A Literature Review

Despite many idiosyncrasies in the needs of

different clinical populations, Creative Music
Therapy has been successfully applied across the
whole spectrum of client groups.

Lydia Leung;SID: 16930634
11/4/2010




This literature review aims to reiterate the fundamental basis and philosophies behind CMT, lending one
an insight into the unique qualities that enable CMT to work with the whole spectrum of client groups
despite many idiosyncrasies in the needs of different clinical populations. Overviews of the work and
research to meet the different goals and aims to improve the well-being of those different clients.
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CREATIVE MUSIC THERAPY
LITERATURE REVIEW

INTRODUCTION TO CREATIVE MUSIC THERAPY (CMT)
Creative music therapy was developed by Paul Nordoff and Clive Robbins as a form of improvisational
music therapy (Nordoff & Robbins, 1977). In 1984, they pioneered the use of music improvisation as a
means of communication with severely disabled children (Hadley, 1999). While they primarily worked
with children, CMT has evolved and extended to meet the needs of a wide range of clients, including
adults and the elderly. The concept and principles of CMT remains the same with all client groups
involved, and the fundamental premise of Creative Music Therapy rest with the belief that musical
response is an intrinsic human trait (Nordoff & Robbins, 1971). Nordoff and Robbins believed that every
person, regardless of their physical or emotional condition, can engage in musical interactions (1977).
They further demonstrated that the use of live improvised music enables the therapist and clients to
actively build a relationship, allowing clients to participate, interact and communicate through music as
a medium.
Music is intrinsic and understood to be inborn in every human being. This self-actualising potential can
be reached via the use of improvisational music, through which an individuals innate creativity is used
to overcome emotional, physical and cognitive barriers (Nordoff & Robbins, 1977). This co-creative
journey through the application of musical improvisation in therapy requires no precondition- the basic
assumption is that no previous formal knowledge of music is required in order to enter into the musical
process (Aldridge, 1989). There are no criteria of artistic expression, as these manifests only in the
immediate music moment (Nordoff & Robbins, 1987). Improvisation applied on a flexible basis permits
active music-making on a level that is adequate and appropriate for both patient and therapist (Aldridge,
1989). Therefore, one can conclude that this type of active music therapy is based on the natural
creative powers and abilities inherent in everybody.
This literature review aims to reiterate the fundamental basis and philosophies behind CMT, lending one
an insight into the unique qualities that enable CMT to work with the whole spectrum of client groups
despite many idiosyncrasies in the needs of different clinical populations, and overviews of the work and
research to meet the different goals and aims to improve the well-being of those different clients.
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PHILOSOPHY IN CMT
Every practice has a theoretical foundation, and creative music therapy is no exception. The question
had been raised whether music therapy can find an external theory that will encompass the field (Aigen,
1991; Ansdell, 1997). Garred (2001) challenged the idea that the integrated theory of music therapy
stems from a mixture of discourses from other fields. He further emphasised that there are unique
features in music therapy that require a foundational theory in order to facilitate a professional
discourse within the field and to establish dialog with other related fields.
What is unique in creative music therapy is the therapeutic use of the non-verbal medium of music
(Nordoff & Robbins, 1977). Garred (2001) questioned the grounds that justify CMT as therapy when
music takes on the central role as a point of departure, stating that one cannot come to a conclusive
answer by simply conducting some empirical research, quantitative or qualitative. The nature of music
itself is a fundamental philosophical issue and one must consider the ontological status of music in CMT
in relation to its role and function in therapy.
Ansdell (1995) makes a distinction between 'music in therapy' and 'therapy in music', phrases which are
reflected in the title of a book written by Nordoff and Robbins: Music in Therapy for Handicapped
Children (Nordoff & Robbins, 1985). Ansdell (1995) describes 'therapy in music' as therapy being a part
of the music, coming as a direct result of being engaged in musical activities, rather than music being a
part of a system of therapy. He then compares music in therapy, where music plays a subordinate role
or function. Bruscia (1987) has made a similar distinction between music in therapy and music as
therapy, the last one stressing the primary role of music as a therapeutic agent, for which he termed as
music as therapy.
CMT uses musical improvisation as a mean of communication with severely disabled children as
mentioned above (Hadley, 1999). Central to the form of communication and closely related to the
values of music is dialogue. Dialogical philosophy has many sides and is in itself a complex question of
the role and status of music in music therapy, stemming from Martin Buber's original formulation of a
dialogical outlook in the book I and Thou (Buber, 1970, first published in 1923). In his publication,
Buber proposed the idea of two fundamentally different way of relating to the world, terming them with
two pairs of words I-Thou and I-It. It refers to experiences and use - something one would talk about,
whereas thou (simplified to you henceforth) refers to living encounter with another being someone
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whom one is talking to. The difference between the two ways of relating may then be seen as the
difference between second and third person relations (Wood, 1999).
One can thus characterize that the I-You relation is immediate and direct relating. Buber held forth that
presence is what constitutes that immediacy. Contrasting you with It, which has no immediate
presence, one can see that the relationship between I-You is a mutual interaction and relationship of
recognizing, accepting and affirming each other. As Ansdell (2005) aptly summarizes, it is a reciprocal
relationship of mutual influence. One can thus apply this concept into music in therapy and music as
therapy. Music that is considered a mean becomes an It, belonging to the technical and practical
mode, subordinating into an expedient measure at hand to be applied on a regular basis for certain
predefined objectives or aims. In consequence, to use music as an It in therapy necessarily brings about
treating humans in an objectifying way. However, music that is considered a reciprocity in the entity of
I-You, both therapist and clients as well as music are interconnected, creating a dynamic relation,
further illustrating how one part can mediate the relation between the other two (Ansdell, 2005).
CMT can be seen as an approach that reflects this dialogical philosophy. Focusing on the interaction, the
relationship building, the music child (to be elaborated upon shortly), and music in the form of flexible
improvisations, one can see that there is no mechanical one-way connection between music and client,
administered by the therapist in CMT (Nordoff & Robbins, 1977).
The other main theoretical point of music-centred reference is to the writings of Victor Zuckerkandl.
Whereas many music therapists have been drawn to theoretical discussions of the energising and
organisational properties of pulse and rhythm, Zuckerkandls (1956) major contribution to music theory
is his elaboration of the dynamic qualities of tone and melody, and Aigen (1999) made the connections
with CMT. Aigen discovered that both Helen Bonny and Paul Nordoff drew inspiration from Zuckerkandl
and his emphasis that, the more one learns about music, the more one understands what it is to be
human and the relationship to others as well as the world around. Zuckerkandl believed in the notion of
homo musicus, where a relationship with music, in some way, is required for people to be fully human.
Serving as a powerful rationale for music therapy of any kind, but particularly for music-centred forms of
practice, CMT could be said to have derived the concept of music child from this basis. Because the
relationship to music is considered an essential aspect of an individuals humanity, no non-musical
rationale is required to explain the benefits of music therapy treatment (AIgen 1999)
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It can thus be said that CMT focuses on the workings of music and interrelationships between client,
therapist and music that allows it to be successfully applied across the whole spectrum of client groups.

