedures. The Arts in Psychotherapy, 68, 101649. https://doi.org/10.1016/j.aip.2020.101649

Millett, C. R., & Gooding, L. F. (2017). Comparing active and passive distraction-based music therapy interventions on preoperative anxiety in pediatric patients and their caregivers. Journal of Music Therapy, 54(4), 460–478. https://doi.org/10.1093/jmt/thx014

Schizophrenia and Music Therapy

Schizophrenia-- a very real and serious mental illness that has no cure, but does have treatment available. The Treatment Advocacy Center states, “Schizophrenia is a chronic and severe brain disorder that interferes with a person’s ability to think clearly, manage emotions, make decisions and relate to others” (Treatment Advocacy Center, para. 1). Managing symptoms of schizophrenia can be a difficult task, but with treatment combined with music therapy there is a way to reduce the negative symptoms. A randomized controlled trial administered by Ulrich et al. (2007) was designed to “examine the effectiveness of music therapy in increasing interpersonal contact, reducing negative symptoms and enhancing QOL of schizophrenic acute care in-patients” (p. 363). This is important information for Music Therapists to assist in helping manage these symptoms or similar ones within this or any population they work with. 

With schizophrenia being “one of the most serious mental disorders,” treatment is necessary, which is why both groups involved in the study--experimental and control-- continued their standard treatments (Ulrich et al., 2007, p. 362). Throughout the study the experimental group received their standard treatments along with music therapy. One of the main focuses during the music therapy sessions was to have the patients working together in a cohesive group. Activities in the sessions included instrument play together on rhythm instruments, singing preferred music, as well as, group discussions. Rhythm instruments were utilized due to the nature of the instrument stopping any sound whenever the player immediately stops playing it, therefore allowing the patients to be in control of their music making. The music therapist utilized an eclectic approach with some behavioristic approaches during the sessions. Data was collected before and after each music therapy session by questionnaires completed by the nurses and patients. 

The three hypothesis’ that were tested included: patients interacting positively with others, music therapy decreasing negative symptoms, and music therapy improving quality of life (Ulrich et al., 2007, pp. 364-367). The results showed for the first hypothesis that there was no difference between groups as assessed by the nurses, but patients in the experimental group indicated that their interaction amongst others had improved, therefore this hypothesis was accepted (Ulrich et al., 2007, p. 365). The results showed for the second hypothesis that there was a decrease of negative symptoms amongst the experimental group, therefore this hypothesis was also accepted (Ulrich et al., 2007, pp. 365-367). Lastly, the results showed for the third hypothesis that there was no difference between the two groups, therefore this hypothesis was rejected. The last hypothesis being rejected could be due to the control group engaging in another activity while the experimental group received music therapy, therefore quality of life was not decreasing for either group. Therefore, this study showed that music therapy can assist with patients interacting with others in a positive way, as well as decrease negative symptoms for schizophrenic patients.  

All in all, music therapy can have a positive effect on psychiatric in-patients’ social interactions and decrease negative symptoms within their daily lives. This study sample included only 37 patients, but still resulted in positive findings. More research of larger samples could open many opportunities for this population. Music therapy has “no negative side effects and costs only moderately” and has shown to be “effective for primary schizophrenic patients for whom negative symptoms are central” (Ulrich et al., 2007, p. 369). Allowing this population to engage in positive treatment such as music therapy, “could increase the patient's abilities to adapt to the social environment in the community after their discharge from the hospital” which would be a very positive outcome for a patient diagnosed with schizophrenia (Ulrich et al., 2007, p. 369).

 -Kennedi Walz, Music Therapy Intern

References

Long Beach Post Partner. (2013, September 12). Mental Health Programs at Community Hospital Long Beach Leave Positive Impact, Fill Void in Community. https://lbpost.com/news/health/mental-health-programs-at-community-hospital-long-beach-leave-positive-impact-fill-void-in-community  (image) 

Treatment Advocacy Center. (n.d.). Schizophrenia – Fact Sheet. www.treatmentadvocacycenter.org/evidence-and-research/learn-more-about/25-schizophrenia-fact-sheet?gclid=Cj0KCQjwwLKFBhDPARIsAPzPi-KYxKmsJfyRtgcUAQCMM_I5kUfvw225OiZlniWk9xfP8W1XwmzAg5saAoUBEALw_wcB. 

Ulrich, G., Houtmans, T., Gold, C. (2007). The additional therapeutic effect of group music therapy for schizophrenic patients: A randomized study. Acta Psychiatr Scand., 116(5), 362-70. doi: 10.1111/j.1600-0447.2007.01073.x.