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Using music as a form of therapy for emotionally disturbed children seems quite natural, given children's innate love of music. How can this form of creativity be used as therapy to help children better communicate feelings and emotions?
Music therapy is defined as "the prescribed use of music by a qualified person to effect positive changes in the psychological, physical, cognitive, or social functioning of individuals with health or educational problems" (American Music Therapy Association, 2003). While music therapy is closely aligned with the behavioral sciences, it is distinct in that it bridges art with science. Two publications by Elio Frattaroli, M.D., (2002, 2001) illustrate the dilemma faced by modern psychiatry in trying to understand mental illness, not only in the science of neurological processes but also in the art of skillful healing relationships.
Music therapists are skillful practitioners who orchestrate their talents to help soothe a wide variety of painful human conditions. While many psychiatrists are aware of the uses of music therapy for the treatment of autism, substance abuse, Alzheimer's disease and pain, far fewer are aware of the exciting work that's being done with children who have serious emotional disturbances.
Children with such disturbances have diagnosable mental health disorders and extreme functional impairment that limit or interfere with the ability to function in the family, school and/or community (Stroul and Friedman, 1994). Conservative estimates from epidemiological studies suggest that 8% to 12% of students ages 6 to 21 suffer from a significant disability, and approximately 8%, roughly 470,000 of this population, are identified through their schools as being emotionally disturbed (U.S. Department of Education, 2001).
A review of the music therapy literature delineates at least three broad domains of functioning where music therapy has been successfully utilized in the treatment of emotionally disturbed children: affect regulation, communication and social/behavioral dysfunction. Assessment and intervention in each of these domains requires strong grounding in developmental theory, a key component in the training of music therapists. Early on, music therapy was identified as an intervention to treat impairments in affective functioning, including reducing levels of anxiety (Cooke, 1969), and as a tool to improve emotional responsiveness (Wasserman, 1972). Music therapy has been well-suited to help improve communication deficits and stimulate nonverbal communication. Numerous positive outcomes in improving social functioning, social awareness and cooperation (Werbner, 1966), and decreasing disruptive behaviors (Hong et al., 1998) have been reported. One of the major contemporary applications for music therapy is working with children who have serious emotional disturbances and high degrees of impulsivity and limited ability to self-regulate (Layman et al., 2002).
Some of the modalities and techniques used in the treatment of emotionally disturbed children include live music production (e.g., playing instruments and/or singing), improvisation, guided imagery (e.g., pairing of visualization with music), creative songwriting and lyric analysis. After a careful assessment of the child's needs and capabilities, music therapists formulate individualized treatment plans that include goals and measurable objectives. Music therapists reinforce and shape targeted behaviors, while dynamically exploring underlying feelings and issues. Music therapists who work on multidisciplinary treatment teams often concentrate on a specific subset of treatment goals or objectives most appropriate for music therapy intervention. These techniques are applied in a variety of community treatment settings, as well as in hospitals, residential treatment centers and partial hospitalization programs. Therapy sessions with children typically last from 30 to 60 minutes and may be structured to include individual, family and group formats.
An advantage of music therapy is that it is an inherently nonthreatening and inviting medium. It offers a child a safe haven from which to explore feelings, behaviors and issues ranging from self-esteem to severe emotional dysregulation. Music therapy techniques can be designed to address more complex issues such as grief, abandonment or deeply conflicted emotions. As a medium, music therapy has enormous range and scope in targeting multiple clinical needs across the gamut of childhood developmental stages. It can set the occasion for a child to establish a meaningful relationship with an adult through musical play and interaction. Music therapy can also facilitate the development of prosocial skills, trust and feelings of positive attachment. Developmentally, almost all children respond to music. This greatly assists in laying a strong foundation for engaging in deeper therapeutic work. Children's natural interest in music is enhanced by the fact that they are occupied in stimulating motor and auditory activities more associated with play or fun than work or therapy. The careful and repetitious orchestration of such multisensory experiences, in the context of a skillful and nurturing relationship, has a remarkable range of clinical benefits.
Music Therapy Applications
The mental health care and child welfare fields are searching for effective therapies that can be utilized with victimized children, especially those who have comorbid disorders. The most heavily researched psychiatric sequelae of victimization is posttraumatic stress disorder, and its most frequently studied treatment is cognitive-behavioral therapy. A concerning gap in the treatment literature is that many emotionally disturbed children suffer from cognitive deficits and developmental disabilities. Research indicates that the average IQ of child welfare populations undergoing intensive mental health treatment is in the low- to mid-80s (Hussey and Guo, 2002). Such intellectual and information-processing deficits render cognitive and verbal therapies less effective for these children than for children with higher IQs.
