Can Music Therapists Synergise With Medical Practitioners to Make Music Therapy Evidence-based?
In July Voices published Sumathy Sundar's first interview, the results of her discussion with Dr Sairam, a specialist in alternative medicine and a researcher into the therapeutic use of Indian ragas. In this her second interview Sumathy turns her attention to a current debate in music therapy, the issue of finding appropriate ways to provide evidence for effective practice especially when aiming to convince the medical profession of the efficacy of music therapy. Her context is cancer care, a research area in which Sumathy has a particular interest and expertise. Her interviewee is Dr Ravi Kannan, a leading cancer specialist working at a Cancer Institute in India.
Dr Ravi Kannan discusses the complexity of research in this area with the wide range of variables and associated ethical and consent issues. He is an advocate of rigorous research that employs objective measures to indicate efficacy, for example in the areas of pain control and the quantity of analgesics. He encourages the use of standardized assessment tools and notes that such tools exist for researching the cancer patient's quality of life in relation to various therapeutic interventions. In the interview Sumathy Sundar introduces the challenge presented by randomized controlled trials (RCTs). There is much debate within music therapy on the use of RCTs. There are some colleagues who are exploring creative ways such as repeated trials with smaller groups to combat the need for the large numbers to satisfy the power ratios and sampling issues demanded by the rigors of experimental design and statistics. Other music therapy researchers are critical of the RCT being used as the 'gold standard' especially when therapists work with individually-created patterns of care delivered in small groups or through individual work. Sumathy points to notions of belief, willingness and receptiveness that are often features of music therapy sessions and present further challenges in the search for objectivity.
Dr Ravi Kannan is supportive of collaborative approaches to research where the music therapist researcher can work alongside other members of the inter-disciplinary team such as doctors, nurses, psychologists, statisticians and others trained in research methodology. He touches on the different ways music could be used in cancer care ranging from the use of background music in a counselling session to its potential use in the palliative care setting, an area where he sees potential for collaborative work and for improving the quality of life of patients.
Together Sumathy and Dr Ravi Kannan introduce points that I hope will be explored by other music therapists and become an on-going topic within the moderated discussion section of Voices. The interview put into context some of our collaborative research based at the Bristol Cancer Centre in the UK. We have been answering some of these challenges raised in the interview by evolving a mixed-methods approach with clear links to the research question being asked. When wanting to research physiological responses to listening to music in a relaxed state or the effects group improvisation we have worked with doctors and psychologists in using saliva testing as indicators of potential change across various physiological parameters. Conversely when researching more psychological changes standardized psychological tests have been used alongside focus groups and more recently in-depth interviews carried out after the music therapy group experience by colleagues experienced in more qualitative procedures. Dr. Ravi Kannan may be interested to learn that the patients were very interested to be told the results of the physiological measures. Were there any physiological changes that could be linked to the music? Although our work is still in the pilot stage and would not meet the rigors demanded by a RCT it was reassuring to be able to report indicative positive results to the patients.
I very much hope that more music therapists working in the cancer field and other areas are encouraged to join in the debate to which this interview makes an interesting contribution.
Leslie Bunt—Series Editor
Bristol, October 2005.
Context
There is an increasing global need for music therapy practice to be evidence-based with more experimental research findings. This is particularly the case as music therapy is introduced as a complementary therapy in many medical settings, with special reference to integrated care. Can music therapy be really evidence-based as is the case in medicine? How practical is it? Can the multidimensional role that a music therapist plays in a therapeutic setting, her skills, the time she spends with the clients and the effects of music, all be compared to a medical approach? Should music therapists collaborate more with health professionals not only in practice, but also in research to make it evidence based? What are the strengths of music therapy in the medical profession?
Oncology is a very challenging area in the medical field and likewise music therapy is challenging in an oncology setting. Many music therapists are interested in working in this challenging speciality in research. Here is an interview with a renowned Indian surgical oncologist, Dr. Ravi Kannan. He is keen on music therapy being a part of the integrated team in cancer care in India and emphasises the need for more research to be carried out that is evidence-based.
Interview
Sumathy Sundar: Dr. Ravi Kannan, Cancer Patient Care is a complex area since it has to address a myriad of issues faced by the cancer patients in relation to stressful and painful procedures, the diagnosis, treatment such as radio or chemotherapy, the prognosis etc. Then there is a need for adopting a holistic treatment approach considering the psycho-oncology issues focusing on patients' perceived unmet psychological, psychosocial and spiritual needs. In this context, music therapy is one of the complementary therapies that is popularly used in the oncology settings in US, UK, Australia and elsewhere. How about in India? Music Therapy is just an emerging discipline here, with no systematic studies in oncology setting having been reported so far, except for a study being conducted at your Institute. In this background, Do you think music therapy can be a potential complementary therapy for cancer patients?
Dr Ravi Kannan: Patient care, as you have put, it is a complex issue. There is the physical component to it and then there is the psychological side of it. The parameters for assessing physical response are well defined while those to assess the psychological component are as yet evolving. The process by which it impacts on disease progression and response to therapy are as yet unclear. Music therapy may form an important component of psychological care in both curative and palliative settings. It needs further study.
Sumathy Sundar: What are the potential areas do you think music therapists can work on in an oncology setting?
Dr Ravi Kannan: Palliative care is definitely one such setting. Pain relief, especially post-operative, may be another situation. Background music during patient counselling sessions may also be worth exploring. There are many other such situations.
