Article Review: International Music Therapists’ Perceptions and Experiences in Telehealth Music Therapy Provision

Telehealth music therapy has become increasingly popular in recent years due to the COVID-19 pandemic. This article explores the benefits, strategies, and implementation of this form of remote healthcare services. Telehealth provides a safe way for clients and therapists to receive and provide therapeutic services, especially for individuals who are immune deficient. It also provides easier access to healthcare for individuals who have limited resources. The American Music Therapy Association (AMTA) released a survey highlighting how music therapists felt about the transition to telehealth in 2020. The study revealed that 74% of the music therapists reported that their clients had positive reactions to TMT, and some clients were even considered to be thriving in new ways. 

This article discusses the benefits, strategies, and implementation of telehealth music therapy. Telehealth is a term used to describe remote healthcare services. These services have been in high demand globally in recent years due to the COVID-19 pandemic. Telehealth provides a safe way for clients and therapists to receive and provide therapeutic services, especially for individuals who are immune deficient. It also provides easier access to healthcare for many individuals who have fewer resources. The COVID-19 pandemic allowed TMT to gain further development due to the decrease in in-person therapy. The American Music Therapy Association (AMTA) released a survey highlighting how music therapists felt about the transition to telehealth in 2020. The study revealed that 74% of the music therapists reported that their clients had positive reactions to TMT, and some clients were even considered to be thriving in new ways. Family involvement in sessions also increased, which also presented positive effects on the treatment as a whole.

When working with technology, there are some drawbacks. Depending on the internet connection and other factors, there can be a lag in music playing or sound quality issues. Some clients may not have access to musical instruments, limiting the interventions that therapists can utilize in therapy. Older adults with dementia may also have difficulty with telehealth without a third party helping them in person. A therapist should always consider these things when determining if a client is a good candidate for telehealth music therapy.

Certified music therapists who had conducted at least ten telehealth sessions participated in a survey on their perspectives of telehealth music therapy. It reviewed their thoughts on the benefits and challenges of TMT, how to improve the practice, and what contributes to successful TMT implementation. Qualitative and quantitative data were collected from 572 music therapists from 29 countries. The majority of the therapists utilized humanistic approaches, followed by integrative and neurologic music therapy (NMT). A majority of them were therapists who also worked in the areas of private practice, followed by healthcare and education. These therapists treated a wide range of clients and diagnoses. However, the most common populations treated were children with developmental delays, individuals with intellectual and developmental disabilities, and mental health patients. When transitioning to TMT sessions, therapists said that there were changes in goal areas, with the most common goal areas being emotional expression, speech and language/communication, mood, anxiety, and cognition. The changes in goal areas depended on the specific needs of the clients. They noted that they mostly utilized singing, music-listening, songwriting, movement, and improvisation interventions. Although there was less success in using live and pre-recorded music in these sessions compared to in-person, the therapists stated that they were successful in utilizing both live and pre-recorded music most of the time. The study also highlighted that almost half of these therapists took additional training courses to improve their knowledge of technology and the implementation of TMT. Clients experienced increased access to music therapy, continuation of services during the pandemic, and therapy in the comfort of their homes. 

During and after COVID-19, TMT has been a way to provide specific individuals with care that they may not have access to otherwise. During the pandemic, TMT provided continuation of care, which was beneficial for therapists and clients. The pandemic made music therapists shift to TMT relatively quickly, and it has most likely advanced since 2020. Data collection for this study was collected from January through July of 2022 and provides a perspective of TMT two years after the onset of the pandemic. Recommendations from the study suggest that MTs should continue to assess if TMT is suitable for an individual and should consider a hybrid treatment plan that includes in-person sessions as well. TMT allows individuals of different circumstances the opportunity to get treatment, and therapists should consider furthering their education on cultural humility and competencies. Overall, telehealth music therapy is beneficial for many populations and can be easily facilitated in most cases by a trained music therapist. In conclusion, implementing this form of healthcare highlights the flexibility of music therapists and their dedication to the specific needs of their clients.

-Lila Finke, Music Therapy Intern

References

Clements-Cortés, A., Pranjić, M., Knott, D., Mercadal-Brotons, M., Fuller, A., Kelly, L., Selvarajah, I., & Vaudreuil, R. (2023). International music therapists’ perceptions and experiences in telehealth music therapy provision. International Journal of Environmental Research and Public Health, 20(8). https://doi.org/10.3390/ijerph20085580

Music Technology for Individuals with Disabilities

Instrumentation is a regularly used form of music that can be enjoyed and played by many. Most instruments are made for the neurotypical individual to use. Over time, instruments have been adapted and adjusted to meet the needs of individuals with various physical, intellectual, or mental disabilities to use and enjoy for themselves. There is a wide range of needs addressed in music therapy sessions. That being said, a music therapist’s job is to find ways to accommodate those needs by adapting various aspects of instruments to meet the client where they are.

