Music as a Psychotherapeutic Modality

An Expert Interview With David Horvath, PhD, PMHNP-BC

Elizabeth McGann, DNSC, RN-BC

November 21, 2011

November 21, 2011 — Editor's note: The therapeutic use of music can be traced back to the ancient Greeks. Today, music therapy is regarded as a reliable psychotherapeutic intervention for people with developmental disabilities, thought or mood disorders, addictive disorders, and dementia. "Gaga or Gershwin? What Every Psychiatric Nurse Needs to Know About Influence of Music on Emotion, Cognition, and Behavior" was featured as a podium presentation at the American Psychiatric Nurses Association (APNA) 25th Annual Conference, held October 19 to 22 in Anaheim, California.

To find out more about music as a psychotherapeutic modality, Medscape Medical News interviewed David Horvath, PhD, PMHNP-BC. Dr. Horvath has more than 20 years of experience in behavioral health nursing, and is currently working as a psychiatric nurse practitioner at the Child and Family Wellness Center in Lake Grove, New York. Dr. Horvath is also an adjunct associate professor at the Hunter-Bellevue School of Nursing in New York City. In addition, he is a professional musician and composer and is affiliated with the Julliard School of Music and the Manhattan School of Music.

Medscape: How did you get interested in music as a psychotherapeutic modality?

Dr. Horvath: I come from a musical family. My father was a professional musician and my mother started giving me piano lessons when I was 5. I went on to study theory and composition at NYU and worked my way through nursing school playing in wedding bands. One day I was returning home from [a clinical rotation] on the subway, and I read a story in the New York Post about a girl who was aroused from a coma upon hearing her favorite Roy Orbison songs. Some years later, I decided I wanted to investigate music and coma arousal for my doctoral work, but the methodological issues were monumental.

As I was working in addiction at the time, it was only natural that I shift my focus to the effect of music on recovery. My data indicated that the clinical application of listener-selected music had a significant positive effect on all factors [e.g., depression, anger] of the Profile of Mood States, suggesting mood improvement. Though I had a theoretical explanation for my findings, I wanted to know more about it.

Medscape: What is the history of music as a psychotherapeutic modality?

Dr. Horvath: The use of music as a psychotherapeutic modality can be traced back to the ancient philosophers. Aristotle and Plato encouraged the use of music to heal the body and the mind, as did Hippocrates and Pythagoras, who used music for tranquilization and mood elevation. Throughout history, music has been used to treat the depressive episodes of European monarchs, including George II of England and King Ludwig of Bavaria. Currently, music therapy is regarded as a reliable psychotherapeutic intervention for persons with developmental disabilities, thought and mood disorders, addictive disorders, and dementia.

Medscape: What does the research show about the influence of music on emotion, cognition, and behavior?

Dr. Horvath: Humans are "hard-wired" to appreciate music, and our musical brains are indeed "forward compatible." Yet, it is difficult to draw causal relationships about the influence of music on thinking, feeling, and behavior because human response to music is contingent on one's cumulative musical experience at any given time, and musical "intelligence" grows slowly and in subtle ways. Traditional brief experimental/control modes of research do not capture the psychological changes that may occur over days, months, or even years with varied musical experiences. We may listen to an unfamiliar piece from the classical music repertoire and, at first, not like it. We hear it again, and something about it catches our attention. Maybe it reminds us of a person, an event, a feeling. We pause, reflect, and maybe arrive at a new understanding about the relationship.

Nevertheless, some patterns of music response are predictable. Major modes are generally perceived as more pleasing than minor modes, and thus are more apt to make people happy. Familiar, consonant music will elicit positive affective responses, while unfamiliar, dissonant music will provoke apprehension and displeasure. Research has demonstrated that ambient music in stores and malls can be manipulated to influence shopping patterns, and classical music played in public areas (street corners, train stations, etc.) has been shown to deter criminal activity. Recent data on prolonged exposure to rap music videos reveals a significant association with social deviancy, increased alcohol and drug use, and increased likelihood of contracting a sexually transmitted disease. Music preference research has shown that highly intuitive people prefer classical music and jazz; hard rock is linked to psychoticism and impulsiveness.

Medscape: How do specific musical forms affect emotion, cognition, and behavior?

Dr. Horvath: This can happen in countless ways. Rousing rhythmic passages can inspire an infantry or get someone on the dance floor. Complex chords and even carefully placed musical fragments can be used to communicate complicated emotional messages. For instance, the sound of 2 contiguous notes constitutes an interval know as a "minor second" — a shrill, dissonant sound often used in film scores to provoke fear, as in "Jaws" or Hitchcock's classic thriller "Psycho". A sustained bass note can convey a sense of being "grounded" or a sense of stability. I would argue that this is the reason bagpipes have such a meaningful presence at funerals. The constant drone serves as a foundation for the melody and creates an impression of security in a time of loss and confusion.

