Family-Centered Music Therapy in the Home

December 1, 2021

Kathryn Trujillo 

Family-Centered Music Therapy in the Home 

Thompson, from the University of Melbourne in Australia, elaborates on the widespread approach of family-centered therapy practice through reflection of case examples and personal experience. Thompson reflects on the family-centered practice model and applies it to Music Therapy (MT) so that early intervention services can support families with children with special needs. From this article, music therapists (MT-BCs) can find support and rationale for a solid family-centered practice method for MT specific sessions. MT, as a field, offers practitioners and families flexibility, in that they are able to travel to family’s homes. Thompson focuses on “promoting interpersonal engagement between children with Autism Spectrum Disorder (ASD) and their parents” (Thompson, p.109) in natural settings, such as their home or preschools with their peers and carers there. 

According to literature found by Thompson, ASD is “a group of neurological disorders with lifelong implications. It is diagnosed based on impairments in social interaction, communicative behavior, and repetitive and stereotyped patterns of behavior or interests” (p.109). There are many approaches to interacting with individuals with ASD, to treating particularly undesired behaviors, and improving communication between both child and parent, or between the child and their peers. Family-centered practicing therapists encourage family participation and collaboration during one-on-one sessions. The central tenet of family-centered practice is that “practitioners and families strive to work together in partnership with an emphasis on building the capacity of the family” (p.109). Family-centered practitioners truly focus on relationships and supporting the parent and child bond. 

MT-BCs provide fun and enjoyable music-based sessions to encourage participation from all or any member of the family in the safety of their own homes. While working with preschool aged children with ASD, Thompson says that “the active participation of the family in MT sessions is considered an essential part of working with them” (p.110). In a home setting, MT-BCs are able to gather more information about the child with ASD through observation of interactions with other family members, the family dynamic, and in the natural family environment. Together, the family and MT set goals and objectives based on goals identified by the family. 

While providing services in the child’s home, MT-BCs are able to share their professional skills with the family. Through reflection, Thompson outlines components of family-centered MT sessions. They are as follows: family-centered practice theory, attune to the child’s mood and behavior, following the child’s lead, enticing the child with motivating activities, presenting with positive affect, acceptance, and affection, MT presenting as a play partner, keeping the child’s anxiety low and assess the need for structure, choice, or control, matching the child’s abilities, and understanding social communication development theories, and finally allowing the child to initiate engagement. By providing therapeutic approaches and interventions within the child’s daily routine, Thompson found that it promotes interpersonal engagement and early social and communication skills which are goals often identified by both the family and treating MT-BC. Family-centered MT sessions allow for growth in interpersonal communication, rapport, and inclusion of all members of the family while providing fun and engaging interventions for the child with ASD. 

Reference: 

Thompson, G. (2012). Family-centered music therapy in the home environment: Promoting interpersonal engagement between children with Autism Spectrum Disorder and their parents. Music Therapy Perspectives, 30, p.109-116.  

Older Adults with Dementia

The population of people who suffer from dementia range from age 65 and older (Keough et al., 2017, p. 182). Previous studies have shown positive linkages between implemented music therapy sessions and positive outcomes amongst patients with dementia.The use of music therapy has increased with this population due to research showing positive patient outcomes. Music therapists utilize music as a tool to connect with individuals with dementia to a subjective state of reality. Statistics demonstrate that approximately five million people possess a form of age-related dementia (Keough et al., 2017, p. 193). Universally, this number is much larger, ranging from 35 to 48 million people (Shibazaki, 2017, p. 468). Worldwide, those diagnosed with dementia require over $818 billion in treatment and care (Shiltz et al., 2019, p. 17). Thus, efforts to combat the detrimental and expensive condition are an urgent necessity.

Dementia is a syndrome that psychologically “affects memory, thinking, orientation, comprehension, calculation, learning capacity, language and judgement” (McDermott et al., 2018, p. 256). Clinically-accepted symptoms of dementia include memory loss, inability to perform simple tasks, personality and behavior changes, and increased levels of agitation (Shibazaki, 2017, p. 468). Such behavioral and psychological symptoms appear in more than 80% of diagnosed dementia patients (Shiltz et al., 2019, p. 17). However, even as the human memory disappears, musical skills and the processing of music are amongst the last to leave (Shibazaki, 2017, p. 268). 

