The challenges and opportunities related to the therapeutic use of music in psychiatry

KEYWORDS:

• Music
• psychiatry
• eating disorders
• obsessive-compulsive disorder
• autism
• social anxiety disorder

1. Music and music therapy in psychiatry

Even though our knowledge about the use of music and music therapy (MT) in psychiatry is increasing, the quality of most published studies is low, and current research often focuses exclusively on the benefits but neglects the potential negative side effects of MT. In this editorial, we explain how to avoid and manage negative side effects of MT in clinical practice and how the scope and the quality of research around the therapeutic use of music in psychiatry can be improved.

‘Music’ is one of the most difficult terms to define because it is a culturally specific and subjectively perceived phenomenon. The Collins Dictionary offers several definitions, for example, as ‘the pattern of sounds produced by people singing or playing instruments.’ However, such a definition would not cover the aspect of listening, the production of rhythms by using everyday items, psychological phenomena like earworms which are repetitive musical thoughts, or cultural phenomena like rap which is the recital of words in a rhythmical manner.

According to the American Music Therapy Association (AMTA), MT is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved MT program. Systematic reviews have reported that MT in addition to treatment as usual alleviates psychiatric symptoms in people with autism spectrum disorder [1], schizophrenia and schizophrenia-like disorders [2], depressive disorders [3], anxiety disorders [4], obsessive-compulsive disorder (OCD) [5], eating disorders [6], sleep disorders [7], substance use disorder [8], dementia [9], and personality disorders [10]. Clinical cases detail and illustrate how music is a useful tool to support coping with aspects of mental health disorders [11,12].

The systematic reviews, however, point out that the evidence for clinical improvement during MT for the above-mentioned psychiatric disorders is moderate, low, or unclear, and that well-designed randomized controlled trials (RCTs) with larger sample size and higher quality standards are needed to confirm the efficiency of adjunct MT for these psychiatric disorders [1–10]. They also indicate that the music intervention is often inadequately and insufficiently described in scientific articles [5,10], and that the authors often do not adhere to reporting guidelines for music-based interventions [13]. Another important finding is that the effects of MT were depended on the number of MT sessions and the quality of the MT provided [2].

According to the World Health Organization (WHO), quality of care is based on the effectiveness of an intervention as well as the evidence-based professional knowledge of the health care professional. Music therapists have a specialized training to facilitate MT in physical and mental health disorders across various settings and bring specific skills and experience which they have acquired through specialized academic and clinical training. However, in clinical practice, music is often used with therapeutic intent by mental health professionals who do not have a specific training as music therapist. Additionally, patients use music as a means of self-help, for example, to distract themselves, to cope with loneliness, for enjoyment, and for mood regulation [14–16].

2. The benefits of music and MT across psychiatric diagnoses

In psychiatric settings, MT can improve self-esteem, social engagement, decrease social isolation, help with anxieties, uplift mood state, contribute to developing a healthy identity that is not related to the mental illness, serve as a means of motivation, and can augment psychopharmacological therapy [15]. Listening to music can be effective for inducing a joyous state or a state of relaxation [16]. However, music perception and the optimal music for MT varies between individuals based on cultural, social, and gender identities and treatment goals [16,17]. Nonetheless, music that is unfamiliar and novel to a client might be mindfully used during MT to explore new sounds, rhythms, and thereby convey emotions.

3. Potential negative effects of music and MT

The way music is perceived or specific music preferences can be symptoms of a psychiatric disorder, for example, musical acoustic hallucinations, earworms, and a desire for exceptionally harmonic music in people with OCD [5].