One example of a way to adapt instruments is by using color coding, whether that be for strings on a guitar or ukulele, color-coded sheet music for bells, or colored dots to use on piano keys. Color coding, according to Dorothy Pino, assisted her guitar students with learning the guitar chords and strings. The students that she taught with these adaptations displayed more confidence and learned the guitar at a much quicker pace than individuals without them. Pino recommends using Orff color order, with C being red and each diatonic pitch remaining in rainbow order. This way, individuals will be more likely to learn other instruments quickly, as that is a universal color system for a variety of other instruments as well. Color coordination is also excellent for clumping and sorting musical sections to provide cues for individuals who may have trouble with knowing what comes next, sight reading, or having difficulty with change.

An article written by Carlin McLellan explores when and why to use music technology within sessions and how modifying musical instruments technologically can be beneficial despite music therapists’ initial hesitations. Some examples of modifications that have been made just recently, following the COVID-19 pandemic, include digital instrumentation, such as ROLI blocks, a Makey Makey connected to an application such as garage band, or even the eye harp, which utilizes client head/eye movements. ROLI blocks are light-up boxes that connect to an application and allow for various sounds to emerge based on where an individual touches the blocks. Similarly, the Makey Makey is an adaptive instrument that uses touch to create sound using an application and wiring to an outside object. These instruments provide musical output in a way that still allows clients to feel that they have autonomy within their musical realm.

The important thing to remember when working with clients is that instruments should be accessible and motivating, meeting them where they are in terms of physicality, cognition, or intellectual level. Instrumentation should provide a structure for meeting goals and objectives, but should also provide feelings of confidence and excitement. Simple switches with instrumentation can make all of the difference for individuals with disabilities and provide that support and structure to achieve the best results possible.

-Mallory McDonald, Music Therapy Intern

References

McLellan, C. (2021). The Accessible Music Model: A Framework for Understanding When, How, and Why to Use Music Technology in Music Therapy. Australian Journal of Music Therapy, 32(1), 113–123.

Pino, D. (2022). Color-Coding for Confident Chording. School Band & Orchestra, 25(5), 24.

Music Therapy and Post-Stroke Aphasia

Aphasia is characterized as a disorder that affects speech, language comprehension, writing, and understanding speech. It can be caused by many different diagnoses, such as a stroke, head injury, brain tumor, language and speech impairments, autism spectrum disorder, or others. The severity of aphasia is determined by the cause, and every individual will have different strengths, weaknesses, and symptoms. Symptoms may include speaking in short sentences, difficulty putting words together, difficulty understanding conversation, mixing up words, and more.

Aphasia can be defined even further through the part of the brain that is affected, such as Wernicke’s or Broca’s aphasia. Music therapy (MT) has the ability to address and treat these areas of need through music interventions. As evidenced by Koelsch, MT helps aphasia patients with communication because many are able to sing despite their inability to speak. Koelsch also found that the brain networks that control singing and speaking slightly overlap, and singing involves more neural connections (Koelsch, 2009).

There are many different ways that music therapists can work with clients with this diagnosis. There are currently many studies that suggest great success when it comes to using MT in rehabilitation after a stroke, especially Neurologic Music Therapy. The Handbook of Neurologic Music Therapy defines Neurologic Music Therapy (NMT) as, “the therapeutic application of music to cognitive, affective, sensory, language, and motor dysfunctions due to disease or injury to the human nervous system,” (Thaut & Hoemberg, 2014, p. 2). The handbook highlights 20 NMT techniques that are backed by evidence to help people with varying diagnoses. Melodic Intonation Therapy (MIT) is a technique that has been highlighted in many studies for treating patients with Broca’s aphasia. MIT is when a neurologic music therapist assists the client in tapping their left arm or hand while humming or singing words or phrases. The significance of tapping the left hand is that it “activates right hemispheric language networks, as spoken language and arm gestures are controlled by the same motor network,” (Thaut & Hoemberg, 2014, p. 142). Rhythm and melody are important therapeutic functions of music in this technique, and a therapist must be trained in NMT to properly use this intervention.