         Studies have shown that increased exposure to music can increase development of one’s neural network functioning, steady the heart rate, decrease blood pressure, reduce high hormonal stress levels and inflammatory cytokines, and provide decrease in pain levels (Sorrell, 2018, p. 15). Music therapy utilizes diverse, therapeutic interventions that can include singing, playing instruments, listening to music (live or prerecorded), creating music, socializing, communicating and expressing (Shiltz et al., 2019, p. 18). Common goals that are targeted in music therapy sessions for older adults can include improving quality of life, increasing positive self-identity, enhancing social experiences, and improving communication (Schall, Haberstroh, & Pantel, 2015, p. 113).

A recent study that specifically analyzed music with dementia, “Music as a Healing Art in Dementia Care,” states that individuals diagnosed with dementia have the ability to retain their clearest memories from the music. Specifically, music that they preferred between the ages 10 and 30 (Sorrell, 2018, p. 16). Music therapists are able to provide a space for engagement and progress in clients through music therapy sessions. For example, research demonstrates that clients with dementia who have been provided music therapy sessions stimulated by active music engagement and active music listening had a high increase of positive social participation (Keough et al., 2017, p. 183). A study, by Ridder and Gummensen that explains the process of music therapy treatment and its benefits on those with dementia, shows improved socialization skills through increased eye-contact and increased initiation to socialize or express personal thoughts (2015, p. 7). Communication is another positive effect from music therapy with this population. Studies have provided evidence that music therapy treatment has improved retention of speech, language (Sorrell, 2018, p. 16), and improvement in breaking repetitive speech behavior (Keough et al., 2017, p. 186). Another impactful category researched to show positive effects is the improvement of mood and quality of life. Music therapy decreases anxiety and depression, and minimizes symptoms of agitation and aggression (Sorrell, 2018, p. 16). These are a few of the many studies that provide clear evidence to show positive effects of music therapy on adults with dementia. 

Music therapy sessions with clients who have dementia can focus on social skills, reality orientation, general quality of life, or client-specific needs (Keough et al., 2017, p. 183). Sessions can include musical improvisation to create dialogue for communication (Ridder & Gummesen, 2015, p. 6), group activities, such as singing, group drumming, and movement activities to improve socialization skills (Keough et al., 2017, p. 183), and utilizing musical instruments as a means of communication to enhance daily skills (Shiltz et al., 2019, p. 18). These are several examples that show what music therapy can provide in sessions, however there are endless interventions music therapists can implement to meet needs. 

While dementia is a devastating condition in the population of older adults, these individuals are positively affected by the music interventions that music therapists create to alleviate symptoms of dementia and tasks that provide the practice of healthy coping mechanisms. 

-Hanlee McCart, Music Therapy Intern

References

Keough, L. A., King, B., & Lemmerman, T. (2017). Assessment-based small-group music therapy programming for individuals with dementia and Alzheimer’s disease: A multi-year clinical project. Music Therapy Perspectives, 35(2), 182–189.

McDermott, O., Ridder, H. M., Baker, F. A., Wosch, T., Ray, K., & Stige, B. (2018). Indirect Music Therapy Practice and Skill-Sharing in Dementia Care. Journal of Music Therapy, 55(3), 255–279. https://doi.org/10.1093/jmt/thy012

Mette Ridder, H., & Gummesen, E. (2015). The use of extemporizing in music therapy to facilitate communication in a person with dementia: An explorative case study. Australian Journal of Music Therapy, 26, 6–29.

Schall, A., Haberstroh, J., & Pantel, J. (2015). Time series analysis of individual music therapy in dementia: Effects on communication behavior and emotional well-being. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 28(3), 113–122. https://doi.org/10.1024/1662-9647/a000123

Shibazaki, K., & Marshall, N. A. (2017). Exploring the impact of music concerts in promoting well-being in dementia care. Aging & Mental Health, 21(5), 468–476. https://doi.org/10.1080/13607863.2015.1114589

