Lea Wolf, MSW & Dr. Thomas Wolf

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EXECUTIVE SUMMARY

In 2009, the Weill Music Institute of Carnegie Hall launched the Musical Connections Program. The program was founded on these premises:

• Music has the power to transform lives and to bring hope and comfort to people in challenging circumstances.
• All people deserve to have great music in their lives.
• Carnegie Hall feels a responsibility to provide and develop programs that respond to community need based on the organization’s mission and civic position.

Musical Connections has taken musicians to settings as diverse as adult and juvenile correctional facilities, homeless shelters, senior service organizations, and hospitals. In these settings, Musical Connections has offered programs ranging from large-scale concerts for several hundred people to in-depth workshops extending over many weeks involving as few as five or six participants. Initial evaluation of the program has demonstrated its profound impact on people’s lives.

Carnegie Hall recently decided to expand Musical Connections nationally based on the idea that the success of local programming’s response to New York City’s needs had implications for communities across the country. One of the aims of a national partnership is to try to find an underlying set of common goals and measures that might offer opportunities for cross site documentation and assessment. A first step in this effort is to ground the work in a broader understanding of theory and practice about the way music connects to the fields in which the program is active. This paper is intended to do that for the field of music and health.

MUSIC’S IMPACT

The paper begins by exploring a core premise of the program: that music can have a transformative impact on people’s lives. Music is a primary force in the lives of individuals, families, and societies. Across cultures and throughout recorded history, humans make music. Rhythm, song, and improvisation punctuate the progress of individual and collective experience, from the melodies of everyday life to the set incantations of ritual. Music activates and shapes the human brain, sharpening the mind’s ability to hear and interpret speech, awakening emotion, and encoding memory. Music has been an element in the survival and development of the human species and musical instinct has its basis in biology.

MUSIC AND THE BRAIN

The power of music to control the spirit has always been understood, but within the last decade, new technologies have made visible the interaction between music and the physical brain. The making and processing of music involves structures, networks, and pathways throughout the brain, from the highest order of conscious reaction to the lowest unconscious levels of response.

Music has been shown to stimulate the brain’s primary engines of human capacity. Musical engagement exercises attentional networks and executive function, evokes emotional response and stimulates the central nervous system, and appears to activate the human mirror-neuron system, supporting the coupling between perceptual events (visual or auditory) and motor actions (leg, arm/hand, or vocal/articulatory actions).

At one time, theories of human brain development argued that there was little or no growth of brain cells after age 30. But recent studies of music and the brain have shown this view to be erroneous. The brain is a plastic organ and music itself has the power to shape the brain’s development into later life. The implications of this finding are huge. Providing opportunities for people to experience music in many settings can have a profound impact on their healthy development. Exposure to music alters the physical structure of the brain. Engaging in musical activities not only shapes the organization of the developing brain but also produces long-lasting changes even after brain maturation is complete. For example, those who frequently play a musical instrument are less likely to develop dementia compared to those who do not, revealing that music works not only to train the brain, but also to protect cognitive functioning.

Music has long been recognized as a powerful force in rehabilitative treatment, used clinically to address impairments in motor function, language, cognition, sensory processing, and emotional disturbances that can result from brain injury. It has been used successfully to induce cognitive repair in patients with stroke, Parkinson’s disease, cerebral palsy, or traumatic brain injury. Indeed, music has the potential to “fix” the brain, by providing an alternative entry point into a “broken” brain system to remediate impaired neural processes or neural connections.

MUSIC AND HEALTH CARE

With respect to health care, music can be an effective intervention with patients of every age. Music offers health benefits throughout life, from those born into the neonatal intensive care unit for whom music mediates medically-necessary stress, through those in hospice care at the end of life who can use music to transcend physical symptoms and declines.

Music is effective with patients with conditions ranging from cancer to schizophrenia to traumatic brain injury, and is used to support patients in staying well by combating the debilitating effects of stress, sleeplessness, and chronic pain. Indeed, today music is integrated into health care at every level. The clinical use of music is now an evidence-based practice that has been proven both to satisfy patients and, very significantly, to lower the cost of care.

