Helen Odell-Miller Qualifications: BAHons; LGSM (MT); SRATh; MPhil Current Positions: Director Music Therapy MA, Anglia Polytechnic University. (APU); Head 3 Clinical Research Specialist, Cambridge and Peterborough Mental Health Partnership NHS Trust.

THE PRACTICE OF MUSIC THERAPY FOR ADULTS WITH MENTAL HEALTH PROBLEMS: THE RELATIONSHIP BETWEEN DIAGNOSIS AND CLINICAL METHOD

 

SUMMARY OF DOCTORAL THESIS

Helen Odell-Miller, 2007

 

1.1 Introduction

This Doctoral study is in two parts. Part I includes five published research articles by the author which represent half of the submitted thesis, and also form the starting point, historical background and thinking for Part II. (Odell-Miller 1999, 2001, 2002, 2003 and Odell-Miller et al 2006). The author is an experienced clinician and researcher, completing a Master of Philosophy in 1989.The articles or chapters in books included in Part I were all publications that were submitted to peer reviewed journals or edited books, and have undergone systematic review as a part of that process. Parts I & II are linked in that the research study in Part II arose from main questions and themes emerging from the publications, mainly in the field of adult psychiatry and looking at links between music therapy and psychoanalysis

The main themes relate to the author's quest for defining how music therapy is placed in the field of adult psychiatry, both clinically and theoretically and how it defines itself in relation to psychoanalytic theory within its own community and to the external world of health care services. Two publications (Odell-Miller 1999 & Odell-Miller et al 2006) also address the search for a research methodology that is suitable for answering questions about how beneficial and effective music therapy is in psychiatry, and for which diagnostic populations.

Following the presentation of the publications and a short discussion about their relevance to the author's questions, Part II of the thesis follows with a survey-based research project designed to answer the main question: 'How are different approaches and techniques of music therapy defined in adult psychiatry, for people from 18-65 years old, which link diagnosis to treatment?'

The research design is both quantitative and qualitative and involves some statistical analysis and qualitative analysis arising from a purposeful survey. It was decided to explore what is described about current practice in the literature, and link this to the results of an in-depth survey from a small sample of five music therapy centres in Europe, in order to find some new knowledge relating to this question. Reasons for this choice are linked to clinical, political and educational perspectives.


Part II: The Survey

In Chapter 7 a link between Part I and II of the thesis is made, and the rationale for the research study is summarised. The background is explained linked to the wider professional field of music therapy and mental health in Europe, and linked to the author's clinical and research experience. Examples of the literature review are given and an introduction to the survey, its design and process are also discussed.

In Chapter 8 the music therapy literature in psychiatry is discussed, leading up to the rationale for the study that new knowledge is needed in the field linking diagnosis to approach and technique in music therapy in psychiatry. Literature is examined from an international perspective and from the point of view of diagnostic categories, comparing and analysing different perspectives.

In Chapter 9 the method of the study is described in detail. It arose from the original ideas which influenced and motivated the researcher. These led to the design of the survey. The implementation of the survey of five established European music therapy services in psychiatry which were recruited as a convenience sample to be case studies is described, and the planned analysis of results using both quantitative and qualitative methods is discussed. The properties of each centre are described, and percentages of time spent by the music therapy treatment team with each diagnosis are summarised. Ethical and clinical perspectives which influenced the design of the study are examined as well as research methodology issues.

In Chapter 10, the results of the qualitative data are presented and analysed for each of the six diagnostic categories and for each of the approaches and techniques that are included in the questionnaire. The results are presented for each diagnosis in order to give an overview of how many centres use each technique and approach within each diagnostic category in rank order so that patterns regarding to what extent each approach and technique is used or not used within each diagnostic category can be seen. For each diagnosis, the qualitative descriptive data given by each centre for all approaches and techniques is discussed and analysed, making some comparisons across centres and diagnoses. Conclusions are drawn for each approach and technique about how much or little they are used by the centres in the study.

In Chapter 11 the quantitative data is presented across all centres settings and diagnoses in order to see to what extent each Approach and Technique is used, not specifically linked to diagnosis, but to ascertain degree of usage. Data is presented through bar charts and descriptive statistics, with some statistical analysis of proportional usage, then linked to the qualitative outcomes already discussed in Chapter 10. Comparative and further conclusions and discussion about the overall patterns and trends is further discussed in Chapter 12.

In Chapter 12, discussions and conclusions are presented relating to the main research question of the study, and to the themes of the thesis as a whole, linking qualitative and quantitative outcomes across all centres and diagnoses. Conclusions are drawn about whether or not a particular technique or approach is used, whether this may be 'indicated' for a particular diagnostic category, and what links can be established to previous published literature. Limitations of the study and its design, implications for education, training and clinical practice are explored. Future indications for research are discussed and proposed, and conclusions drawn from the thesis as a whole and the study in particular.