Shiltz, D. L., Lineweaver, T. T., Brimmer, T., Cairns, A. C., Halcomb, D. S., Juett, J., Beer, L., Hay, D. P., & Plewes, J. (2018). “Music first”: An alternative or adjunct to psychotropic medications for the behavioral and psychological symptoms of dementia. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 31(1), 17–30. https://doi.org/10.1024/1662-9647/a000180

Sorrell, J. M. (2018). Music as a healing art in dementia care. Journal of Psychosocial Nursing and Mental Health Services, 56(7), 15–18. https://doi.org/10.3928/02793695-20180619-04

Preoperative Music Therapy for Pediatric Ambulatory Surgery Patients: A Retrospective Case Series

In 2016, Gooding and colleagues sought to understand the effect of Music Therapy (MT) services on preoperative anxiety in children who were receiving same day surgeries in ambulatory surgery centers. 103 pediatric patients, between the ages of 2 and 9 years old, undergoing various ambulatory surgical procedures in a hospital-based ambulatory clinic participated in the MT protocol (Gooding et al., p. 192). Gooding and colleagues conducted a pilot MT program for the patients who elected to receive MT services from board certified music therapists (MT-BCs), prior to their operations. The patients’ doctors provided consent and patients and their families elected to receive MT services. The research done by Gooding’s team is considered a quasi-experimental quantitative study due to the lack of random assignment of participants. According to Gooding, the purpose of this study was to investigate the effect of preoperative music therapy services on “child distress, coping, and anxiety behaviors, parental perceptions of treatment, and parent satisfaction in a pilot music therapy program in an ambulatory surgery center” (p.192). 

The effects of music therapy services on stress, coping, anxiety, parental perceptions, and parent satisfaction were measured and collected from the patients who participated in preoperative MT interventions at the ambulatory surgery center. In addition, background information, how the patient was seated, who was present with them when the MT-BC entered, and the type of surgical procedure they were waiting for was also collected. The researchers relied upon the MT-BC’s observations of the “initial affect, ending affect, and behavioral responses'' (192) of the patient based on the Gale Encyclopedia of Childhood and Adolescence and on the parent-completed questionnaire completed after the MT session. Two standardized instruments were used: Modified Yale Preoperative Anxiety Scale (YPAS-m), and the Child-Adult Medical Procedure Interaction Scale-Short Form (CAMPIS-SF). These tests were administered by the MT before and after MT services. 

The MT-BC collected the data for analysis during each 30–45-minute session prior to the surgery. The sessions followed the same format but were adjusted to meet the needs of the individual patient, their family, and the flow of the surgical center. The MT-BC provided live music, age-appropriate instrument play, singing, and musical games to distract the patient during preoperative preparation. The MT-BC also provided positive reinforcement, distraction, and procedural information when applicable. Most patients showed positive affect towards MT services prior to operation. There were two affect categories: pleasant types of affect and unpleasant types of affect. More children experienced pleasant affects than those that experienced unpleasant affects. Patients responded to the MT interventions by singing along, playing instruments, moving to the music, and by maintaining attention towards the MT-BC. Post-intervention scores--for amount of perceived stress, coping, anxiety, and parental perceptions--were higher and better than the pre-intervention scores. The overall results from the study “suggest that children tended to show desirable behavioral responses and low levels of distress during preoperative music therapy treatment” (p.198). 

Of the parents that were present with their child during the preoperative MT session, 70% completed the Parent Procedure Questionnaire and wrote comments about the services received. Comments included “expression of gratitude, enjoyment of the child and or parent, benefits of MT for the child or parent, praise for the MT-BC of the facility, expressions of approval for the idea of continued preoperative MT, desire for MT in the future, feelings that MT was a pleasant surprise, feelings that MT was a helpful distraction, and statements that they would recommend MT services to others” (p.198). Reducing preoperative anxiety, through MT, improved the experience of both the patient and the parent or guardian with them. 

According to the findings of this study, MT services which addressed preoperative anxiety for both the child and parent, were extremely beneficial. If done well and efficiently to follow the flow of the ambulatory surgical center, MT services would be an asset and improvement upon the ambulatory surgery center’s services. The findings of this study also suggest that MT reduces preoperative anxiety, improves the perception of quality of care, and improves the overall experience for both the patient and their family. Two limitations of this study were the quasi-experimental design and the limited researchers available for data collection. Future studies should consider a truly experimental design and the MT-BC providing services should solely focus on the interventions, while another researcher focuses on data collection. In this study, the MT-BC provided the services and collected the data, which “may have increased the potential for bias” (pg. 198).  