In a study conducted by Hatayama, et al., the results demonstrated that a patient with nonfluent aphasia (associated with Broca’s area) demonstrated great improvement in fluency of speech, reading, spontaneous speech, and conversation after 52 months of treatment. Before treatment started, the client was only able to speak one word. (Hatayama, et. al, 2021). In a recent meta-analysis by Leonardi, et al., they concluded that music therapy in general has the ability to improve spontaneous speech, communication, naming, and repetition in patients with post-stroke aphasia. (Leonardi, et al., 2018). This study also highlights the progress clients are able to make in MT when therapists utilize Speech-MT for Aphasia (SMTA). Dynamics, tempo, and meter are musical elements that the therapist uses to improve sound, word, and sentence levels. In many interventions that target speech needs, clients and therapists will work on therapeutic singing together or utilize simple melodies to form words and sentences. When therapists look for interventions that will assist in the recovery of speech after a stroke, there are many different evidence-based techniques. It is important to understand the specific parts of the brain that are affected when treating a patient with these needs.

-Lila Finke, Music Therapy Intern

References

Hatayama, Y., Yamaguchi, S., Kumai, K., Takada, J., Akanuma, K., & Meguro, K. (2021). Music intonation therapy is effective for speech output in a patient with non-fluent aphasia in a chronic stage. Psychogeriatrics, 21(3), 430–433. https://doi.org/10.1111/psyg.12667

Koelsch S. A neuroscientific perspective on music therapy. Ann N Y Acad Sci. 2009;1169:374–384.

Leonardi, S., Cacciola, A., De Luca, R., Aragona, B., Andronaco, V., Milardi, D., Bramanti, P., & Calabrò, R. S. (2018). The role of music therapy in rehabilitation: Improving aphasia and beyond. International Journal of Neuroscience, 128(1), 90–99. https://doi.org/10.1080/00207454.2017.1353981

Thaut, M. & Hoemberg, V. (2014). Handbook of neurologic music therapy: Vol. First edition. OUP Oxford.

Music Therapy, TBI, & NMT

A TBI, or traumatic brain injury, is caused when a sudden injury or trauma damages the brain. This can cause mild, moderate, or severe damage, which may be permanent depending on the severity. According to Johns Hopkins Medicine, there are two types of TBI: those being penetrating, which occurs with a break in the skull and closed, which occurs when there is an injury directly to the brain in the enclosed skull caused by shaking. There are a multitude of causes, the most common being falls, motor vehicle accidents, assaults, and being struck by or against a blunt object. Traumatic brain injuries can cause symptoms such as paralysis in facial muscles, loss of smell, taste, hearing, or vision, memory loss, comas, clumsy movements, etc. Depending on the severity of the TBI, individuals may not be able to recover fully.

Music therapy can be a beneficial tool for recovering some of the symptoms caused by TBI. According to a mini-study conducted in 2023, music therapy was beneficial for improving gait, speed, stride length, and balance. The researcher, Ghai, selected individuals and had a randomized control group that did not receive MT and a group that did. The individuals who received music therapy showed success and more rapid improvement in areas involving gait and gross motor movements. Various techniques of music therapy were used to treat these clients, including rhythmic exercises, predetermined frequency of rhythm, high and low-pitched tones, and neurological music therapy techniques.

In a different study conducted by Wheeler (et al.,), the researchers attempted to uncover how music therapy affects the mood and emotional behaviors of individuals who have suffered from a TBI or stroke. The study was conducted with ten different participants who suffered from a stroke or TBI at the same rehabilitation center. Each of them had a moderate to severe diagnosis. The music therapy sessions each had a structure of an “opening activity” focused on feelings, and after, music therapists used singing, instrumental songs, lyric substitution, lyric analysis, etcetera, to work on addressing heavy feelings and discuss new techniques for emotional expression. The researcher’s conclusion indicated that individuals who received more music therapy sessions had improved emotional regulation and expression as opposed to individuals who had few sessions completed. Music therapy can be a tool for individuals suffering from TBIs. As addressed, emotional and motor needs are two of the several major areas of need for individuals who have experienced a traumatic brain injury.