CMT AND LEARNING IMPAIRMENTS
Nordoff and Robbins (1977) developed the concept of Music Child, the term which denotes an
organisation of receptive, cognitive and expressive potential that triggers self awareness and stimulates
the child to participate in order to reach those capabilities (Thompson, 1991). Applicable to the needs of
the learning impaired, intellectually or emotionally disabled clients, their conditions are isolated and the
therapist seeks to draw out the expressive freedom and intelligence that lays dormant beneath the
illness (Nordoff & Robbins, 1977). For these clients, personality development and social integration is
essential, and to aid in bypassing the learning disorders, the music child becomes an important unit of
sensory and perceptual functioning (Nordoff & Robbins, 1985). To foster this creative entity known as
music child, elements of melody and rhythm in improvised live music is important in addressing
attentional, sequential and memory dysfunction (Thompson, 1991). By gradually exposing the music
child to further complex musical structures, self confidence can also be nurtured and a healthy self
image promoted (Thompson, 1991).
Aldridge (1989) also emphasized the importance of rhythmic interaction for the development of
language and socialization in child development. From birth, an infant is physiologically entrained within
the rhythmic structure provided by the parent (Standley & Walworth, 2010). Through the modification
of both the infant and parents own behaviours to fit each others structure, arousal and affection as
well as attention are shared within the rhythm of a relationship (Standley & Walworth, 2010). In much
the same case, Vandenberg (1991) alludes to this relationship as an elaboration from the primitive form
of attunement. It can thus be seen that the structural environment affects the development of learning
skills greatly. CMT provides this flexible and sensitive environment that can be modified to meet the
needs of the clients to enhance communicational possibilities according to each individuals potential.
Thompson (1981) worked with a child with developmental delay, as well as an array of difficulties with
vestibular function, visual perception and personal self esteem. He determined that the goals for David
were to maximise attention span, memory and promote self image. Through the use of improvisational
live music in the form of Creative Music Therapy, Thompson matched Davids creative playing on a range
of instruments. Initially, Davids playing was passive or reactive, but he later developed the active
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initiative to suggest changes to the musical interaction. A full multidisciplinary assessment of David later
revealed neuro-developmental deficiencies were the causes of his learning impairments. Despite this,
Thompson concluded that by providing an accepting and adaptable environment in therapy, music not
only aided David by lessening anxiety, but it also had the potential to amplify and accelerate the
progress of therapy in other disciplines. He further stated that creative music therapy is not only an
attribute of optimum health, but also a way to develop personal potential.
This study reiterates CMTs concept of music child- to communicate with the innate musicality that is
within each individual and providing a safe and flexible environment to meet that child. In the field of
Learning Disabilities, helping clients find confidence and cognitive strengths to compensate for
weaknesses and barriers of illnesses which allows for the discovery of a creative self.

