Anxiety is one of the leading challenges which patients with cancer encounter along the path of diagnosis and treatment. Psychological distress commonly appears around the time of the diagnosis as well as in various pre-, during-, and post-treatment settings (surgery, chemotherapy, etc.).1 The prevalence of anxiety in cancer care ranges from 35 to 38 percent but may reach higher percentages in different treatment settings and in various populations.2,3 Patients with anxiety may report a variety of emotional concerns including elements of depression, anger, existential fear, distress regarding their body image, etc. On the other hand, patients may not recognize or admit to having any level of psychological distress. Somatic symptoms that may express anxiety or over-lap with emotional concerns can include fatigue, dyspnea, and insomnia. These symptoms may impair patients’ quality of life (QOL) and well-being in different settings: during active oncology treatment, during palliative care, and during survivorship.
Several psychological interventions have been theorized and put into practice over the last few decades with the purpose of alleviating anxiety as well as depression, sleep disorders, and other manifestations of psychosocial distress among cancer patients. Interventions aimed at improving the emotional distress of patients receiving chemotherapy include pharmacotherapy, psycho-oncology counseling,4 art therapy,5 and a variety of complementary medicine modalities (e.g. guided imagery, meditation, yoga, acupuncture and others).6 Interventions may be individual- or group-oriented, short- or long-term, and based on a multitude of working theories. An important distinction must be made between standard interventions (also called symptom-oriented interventions), and patient-tailored interventions. The former are identical for each patient receiving the therapy in question, are not necessarily conducted by a therapist, and do not necessitate therapeutic relations with the subjects; the latter are always conducted by an expert therapist and are fitted in an individual manner to each patient, even in a group setting.
Music therapy is another viable option for a psycho-oncology intervention aimed at alleviating anxiety, as well as treating physical, emotional and spiritual disharmonies. Music therapy interventions can be categorized as either standard or patient-tailored. Standard interventions, which commonly include listening to pre-recorded music chosen by the medical staff, a musician, or by the patients themselves, have been found to be clinically significant in reducing anxiety, adverse effects of pain, blood pressure, nausea and vomiting during chemotherapy.7-12 While such standard interventions are the most common ones to employ music as a therapeutic agent,13 mostly as a calming effect, patient-tailored musical therapies are prevalent as well, and include such techniques as live music-playing, song-writing, and free or structured improvisation sessions. Interventions such as these have also been found to be effective in reducing anxiety, pain and fatigue, alleviating mood swings, and lowering blood pressure.14-17 Patient-tailored interventions are carried out by a trained and qualified music therapist, and the music itself is conceived as a healing factor which enhances the impact of the therapist-patient therapeutic relationship.
In this article, we present a case study of a female patient who was referred by her oncologist to an integrative medicine consultant (a physician trained in complementary medicine) aiming to improve her QOL during chemotherapy. The consultation was followed by weekly treatment sessions provided by the Integrative Oncology Program (IOP) implemented in 2008 within the oncology service of the largest health maintenance organization in northern Israel.18 The patient’s supportive treatment included weekly music therapy sessions provided by a trained music therapist specializing in a unique method of music therapy based on Anthroposophic medicine (AM), a scientific and spiritual approach to medicine that purports to stimulate patient’s self-healing.19
Eva, a 64-year-old married woman, mother of 4 children and 7 grandchildren, was diagnosed with locally advanced ovarian cancer (stage IIIc) following extensive gynecological surgery. Eva’s oncologist referred her to IOP consultation intended to improve her QOL along the six chemotherapy cycles. Eva received integrative supportive care that included weekly acupuncture sessions, dietary consultations, herbal treatment with wheat grass juice, twice-weekly sub-coetaneous injections of Viscum Album (Mistletoe), and weekly AM music therapy sessions aimed at alleviating Eva’s tinnitus, anxiety, and chemotherapy-induced neuropathy afflicting her feet and hands. Eva reported significant improvement of the aforementioned symptoms and concluded chemotherapy hoping for a complete cure.