-Kathryn Trujillo, Music Therapy Intern

Reference:

Gooding, L., Yinger, O., & Iocono, J. (2016). Preoperative music therapy for pediatric ambulatory surgery patients: A retrospective case series. Music Therapy Perspectives, 24, p.191-199 DOI:10.1093/mtp/miv031

Influence of MT and Music-Based Interventions on Dementia: A Pilot Study

Article Summary by Kathryn Trujillo 

According to the authors, and the World Health Organization (WHO), more than 55 million people live with dementia worldwide. Dementia causes deterioration in cognitive functioning, and “negatively affects memory, thinking, orientation, understanding, calculation, ability to learn, language, and judgment” (Dahms, p.13). There are three stages of dementia: early, middle, and late. Depending on the characteristics and symptoms expressed by individuals living with dementia,  Common symptoms of dementia, from early to late progression, are forgetfulness, losing track of time, becoming lost in familiar places, forgetful of recent events or people’s names, behavioral changes, repeating questions, an increasing need for assisted self-care, and behavior changes that can escalate to include aggression (WHO, 2021, p. 1). The study by Dahms, Eicher, and colleagues titled “Influence of Music Therapy and Music-Based Interventions on Dementia: A Pilot Study,” though conducted in Germany, has results which should be considered in the care of those living with dementia here in the United States. Dahms and colleagues implemented music by following guidelines set by the National Dementia Plan. According to Dahms, nursing homes in “other countries of the world (such as Australia and the United States)” also act according to the National Dementia Plan (p.14). This study provides evidence that when Music Therapy (MT) and technology music-based interventions (TMBI) that are a part of a patient’s daily routine, decrease agitation and apathy of those living with dementia in nursing homes.

Dahms and colleagues focused on the influence of individual MT, group MT, listening to background music, group music with movement, and presence of a music program in the common room on disruptive behaviors of those living with dementia in 3 separate nursing homes across Germany. Terms used synonymously to describe behavioral symptoms being observed were “disruptive behavior” (e.g agitation) and “social behavior” (e.g. apathy) (Dahms, p. 18). The primary research question was, “what was the frequency of use and acceptance of the different music interventions (MT and TBMI) offered to people with dementia in nursing homes” (Dahms, p.15)? The purpose of the study was to evaluate the use, acceptance, and interaction of music on people with dementia living in nursing homes across Germany (Dahms, 2021). Three nursing homes, two in Berlin and one in Stuttgart, Germany were included in the study. 30 people between the ages of 65 and 97 years, and diagnosed with dementia, were included in the study. Considering that those with dementia were dependent on full time caregivers, the related caregivers (RPs) answered questionnaires on behalf of the included residents before, during, and after the study took place. All questionnaires “included questions on the following topics: instrumental activities of daily life that influence the behavior of people with dementia (e.g disruptive behavior), depression, quality of life...and about expectations of MT and TBMI” (Dahms, 2021, p. 17). 

The goal of each MT and TMBI intervention was to investigate their usage by people with dementia over time. MT is unique, in that board-certified music therapists (MT-BCs) individualize each intervention to the preferences and likings of each study participant. The use of music is purposeful and intentional. Interventions were presented under 6 different conditions: group MT, individual MT, background music during meals, background music during exercise, CD in the common room, and individual listening time with a radio. Group MT was conducted once a week for 45-minutes, with 5 study participants, but when other nursing home residents stepped in, the group size varied (Dahms, p.19). The interventions presented were live, improvised, facilitated by an MT-BC on guitar or accordion, and singing bowls and percussion instruments were given to participating group members. Individual MT was provided bi-weekly for 30-minutes, and facilitated by an MT-BC on guitar. Background technology based music (TBMI), was played by caregivers on a daily basis during meals for all study participants for 4-minutes with a CD player (Dahms, p. 19). Music was played on a television (TV) for a group music class with movements. Group music with movement was provided every two weeks for 60-minutes with a certified fitness trainer for physical activation. A music program in the common room was available to each participant for 6 hours through a TV and accompanied by lyrics and visuals, daily. Individual radio time was provided twice a day for 30 minutes in each resident’s room and individualized to meet their personal needs (e.g volume, playing speed, genre). 