CMT AND COMMUNICATION/ SOCIAL ISSUES
The fundamental basis of music child and the underlying therapeutic significance of musical
improvisation in the approach of CMT lie in communication. Ruud (1990) considers musical
improvisation as a kind of 'proto-communication', providing a general background for communication
and interaction. From an aesthetic perspective, musical communication is an important way to define,
differentiate, investigate and point towards nuances in inner life (Rudd 1990). Sawyer (1996), a jazz
musician, describes live improvisation as a kind of conversation, where by listening to others, one can
hold a conversation and express emotions triggered consciously or subconsciously by the music.
Aldridge (1996) states that the underlying foundations of communication comprise of pace, phrasing,
rhythm pitch, intonation and sound of speech. He draws the connection that these qualities are
essentially musical in nature and emphasises their importance in therapy. It is through improvisation
that CMT uses these qualities to form the framework for structure and assessments of sessions (Aldridge,
1996). As CMT involves the development of musical skills and expressive freedom, both recreative and
improvisational techniques are used (Aldridge, 1995).
This illustrates the highly communicative character of improvised music experienced on an emotional
level. It is this experience of the immediacy and spontaneity through creative improvisation that may
have a more fundamental and liberating effect than a spoken message, where lexical content form of
which may be limiting. Studies such as that of Edgerton (1994) provide evidence of the effectiveness of
CMT approach on the communication behaviour of children with autism, revealing that improvisational
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music used in therapy sessions significantly and constantly increased the communication behaviours of
each child over a period of ten sessions.
CMT is, however, not only effective in improving communication skills for clients with autism alone- it
can also helps clients with emotional issues and depression gives creative expression of their
experiences and feelings. They are encouraged to express not only their pathologies but also their
potentials in their individual life processes (Aldridge & Aldridge, 2008). Experiencing both expressions
supports recovery. CMT allows patients with depression to express their symptoms and the emotions
and condition involved, thus gaining immediate access to their internal mental processes. This form of
creative music therapy does not focus on a person's deficits but rather on the development of individual
inclinations and potential, providing an opportunity to experience one's own self on a new level in the
moment of musical creation (Aldridge & Aldridge, 2008). The way in which a client forms his identity in
creative music making will indicate how he intends to cope (Aldridge, 1996).
It has thus been known that music affects portions of the brain and therapy is used to manage emotions,
social interactions of individuals. Therapeutically CMT has been known to be effective in patients with
various psychiatric illnesses such as schizophrenia and depression (Boso et al., 2006). Research by Nayak
et al. (2000) has shown that music therapy is empirically associated with a decrease in the latter,
improving the mood of clients and reducing the state of anxiety. Nayak et al.'s studies show improved
social interaction where clients are more actively involved and cooperative in music therapy during
stroke recovery programs. Magee & Davidson (2000) further studied the positive involvement of clients
with the environment, raising awareness and responsiveness and improvement in social skills.