Several months following the conclusion of the chemotherapy, Eva’s son was hospitalized in a comatose state following severe head trauma. Shaken by this, Eva faced a grave diagnosis of ovarian cancer recurrence manifested with pelvic and liver metastasis and the need to initiate chemotherapy again. Eva asked to renew the integrative supportive care and scheduled a meeting with the integrative physician (IP), hoping to alleviate her anxiety. The IP’s treatment plan goals focused on improving her anxiety, fatigue, nausea, emotional concerns, and neuropathy. The treatment, which was coordinated with Eva’s oncologist, gyneco-oncologist, nurse, psycho-oncologist and family physician, included renewal of Viscum Album injections, weekly sessions of acupuncture and AM-based music therapy sessions.
The music therapy’s objective was to improve Eva’s QOL along each of the 3-week chemotherapy cycles: to alleviate nausea, fatigue, and pain as well as to relieve anxiety and depression accentuated by Eva’s concern for her hospitalized son and her own health condition. Music therapy aimed to alleviate emotional and spiritual concerns, to harmonize breathing, to improve chemotherapy-induced neuropathy, and to aid Eva in finding her own healing powers and in connecting to the meaning of her life.
During the first two weeks following each chemotherapy cycle, the music therapist focused on improving chemotherapy side-effects, by reducing nausea, fatigue and strengthening Eva’s body and her vitality, perceived in AM as life forces. The therapy included mostly receptive music therapy – active listening by the patient to individually-tailored music, composed by the therapist especially for Eva, played on an alto lyre (a string instrument). Eva only listened, since she was too weak to actively play an instrument or sing in the week that followed chemotherapy.
However, during each 3rd week following chemotherapy (the week preceding the next chemotherapy cycle), another music treatment modality became available. Eva felt stronger at that phase and was keen to work with her music therapist using the process of clinical composition. Clinical composition is perceived as a treatment strengthening the patient’s soul forces and his or her self-awareness. Clinical composition is a process through which original music is composed by the patient, with the therapist’s guidance, in relation to a verse written by the patient or by another person (music may also be composed without lyrics). Eva chose to write her own poem and compose her chosen tones to it through the clinical composition process (Figure 1). Choosing her own words gave Eva hopefulness and a sense of empowerment. It was a challenge for her to find the words that best voiced what she was feeling and what she desired to choose as her motto. The poem is mainly about Hope. It relates to her hopefulness and her yearning to have a normal family life (as she called the hour of grace, including her son’s recovery).
The clinical composition process continued along the six chemotherapy cycles with choosing the tones played on the alto lyre or Eva singing her inner music. A very demanding part of this therapy is choosing the first tone with which to begin the composition. Eva listened carefully to tones she played herself, and chose the most fitting one. Quite decisively she turned to the B tone. Eva listened to the tone several times and ultimately was very confident with her choice of B as the beginning tone.
In the following session Eva continued her search for the most fitting tones and intervals for the following parts of the text. The intervals were small at the beginning of the composition, and the tones were repeated several times. The first sentence consisted of only 3 tones – B, A, G. The 2nd composed sentence also remained within the confines of these 3 tones, using repetitions. Eva felt that the small intervals expressed her modest hope, careful hope, not too daring hope, an evolving hope. The 3rd sentence, however, starting with the word HALEVAY (wishfully in Hebrew) rises with an interval of a fifth and then higher, with another interval of a fifth up to the higher C – spanning more than an octave from the beginning of the composition. In this part of the composition there was larger movement in the composed music, more tones were added, with less repeating tones, and the intervals were wider. Eva also used more tones for one syllable in the last part, and decided to add repeating words in the text to enhance the quality of Hope. The composition ends with the tone E – not too high, nor too low, but as kind of in the middle. The clinical composition process was concluded at the same time the 6th chemotherapy cycle ended. Eva felt satisfied with the process and the final composition, feeling deeply connected to it. She could feel how her own forces of hope and will were strengthened, together with the unexpected awakening of her son from his one-year comatose-state; both occurred parallel to the conclusion of Eva’s composition.
