are outlined below:
• Introduction to Songwriting
o Improvising incorporating story creation or client’s life story o The therapist proposes idea in discussion
• Formulation of Lyrics
o Brainstorming themes (client and therapist)
o Words are spontaneously suggested (client or therapist)
o Words related to client issues are suggested (client or therapist) o Client brings precomposed lyrics
• Development of Music
o Improvised (client and therapist)
o Improvised melody over structured harmonic frame (client and/or therapist) o Clients create melody and harmony
o Therapist offers ideas in short fragments or chords of melody and harmony, accepted or rejected by client
• Writing Down a Song o Lyrics only o Lyrics and melody
o Lyrics, melody, and basic guitar/piano chordal harmonic structure •
Performing a Song
o The song is performed by client and therapist together o The song is performed to staff and other clients
o The song is performed to family and friends • Recording of Song
o The song is recorded by client and therapist
Throughout the experience, the therapist needs to be mindful of the client’s word choices, including where they place themselves within the song. Additionally, the therapist may need to shape the client’s words into a verse. While doing so, they need to make sure they capture what the client communicates, not what they think the client is communicating. This can be done verbally with such statements as: “What I hear you saying is this …?” “Do the words capture what you were communicating, or does something need to be changed?” “Would you like this to go like this or should we change the order of this?”
Adaptations.
Story songs are a specific type of songwriting. A story song is an imaginative story created by a client with the support of the music therapist, through music that depicts the client’s situation or understanding of his or her situation. This may be done vocally, instrumentally, or as a combination of vocals and instruments. The musical structure of a story song is similar to that of a story and includes the following elements: recitative, theme, conflict, variations, and resolutions (Rubin-Bosco, 2007). The creation of story songs can take several sessions, so it is best to use this technique with chronic pain patients being seen in an outpatient setting. Story songs are a great way to support clients in their process of accessing, exploring, and expressing their experience of pain and can easily be adapted for group situations.R
ESEARCHE
VIDENCEResearch on music therapy and pain indicates that music therapy techniques are effective for a variety of procedural, acute, and chronic conditions. Furthermore, music therapy is more effective than music medicine interventions and, when used in combination with analgesics, has been found to reduce the dependency on pain medication (Dileo & Bradt, 2005). The following is a review of literature on music therapy in the management of adult pain, separated by music therapy methods employed.
Receptive Music Therapy
The earliest studies on the effectiveness of music therapy for pain management involve receptive music therapy methods. Bright (1972) suggested using music for relaxation purposes before attempting physical therapy in older adults. Masler (1986), in a review of the literature on music therapy and pain, reported that music could be used to teach pain management techniques to promote awareness of the body and in turn reduce pain. Cook (1986) researched the benefits of music therapy with inpatient cancer patients. She found that listening to classical music was effective in decreasing analgesic intake with cancer patients as well as addressing insomnia. Beck (1991), in a study investigating the therapeutic effects of music therapy, found that cancer patients who listened to music twice per day reported a significant decrease in their need for pain medication. Robb, Nichols, Rutan, Bishop, and Parker (1995), in an investigation on music assisted relaxation, found the following characteristics of music were most desirable for relaxation purposes: slow to moderate tempo at or below the resting heart rate (60–72 bpm); rhythm should be smooth, flowing, and without sudden changes; melodies should be slow, sustained, and progress by step; pitch should be low, as high pitches tend to elicit tension; dynamics should be soft to moderately loud. Lastly, Magill (2001) stated that music therapy techniques for pain management provide resources that can soothe and relax, promote comfort and inner peace, enhance communication and enhance the development of improved coping skills.
Madson and Silverman (2010) investigated the effects of live, patient preferred music on relaxation, anxiety, pain perception, and nausea in adult solid organ transplant patients. Results indicated significant improvement in self-reported measures of relaxation, anxiety, pain and nausea. Furthermore, the researchers reported increased positive verbalization and increased positive affect. In a similar study, Chaput-McGovern and Silverman (2012) investigated the effects of live, patient preferred music on measures of relaxation, anxiety, and pain in post-operative oncology patients. Results indicated live music listening significantly decreased pain perception and anxiety levels while increases measures of relaxation.
