boy playing flute
Music Is Hope

What Makes Music Therapy Different

The Difference Between Music Therapy and Musical Entertainment

by C. Gourgey Ph.D.

Since music therapists produce music, they may be confused with other people who do the same. These may be music volunteers, or staff members who do music as a sideline. It is common simply to equate music with music therapy. It is therefore helpful for patients and families to know something about music therapy, and it is essential that staff members understand the difference between music therapists and paraprofessionals or volunteers who happen to be doing music while visiting the patients.

There are many misconceptions about music therapy, and specifically music therapy in a setting like hospice. The most common misunderstanding is that music therapy is just entertainment. It is therefore helpful to look at the differences between music as entertainment and music as therapy.

Credentials and Training

First of all, music therapy is a clinical specialty. Music therapists have formal training not only in music but in psychology and in the assessment of psychological conditions. An accredited training program in Music Therapy includes extensive course work, field work, and a clinical internship. After graduation, the candidate must pass an exam to become nationally certified by the Certification Board for Music Therapists. The credential “MT-BC” means “Music Therapist, Board Certified.”

In addition to national certification, individual states have their own licensing requirements. In New York State, where I practice, music therapists are required to be licensed and are considered mental health practitioners. To work independently a music therapist must have the credential Licensed Creative Arts Therapist (LCAT), whose scope of practice is defined as follows (from Mental Health Practitioners Guide to Practice, Office of the Professions, New York State Education Department):

  1. The assessment, evaluation, and the therapeutic intervention and treatment, which may be either primary, parallel or adjunctive, of mental, emotional, developmental and behavioral disorders through the use of the arts as approved by the Department [of Education of New York State]; and

  2. The use of assessment instruments and mental health counseling and psychotherapy to identify, evaluate and treat dysfunctions and disorders for purposes of providing appropriate creative arts therapy services.

Levels of Music Therapy

The difference in what a music therapist does and what an amateur musician does is not in what the music sounds like but in how it is selected and used. The music therapist carefully chooses music suited to each individual situation, on a number of simultaneous levels:

  1. Cultural. Music from the patient’s own cultural or ethnic background gives the patient a sense of familiar surroundings, decreasing feelings of isolation and “institutional depression.” A music therapist must therefore be familiar with music from many different cultures.

  2. Emotional. Music is selected to show recognition of emotions the patient is experiencing. This can involve some delicate judgment calls. For example, if the patient is sad, do I sing a sad song to let the patient know I understand, or a happy song to help the patient feel better? Certain psychological assessments go into making such decisions. For example, sometimes going right to a happy song only helps patients (and more often, family members) avoid dealing with difficult feelings. Other times, however, it can meet a genuine need for relief from grief or depression. For such reasons music therapists receive extensive psychological training as well, in both individual and group processes.

  3. Psychological. Psychological issues have to do not only with what the patient feels but also with the patient’s relationship to self and others. Patients may experience a whole range of reactions, including feelings of isolation, depression over the prospect of death or the loss of independence and control, guilt over failing to meet familial responsibilities, anger at self or at others. Any of these issues can be expressed and dealt with through music, which may be less threatening to the patient than trying to discuss them directly.

  4. Spiritual. This involves questions about life’s meaning, faith, hope, loss, and despair. Facing death forces an individual to the boundary of life itself, where one’s usual coping mechanisms may begin to fail. I often use music to strengthen a patient’s faith if the person is religious, or to help patients find and strengthen their inner resources if they have no traditional religious background. At this level music therapy becomes a form of pastoral care. A knowledge of different faith traditions is therefore also very important.

In their own way, families suffer as much as the patient, and often they suffer more. Sometimes I work more with the family members than with the identified patient. And usually, I don’t even tell them. I work on several different levels at once, singing to the patient a song whose real intent is to help heal the anxiety of the family members who are present. Or I may just play directly for the family member, to offer some relief from stress. I once sang for an hour to the daughter of one patient as she lay down in the next bed, nearly exhausted from weeks of caregiving with hardly any relief.

Sometimes the object of music therapy is the room itself. The air in the room can become filled with the fears and tensions of patients and visitors. The right choice of music can “clear the air,” creating an atmosphere in which all present can drop their fears for the moment and feel themselves in communion. There is no “all-purpose” music for this. Once while in a room with a patient and visitors from her church, I sensed the frantic feelings of the visitors as they tried without success to communicate with her. The room was much too full of noise, both verbal and emotional. I sang some hymns from their church, which they all knew, which united their spirits, and which allowed them to perceive the patient’s wordless gestures of response.

Sometimes music therapy brings families together. The son of one patient happened to be a folk guitarist. He brought his guitar and we would play duets, bouncing songs back and forth. Meanwhile his sister was listening, taking much joy from the music and from our interaction. Later I found out that the relationship had been very strained, and that this brother and sister had not spoken in ten years. Reunited through caregiving and music, they found they could enjoy each other’s company once again.

Music therapy can often go where words no longer reach. Recently a man in the very advanced stages of lung cancer came to the hospital unit. He could no longer speak, but was extremely restless. I sat next to him and played soft improvisations on my flute, responding to his movements, until he became calm and still.

I have worked with other patients suffering intense fear and unable to respond even to simple questions about what is bothering them. I often find that singing to them, even without my guitar, helps calm them down, if in the tone of my voice I can express a certain softness, the reassuring or even prayerful presence that they need. Music is always a direct communication between myself and the patient, even when words are useless.

The deepest level on which music therapy works is the spiritual. Spirituality has to do with the awareness of a meaning and power beyond the self and greater than the self. For those who identify this meaning with God, I have music from many different religious traditions. For others, I may sing about the power of love to draw people together and give life meaning, or find some other way to provide patients and their families with comfort and hope.

One patient of no particular religious background found herself turning to the spiritual as death was approaching. She could hardly speak, but her mind was clear. Every time I came to visit, she asked me for just one song, “Shall We Gather by the River” (an American spiritual made famous in the setting by Aaron Copland):

Soon we’ll reach the shining river,
Soon our pilgrimage will cease,
Soon our happy hearts will quiver
With the melody of peace.

Through these words she anticipated a peaceful end to her journey. Her tranquility while listening to the song told me that faith had come to her at last.

Beyond the Music

Music therapy is always a two-way process. I am constantly responding and adjusting to the patient’s responses. This is why tape recordings are no substitute for the human contact of the music therapist, even though they often can provide some measure of comfort or relaxation. Music therapy goes beyond comfort to become active communication. I don’t sing just to make the patient feel good or to perform the songs that I know. In the music, I am always telling the patient something. I am saying, “I hear what is on your mind. I understand what you say. Let me bring you now to a good place, a place from your childhood, or a place of rest and tranquility, or a place of hope and faith.” Or I am saying, “I hear the sighs too deep for words, let me at least give them notes of music, and together we will just let them be.” There are many messages taking many forms. The music is always more than the notes that are played or the words that are sung. It is a bond of intimacy between myself and those who hear me.

By now you have a clearer idea of how music therapists differ from people who just come to visit singing songs. If, however, a patient or family member who sees me coming expresses happiness that the “entertainment” has arrived, I say nothing to dispel that idea - for that happiness is also part of the therapy!

July 2004 / rev. January 2006