The impact of music therapy versus music medicine on psychological outcomes and pain in cancer patients: a mixed methods study

Abstract

Purpose

The purpose of this study was to compare the impact of music therapy (MT) versus music medicine (MM) interventions on psychological outcomes and pain in cancer patients and to enhance understanding of patients’ experiences of these two types of music interventions.

Methods

This study employed a mixed methods intervention design in which qualitative data were embedded within a randomized cross-over trial. Thirty-one adult cancer patients participated in two sessions that involved interactive music making with a music therapist (MT) and two sessions in which they listened to pre-recorded music without the presence of a therapist (MM). Before and after each session, participants reported on their mood, anxiety, relaxation, and pain by means of visual analogue and numeric rating scales. Thirty participants completed an exit interview.

Results

The quantitative data suggest that both interventions were equally effective in enhancing target outcomes. However, 77.4 % of participants expressed a preference for MT sessions. The qualitative data indicate that music improves symptom management, embodies hope for survival, and helps connect to a pre-illness self, but may also access memories of loss and trauma. MT sessions helped participants tap into inner resources such as playfulness and creativity. Interactive music making also allowed for emotional expression. Some participants preferred the familiarity and predictability of listening to pre-recorded music.

Conclusions

The findings of this study advocate for the use of music in cancer care. Treatment benefits may depend on patient characteristics such as outlook on life and readiness to explore emotions related to the cancer experience.

Introduction

Music interventions have been used to address a variety of symptoms in cancer patients including anxiety [1, 2], stress during chemotherapy or radiation therapy [3, 4], mood disturbance [5], and pain [6]. The use of music in cancer care can be situated along a continuum of care, namely from music listening initiated by patients, to music medicine (pre-recorded music offered by medical personnel for symptom management) and to music therapy (the psychotherapeutic use of music). Several authors have argued for a clear distinction between these areas of practice when researching the efficacy of music interventions [79]. Whereas music medicine (MM) does not involve a systematic therapeutic process, music therapy (MT) requires the presence of such a process developed between the client and a trained music therapist through personally tailored music experiences including listening to live, improvised, or pre-recorded music; playing music instruments; improvising music; and composing music [7, 8].

We situate the use of music for symptom management within a biopsychosocial framework. On a neurophysiological level, listening to music may reduce anxiety through suppressive action on the sympathetic nervous system [10]. Additionally, its pain-reducing and mood-enhancing effects have been attributed to amygdala mediation [11, 12]. Cognitively, music helps patients focus their attention away from stressful events to something pleasant and soothing. Moreover, music listening may activate imagery, offering a temporarily escape from the reality of cancer diagnosis and treatment. Importantly, music provides patients with an aesthetic experience that can offer comfort and peace during times of distress. Psychosocially, interactive music making within a therapeutic relationship provides a deeply humanizing and validating experience for the patient. These experiences offer opportunities to explore and process emotions in a creative process unique from other therapeutic disciplines and facilitate meaning making through music-evoked reflections [7].

Results of a Cochrane systematic review on the use of music interventions with cancer patients indicate that music interventions may have beneficial effects on anxiety, pain, mood, quality of life, and physiological responses [7]. The review authors concluded that more randomized controlled trials (RCTs) are needed to directly compare the effectiveness of MM versus MT interventions with cancer patients so that the impact and clinical role of each can be better understood. The current study was in direct response to this recommendation, namely to (1) compare the impact of MT versus MM interventions on psychological outcomes and pain in cancer patients and (2) enhance understanding of patients’ differential experiences of these two types of interventions.

Methods

Design

We firmly believe that research methodology should be driven by research questions rather than by an a priori stance regarding superiority of research method. Therefore, we adhere to pragmatism as our philosophical stance [13]. We used a mixed methods research approach in which both quantitative and qualitative data are gathered and integrated, resulting in interpretations that are grounded in the combined strengths of both data sets [14]. Specifically, we employed a mixed methods intervention design in which qualitative data (i.e., semi-structured exit interviews) were embedded within an RCT [15]. The purpose of the interviews was to (a) bring greater understanding of cancer patients’ experience of music interventions and (b) give participants the opportunity to share in their own words the impact of the interventions on their well-being.