A few studies have investigated the use of song communication in the management of pain. Colwell (1997) reported on the use of song choice with a chronic pain patient. She concluded that song choice aided in distracting the patient, increased relaxation, and decreased use of narcotics for pain management. Krout (2001) investigated the effects of single session music therapy sessions to address the needs of hospice patients. Results indicated that song choice was a type of music intervention useful to decrease pain perception and increase physical comfort in hospice patients. Lastly, Ghetti (2011) investigated the effects of music therapy with transplant patients. She reported that active engagement through song choice significantly decreased pain perception and negative affect of liver and kidney transplant patients.
Several studies have investigated the effectiveness of music and imagery techniques for pain management. Bonny (1986) stated that music enhances the flow of images and that kinesthetic, visual, or emotional images can be used in treating various diseases. Imagery nurtures creativity and is a means through which feelings, ideas, associations, and perceptions of pain can be realized, identified, and processed (Magill-Levreault, 1993). The use of live, improvised music facilitates the imagery process as the music is generally created with the mood, tempo, and timbre that meet the patient’s needs. Imagery used in conjunction with carefully selected music can reduce pain and effect muscle relaxation; it can also be used to explore inner feelings, memories, and life issues (Bonny, 1986; Rider, 1985). Jacobi (1995) investigated the effects of BMGIM with rheumatoid arthritis sufferers. Individuals received ten BMGIM sessions which resulted in significantly decreased pain perception and psychological distress. Allen (2001) found that music-assisted relaxation significantly decreased pain and anxiety in postoperative older adults in a rehabilitation setting. Allen (2008) explored the use of music and imagery for addressing advanced cancer pain in hospitalized cancer survivors. She found that music-evoked imagery decreased pain perception as well as addressed the emotional and spiritual components of the pain experience.
There is limited literature addressing entrainment for pain management. Rider (1985) found that entrainment was more effective than preferred music in producing desired physiological changes. Dileo & Bradt (1999), in an overview of entrainment and pain related suffering, reported that entrainment allows for patient confrontation with the pain along with increased awareness that there are sounds that heal. Furthermore, they reported that the patient’s externalization of the pain and the therapist’s resonance with the patient’s pain experience provide necessary healing components. Lastly, Dimaio (2010) explored entrainment and the creation of healing music with hospice patients. She reported that entrainment can address a client’s pain, include the client in the process, offer dignity by emphasizing the client’s experience of pain, and offer hope in decreasing that perception of pain.
Improvisational Music Therapy
A very limited number of studies were found in relation to improvisational methods for pain management in the adult medical patient. Krout (2001), in an examination of single-session music therapy with hospice patients, reported improvisation as one method used in decreased pain perception. Accordingly, improvisation may be effective for enhancing physical comfort and relaxation in hospice patients. Magill (2011) investigated bereaved caregivers reflections on the role of music therapy. Results indicated vocal
and instrumental improvisational techniques were beneficial in exploring feelings and issues that frequently compounded the pain experience.
Re-creative Music Therapy
A few studies have examined the benefits of therapeutic singing on the pain experience. Krout (2001), in an investigation of the effectiveness of single music therapy sessions, found singing beneficial in decreasing pain and increasing physical comfort in hospice patients. Kenny and Faunce (2004) investigated the effects of group singing on mood, coping, and perceived pain in chronic pain patients. Results indicated that group singing increased active coping skills and decreased pain perception. Lichtensztejn (2009) investigated the clinical use of piano with patients experiencing pain related breathing distress. She reported that actively engaging in singing decreases pain, as it encourages patients to regulate their breathing while letting go of their pain. Lastly, Skingley and Vella-Burrows (2010) investigated the therapeutic effects of singing for older adults. Results indicated that singing was an effective tool for decreasing pain perception of osteoarthritis patients in a nursing home setting.
Compositional Music Therapy
Songwriting may be an effective tool in addressing a patient’s pain experience, however there is limited research investigating its effectiveness. Krout (2001), while investigating the effects of single music therapy sessions, found songwriting effective in decreasing pain and increasing the comfort of hospice patients. Magill (2001), in research on the benefits of music therapy with advanced cancer pain, mentioned songwriting as a valuable technique to explore to address the total pain experience. Lastly, Curtis (2011), in an investigation on the effects of university community project, reported that songwriting was one method used to decrease pain, facilitate relaxation, and increase quality of life in palliative care patients.