Music can also have harmful effects as it has been found to potentially elicit negative emotions and traumatic memories [14]. The way music is presented might trigger illness-related and unpleasant thoughts, for example, when people with anorexia nervosa watch music videos that show slim dancers, or the content of the songs is derogative toward the female body [6]. The powerful nature of music has fostered exploration into understanding how music is used in ways that are healthy and unhealthy. Saarikallo et al. developed an assessment for clinicians, the Healthy-Unhealthy Uses of Music Scale that reflects aspects of musical engagement and whether they have a positive or negative impact on depression as it relates to mood, emotions, coping, interpersonal relationships, self-esteem, and identity [18]. This tool helps clinicians understand how a patient is engaging with music and if they are doing so in ways that are helpful and/or harmful. Examples of items that cover harmful uses of music in this questionnaire are as follows: I hide in my music because nobody understands me and it blocks people out; I like to listen to songs over and over even though it makes me feel worse; music gives me an excuse not to face up to the real world; music leads me to do things I shouldn’t do [18].

Patients might have experienced acoustic trauma. For example, discotheque music, rock concerts, and loud music from personal music players can lead to transient or permanent hearing loss, particularly in teenagers and young adults [19]. Clients who are musicians have an increased risk for performance-related musculoskeletal disorders, performance-related pain, motor control deficits, and focal dystonia [20–22].

In addition to music and music performance, its application of music during MT may produce negative or undesirable responses even though this has not been widely addressed in the literature. It has been suggested that such potential side effects of MT may arise from the components present in MT sessions (i.e. the client, the music, the music therapist, and session context) and the dynamics connecting these components [17]. Table 1 lists the potential negative side effects of MT arising from factors related to the music stimulus, the music therapist, the application of music, the therapeutic relationship, the client’s associations with music and ecological factors. For further information on potential and reported side effects of MT see [17].

Table 1. Potential negative side effects of MT arising from factors related to the music stimulus, the music therapist, the application of music, the therapeutic relationship, the client’s associations with music and ecological factors. Some of the presented information is based on [17].

	Factors	Potential negative side effects
Music stimulus	– Overwhelming vibrations, sensations, or perceptions – Overstimulating music – Overly complex music – Under-stimulation	– Distress – Musicogenic seizures – Boredom
Music therapist	– Inadequate clinical training – Practicing outside one’s scope of practice – Difficult personality traits – Improper motivations – Poor decision-making or responsiveness – Poor self-awareness – Avoidance of feedback or supervision	– Impaired psychological safety in the therapeutic space – Regression – Resistance
Application of music	– Nonadherence to treatment protocols – Poor planning – Nonresponse to a client’s negative reactions	– Distress – Impaired communication abilities
Therapeutic relationship	– Unresolved transference or countertransference – Verbal, emotional, financial, or sexual abuse – Accepting gifts – Becoming friends with a client	– Hazardous psychodynamic – Impaired therapeutic progress – Psychological trauma – Worsening of the mental health condition
Client’s associations with music	– Historic associations – Emotional associations – Knowledge about the music	– Triggering of traumatic memories – Negative emotions – Negative memories – Relapse into substance abuse – Memory of acoustic trauma
Ecological factors	– Space where the MT takes place – Cultural background and identity – Ideologies and attitudes – Violation of a taboo in the client’s culture – Incognizance of culture-related pathophysiological factors	– Non-attendance – Feeling of ostracism – Psychological harm – Reinforcement of harmful ideologies

4. How to avoid and manage side effects of music and MT

As people with mental health problems might spend many hours per day listening to music [14], and music can have negative effects, every clinician should ask their patients about their history with music and their uses of music.

Even though other health care professions might facilitate circumscribed, specific, and limited music interventions, the consistent use of music-based interventions should be the responsibility of a fully trained, qualified, and credentialed music therapist.

Probably everyone has some difficult memories or experiences around music: A song that one cannot stand, that is boring or annoying, contains triggering lyrics, holds memories of ambitious parents who wanted their child to learn to play an instrument, music that was played during someone’s wedding of a marriage that did not last, or a favorite song of a close family member who died. Understanding the music and songs that comprise the landscape of someone’s life is critical when planning a music listening experience. Since it may involve listening to music that is connected to a difficult emotion or a challenging moment in their life. Therefore, careful consideration and planning is needed to ensure the individual is ready therapeutically to address these emotions or issues. For the listening experience, clear signs of communication should be established between the patient and the therapist before music is applied.