Music has also been shown to enhance the experience of patients waiting for well visits – improving individual perception of the hospital, enhancing the speed and efficacy of staff performance in surgery, and even ameliorating the anxiety of patients being weaned from mechanical ventilation. Music has the potential to minimize the procedural and environmental demand that the conditions of the Intensive Care Unit place on patients, and it can engage and help to retain typically elusive patient-groups in areas such as mental health and substance abuse. Additionally, music has the potential to encourage people to commit to routine and necessary preventive care.

STAFF

Each of the arts can be an effective tool for motivating, empowering, and developing staff. Many arts-based programs and encounters can help staff to affect positive change in their working environment and to address personal and professional development aims, yet music appears especially effective in addressing the needs of caregivers. This is particularly true for stress. For example, targeted music experiences have helped nurses relax, rejuvenate, and re-focus, enabling them to do their work with renewed energy.

Staff experience is also improved by those musical interventions that ease patient conditions, making patients more comfortable and rendering them easier to care for. For example, the use of music can contribute to work satisfaction for staff by soothing patient populations whose condition can incline them to agitation or disruptive behaviors.

RESEARCH ON SPECIFIC CONDITIONS

This paper highlights selectively some of the extensive research on ways in which music has been used to promote health in specific areas of illness and/or care. While research is growing, many studies are still limited to a few patients or to mostly qualitative techniques, which is a concern when music advocates try to make their case to medical professionals or administrators who hold decision-making authority about staffing and treatment. Nevertheless, for each area there is a body of research correlating music with health improvements and specific papers are cited.

Conditions and areas of treatment for adults include:

1. Pain, Stress, and Anxiety
2. Oncology
3. End of Life
4. Gerontology
5. Parkinson’s Disease
6. Alzheimer’s and Dementia
7. Mental Health
8. Substance Abuse
9. Rehabilitation
10. Veterans

Pediatric conditions and area of treatment include:

1. Labor
2. Neonatal Intensive Care/Premature Infants
3. Learning and Development
4. Autism
5. Adolescents
6. Pediatric Illness

MUSIC THERAPY

Programs that bring professional musicians into hospitals introduce one kind of musical intervention (performances and workshops) into a health care environment where a very different kind of musical activity has long dominated. That activity is called Music Therapy.

Music therapists are professionally trained and credentialed health professionals. They come to their work having completed a standardized curriculum that is comprised of an academic program, 1200 hours of clinical training, and a supervised internship. The therapeutic experience they offer can take many forms but it relies on a real-time relationship between a clinician and a client (or clients). There is a concentrated focus on the client’s evolving affect and expression and a concomitant adjustment in therapy in a session.

According to at least one well-known music therapist, the kinds of musical experiences offered by outside musicians coming into health care settings generally lack several of the critical components of a music therapy encounter:

• Often they are not elective: a patient cannot opt out of hearing the music.
• The experiences are not targeted to individual patients’ condition, mood, treatment plan, or essential self as therapy is.
• Most often they are not sustained or repeated overtime.
• They are not geared to respond to changes in patients moment-by-moment or to those observed over time.

Yet the evidence from some of these programs is that many of the elements mentioned above can be built into an intervention by a professional musician. It is also true that sometimes musicians offering a performance can reach clients who are not engaging therapeutically, or a performance can elicit an entirely different emotional response from that yielded by therapeutic technique. In any case, the imperative of careful calibration of selected music and performances in real time based on the responses of the patients is a valuable lesson that music therapy can teach the professional musician going into health care settings.

In spite of over half a century of positive outcomes for patients, music therapy has not been fully or routinely integrated into health care. Part of the challenge is the trend in health care towards an evidence-based model, one that has subjected longstanding clinical practice to a new level and vocabulary of scrutiny. Music therapy often suffers from the perception of simply not measuring up when it comes to evidence of outcomes. In addition, music therapy is not always welcomed by medical personnel or institutions: it has the potential to introduce unpredictability and additional people into treatment space and planning.

