Interview by Kellie Rowden-Racette
Although music has been used therapeutically since ancient times, the profession of music therapy has been recognized in the United States since 1950. Like speech-language pathology, music therapy plays a role in the treatment of patients with a wide array of symptoms, including those related to cognition and communication. Kate Gfeller is a faculty member in the School of Music and the Department of Communication Sciences and Disorders at the University of Iowa in Iowa City. She explains the role of music therapy, and how music therapists can complement the work of SLPs.
What is music therapy and what is its goal?
According to the American Music Therapy Association, music therapy is the use of music to address physical, emotional, cognitive, and social needs of individuals of all ages. So basically, music serves as a tool to achieve nonmusical goals. Most people enjoy and respond to some type of music. People can engage in music through listening, singing, playing instruments, and movement throughout their lives. From a psychosocial standpoint, music therapy can help patients with mood regulation, and we find that preferred music can also increase attention and motivation. This is pretty important, because a lot a therapy can be tedious and discouraging.
What can music therapy do for communication disorders?
Like speech, music has rhythm, a pitch aspect, and spectral features or timbre. Research indicates that there are some shared neural networks between speech and music. However, there are also significant differences in the way speech and music are perceived and produced. Music engages broad neural networks, and can involve coordinated auditory motor patterns. It is hypothesized that for some patients, the therapeutic use of music can recruit intact neural networks to facilitate residual functions in damaged areas of the brain, which might improve speech production.
Certainly, music therapists don't have a franchise on using music in therapy. Speech-language pathologists can use it as well. But, music is our primary therapeutic tool, and we have a large repertoire of music-based interventions suitable for patients of different ages, backgrounds, and therapeutic needs.
What kind of training is required to become a music therapist?
A university curriculum approved by the American Music Therapy Association includes a combination of courses in music, behavioral sciences, and more biologically based or medical classes. With regard to music, music therapists complete extensive coursework in music theory, music psychology, and sociocultural aspects of music. They must also develop excellent performance and flexible functional music skills. Then they complete didactic courses in music therapy, a supervised practicum, and field-based internships.
Music therapy students also complete courses in behavioral sciences, anatomy and physiology, and research methods. Finally, because most music therapists will work as part of a treatment team, part of training includes learning about the unique roles and importance of other health care professionals, including speech-language pathologists, psychologists, and physical therapists.
What types of populations do music therapists work with?
Those populations most commonly served are individuals with behavioral and emotional disorders and developmental disabilities, including individuals with autism spectrum disorder—which is also, of course, a communication disorder. We also work with older adults, such as individuals with Alzheimer's disease, and with hospice patients. Though it may seem counter-intuitive, we also work with persons with hearing impairments. The advantage of music with that population is that the broad frequency and dynamic range of music, and song lyrics in conjunction with music, can be very effective tools when working on speech-language and auditory training goals, such as sound detection, discrimination, localization, and comprehension.
What does a typical music therapy session look like?
That is probably the hardest question to answer. What would be a "typical" session in most any health care profession? If you are a speech-language pathologist working with children who are pre-lingually deaf, and you're working on vocabulary development, you are going to have a very different therapy session than if you are working with an elderly patient with aphasia. This also holds true for music therapists. But, I will say that in most therapy sessions, the music therapist first needs to establish rapport because the therapist-patient alliance is really important. You need to understand the interests and background as well as needs of your patients so that you can select music that's going to be engaging and motivating to them. In addition to selecting music that is age-appropriate, the therapist needs to select music that is culturally sensitive. So for example, I probably wouldn't be using the song "Silent Night" if I were working with a Jewish client. I'd evaluate the patient's current functional level on target variables, I'd determine their musical preferences, and then I'd facilitate interventions suitable for target goals and objectives. Music interventions might include listening to music, singing, playing instruments, music improvisation, song writing, or moving to music.
What about patients with aphasia? What is the role of a music therapist with this population?
I consider a speech-language pathologist to be the primary therapist for someone with aphasia, so perhaps the speech-language pathologist finds that an individual seems to have more fluent production when they're singing than when they're speaking. Or maybe their patient is having some difficulties with management of respiration or vocal intensity. The speech-language pathologist might want to work with a music therapist in some initial sessions, using the singing of familiar songs to help promote more fluent production. This can help the patient gain some confidence, motivation, and a sense of success in those initial and sometimes difficult stages of rehabilitation.
Other music-based interventions might include incorporating oral, motor, and respiratory exercises through vocalization, singing, and instrument play. That might promote a more productive rate of respiration, phoneme production, or vocal intensity. The rhythm of music can be used as a cue to control the rate of speech. The singing exercises, which engage the auditory-motor feedback loop, can take advantage of shared networks that underlie both singing and speech. One of the advantages of singing is that, compared with speech, there's more continuous voicing. There is also a slower rate of phonation, which gives a little bit more time for distinguishing and processing individual phonemes. So the tempo or rhythm of singing, along with the melodic contour, can improve the speech rate, articulation, and prosody. It's also hypothesized that the syllable chunking of prosodic features might also enlist more right hemisphere support.
When is it appropriate to use music therapy in aphasia?