Rationale and background to the study

The reason for undertaking this research was that at the time of writing there were few comprehensive texts on the subject within the field of music therapy worldwide, and those in existence originated in the USA (Unkefer 1990, Wheeler 1983, 1987). For this reason the study takes a European focus.
The agencies involved in the provision of health services in many countries, for example in the United Kingdom include 'Purchasers' and 'Providers', who often need more detailed information about why certain treatments are effective for certain groups. In addition, the National Institute for Clinical Excellence (NICE) in the UK also evaluates the efficacy and relevance of treatments before recommending their application to the general population. The need for this information is becoming more necessary as other similar treatments are more specific about stating that certain treatments are effective with certain diagnostic groups or problems.
One example of this which inspired the study is found in a review of effective psychotherapy treatments for with people with schizophrenia (Roth & Fonagy 1996). Family intervention programmes aimed at modification of the support network of the schizophrenic person, and cognitive-behavioural treatment of acute symptoms are mentioned as effective treatments, but not arts therapies.
Arts therapies are mentioned briefly, as treatments of choice for patients in a recent DOH survey 'Treatment Choice in Psychological Therapies and Counselling' (Parry 2000), but there is a lack of information relating to types of interventions related to diagnosis. This gives the impression that music therapy might be out of synchrony with some other treatments such as psychotherapy (Roth & Fonagy ibid), which increasingly define treatments within the framework of evidence-based practice. Whilst some have attempted to draw anecdotal evidence and guidelines for practise linked to diagnostic groupings (Unkefer 1990, Wheeler 1983,1987), there is little systematic literature about theory, practise and research in the field of music therapy, which takes diagnosis into account.

In addition to the clinical need for the study, music therapy training courses, particularly in the UK, would benefit from some clear descriptions and guidance about which approaches and techniques are most suitable for which diagnostic groups in adult mental health, so that future music therapy practitioners can respond flexibly and appropriately to clinical demands and patient need.

In music therapy general research and case study literature, there is often an omission of diagnostic information relating to the rationale for music therapy approach and technique (Proctor 1997, Odell-Miller 1999, 2001, 2002, 2003) or little emphasis upon diagnosis. Authors who do refer to specific diagnostic groups in more specialised rather than general survey-type articles, often confine their research or explorations to that category, rather than comparative analysis. For example, Pavlicevic & Trevarthon (1994) discuss research with people with schizophrenia and music therapy, with significant outcomes. On the one hand they show a distinct appreciation of the diagnostic considerations, by adapting an approach previously developed for work with children, specifically for adults with schizophrenia. However there is no detailed discussion about why improvisation in particular might be beneficial or not for this population as opposed to others interventions such as using composed song, for example.

It was concluded (including the chapters by this author in Part I of this thesis), that there is little generic comparison of techniques and approaches, or discussion of why certain techniques and approaches might be suitable for one population, but not another, in the literature specifically for adults with mental health problems, and particularly in European literature. .

In summary, the main relevant existing texts are Unkefer (1990, revised 2005), and Wheeler (1987), both from the United States, who have collected information together, and do discuss and compare appropriate approaches related to diagnosis.

Introduction to the Survey

The main research paradigm was a non-probability survey based study, where purposive sampling using a convenience model was used to recruit a small and relevant sample of established clinical music therapy departments. There were six main categories, schizophrenia, bi polar disorder, depression, anxiety, eating disorders and personality disorders), nine approaches and twelve techniques listed below.

TECHNIQUES     / APPROACHES
Singing Composed Songs / Supportive Psychotherapy
Free Improvisation with minimal talking / Psychoanalytically Informed
Free Improvisation and Talking/interpretation / Client Centred
Free Improvisation with structures such as turn taking
or play rules / Behavioural
Theme based improvisation / Developmental
Activity-based / Analytical Music Therapy
Song Writing / Creative Music Therapy
Musical Role Play etc / Activity-Based
Receptive music using live music / Guided Imagery in Music
Receptive music using recorded music
Imagery in music
Music for Relaxation as part of a relaxation programme

A questionnaire was devised to gather in-depth criteria- based data, which was then analysed. The five centres included 23 music therapists in total. The objective was to target well-established music therapy services where there is a body of knowledge not necessarily formulated into external publications, but which exists in practice or in unpublished reports or documents.

Summary of Main Findings and Conclusions
Finding 1: There were differences between the centres as to the level of detail they provided to support decisions they made linking approaches and techniques to diagnosis.

2. Music Therapy Centres in the study variably defined what they do and why they do it linked to diagnosis.
3. In some cases this was substantiated very thoroughly, with case examples and clear reasoning.
4. In other centres this was not substantiated thoroughly, with sparse and limited reasons given for using chosen approaches and techniques.

Finding 2: Music Therapy approaches with a Supportive Psychotherapy approach or a Psychoanalytically Informed approach were used most often, and ranked first or second in every diagnostic category.