Data was primarily collected through physical questionnaires filled out by the related caregivers, and then turned into digital data using Microsoft Excel. Researchers used IBM’s SPSS Statistics 27 program to evaluate data from the questionnaires. The study was separated into four test phases and questionnaires were filled out at each phase. Data was then analyzed at timepoints “T2 and T3, using bivariate and multivariable analysis. For example, one variable, the “frequency of use on MT and TBMI” was split into two sub variables to distinguish the sample between “residents with high usage” and “residents with low usage” (Dahms, p20). Researchers used nonparametric Mann-Whitney U-tests on scores for agitation, apathy, and depression,  independent sample t-tests were used for quality of life, and a Friedman test was used to further evaluate the influence of MT and TBMI on agitation (Dahms, p.21). 

There were three primary limitations to Dahms’ and colleagues’ study. The first limitation was that all participants relied on caregivers due to late stage dementia, and their declining health made it impossible for participants to provide self-assessments on the questionnaires. The second limitation was that acceptance of the use of technology was not assessed. Participants relied on related caregivers to physically set up and start the music using technology. The third limitation was that the study’s “eight-week intervention phase was not sufficient enough to detect long-term effects in people with dementia with respect to the parameters studied” (Dahms, p.32). Though there were limitations to this study, the design, implementation, and results are supported by previous research. 

Results of Dahms’ and colleagues' study stated that 83% of participants with dementia did listen to music regularly, that some residents still handled this activity independently, while the majority of people with dementia were dependent on the support of their caregivers for it (Dahms, p.e21). According to the responses from RPs on the questionnaires, the reasons for nonuse of MT or TBMI was due to health problems of the residents, loss of memory about the existence of the music interventions, their tendency to retreat, and motor restlessness. On p.22 it states that “the frequency of use of the TBMI, for example, karaoke and biography-specific favorite music, was lower than the frequency of use of the personnel-guided music interventions.” A majority of the residents with dementia preferred the individualized active music therapy sessions with an MT-BC. Group MT was rated the best, followed by group music with movements, and individual MT. Overall, this study suggests that individualized MT and group MT, provided by an MT-BC, can reduce agitation and apathy of inpatient nursing home residents living with dementia. 

-Kathryn Trujillo, Music Therapy Intern

Reference: 

Dahms, R., Eicher, C., Haesner, M., & Mueller-Werden, U. (2021). Influence of music therapy and music-based interventions on dementia: A pilot study. Journal of Music Therapy, 58(3), e12-e36. doi:10.1093/jmt/thab005

World Health Organization. (2021, September 2). https://www.who.int/news-room/fact-sheets/detail/dementia

MT & Approaches to Behavior

Rationale and Support for 3 Behavioral Approaches within Music Therapy

Music therapists (MT-BCs) who work with children, youth, and young adults use music-based interventions to address specific behaviors. Behavior, as defined by the American Psychological Association (2020), is “an organism’s activities in response to external or internal stimuli, including objectively observable activities, introspectively observable activities, and nonconscious processes” (2020). Below is rationale and support for three different MT philosophical approaches and their corresponding strategies that address behavior of children and youth. 

The Cognitive Behavioral Theory (CBT) approach is centered around the belief that how we think, how we feel, and how we act are all interrelated. Our thoughts and feelings determine our behavior, which in turn, determines our thoughts and feelings. The CBT model looks like this: 

(McLeod, 2019).

Practicing MT-BCs who are trained and influenced by CBT help clients realize that their positive, uplifting thoughts can bring about more positive outcomes, while their negative, self-destructive thought patterns bring about more upsetting outcomes. Negative interpretations of events influence behavioral patterns which reinforce distorted thinking (McLeod, 2019).. In turn, positive interpretations of events influence behavioral patterns which reinforce healthy thinking. Cognitive-behavioral therapy helps people to develop alternative ways of thinking and behaving which aim to reduce their psychological distress. One strategy often used by cognitive behavioral therapists is assigning “homework” for clients, such as keeping a journal of thoughts, or noting how many times a particular negative thought enters their minds each day. Through increased self awareness, behavior can begin to change. MT-BCs use music, which is reality-based and structured, to increase self-awareness of thoughts, bring attention to emotional content, and more. MT-BCs can also assign “homework,” such as journaling about thoughts which can be used in song-writing during the next session, assigned listening to preferred music and bringing specific lines or full songs to discuss in a lyric analysis intervention. Music-based interventions and intentional verbal processing, related to the music intervention, are used to guide the client to a state of self awareness or identification of emotion and its corresponding behavior. 