The described therapeutic process with Eva is an example of one method of working with music therapy, arising from the Anthroposophic medicine approach to patients with cancer. The AM music therapist’s goals were directed towards empowering Eva’s inner strength. This patient-centered approach combines two complementary forms of therapy: receptive listening and clinical composition. The receptive component was expressed by the live music composed and played to Eva by the therapist. Nevertheless, this receptive gesture is not a form of passive listening but rather requires mindful and attentive listening – an active form of listening in contrast to recorded background music, for example. Although recorded music may be performed professionally, live music integrated in an individual-centered context may offer deeper therapeutic benefits. The therapist may modify and attune the music to the patient’s breathing rhythm. In Eva’s case, receptive AM music therapy was aimed at empowering her physical and physiological realm, to deepen and regulate her breathing, and to alleviate the severity of nausea, fatigue, and other chemotherapy side-effects.
The second form of music therapy – clinical composition – calls for an active process of a different kind. With her therapist’s guidance, Eva chose the poem’s lyrics, tones, intervals, and the correspondence between words and music. This active process called for Eva to create her own song, listen very attentively to the different tones and the different relations between the tones (intervals), and to make decisions for tones, rhythm, repetitions, etc. through her attentive listening. In the composition process, Eva could express her own inner voice.
In Anthroposophic music therapy, live music is used. Live music contains delicate overtones, warmth and life qualities, which are absent from recorded music. Singing, listening, and composing were dominant in Eva’s music therapy, where verbalizing was less emphasized. Music was the main healing element rather than simply a means for inducing psycho-therapeutic verbal intervention.
Compared with AM music therapy, other music therapy approaches differentiate between two levels of intervention: a passive treatment based on listening to music (be it live or recorded), and an active treatment where the patient is the one playing the musical instrument. The primary goal of the passive music therapy is promoting a sense of calmness, which has been shown to help also in reducing chemotherapy side effects (e.g. nausea and vomiting).9
Active music therapy, individually-tailored as it is, aims at improving patient QOL, alleviating specific adverse symptoms of the chemotherapy, and for the most part is considered a viable psycho-therapeutic instrument allowing for the process of verbal psycho-therapeutic communication
In contrast, as we can see in the case of Eva, the goal of the therapeutic intervention was not to facilitate verbal communication. Rather, AM music therapy considers music as a healing element; music IS the therapy. In AM’s perspective, music is the element responsible for alleviating the adverse symptoms of chemotherapy (and not indirectly so, such as by targeting anxiety or promoting calmness); the tones, intervals, rhythms, the activity in singing exercises and composition – the musical qualities themselves – influence the body’s organs and physiology. Through clinical composition, the patient can gather his/her very own innate potential for healing and thus build real new forces. An additional comparison is called for, between the practice of receptive listening in AM music therapy and passive listening within other approaches of music therapy be it to recorded or live music. Live music is a prevalent therapeutic technique in many patient-tailored interventions, a therapy aimed at alleviating chemotherapy-related adverse symptoms, such as fatigue and nausea. Such interventions have little to distinguish them from what we have called receptive listening, in that they require the listener’s attentiveness, mindfulness to one’s surroundings, with music suited to the patient’s needs and concerns. Indeed, such passive listening often moves the listener to active participation to some extent (e.g. humming along with the therapist, clapping her hands to the beat).20 One can differentiate between three levels of music therapy aimed at patients at various stages of chemotherapy, and tempered by the specific goals of the therapy:
Standard passive therapy: utilizing recorded music as a backdrop before or during the chemotherapy treatment, aimed at alleviating anxiety
Patient-tailored passive therapy: using live music: an individual therapy aimed at alleviating side-effects of chemotherapy
Active music therapy: an active individual therapy aimed at procuring the patient’s emotional and spiritual potency for the purpose of empowerment and growth.
These three levels of music therapy intervention pose various challenges for research aimed at determining their efficacy. It could, for instance, better explain why previous research found interventions using a patient-centered approach utilizing live music to be significantly more effective in alleviating distress, when compared to standard interventions using recorded music.21 Unsurprisingly, the vast majority of research on music therapy focuses on interventions of the standardized treatment type, which is exclusively passive in nature. Studies into individual, patient-tailored music therapy is significantly more challenging, for various methodological reasons not the least of which is the formatting of a control group.
We hope that this case study will encourage the conduct of future research into the efficacy of music therapy in general, and more specifically of Anthroposophic medicine music therapy and patient-centered, individual interventions with music. We recommend integration of qualitative studies as well as prospective clinical preference studies to explore the impact of patient-tailored music therapy on patients’ QOL in the broad bio-psycho-spiritual context.