This study was approved by an Institutional Review Board, and informed consent was obtained from all participants. Thirty-one participants completed two MT sessions and two MM sessions within a 2-week timeframe. Using a list of random numbers, participants were randomized to one of two treatment sequences consisting of two MT sessions followed by two MM sessions or vice versa. The use of sequentially numbered, opaque, sealed envelopes ensured allocation concealment.

Participants

Thirty-one adult cancer patients at an urban hospital were recruited between August 2012 and June 2013. Patients were eligible if they were currently receiving inpatient or outpatient cancer treatment; were proficient in English; and did not have a cognitive impairment, psychotic disorder, or hearing impairment. The mean age was 53.8 years and 67.7 % were female. Demographic characteristics are summarized in Table 1.

Table 1 Participant characteristics (n = 31)

As this was considered a pilot study, no a priori sample size was computed. Instead, we anticipated that this study would provide standard deviation estimates to guide future large-scale trials (see Fig. 1 for participant flow).

Fig. 1
figure1

Participant flow chart

Interventions

Music therapy

MT sessions were provided by a board-certified music therapist and lasted 30 to 45 min each. The aim of the sessions was to help patients manage stress, mood, and pain and to provide psychosocial support. After a brief discussion about current concerns, the music therapist offered live music based on patient needs. She invited participants to sing and/or play an instrument (e.g., xylophone and small percussion instruments) along to a familiar song or improvised melody. These experiences were followed by additional songs, co-created instrumental or vocal improvisations, songwriting, or music-guided breathing exercises. The therapist provided ample opportunity for verbal processing of emotions and thoughts evoked by the music.

Music medicine

At the start of the study, participants were asked to list their music preferences on a demographic information sheet. Based on this information, we created individualized playlists. The music therapist met with each participant at the start of the MM session to deliver an iPod with the patient’s playlist. The music therapist made sure the patient was able to operate the iPod, but no further assessment took place. Participants were asked not to engage in other activities while the music played. The music therapist then left the room. MM sessions lasted 30–45 min.

We minimized expectation effects of participants throughout the study by referring to both treatment conditions as music sessions rather than referring to one intervention as music therapy.

Measures and data collection

Mood, anxiety, and relaxation were measured with a visual analogue scale (VAS), a 100-mm line; the length of which represents a continuum of an experience such as mood. Pain intensity was measured by means of an 11-point numeric rating scale (0–10) [16].

All participants were invited to participate in an audio-recorded semi-structured, open-ended exit interview. Interview questions focused on the participants’ experiences of the music sessions in general and about their differential experiences of the MT and MM sessions. Participants were also asked which of these they would like to receive for future treatments. A blinded outcome assessor collected the quantitative outcome data immediately before and after each music session. After the final session, the outcome assessor conducted the exit interview.

Data analysis

Quantitative analysis

Data were entered into RedCap [17] and exported to SAS/STAT® software for analysis. Average pre- and posttest scores were computed for the two sessions of each treatment condition. We utilized these averages for comparisons within and between conditions. In the event of skewed data, Wilcoxon rank sum tests were used to test the within-condition differences. Otherwise, paired t tests were used. Paired t tests on the difference scores were used to test for between-condition differences.

Qualitative analysis

The interviews were transcribed verbatim and reviewed for accuracy. The transcripts were imported into MAXQDA 11 [18] and analyzed by two coders (NP, JB) using theoretical thematic analysis procedures as outlined by Braun and Clarke [19]. Theoretical thematic analysis is aimed at identifying and analyzing patterns driven by an a priori theoretical framework or specific research questions. The coding was guided by the following research questions: (1) What do participants report as treatment benefits or harms? and (2) How do they describe their (differential) experiences of the two types of music interventions? Themes were identified using a semantic approach [19] in which themes are derived from “the explicit meaning of the data and the analyst is not looking for anything beyond what a participant has said” [19] (p. 84).