S
UMMARY ANDC
ONCLUSIONSPain can be an overwhelming experience that impacts physical, psychological, interpersonal, and spiritual well-being. Pain and music share several characteristics. Both are multifaceted phenomena that manifest and affect people in different ways. Furthermore, pain and elements within music can be described with similar adjectives: tightening, tension and release, resonating, evocative, etc. Music therapy can offer patients a nonthreatening, physically noninvasive treatment with the potential for accessing inner resources while generating desired outcomes. It can be an effective therapy, giving patients an active role in their treatment and a form of symbolic expression. This allows patients to safely explore and experience a unique way of healing.
Research on music therapy and pain overwhelmingly favors music listening interventions as well as interventions to address acute pain conditions. As we are facing a health care crisis in regard to chronic pain, music therapy research needs to investigate the effectiveness of various music therapy methods in addressing the physical, social, emotional, and spiritual needs of chronic pain patients. This includes various methods of music therapy in addressing the chronic pain experience.
R
EFERENCESAllen, J. (2001). The effects of music therapy, preferred music listening, and standard treatment on perceived pain and anxiety of post-operative older adults in a rehabilitation setting. Unpublished manuscript.
Allen, J. (2008). Music-evoked imagery in the treatment of oncological pain. Unpublished manuscript. Ambler, N., Williams, A., Hill, P., Gunary, R., & Cratchely, G. (2001). Sexual difficulties of chronic pain
patients. Clinical Journal of Pain, 17(2), 138–142.
American Academy of Pain Medicine (n.d.). Facts and figures on pain. Glenview, IL: American Academy of Pain Medicine. Retrieved from: http://www.painmed.org/patientcenter/facts_on_pain.aspx American Pain Foundation (2012). Pain facts & figures. Retrieved from:
http://www.painfoundation.org/media/resources/pain-facts-figures.html. Accessed August, 2012.
American Pain Society. (2006). Pain Control in the Primary Care Setting. Glenview, IL: American Pain Society
American Society of Anesthesiologists, Task Force on Pain Management, Chronic Pain Section. (1997). Practice guidelines for chronic pain management. Anesthesiology, 86(4), 995–1004.
American Society of Anesthesiologist. (1997). Practice guidelines for chronic pain management.
Anesthesiology, 86(4), 995-1004.
Apfelbaum, J., Chen, C., Mehta, S., & Gan, T. (2003). Postoperative pain experience: Results from a national survey suggesting postoperative pain continues to be undermanaged. Anesthesia &
Analgesia, 97, 534–540.
Bailey, L. (1986). Music therapy in pain management. Journal of Pain and Symptom Management, 1(1), 25–28.
Bair, M., Kroenke, K., Sutherland, J., McCoy, K., Harris, G., & McHorney, C. (2007). Effects of depression and pain severity on satisfaction in medical outpatients: analysis of the Medical Outcomes Study. Journal of Rehabilitative Research Development, 44(2), 143–152.
Baliki, M., Geha, P., Apkarian, A., & Chialvo, D. (2008). Beyond feeling: Chronic pain hurts the brain, disrupting the default-mode network dynamics. Journal of Neuroscience, 28(6), 1398–1403. Beck, S. (1991). The therapeutic use of music for cancer-related pain. Oncology Nurse Forum, 18, 1327–
1337.
Berry, P., & Dahl, J. (1998). Barriers to adequate pain management: An Ishikawa (Fishbone) diagram. University of Wisconsin–Madison: Institutionalizing Pain Management Project
Bonny, H. (1986). Music and healing. Music Therapy, 6, 3–12.
Bouhassira, D., Lanteri-Minet, M., Attal, N., Laurent, B., & Touboul, C. (2008). Prevalence of chronic pain with neuropathic characteristics in the general population. Pain, 136(3), 380–387.
Breivik, H., Collett, B., Ventafridda, V., Cohen, R., & Gallacher, D. (2006). Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. European Journal of Pain, 10(4), 287– 333.
Bright, R. (1972). Music in geriatric care. Sydney: Agnus & Robertson. Brokoff, D. (2001). Chronic pain: A new disease. Hospital Practice , 35(7), 45.
Bruehl, S., Chung, O., Jirjis, J., & Biridepalli, S. (2005). Prevalence of clinical hypertension in patients with chronic pain compared to nonpain general medical patients. Clinical Journal of Pain, 21(2), 147–153
Bruscia, K. (2000). A manual for level one training in guided imagery and music. Unpublished.