Conversely, as some music therapists indicate, an incessant repetition of notes, phrases, or rhythms could be considered a musical metaphor for being "stuck", reinforcing an impression of "going nowhere." In comparison with pop songs of the 60s, 70s, and 80s, most current top-40 songs, unfortunately, are guilty of this. Lacking melodic and harmonic development, the listener is left with a smattering of rudimentary chords or chord fragments, not nearly enough to express nuances of emotion or feeling. In fact, after doing a quantitative analysis of chord use in pop music from 1980 to 2010, I calculated a 65% decrease in the use of chords in top-10 songs from 1980 (8 chords) to 2010 (2.8 chords). Young people have become captive audiences of endlessly repetitive truncated musical forms. The traditional song form as we know it has practically disintegrated.

Medscape: What recommendations do you have regarding the implementation of music in clinical settings?

Dr. Horvath: It is important that clinicians expose their clients to the best music possible. By "best," I am referring to music that has the right ingredients: harmonic and melodic development, and lyrical/musical consistency. Good music is like good research; it has internal validity, reliability, and replicability. The melodic and harmonic properties should convey the intended meaning of the piece and the appropriate emotional dynamics. A good example of this is the song "If I Loved You" from the musical "Carousel." The composer, Richard Rodgers, adroitly used an ambiguous-sounding (diminished) chord to underscore the word "loved", reflecting the ambivalence of the character. Replicability also indicates quality. Beethoven symphonies have been recorded hundreds of times by various artists. Songs by Cole Porter, George Gershwin, and the Beatles have been recorded by dozens of performers.

That being said, one should never try to impose music on someone else or try to shape his or her listening habits. New music is slowly assimilated into the mind, and often requires repeated hearing before being appreciated. Keep classical music or jazz on in the background. Let the transition happen naturally. Playing hits of the 70s and 80s (Earth Wind and Fire, Stevie Wonder, Chicago) is a good way to help adolescents bridge the gap from rap to more harmonically rich offerings. Having music enjoyment groups is another good idea. Use varied selections of all genres.

Medscape: Are there challenges in implementing musical modalities?

Dr. Horvath: People tend to be very invested and protective of their favorite musical choices and performers, often equating the attractiveness of a performer with the quality of their music. They may resist exposure to new genres of music or alternative selections. Proceed gently and passively.

Medscape: Are there resources or "best practices" available to providers regarding music as an intervention?

Dr. Horvath: There is no "best" music for any particular problem. What might be soothing music to one person may be aggravating to another. One of the participants in my study was in a rage on the last day of his testing. He almost refused to participate, but finally agreed if he could listen to a recording of "My Favorite Things" by John Coltrane; a rendition that one would never characterize as calming. Yet, within 20 minutes, he was relaxed and cooperative. Stay with preferred, familiar music for relaxation and comforting.

For musical and emotional growth, the best resources are on the radio — classical and jazz stations, XM/Sirius, oldies, etc. Patronize your local symphonies. Tempt yourself and your patients. If you like Celine Dion, try Andrea Bocelli. If you like him, move over to an opera. Many movie theatres now feature "Live at the Met" performances, allowing masses of people to see and hear live opera for the price of a movie and a bag of popcorn. Even if you don't like something upon first hearing, stick it out. Think about what you like or don't like about the piece. Listen to the music from top to bottom, front to back, side to side. This should be familiar territory for nurses who pride themselves on their listening skills.

Medscape: Can you explain the role of the music therapist in the healthcare team?

Dr. Horvath: Music therapists are often employed in behavioral health and skilled nursing settings and institutions where the normal verbal pathways of communication are compromised, or opportunities for enhancing one's quality of life are desired. As such, music therapists are often involved in facilitating the playing of instruments with patients, sing-a-longs, or simply performing and singing. They compliment the healthcare team by resonating with the patient's musical experiences and preferences and activating pleasurable or memorable experiences with them.

Medscape: What type of educational preparation is required to become a music therapist?

Dr. Horvath: Music therapists typically are educated in baccalaureate-based music therapy programs, and many go on to earn graduate degrees in music therapy or affiliated disciplines. However, many untrained therapy aides engage in musical activities with patients.

Medscape: How can nurses best collaborate with music therapists?

Dr. Horvath: Nurses can best collaborate with music therapists by discovering the musical likes and dislikes of patients, and by employing their preferred music in a wide variety of nursing care activities, from activities of daily living, to wound care, relaxation, palliation, etc. Together, nurses and music therapists can design musical "care plans" that meet the unique musical needs of patients.

Medscape: What are the 2 most significant aspects of your presentation?

Dr. Horvath: It is important to promote awareness that advanced musical forms — classical, jazz, some sophisticated pop, and country — possess the same temporal dynamics as human emotions — joy/despair, conflict/resolution, tension/resolution, agreement/disagreement. Music can help us and our patients understand feelings and thoughts in a nonconfrontational manner, and deal more effectively with the issues that we encounter through our lives.

Medscape: Is there anything you would like to add?

Dr. Horvath: Think about your life as a symphony. Would it have only 3 chords? A 4-note melody? Has your life been endlessly repetitive? Probably not. Seek out music that proclaims your reality, your dreams, and your passions.

Dr. Horvath has disclosed no relevant financial relationships.

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