FURTHER ISSUES AND OPPORTUNITIES FOR MUSIC AND HEALTH CARE

A. The nature of the interaction: No one has identified precise components and range of facilitated musical experiences in health care settings though we know that facilitated music experience exists on a continuum from a single performance without talk by a musician to the full therapeutic experience over time of a highly trained music therapist utilizing his or her interpersonal skills, knowledge base, and in some cases training as a professional musician. But this gross distinction doesn’t help very much and it has, in some cases, worked against the most cooperative strategies within health care settings. Perhaps what is needed is a more precise taxonomy of ways that professionals can interact musically with a range of patients together with opportunities and challenges posed by a variety of scenarios.

B. Access: In hospitals, clinics, or senior centers, musical outreach is often considered as entertainment, environmental enhancement, or recreation, and not a clinical intervention. Accordingly, access can be quite limited. Visiting musicians meet only those patients that the hospital staff deems healthy enough to handle the experience – in those spaces designated by the facility. In many places, gaining access is a challenge. Because the introduction of professional musicians into the health care environment can be perceived as an intrusion by some, advocacy by staff within the institution is critical – often the higher in the authority chain the better.

C. Dose and duration: Two intriguing questions in the area of music and health care are:

• How much music does it take to make a difference?
• How long do results last?

The question of frequency of exposure required to glean benefit is a subject of research. Not surprisingly, many studies correlate superior effects on patients to increased frequency of music intervention. But the long-term measurable benefits of music interventions are difficult to document. Certainly any form of program design or evaluation should take into account the effects of both dose and duration on intended outcome.

D. What music for which people? The delivery of music that is “appropriate” in health care settings is more than an issue of satisfying a generic checklist of do’s and don’ts. The brain of each individual patient has picked up musical building blocks from the local sonic environment in infancy and developed preferences based on this experience. To the extent possible, music needs to be tuned to resonate with patients’ particular and deep-rooted musical instinct. The evidence for this is overwhelming – patient preferences and prior musical experiences are vital determinants of the ultimate success of any intervention. Ideally music should be relevant to its listeners in terms of culture, genre, mood, and era of origin. Yet because music is an inherently evocative medium, performers also need to be cautious not to evoke too much feeling.

E. Research: What do we know and how reliable is our knowledge? A growing interest in music and health has created an explosion of research over the last decade. But the research has generally been performed on limited populations (small numbers make statistical validity much more difficult), and analysis rarely factors in the implications of the demographic sample and often does not control for other factors in the environment. Live musical performances regularly garner enthusiastic reviews from patients and from staff, and have the potential to transform the experience of both patients and their caregivers, but their effects can be difficult to quantify.

Few studies so far document the effects of the kind of programs offered by Musical Connections or by other organizations doing the work of community engagement in the field of music and health, due in part due to the methodological considerations mentioned above. This work is widespread and deserving of consideration by research. The design of effective evaluation and research protocols is a challenging proposition, yet the work requires documentation, assessment, and evaluation in order to persist and evolve. One contribution that the Musical Connections program and others like it can make is to introduce greater rigor into that process of evaluation and documentation, which could help to address the problem.

F. Technology: New possibilities: The use of music in health care is being transformed by technology. Already, technology is used to offer relaxation and entertainment, enabling patients to access individualized pre-recorded content. New, easy-to-use devices allow the recording of sound and lyrics in the moment and this makes possible a new kind of “play,” allowing a patient who may not be comfortable producing music in traditional ways to engage in music-making without singing or playing an instrument. Because so many adolescents record and sample music already, technology can also provide an avenue of access to this age group.

With new technologies becoming more prevalent in health care settings, those who care about the quality of musical interactions need to become involved with the planning of content and use. One lesson from the almost universal presence of television in hospitals is that technology often seeks the lowest common denominator of content. High quality content needs advocates who can make a clinical case for its use.