Sometimes a music therapist may be brought in to help with those oral, motor, and respiratory exercises. This can provide a nice foundation to help the patient prepare for more difficult forms of speech production. In some cases, a music therapist might co-treat, or consult with the SLP on Melodic Intonation Therapy (MIT). Of course, there's a lot of discussion about how to do MIT. My understanding is that there may be quite a few variations in protocols. But in general, it involves progressing from maybe a two-word to a five-word phrase, using the melodic contour, to help with prosody and with word fluency. There is often a rhythmic tapping on the left hand as the patient vocalizes. Some music therapists have found patients with particularly poor fluency may benefit from phrases that are somewhat more melodic and that have a slightly larger pitch range than the more monotonic prosody that's used in traditional MIT. They've also found that an initial warm-up with familiar melodies can also seem to help with production.
What are some appropriate ways for music therapists and speech-language pathologists to collaborate?
That's a really good question. The mechanism for collaboration is going to vary, depending on the organizational structure of the agency, who's involved, and the particular patient's needs. I really want to emphasize that, from the music therapy perspective, the SLP would be the primary therapist for diagnosis and assessment of primary goals and objectives for individuals with communication disorders. But if the SLP feels that the patient is not making adequate progress using more conventional approaches, then they might want to co-treat with a music therapist, or the music therapist might consult on a particular set of objectives. There may also be special cases in which a patient is highly motivated by music, or a specific therapy goal may lend itself to a music-based intervention.
One thing to keep in mind is that some SLPs are very comfortable with singing and using music, while others are not. That's one of the places where a music therapist might have more in-depth and flexible use of musical tools that could be helpful to the SLP. In some cases, a multidisciplinary model might be appropriate. A music therapist and an SLP are both part of a treatment team, but the music therapist and the SLP will identify individual goals that each of them work on best with their respective disciplinary approach. A more interdisciplinary model would involve the treatment team working together on the same goals. Each discipline would provide individual assessments, and share that information.
In a trans-disciplinary model, there may be role release, and various professions work together on the same goals and objectives, sometimes even co-treating. The process of therapy may include the SLP taking the lead one time, and the music therapist taking the lead in another session. In collaboration, the music therapist might show the SLP those aspects of using music that are less comfortable. Conversely, the SLP may coach the music therapist on the approach to MIT, or some other type of exercise that they'd like the patient to work on.
What factors determine what model you use? How do you decide which is the best approach?
Again, it depends on the agency and the organizational structure. There are practical issues that need to be worked out, such as scheduling and reimbursement. Let's say, for example, that you're working with individuals in a nursing home. Perhaps the speech-language pathologist comes to the nursing home once a week. But it would really benefit a given patient to have more opportunities to practice speech fluency exercises. If a music therapist can develop a coordinated plan with the SLP, and the music therapist is a regular staff member of the facility, the music therapist may be able to provide additional exercises and support in between speech-language therapy sessions.
However, in some cases, because of reimbursement or because of the organizational structure, that type of role release just isn't realistic. Also, some people just have a more natural comfort with working with other disciplines than others. If you wish to feel more comfortable in collaboration, you might want to request in-service training to learn about music therapy. Or the speech-language pathologist might observe a music therapist, or vice versa, to find out whether collaboration is something that's going to work for your patient caseload, and will fit within the agency's guidelines.
Isn't observing other professionals part of the training that music therapists go through?
Actually, one of our professional competencies, under the American Music Therapy Association, is awareness of and understanding of the roles of other health care professionals. We talk in our classes about the valuable contributions of other health care professionals. We discuss that music therapists sometimes act as a primary therapist, but sometimes they have a secondary role. If we are putting the patient first, we want to work very smoothly as a member of the team, to make sure that the patient's needs comes first.
One of the ways we have promoted collaboration here at Iowa is having our students co-facilitate sessions. For example, in clinic programs for children with communication disorders, my students and I facilitate music therapy sessions, and the speech-language pathology students either observe or sit in. Then my music therapy students go and observe speech-language pathology sessions or audiology sessions. So it actually becomes just a very natural part of the clinical training of the SLPs, the audiologists, and my music therapy students. In addition, I provide lectures related to music therapy for classes in communication sciences and disorders, and I have faculty from CSD lecture in music therapy classes about topics like aphasia, autism, cochlear implants, and hearing aids.
Where is music therapy headed?
It's exciting that there's quite a bit of basic research regarding perception and production of music and some of the shared or unique neural networks that are enlisted for speech and for music. But in my mind, we will move forward much more rapidly if we can have more collaborative research between SLPs, audiologists, and music therapists on specific music protocols and applications...as opposed to saying, "Oh, music therapy is good for everybody." I don't think that it is. I think we need to be much more specific and well-informed in our approach. Music therapy approaches are superb for some goals, but not the best approach for others. I hate seeing over-exaggerations about what music therapy does, because that's not helpful. That sets up unfortunate expectations and makes it difficult for the SLP to work with parents or patients who start with unrealistic notions. Music therapy certainly can be very beneficial, but therapy often involves hard work, no matter what the primary approach. So the more accurate we can be in communicating what we do, the better off I think we'll all be.
Kate Gfeller, PhD, is the Russell and Florence Day Chair of Liberal Arts and Sciences at the University of Iowa, where she directs the graduate program in music therapy. Contact her at firstname.lastname@example.org.