Fortunately, music therapy is ideally suited to help fill this gap, and researchers are beginning to formally investigate its application. A common dynamic that child therapists encounter is the reluctance of traumatized children to engage in direct therapeutic work. Often, it is particularly difficult for children with low IQs to verbally express traumatic events, especially if the trauma occurred early in life when verbal skills were still emerging (Robb, 1999). Because of this, indirect and nonverbal forms of communication such as music can be highly effective avenues for treating victimized children.
Music has the potential to bypass the defensive operations of the higher cortical functions of the brain and move directly to the limbic system where emotions are processed. Music is also thought to stimulate right-brain functioning, which is associated with imagination and feelings, especially feelings of sadness (Montello, 1999). Research has found that early trauma affects the developing nervous system, causing chronic states of over-arousal in traumatized children. Music is an ideal way to help these children self-regulate and soothe as it creates a middle ground between over-arousal and numbness and helps the child to experience a state of stability (Montello, 1999). The immediate success that children experience in the music therapy setting can provide a boost to self-esteem and create a successful, nonthreatening environment in which the therapist can help the child to decrease symptoms of arousal or disinhibition.
The robust conceptual framework of music therapy affords tremendous flexibility and range of application. Music provides a curative mechanism for abused children to use symbols (e.g., sounds) to externalize their internal world and process overwhelming emotional material from a safer distance. This externalization process can serve as a vehicle of gradual exposure, whereby children naturally, and at their own pace, encounter, organize and better manage their dysregulated affects and anxieties.
Music therapy is also a powerful tool for helping children in foster care (Layman et al., 2002), particularly as they negotiate issues related to attachment and loss. While most of these children have been placed in foster care due to abuse or neglect, many have also experienced multiple early significant disruptions in their primary caregiver relationships. Such disruptions severely impair children's capacities to form trusting relationships and can lead to the development of a spectrum of attachment-disordered behaviors. Music therapy has been utilized to promote the establishment of trust and the development of reciprocal interactions (Hong et al., 1998). Music improvisation, for example, provides children with a nonverbal way to connect with the music therapist as a means of establishing a safe, therapeutic relationship.
Creativity is required by the music therapist in order to adapt the broad range of treatment techniques to the individualized needs and presentations of the child. As children practice and gradually acquire new relational and behavioral skills, they are helped to transfer these skills to other relationships, such as adoptive parents or foster caregivers, that are outside the music therapy context and into their natural environments.
"Sarah" was a 9-year-old African-American female with a history of sexual abuse, neglect and abandonment. The focus of her music therapy treatment addressed self-regulation and prosocial skill development. Music therapy sessions included improvisation, lyric analysis, live music production and songwriting. The structure of the sessions was activity-based and included use of visual aids to create a concrete and multisensory process.
The "Feelings Faces" improvisation activity used with Sarah explores musical expression of feeling states to encourage development of a feelings vocabulary. Pictures of actual people, each with a different affect (e.g., happy, sad, mad, scared), were first viewed and discussed. Then, Sarah and the music therapist took turns selecting a "feelings face" and improvising music on the piano that matched that feeling state. Each took turns guessing what feeling was being musically expressed. Sarah played loudly and aggressively to portray a mad feeling and softly to portray a sad feeling. The therapist encouraged Sarah to discuss and process circumstances and events in her life that contributed to these different feeling states.
"Helping Hands" is a more advanced lyric analysis activity that helped Sarah decrease her aggressive behavior and increase prosocial behavior. Printed lyric sheets of the song "Hands" by the recording artist Jewel were distributed, along with blank sheets of paper. Sarah was encouraged to follow the lyrics and actively listen to the meaning of the song. The recording was then played a second time (at a lower dynamic level), and Sarah was directed to trace around each of her hands on the blank sheets of paper. She was then asked to write or draw on each finger of her left hand one way in which she could use her hands to help others (e.g., handshake, kind touch, wave hello, help with chores). She was asked to write or draw on each finger of her right hand one way in which hands could be used to hurt others (e.g., hit, push, grab). Sarah and the therapist examined ways to use hands to help others and how to avoid using hands for hurtful behaviors. Sarah's foster mother used a sticker token economy to reinforce the times when Sarah used her hands in helpful ways.
As the evidence supporting the utility and effectiveness of music therapy continues to accumulate, stronger research designs are needed to directly compare music therapy with other child therapies. The rigor of this type of testing is at the core of the evidence-based practice movement. In addition, the next generation of music therapists will pioneer the integration of music with multimedia treatment methods and computer-assisted technologies. These emerging technological capacities will provide new and innovative instruments for music therapists to use in modern psychiatry's struggle to "heal the soul in the age of the brain."
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