Carr, D.B., Jacox, A.K., Chapman, C.R., Ferrell, B., Fields, H.L., Heidrich, G (III)., Hester, N.K., Hills, C.S. Jr., Lipman, A.G., McGarvey, C.L., Miaskowski, C.A., Mulder, D.S., Payne, R., Schechter, N., Shapiro, B.S., Smith, R.S., Tsou, C.V. & Vecchiarelli, L. (1992) Acute pain management: Operative or medical procedures and trauma. Clinical practice guideline. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, AHCPR Pub. No. 92-0032
Chapman, C. & Syrjala, K. (2001). Measurement of pain. In J. Loese, S. Butler, C. Chapman, & D. Turk (eds), Bonica’s management of pain, 3rd edition. (pp. 310-328). Baltimore, MD: Williams & Wilkins.
Chaput-McGovern, J., & Silverman, M. (2012). Effects of music therapy with patients on post-surgical unit: A pilot study determining maintenance of immediate gains. The Arts in Psychotherapy,
39(5), 417–422.
Colwell, C. (1997). Music as distraction and relaxation to reduce chronic pain and narcotic ingestion: A case study. Music Therapy Perspectives, 15(1), 24–31.
Commission on Accreditation of Rehabilitation Facilities. (1998). Standards manual for and interpretive
guidelines for medical rehabilitation. Tucson, AZ: Commission on Accreditation of Rehabilitation
Facilities.
Commission on Accreditation of Rehabilitation Facilities. (1999). Standards manual for and interpretive
guidelines for medical rehabilitation. Tucson, AZ: Commission on Accreditation of Rehabilitation
Facilities.
Committee on Advancing Pain Research, Care, and Education. (2011). Relieving pain in America: A
blueprint for transforming prevention, care, education, and research. Washington, DC: Institute
of Medicine of the National Academies.
Cook, J. (1986). Music as an intervention in the oncology setting. Cancer Nursing, 9, 23–28.
Curtis, S. (2011). Music therapy and the symphony: A university community project in palliative care.
Music & Medicine, 3(1), 20–26.
Dahl J.& Gordon D. (2002). The Joint Commission standards: A progress report. American Pain Society
Bulletin, 12(1), 11–12.
Dick, B., & Rashiq, S. (2007). Disruption of attention and working memory traces in individuals with chronic pain. Anesthesia and Analgesia, 104(5), 1223–1229.
Dileo, C., & Bradt, J. (1999). Entrainment, resonance, and pain-related suffering. In C. Dileo (Ed.), Music
therapy and medicine: Theoretical and clinical applications (pp. 181–188). Silver Spring, MD:
American Music Therapy Association.
Dileo, C., & Bradt, J. (2005). Medical music therapy: A meta-analysis and agenda for future research. Cherry Hill, NJ: Jeffery Books.
DiMaio, L. (2010). Music therapy entrainment: A humanistic music therapist’s perspective of using music therapy entrainment with hospice patients experiencing pain. Music Therapy Perspectives,
28(2), 106-115.
Finley, G., & Schechter, N. (2003). Sedation. In N. Schechter, C. Berde, & M. Yaster (Eds.), Pain in
infants, children, and adolescents, (2nd ed.) (pp. 563–577) Philadelphia, PA: Lippincott Williams
& Wilkins.
Fenwick, C., Chaboyer, W., & St. John, W. (2012). Decision-making processes for the self-management of persistent pain: A grounded theory study. Contemporary Nurse, 42(1), 53–66.
Fine, P. (2011). Long-term consequences of chronic pain: Mounting evidence for pain as a neurological disease and parallels with other chronic disease states. Pain Medicine, 12, 996–1004.
Flor, H., Fyrich, T., & Turk, D. (1992). Efficacy of multidimensional pain treatment centers: A meta- analytic review. Pain, 49, 221–230.
Fox, C., Berger, D., Fine, P., Gebhart, G., Grabois, M., Kulich, R., Lande, S., McCarberg, B., & Portenay, R. (2000). Pain assessment and treatment in the managed care environment. A position statement from the American Pain Society. Glenview, IL: American Pain Society. Retrieved from:
http://www.painanddisability.com/pain/pain_assessment.html
Galer, B., & Dworkin, R. (2000) A clinical guide to neuropathic pain. Minneapolis, MN: The McGraw-Hill Companies, Inc.
Gardstrom, S. (2007). Music therapy improvisation for groups: Essential leadership competencies. Gilsum, NH: Barcelona Publishers.