Sumathy Sundar: As a researcher in an oncology setting, I feel that a music therapist has to work as a health psychologist too. Providing information support on the treatment procedures, side effects of the treatment, the do's and don'ts during the treatment, the adherence of the treatment, apart from giving emotional support. What do you think can be the role of music therapist in an oncology setting?
Dr Ravi Kannan: I do not think that a music therapist should provide health information. Working in tandem with other medical and paramedical staff, they could reinforce certain information like the hope of cure, cancer prevention, early detection etc. It must be tailored to the individual patient at hand.
Sumathy Sundar: What skills do you think a music therapist should have working with cancer patients? I feel in my experience that listening skills are very important. The patients expect the music therapist to spend a lot of time with them.
Dr Ravi Kannan: Like with all forms of counselling, listening abilities and time are of utmost importance.
Sumathy Sundar: The belief of the Music therapist about the effect of the therapy plays a major role and has a considerable bias in the assessment in music therapy studies. Also the socially desirable responses from the patients make the assessment biased. Do you think the attending oncologist can help in the assessment in music therapy research about the effect, whether it is pain or quality of life or be it any symptom, especially when the symptom assessment is by self report?
Dr Ravi Kannan: Certainly. Without evidence, no form of treatment would be acceptable.
Sumathy Sundar: There are so many variables in cancer research. Also there are a large number of variables in music. How practical or rather effective do you think music therapy research is considering these issues?
Dr Ravi Kannan: I agree that this is more complicated than say testing the value of an anticancer drug. But it can be done. Psychological assessment scales are available today, Quality of Life (QOL) issues and instruments to assess them have been constructed. Pain can be objectively scored.
Sumathy Sundar: Do you think that the effect of music can be evaluated in a scientific crucible? We only try to dismiss or tend to ignore many powerful elements of humanity in our demands to diagnose, control and eliminate the variables. The love, compassion, faith and the spiritual bliss that the Indian ragas give—how can they be evaluated? It can only be experienced. Can we get any evidence for these experiences?
Dr Ravi Kannan: Some of them yes.
Sumathy Sundar: A randomised controlled trial (RCT) is one of the important acceptable methods of evaluating the effect of any intervention in the medical field. But when belief, willingness and receptiveness are the issues involved in music therapy sessions, a RCT becomes challenging. Also do you think a RCT can be a suitable way to evaluate the effects of music in cancer patients?
Dr Ravi Kannan: Yes with objective end points like for example pain relief and the quantity of analgesics.
Sumathy Sundar: In the absence of specific tools developed for music therapy in cancer patients, can the assessment tools specifically developed for cancer patients for symptom measurement with relation to cancer pain—CRF, QOL and Insomnia, situational anxiety etc.—be used in music therapy research and assessment?
Dr Ravi Kannan: Yes.
Sumathy Sundar: These standardized tools may help the researcher in an objective assessment of the symptoms. But how relevant are they in assessing the actual effects of music?
Dr Ravi Kannan: They will help in a RCT.
Sumathy Sundar: What are the ethical considerations involved if experiments are to be tried with cancer patients on blood levels of neurotransmitters as cognitive and behavioural modulators? They might show some significant results and also the immune system response after music as therapy. Music has a potential to increase endorphins which are natural opioids. So say some foundational studies. How practical it is to measure the levels of endorphins? What are your views regarding such studies to measure the levels of endorphins? Or even serotonin? Do you think these kinds of studies are necessary?
Dr Ravi Kannan: These could be done with informed consents from volunteer patients with advanced cancers. But biochemical parameters have no relevance if they do not manifest in terms of clinical benefit. Without such impact, it would merely remain as a piece of research for a doctoral thesis.
Sumathy Sundar: Is such research possible with the ethical considerations?
Dr Ravi Kannan: Yes.
Sumathy Sundar: Should Music therapy like drug research be tried with animal samples and then humans?
Dr Ravi Kannan: I do not know, I've no knowledge of animal psychology.
Sumathy Sundar: Is it possible to conduct these experiments by a music therapist all by herself?
Dr Ravi Kannan: Any such research is best done in collaboration with allied specialists in psychology, neurology, nursing and medicine.
Sumathy Sundar: How knowledgeable must she be to carry out these studies?
Dr Ravi Kannan: An in depth knowledge of psychology, statistical methods and of course cancer - disease process, treatment and treatment impact would be needed.
Sumathy Sundar: I feel it is only here the music therapist should work in synergy with the medical professionals. Oncology being a complicated branch in medicine and though music therapy is interdisciplinary, mere working knowledge in oncology setting may not be a enough to pursue complicated studies involving neuro transmitters. For instance she could collaborate with a pathologist or an oncologist for research. What are your views?
Dr Ravi Kannan: Certainly.
Sumathy Sundar: How do you think music therapy can help in palliative care setting? To work in a palliative care setting, do you think music therapists should be trained in any specific way?
Dr Ravi Kannan: This is probably the most promising and possibly the immediate area where music therapists can commence work on. Any activity which improves the QOL of terminally ill patients is worth the effort. Knowledge of palliative care, cooperation with palliative care physicians is important.
Sumathy Sundar: Thank you Dr. Ravi Kannan. The interview was very interesting and will be informative to many music therapists who are practising and researching in clinical settings. I thank you on behalf of Voices for sharing your valued experience and knowledge with us and for your guidance and suggestions for evidence-based Music Therapy.