Integration of data sets

After completion of the quantitative and qualitative data analysis, the two data sets were compared to examine (dis)congruence of the findings. In addition, we created a joint display [15] of quantitative and qualitative findings to examine differential experiences of participants whose quantitative data profile indicated much greater benefits in MT than in MM or vice versa.

Results

Quantitative results

The quantitative data indicate that the MT and MM sessions were equally effective in improving anxiety, mood, relaxation, and pain. There was no statistically significant difference between the conditions for these outcomes (Table 2).

Table 2 Comparison of mean difference scores between treatment conditions

The majority of the participants (77.4 %) expressed a preference for receiving MT sessions for the remainder of their cancer treatment or future treatments. Figure 2 depicts participants’ treatment preference alongside reasons for preference as gleaned from the qualitative data.

Fig. 2
figure2

Treatment preference and associated reasons

Qualitative results

Thirty participants completed the interviews. The qualitative analysis resulted in eight key themes organized into two clusters:

  1. 1.

    Common themes: Themes related to treatment benefits experienced across the treatment interventions.

  2. 2.

    Unique themes: Themes that were unique to MT or to MM sessions.

The themes are discussed below and presented in Table 3, with example quotes.

Table 3 Themes from qualitative data

Common themes across treatment interventions

The qualitative data suggest that engagement in MT and MM sessions was both beneficial for symptom management (Theme 1). The music enabled participants to escape from stress in general and from worries related to the cancer diagnosis and treatment specifically. Experiencing music as relaxing, peaceful, and soothing was the most commonly stated benefit. Participants furthermore commented that engaging in music was fun and lifted their mood. Noteworthy is that many participants appreciated the playfulness of interactive music making (musicking) and “feeling like a child again” in the MT sessions.

Many references were made to memories elicited by music (Theme 2), including childhood memories of carefree times. Music also facilitated connection to the pre-illness self. Music experiences were meaningful because they helped participants bridge the past (Who was I?), present (Who am I now?), and future (Who will I be? Will I survive?). However, for some participants, music evoked intense memories of loss and trauma.

Numerous references were made to the fact that music offers hope for the future and inspiration to move forward (Theme 3). When confronted with a diagnosis of cancer, people need hope and reassurance. The beauty of music stands in sharp contrast to the hopelessness that a diagnosis of cancer may bring as illustrated by the following participant quote: “When the doctor first tells you that you have a cancer you feel like tomorrow is your last day, but the music makes you feel like there’s a future.”

Themes unique to music therapy sessions

Many participants commented on the importance of the presence of the music therapist (Theme 4). This presence added a valuable dimension to the music experience, namely one of feeling cared for and supported. In addition, several participants stated that they experienced the live music quite differently: “It felt like some of the music when she would play, I could feel it in me, like something like rush right through me like a good vibe right through my body.” Participants who expressed a preference for MT for future treatments identified the musicking and the music therapist’s empathy and support as main reasons (Fig. 2).

A large number of comments spoke of the importance of creativity. One participant, in particular, provided a beautiful metaphor for the creative process: “When I had to participate with the xylophone thing…that made me feel good. You know, like a rush…like if you see a flower…and the flower is blooming and then you go and again and it keeps blooming and blooming until it blooms all the way. Like that.”

Finally, participants valued the opportunity to release emotions not usually expressed as reflected in this quote by a male participant: “I remember one time when I was upset and I didn’t really know Amy that well and I opened up to her and I cried. That is not easy for me to do around someone I know, let alone someone I’m just meeting…Because, you know, the macho myth, man are not supposed to cry and all that”. Music, coupled with the therapeutic relationship, made it safe for these emotions to surface and be explored.

Themes unique to music medicine sessions

A minority of participants expressed a clear preference for listening to pre-recorded music. Some desired to hear the original recording rather than the music therapist’s rendition of the song (Theme 6) because they wanted to hear specific musical elements (e.g., accordion and percussion section). Others felt more comfortable listening to pre-recorded music because of familiarity and because they felt insecure about making music (Theme 7).