Ghetti, C. (2011). Active music engagement with emotional-approach coping to improve well-being in liver and kidney transplant patients. Journal of Music Therapy, 48(4), 463–485.
Grachev, I., Fredrickson, B., & Apkarian, A. (2000). Abnormal brain chemistry in chronic back pain: An in vivo proton magnetic resonance spectroscopy study. Pain, 89(1), 7–18.
Grocke, D. & Wigram, T. (2007). Receptive methods in music therapy: Techniques and clinical
applications for music therapy clinicians, educators, and students. Philadelphia, PA: Jessica
Kingsley.
Gureje, O., Von Korff, M., Simon, G., & Gater, R. (1998). Persistent pain and well being: A World Health Organization study in primary care. Journal of the American Medical Association, 280(2), 147– 151.
Hutchinson, R. (2007). Challenges in acute postoperative pain management. American Journal of Health
System Pharmacy, 64(6 Suppl), S2–S5.
International Association for the Study of Pain, Task Force on Guidelines for Desirable Characteristics for Pain Treatment Facilities. (2009). Desirable characteristics for pain treatment facilities. Glenview, IL. International Association for the Study of Pain. Retrieved from: http://www.iasp- pain.org/AM/Template.cfm?Section=General_Resource_Links&Template=/CM/HTMLDisplay.c fm&ContentID=3011
International Association for the Study of Pain Subcommittee on Taxonomy. (1986). Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association of Pain, Subcommittee on Taxonomy. Pain Supplement, 3, S1– S226.
International Association for the Study of Pain. (1979). The need for a taxonomy. Pain 6(3), 246-248. Jacobi, E. (1995). The efficacy of The Bonny Method of Guided Imagery and Music as experiential
treatment in the primary care of persons with rheumatoid arthritis. Dissertation Abstracts
International: Section B: The Sciences & Engineering, 56(2–B), 1110.
Jacox, A., Ferrell, B., Heidrich, G., Hester, N., and Miaskowski, C (1992). A guideline for the Nation: Managing acute pain. American Journal of Nursing 92(5), 49-55.
Kehlet, H., Jensen, T. S., & Woolf, C. J. (2006). Persistent postsurgical pain: Risk factors and prevention.
Lancet, 367(9522), 1618–1625.
Kenny, D., & Faunce, G. (2004). The impact of group singing on mood, coping, and perceived pain in chronic pain patients attending a multidisciplinary pain clinic. Journal of Music Therapy, 41(3), 241–258.
Krout, R. (2001). The effects of single-session music therapy interventions on the observed and self- reported levels of pain control, physical comfort, and relaxation of hospice patients. American
Journal of Hospice & Palliative Medicine, 18(6), 270–283.
Leadley, R., Armstrong, N., Lee, Y., Allen, A., & Kleijnen, J. (2012). Chronic diseases in the European Union: The prevalence and health cost implications of chronic pain. Journal of Pain & Palliative
Care Pharmacotherapy, 26(4), 310–325.
Lichtensztejn, M. (2009). The clinical use of piano with patients suffering from breathing distress related to pain. In R. Azoulay & J. Loewy (Eds.), Music, the breath and health: Advances in integrative
music therapy (pp. 213–222). New York: Satchnote Press.
Logan, H. (1998). Applied music-evoked imagery for the oncology patient: Results and case studies of a three month music therapy pilot program. Unpublished manuscript.
Loewy, J. (1999). The use of music psychotherapy in the treatment of pediatric pain. In C. Dileo (Ed.),
Music therapy and medicine: Theoretical and clinical applications, (pp. 189-206). Silver Spring,
McCaffery, M. & Beebe, A. (1989). Pain: Clinical manual for nursing practice. St. Louis, MO: C.V. Mosby.
McCaffery, M., & Pasero, C. (1999). Assessment: Underlying complexities, misconceptions, and practical tools. In M. McCaffery & C. Pasero (Eds.), Pain: Clinical Manual 2 (pp. 35–102). St. Louis, MO: Mosby.
McCarberg, B., Nicholson, B., Todd, K., Palmer, T., & Penles, L. (2008). The impact of pain on quality of life and the unmet needs of pain management: Results from pain suffers and physicians
participating in an internet survey. American Journal of Therapeutics, 15(4), 312–320. McCracken, L., & Iverson, G. (2002). Disrupted sleep patterns and daily functioning in patients with