CMT AND MOTOR/ COGNITIVE DISABILITIES:
Following in close relation to communication is that of motor coordination and motor responses. This is
a vital development that enables communication and involves many integrated skills. The improvement
of motor skills and development of fine motor reflexes relates not only to the development of children,
but is applicable in rehabilitation wards, aged care and a wide range of clients. Wigram (1995) states
that non-verbal communication such as the playing of musical instruments against improvised music as
a background, demands manipulative and perceptual skills, which, in turns, improves hand-eye co-
ordination.

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Through many of the play songs and movement songs composed and used in the CMT approach,
gestural activities are utilised and this aids in the use of purposive co-ordinated movements (Nordoff &
Robbins, undated). These specially composed songs offers a form of communication without words and
enhances active listening and performing. Von Hofsten (1993) understands the co-ordinating of action
as a purposive dynamic future-oriented interaction between the individual and the external world. He
explains that actions spontaneously produced and controlled movements require a structured medium
which encourages those movements to follow a time structure that is both stimulating and flexible.
Research by Schauer & Mauritz (2003) has shown the use of music in the recovery of motor skills,
walking and an increased success rate in victims of stroke (Kim, 2005; Schauer & Mauritz, 2003). Schauer
& Mauritz purported that walking in humans involves the continuous communication between three
processes; motor, cognitive and perceptive. They hypothesized that rhythm and percussion of auditory
cues may aid and influence the movements of an individual. As stroke patients are often left with
abnormal gait function that can be characterized by features such as asymmetry in stance and swing
time, a decreased stride length, slowed gait velocity, and poor joint control (Schauer and Mauritz, 2003),
recovery can be enhanced with the use of extensive motor training. They further showed that gait
training using an auditory feedback of the patients own steps with a musical accompaniment produced
greater improvements than those in the conventional gait therapy control group. Significant
improvements were seen in the intervention group and the researchers concluded that all three
processes (motor, cognitive and perceptive) were in some way influenced by the musical stimulus,
producing an overall improvement in walking. Kravitz (1994) suggested that the beat in music may
improve gait regularity by allowing individuals to find a desired rate of movement.
It can be seen that movement plays a huge part in non-verbal communication and co-ordinations
dependent on wider body awareness and that through the use of improvisational or pre-composed
music that is flexible in rhythm and provides auditory stimulation, improvements can be made. Studies
have shown that such active interplay of music therapy is effectively performed on a wide spectrum of
clients, ranging from children with developmental delay and autism, to adults and stroke victims.

CMT AND SELF IDENTITY
As previously stated, gestures and movement allows for non-verbal communication and the expression
of the self. Langer (1992) considers music as a presentational, non-discursive symbol and musical
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improvisation as an essential means of expression in therapy. Aldridge (1996) describes the perception
of improvised music as a nonverbal, qualitative, holistic awareness that is emergent with the
phenomenon of music that is being performed that very instant. He further states that active
improvisation allows the involvement of clients in a large variety of cultural values and standards.
Against this background, musical improvisation with its flexible, variable character provides a good
opportunity to react to and address the differing cultural backgrounds of clients (Aldridge 1996).
Improvisational music in CMT also has the element of the unknown, not predetermined and located in
the future, which plays an important part in the therapy concept (Pavlicevic, 1997). In the sphere of arts,
this unknown aspect is also a characteristic feature in the creative process and may gain significance in
the healing process since this encounter with the unknown is the essence of illness (Pavlicevic, 1997).
For clients, this is an excursion into insecurity accompanied by the fear of losing one's identity (Aldridge,
1990). Patient and therapist both are involved in this encounter with the unknown, and both may make
this experience in improvisation. Creative activity, however, allows one to do more than just expressing
symptoms and pathology, it also enables the expression of potentials (Aldridge 1996). By literally playing
with ones future aspect, suggesting positive possibilities and ways for development, anticipation is
invoked within the playing. The future is invited into the present and in place of the sick client is a
competent performer (Aldridge 1996). Such creative agency, in mutuality, is the basis of being an
empowered human being, the finding of an identity and the discovery of the self.