Theme 8, wherein a preference for listening to music alone was reported, arose from comments from a small number of participants but provides important guidance to music therapists who work in oncology. First, listening to music via headphones enables a greater focus on the music for some participants. Second, when a therapist is in the room, there is a spoken or unspoken expectation of interaction. One participant stated that he felt “watched” when somebody is in the room, and this prevented him from truly feeling the music.

Integration of quantitative and qualitative results

The qualitative findings were congruent with the quantitative results, namely both types of music interventions were effective for symptom management. Whereas the quantitative results informed us about the extent of improvements, the qualitative analysis provided additional information regarding: (1) how music may have brought about the improvements, (2) additional benefits experienced by the participants, and (3) challenges and risks associated with the use of music interventions.

We were also interested in exploring if and why certain patients benefited more from MT than MM sessions or vice versa. To this end, we computed an overall z-score for each participant to reflect overall improvement per condition. Based on these z-scores, we created four typologies [15], namely participants who showed (a) great improvement in MT but much less or no improvement in MM, (b) great improvement in MM but much less or no improvement in MT, (c) great improvement in both conditions, and (d) worsening in both conditions. Table 4 presents the experiences for participants that fit these typologies. The range of z-scores represents the scores of the four most extreme cases for each typology. This joint display provides insights into how patient characteristics and attitudes may impact treatment benefits. For example, patients who value the therapeutic relationship and the creative aspect of musicking appear to benefit more from MT sessions than from MM sessions. In contrast, patients who are apprehensive about playing instruments and exploring feelings related to cancer may benefit more from listening to pre-recorded music.

Table 4 Joint display of patient experiences per treatment benefits

Discussion

Our findings are congruent with the current literature, namely that MT and MM interventions have beneficial effects on anxiety, pain, mood, and level of relaxation in cancer patients [7]. Our quantitative results indicate that, on average, MT and MM interventions are equally beneficial for symptom management. However, the qualitative findings and the integration of the quantitative and qualitative data sets provide a more nuanced understanding of treatment benefits.

Symptom management is achieved by escaping the reality of cancer through distraction, imagery, and pleasant memories elicited by the music. Through its aesthetic qualities, music furthermore offers comfort and peace during times of distress, lifting people’s spirit and improving their sense of well-being. Similar findings were reported in a study exploring adult cancer patients’ use of music [20].

Even though MM interventions typically aim to achieve symptom management [7], our qualitative data suggest that listening to pre-recorded music frequently goes beyond a mere reduction of symptoms. First, music helped to bridge pre-illness identity to present identity and facilitated reflection on existential issues. Renegotiating one’s pre-illness identity and self-narratives in light of the severe “biographical disruption” caused by cancer is important for experiencing well-being in face of a life-threatening illness [2123]. Similar to other studies [20, 21], the data furthermore suggest that music gives meaning to people’s life and embodies hope for survival. Given the existential reflections evoked by music, the presence of a music therapist may be particularly important. Several participants specifically commented about the value of being able to discuss these issues with the music therapist.

Even though listening to pre-recorded music offered health benefits, most participants expressed a preference for MT services for future treatments. The therapeutic relationship, interactive music making, and emotional expression were dominant themes in patients’ narratives about their experiences of the MT sessions, reflecting the importance of human relating and empathy in cancer care. Furthermore, musicking helped patients tap into their inner playfulness and creative selves. These are important resources that, when strengthened, may facilitate resilience in the face of life’s challenges [24]. The MT sessions also enabled participants to access and release suppressed and repressed emotions, especially emotions related to grief. They relied on the therapist for further processing of these emotions verbally and/or musically. Music therapists are trained to go beyond offering verbal support. For example, they may musically accompany the patient’s emotional expression, audibly reflecting the emotions and providing a safe musical container for continued exploration.