5. Combining music with other treatment approaches

The accessible nature of music and its capacity to be integrated with other treatment modalities have fostered increased use in clinical settings and research related to its applications. In recent years psychedelic-assisted psychotherapy with psilocybin has been an emerging therapy with great promise for depression, drug and alcohol use disorder, post-traumatic stress disorder, and eating disorders [22]. Modern psychedelic therapy methods incorporate music as a key element because music is an effective emotional and hedonic stimulus that can be useful in amplifying changes in emotional responsiveness following psychedelic treatment [22].

6. Expert opinion

Benefits of the therapeutic use of music have been reported for people with specific mental health disorders [1–10]. Additionally, active (composing, improvising, singing, playing an instrument) or receptive (listening) experiences in MT might achieve overarching treatment goals across various diagnostic categories. Those overarching goals include an improvement of mood, self-confidence, body perception and motivation; conveyance of hope; the formation of an individual healthy identity or a therapeutic group identity; and the promotion of group cohesion and social interaction [15,16]. However, standardized, systematic, randomized, and controlled transdiagnostic research, particularly RCTs, are necessary to prove this. To promote the development of MT in mental health further, we would also like to advocate for an integrated biological understanding of human musicality which includes tonality, rhythm, reward, and sociality [23].

When publishing studies on MT, guidelines how to report the interventions [13] should be followed. As music plays a significant role for most people, including those with mental health disorders, clinicians should ask patients about their use of music. Further, we recommend the use of the Healthy-Unhealthy Uses of Music Scale [18].

Occasional studies and clinical case reports have shown that making or listening to music can have side effects in psychiatric settings [17]. Such potential adverse effects comprise the evocation of traumatic memories and negative emotions, such as anxiety or shame; the triggering, maintaining, or worsening of disease-related symptoms; irritation or boredom; and ostracism. A standardized, consistent, and systematic measurement, evaluation, and reporting of the side effects of MT for the care of psychiatric patients is currently lacking, but necessary to assess their relevance, severity, and long-term consequences. Table 2 summarizes the challenges and action points for the therapeutic use of music in psychiatry.

Table 2. Challenges and action points for the therapeutic use of music in psychiatry.

Challenges	Action points
– Changed perception of music (e.g. in autism, OCD) – Music symptoms part of the psychiatric disorder (musical hallucinations, earworms) – Clients may use music in unhealthy ways – Lack of RCTs with appropriate sample size – Side effects not systematically collected – Many publications of scientific studies are difficult to understand because the MT interventions are not adequately described	– Regular history taking of healthy and unhealthy use of music – Sufficiently powered RCTs testing MT for mental health disorders – Studies to understand the biological underpinnings of the therapeutic and the potential negative side effects of MT – Standardized systematic measurement of side effects of MT – Register of MT side effects

Overall, published research indicates that MT is overall beneficial for and effective in people with mental health problems. Slight improvements have already been reported after only a few therapy sessions, but longer courses or more frequent sessions have been shown to achieve more substantial benefits [2,24]. The presence of a dose – response relationship increases the confidence that the effect can be attributed to MT itself [24].

However, therapists need to be aware of its potential side effects. There is a scarcity of high-quality randomized controlled studies (RCTs), and potential negative side effects of music and MT are under-researched.

Declaration of interest

H Himmerich is the chief investigator for an NIHR HTA-funded feasibility study testing olanzapine in young patients with anorexia nervosa (AN) and the principal investigator of a COMPASS Pathways-funded and -sponsored proof-of-concept study testing psilocybin in AN. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

H Himmerich has received salary support from the National Institute for Health and Care Research (NIHR) Biomedical Research Centre (BRC) at the South London and Maudsley NHS Foundation Trust (SLaM) and King’s College London (KCL).