CONCLUSION:
Creative Music Therapy utilises the fundamental musical elements such as rhythm and pulse in live
improvisational music to build a relationship with clients. Its foundation lies in creating a working
relationship with clients via the concept of the "music child" and communicating through music as a
medium, reflecting Bubers dialogical philosophy. While CMT was originally catered to children with
disabilities, it has evolved and is applicable across the wide range of client groups and their various
needs, be it with communicative skills, motor skills and self identification amongst others. Particularly in
the case of self-identification, it has been discovered that CMT was largely influenced by Zuckerkandl's
emphasis on dynamic qualities of tone and melody. Aigen (1999) argues that the reason for undertaking
music-centred work is not solely to reap benefits that are of non-musical nature, but that the motivating
factor is for clients to make music or listen to music with the therapists. Ultimately, by encompassing
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music in its entirety, CMT can be seen as a specialized application of music which has been successfully
applied across the whole spectrum of client groups, despite many idiosyncrasies in the needs of
different clinical population.

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REFERENCES:

Aigen, K. (1991). The roots of music therapy: Towards an indigenous research paradigm. Unpublished DA
dissertation, New York.
Aigen, K. (1999) The true nature of music-centred music therapy theory. British Journal of Music Therapy
13(2): 77-82
Aldridge, D. (1989) Music, Communication and medicine: discussion paper. Journal of the Royal Society
of Medicine 82.
Aldridge, D. (1996). Music Therapy Research and Practice in Medicine: From out of the Silence. Jessica
Kingsley, London.
Aldridge, G. & Aldridge, D. (2008) Melody in Music Therapy: a therapeutic narrative analysis. Jessica
Kingsley Publishers, London.
Ansdell, G. (1995). Music for Life. Aspects of Creative Music Therapy with Adult Clients. London and
Bristol, Pennsylvania: Jessica Kingsley Publishers.
Ansdell, G. (1997). Musical elaborations: What has the new musicology of say to music therapy. British
Journal of Music Therapy, 11(2), 36-44.
Bruscia, K. E. (1987). Improvisational models of music therapy. Springfield, IL: Charles C. Thomas.
Boso, M. et al. (2006) Neurophysiology and neurobiology of the musical experience, Funct Neurol 21(4),
187-191
Buber, M. (1970). I and Thou (Walter Kaufmann, Trans.). New York: Charles Schribner's Sons.
Garred, Rudy (2001). The Ontology of Music in Music Therapy: A Dialogical View. Voices: A World Forum
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http://www.voices.no/mainissues/Voices1(3)Garred.html
Hadley, S. (1999). A Comparative Analysis of the Philosophical Premises Underlying Creative Music
Therapy and Analytical Music Therapy. The Australian Journal of Music Therapy, 10, 3-19.
Kravitz, L. (1994). The effects of music on exercise. IDEA Today, 12(9), 56-61.
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Student ID: 16930634 Page 12 of 13 Course Unit 100912
Magee, W.L. & Davidson, J.W. (2002). The effect of music therapy on mood states in neurological
patients: A pilot study. Journal of Music Therapy 39(1) 20-29.
Nayak, S. et al. (2000). Effect of music therapy on mood and social interaction among individuals with
acute traumatic brain injury and stroke. Rehabilitation Psychology 45(3), 274-283.
Nordoff, P. & Robbins, C. (undated) Songs for Children, United Music Publishers
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Michigan
Nordoff, P. & Robbins, C. (1977) Creative Music Therapy: Individualized treatment for the Handicapped
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Pavlicevic, M. (1997) Music Therapy in Context: Music, Meaning and Relationship, Jessical Kingsley
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Schauer, M. & Mauritz K.H. (2003). Musical motor feedback (MMF) in walking hemiparetic stroke
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Schmid, W. (2006) Maintaining dialogue - active music therapy for people living with Multiple Sclerosis,
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Von Hofsten, C. (1993), Action in development. Developmental Science, 10: 5460.
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