The findings of this study offer important guidance for the use of music with cancer patients. The results suggest that music lifts patients’ mood, reduces anxiety, brings peacefulness, and helps to manage pain. This is in line with previous research demonstrating that the everyday use of music can be an important resource for enhancing one’s well-being and sense of empowerment [20, 25]. However, the mixed methods analysis suggests that treatment benefits may depend on certain participant characteristics. Even though most participants experience greater well-being when engaging in music interventions, our joint display of participant experiences and attitudes per treatment benefits suggests that listening to music may cause distress as well, especially for patients who have a negative outlook on life. Such patients may be at greater risk for music’s powerful capacity to access sad and traumatic memories. Given their emotional vulnerability, the surfacing of such memories may be highly distressing. At the same time, these patients appear not to benefit from musicking either as they perceived their music making skills as inadequate. The notion of musical competence has been reported elsewhere as a potential barrier to patients’ enjoyment of music therapy sessions [26]. Therefore, it is important to carefully assess the emotional state of patients before offering music for symptom management. These patients may be better served by listening to music in the presence of a music therapist who can help with processing of emotions. Music therapists should be mindful that in short-term care delivery, these patients may not benefit from musicking as they may need a longer timeframe to develop a trusting relationship with the therapist as well as with music. In contrast, patients who strongly believe in the power of music and who value the opportunity to process emotions with the therapist appear to greatly benefit from both types of music interventions.

The qualitative data furthermore indicate that some patients prefer the familiarity of their own music. During this challenging time in their life, patients have a great need for stability and emotional security [27]. Self-selected music presents predictable musical and emotional content, therefore providing a safe holding environment. Repetitive listening to songs may bring a sense of order to the chaos, and the aesthetic beauty of the music may feel like a warm blanket for one who is shaken and afraid. Self-selected music has been described in the literature as a powerful means to “constitute ontological security” through creating a sense of “aesthetic belonging” [21] (p. 131–132).

Limitations and research recommendations

The results of this study are based on a small sample size, and the majority of the patients were female and black. This limits the extent to which these findings can be generalized to other patients. In addition, although some patients readily benefit from MT sessions, others may need additional time for relationship building and therefore more sessions may be needed. It is likely that the patients who enrolled in this study already had a special affinity for music. Finally, this study had research funding available for the creation of individualized playlists. This may not be feasible in all settings.

Both MT and MM appear equally effective for symptom management. Although this is a small-sized study, it does present the question of whether comparative RCTs for music interventions focused on symptom management are a worthy research investment. We suggest that future research efforts should instead aim to enhance understanding of (a) how each of these interventions can be optimized for symptom management, (b) how music interventions can best serve patients along the cancer treatment trajectory, and (c) what unique aspects MM and MT interventions contribute to the care of patients.

Conclusions

The findings of this study advocate for the use of music in cancer care. Listening to pre-recorded music may enhance symptom management. In addition to symptom management, music therapy, offered by a board-certified music therapist, offers psychosocial support and may strengthen inner resources. This study provides guidelines aimed at stimulating continued reflection and awareness in clinicians about the use of music with adult cancer patients. Given our findings, in particular the strong preference for music therapy services by patients, it is recommended that music therapy is made available to cancer patients during active cancer treatment. The findings furthermore indicate the need for patient assessment by a board-certified music therapist to determine which music interventions will most effectively address the in-the-moment needs of patients. Finally, the availability of a music therapist is recommended even when listening to pre-recorded music is offered since music can evoke strong emotional responses and psychotherapeutic support may be needed.

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Acknowledgments

Research funding for this project was provided by the Drexel College of Medicine Cancer Program. We would like to thank Dr. John W. Creswell for his feedback on this manuscript and Dr. Michael D. Fetters for his input regarding the joint displays of quantitative and qualitative data.

Conflict of interest

The authors report no conflict of interest. The authors have full control of all primary data and agree to allow the journal to review their data if requested.

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Correspondence to Joke Bradt.

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Bradt, J., Potvin, N., Kesslick, A. et al. The impact of music therapy versus music medicine on psychological outcomes and pain in cancer patients: a mixed methods study. Support Care Cancer 23, 1261–1271 (2015). https://doi.org/10.1007/s00520-014-2478-7

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Keywords

  • Music therapy
  • Cancer
  • Symptom management
  • Mixed methods research