- Mallory McDonald, Music Therapy Intern

References

Ghai, S. (2023). Does Music Therapy Improve Gait after Traumatic Brain Injury and Spinal Cord Injury? A Mini Systematic Review and Meta-Analysis. Brain Sciences (2076-3425), 13(3), 522. https://doi.org/10.3390/brainsci13030522

Mayo Foundation for Medical Education and Research. (n.d.). Traumatic brain injury. MayoClinic.https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/symptoms-causes/syc-20378557

U.S. Department of Health and Human Services. (n.d.). What causes traumatic brain injury (TBI)?. Eunice Kennedy Shriver National Institute of Child Health and Human Development. https://www.nichd.nih.gov/health/topics/tbi/conditioninfo/causes#

Wheeler, B. L., Shiflett, S. C., & Nayak, S. (2003). Effects of Number of Sessions and Group or Individual Music Therapy on the Mood and Behavior of People Who Have Had Strokes or Traumatic Brain Injuries. Nordic Journal of Music Therapy, 12(2), 139–151. https://doi.org/10.1080/08098130309478084

The Effect of Music Therapy on Patients With Dementia

Dementia is an umbrella term for the mental decline that affects daily living in older adults. Some forms of dementia include Alzheimer’s Disease, Lewy Body Dementia, Frontotemporal Dementia, Huntington’s Disease, Parkinson’s Disease, and more. The disease is progressive and currently has no cure. These diagnoses are often caused by changes in the brain with old age, genetic predisposition, and environmental factors. Symptoms of dementia include, but are not limited to, memory loss, behavioral changes, personality changes, confusion, difficulty with daily tasks, getting lost, social withdrawal, depression, difficulty conversing with others, and more. Music therapy is an allied health profession that can utilize evidence-based music interventions to treat symptoms of dementia.

The most common symptom areas that music therapists address with dementia patients are behavioral and psychological symptoms in dementia (BPSD), psychosocial, memory recall, mental health, and quality of life. Live receptive music listening, group therapy, active music therapy (instrument play), and other approaches are considered effective forms of treatment for different symptoms when done over longer periods.

In an umbrella review from Garrido (et. al), several studies found that music therapy interventions and therapeutic singing had a positive effect on BPSD symptoms and improved them in comparison to those without music therapy treatment. Garrido (et. al) also discussed that music therapy decreased anxiety levels and elevated the mood of people with dementia. Garrido (et. al) also stated that the reported benefits of music therapy participation were, “positive effects on mood and well-being; increases in energy level; cognitive stimulation; collective bonding and peer support; a sense of contributing to something bigger and more aesthetically beautiful; increases in confidence; motivation and self-esteem; and a sense of personal transcendence,” (Garrido, et. al, 2019, p. 271). For cognitive needs, Moreno-Morales (et. al) found that receptive music therapy interventions, such as music listening, are one of the most effective. The study discusses that the positive effects could be due to activation in several parts of the brain. Activating these areas of the brain could create new connections, which promotes neuroplasticity. When researching the effect of music therapy on Alzheimer’s dementia, Gómez Gallego (et. al) found that music therapy improved hallucinations, agitation, delusions, anxiety, and other psychological symptoms. The results highlighted that music therapy “increases the level of tolerance to stressful environmental stimuli that may trigger such symptoms,” (Gómez Gallego, et. al, 2017, p. 305). Receptive music therapy may allow the autonomic nervous system to remain calm, which decreases the activation of the parasympathetic nervous system. When addressing quality of life, psychosocial, and mental health needs, group music therapy increases positive moods and promotes social relationships. Furthermore, the study found that cognitive function, memory recall, language understanding, speech development and processing, and more all improved. All of these improvements are most likely due to increased spatial orientation, singing and being social with others, music-associated memories, and brain plasticity.  

The studies above found results from studies that utilized individual and group music therapy treatment, and music therapy was effective in both settings. A range of results can be found depending on the setting, interventions, and individuals in the music therapy sessions. Music therapists have the ability to assess and treat the needs of others in various settings with evidence-based music interventions to treat the non-musical needs of many populations. Although dementia is not reversible, long-term music therapy treatment is evidenced as a successful solution for decreasing a variety of symptoms within this population.

-Lila Finke, Music Therapy Intern

References 

Dementia. (2023, March 15). World Health Organization (WHO). Retrieved July 6, 2023, from https://www.who.int/news-room/fact-sheets/detail/dementia 

Gómez Gallego, M., & Gómez García, J. (2017). Music therapy and alzheimer’s disease: Cognitive, psychological, and behavioural effects. Neurología (English Edition), 32(5), 300–308. https://doi.org/10.1016/j.nrleng.2015.12.001 

Garrido, S., Baird, A., & Tamplin, J. (Eds.). (2019). Music and dementia: From cognition to therapy. Oxford University Press.

Moreno-Morales, C., Calero, R., Moreno-Morales, P., & Pintado, C. (2020). Music therapy in the treatment of dementia: A systematic review and meta-analysis. Frontiers in medicine, 7, 160. https://doi.org/10.3389/fmed.2020.00160