Similar to Cognitive-Behavioral Theory is Dialectical Behavior Therapy, or DBT. “Its main goals are to teach people how to live in the moment, develop healthy ways to cope with stress, regulate their emotions, and improve their relationships with others” (Schimelpfening, 2021, paragraph 1). DBT strategies are used in group therapy and individual therapy sessions. Common strategies used by DBT therapists are core mindfulness skill development, distress tolerance skill development, interpersonal effectiveness, and emotional regulation strategies. DBT provides clients with the opportunity to develop skills to improve their quality of life. In 2015, Chwalek and colleagues interviewed MT-BCs who were using DBT and concluded that, though few, MT-BCs valued and saw the benefit of DBT strategies within therapy. MT-BCs provide music-based interventions that in their nature address self-esteem, mindfulness, improving social skills, increasing self-confidence, building stress tolerance, improving communication skills, and learning positive peer interactions (Chwalek, 2015, p.297). 

Person-centered therapy, or humanistic therapy, was developed by Carl Rogers in the 1940s. A person-centered therapist is authentic, provides the client with genuine empathy, and unconditional positive regard (Unknown, 2018, paragraph 3). Music can be uniquely used in a person-centered fashion when the therapist is working from a person-centered approach. For example, a person-centered intervention may include allowing the patient to write their own lyrics, discuss lyrics, or improvise melodies in a way that affirms and accepts their experience with no attempt to correct or judge the client. Music is a non-threatening and non-verbal form of building relationships, communication, and interpersonal connection, so it has inherent qualities appropriate for the person-centered approach. In 2015, McCaffrey and Edwards interviewed six psychiatric patients, all who had participated in MT sessions, about their experience. The most common theme that appeared in the interviews was that in its nature, MT is person-centered. According to participant L, one-on-one MT sessions provided “a space in which he feels acknowledged as a unique and individual person” (McCaffrey, p.129). Within MT sessions there is often opportunity for autonomy, choice, and expression of individual wants or needs. In many cases, expressing wants and responding to opportunities of binary choices, is an objective or goal set by the treating MT-BC. In their interview, participant L stated that “in the music therapy environment, choice, direction, and leadership were encouraged by his therapist” (McCaffrey, p.130), which was similar to the experience of other participants in the study. 

MT-BCs can use music to address behaviors, improve behaviors, increase self-efficacy, improve self-esteem, and more by presenting interventions with additional background in CBT, DBT, and person-centered psychological approaches. Those who specialize in and work with children or youth may be influenced by one or more than one of the psychological orientations and strategies discussed above. 

-Kathryn Trujillo, Music Therapy Intern

References:

APA Dictionary of Psychology. (2020). American Psychological Association. https://dictionary.apa.org/behavior 

Chwalek, C., & McKinney, C. (2015). The use of dialectical behavior therapy in music therapy: A sequential explanatory study. Journal of Music Therapy, 52(2), p.282-318, https://doi.org/10.1093/jmt/thv002

McCaffrey, T., & Edwards, J. (2016). Music therapy helped me get back doing: Perspectives of music therapy participants in mental health services. Journal of Music Therapy, 53(2), p.121–148, doi:10.1093/jmt/thw002 

McLeod, S. A. (2019). Cognitive behavioral therapy. Simply Psychology. https://www.simplypsychology.org/cognitive-therapy.html

Schimelpfening, N. (2021, July 9). What is dialectical behavior therapy (DBT)? Verywell Mind. https://www.verywellmind.com/dialectical-behavior-therapy-1067402

Unknown. (2018). Person-centered therapy (Rogerian therapy). Good Therapy. https://www.goodtherapy.org/learn-about-therapy/types/person-centered