Finding 3: The Techniques Free Improvisation with minimal talking and Free Improvisation with talking/verbal interpretation are ranked highest for all diagnoses, but with some additional differences between psychotic disorders and non-psychotic disorders.

Finding 4: For psychotic disorders, using Composed Songs is ranked joint first with either Free Improvisation with Minimal Talking, or Free Improvisation with Talking/Interpretation, for both schizophrenia and bi-polar disorders, and there is less emphasis upon using techniques requiring symbolic thinking.

Finding 5: For non-psychotic disorders, Techniques that require more symbolic thinking such as Theme based Improvisation, Musical Role Play and use of other media, and Free Improvisations using structures such as play rules are ranked jointly first, or near the top of ranking orders for anxiety, depression, eating disorders, personality disorders.

Finding 6: Schizophrenia and personality disorder diagnoses are given the highest percentage of music therapy treatment input across all centres.

Finding 7: Personality disorder receives the most attention from music therapy centres in the study, concluded both from the amount of qualitative data collected and the fact that in three out of five centres personality disorders are a major percentage of case load, from 25% - 50%.

Finding 8: Psychotic disorders, incorporating bi-polar disorders and schizophrenia, emerged as a priority group in all centres.

Finding 9: Anxiety and depression receive the least attention from music therapy centres in the study, concluded both from the amount of qualitative data collected and the fact that in some cases only two out of five centres said they saw people with this diagnosis as their main diagnosis.

Finding 10: Respondents were often unable to link their yes and no answers with specific reasons as to why they did or did not use a particular technique or approach, and this was often related to lack of training in some
cases.

Finding 11: What music therapists do in the room with the patient in these settings (whether or not linked to specific diagnoses); and the reasons why they do it; often appear similar across centres where detailed case material was provided. However the similar case material was often categorised and defined under different, sometimes specifically developed approach 'titles'.

Future Directions

The study establishes some commonalities in current practice in the centres included in the survey, and points to the need and possibility for guidelines to be drawn up for clinical and educational purposes from the findings of the study about specific approaches and techniques which are used in adult psychiatry and why they might be particularly useful. It also points to the need for further research studies to be undertaken in music therapy of a diagnostic-specific nature.

 

References
Cassity, M. & Cassity, J., (2006) Multimodal Psychiatric Music Therapy for Adults, Adolescents and Children: A Clinical Manual. (Third ed). London: Jessica Kingsley.

Gold, C., Heldal, T., Dahl, T.,& Wigram, T., (2006) Music Therapy for Schizophrenia or Schizophrenia-like Illness. London: The Cochrane Database of Systematic Reviews. Issue 4.

Odell-Miller, H. (1999)'Investigating the value of Music Therapy in Psychiatry: Outcome related to reasons for referral' In Wigram A, de Backer J. Pub.(eds). Clinical Applications of Music Therapy in Psychiatry. London: Jessica Kingsley.

Odell-Miller, H., (2001) 'Music Therapy and its Relationship to Psychoanalysis' In Searle, Y & Streng, I. (eds). Where Analysis Meets the Arts. London: Karnac pp 127-152.

Odell-Miller, H., (2002) 'One Man's Journey and the Importance of Time'. In . Davies A, Richards, E (eds) Music Therapy and Group Work. London Jessica Kingsley.

Odell-Miller, H., (2003) 'Are Words Enough' In King, L & Randall, R. (eds). The Future of Psychoanalytic Psychotherapy London :Whurr.

Odell-Miller, H., Hughes, P, & Westacott, M (2006) 'An Investigation
into the Effectiveness of the Arts Therapies for Adults with continuing
Mental Health Problems. 'Psychotherapy Research' 16 (1): 122-139
Parry et al. (2000). Treatment Choice in Psychological Therapies and Counselling. (2001). London: Department of Health Publication. Ref No. 23454

Roth, A. & Fonagy, P. (1996) What Works for Whom?: A Critical Review of Psychotherapy Research New York: Guilford,

Pavlicevic, M., Trevarthen, C; Duncan, J (1994) Improvisational Music Therapy and the Rehabilitation of Persons Suffering from Chronic Schizophrenia.
Journal of Music Therapy XXX1 (2) 86-105

Proctor, S. (1997) Predictability within the therapist's musical input: its significance for clinical process in music therapy with adults with mental health problems. Unpublished MA Thesis. (Nordoff- Robbins Library)

Wheeler, B. (1983) A psycho-therapeutic classification of music therapy practice: A continuum of procedures. Music Therapy Perspectives 1(2), 8-12.

Wheeler, B. (1987) Levels of Therapy : The classification of Music Therapy goals. Music Therapy 6 (2) 39-49

Unkefer, R.,(1990) Music Therapy in the Treatment of Adults with Mental Disorders. New York & Toronto: Schirmer Books