[Position Paper]

Fostering Intimacy through Musical Beginnings: Exploring the Application of Communicative Musicality through the Musical Experience of Parents in a Neonatal Intensive Care Unit

By Elizabeth McLean


This paper explores the powerful role of musical moments in fostering intimacy for parents and their hospitalised infant in a neonatal intensive care unit (NICU). Grounded in Malloch & Trevarthen’s theory of communicative musicality (2010a), a critical and contemporary perspective on this theory underpinning early musical interactions is presented, advocating for greater exploration of the parents’ perspective to support a deepened understanding of the potential of music for supporting intimacy in the beginnings of life. Two case vignettes from my doctoral research illustrate how shared musical moments can foster intimacy for the hospitalised infant and parent in a NICU, calling for consideration of context and culture when exploring how musical beginnings can foster intimacy.

Keywords: communicative musicality, intimacy, parents, music therapy, musical moments, NICU

Editorial note: In 2016, Voices hosted a special edition to accompany the launch of a Massive Open Online Course (MOOC) on the topic of "How Music Can Change Your Life". Thirteen authors agreed to develop position papers for the MOOC, with two articles being developed to accompany each of the six topics within it. Each author has highlighted the theorists and researchers who have influenced their thinking, and included references to their own research or music practices where appropriate. These papers have been written with a particular audience in mind—that is, the learners who participate in the MOOC, who may not have had previous readings in any of the fields being canvassed. We hope that you find these articles interesting, whether reading as a MOOC learner, a regular VOICES reader, or someone who is discovering VOICES for the first time.

Intimacy Through Early Musical Beginnings

There is an exchange there- there is communication [….] when you are singing to him, it gives me the impression that he is not- he is getting more from that than just talking to him [….] for me it is a deeper connection and a deeper bond- bonding experience than just talking to him through the isolette (Zander, father of Evan, describing his experience of sharing music with his son in the NICU shortly after Evan was born[1])

The notion of music as an interpersonal process shared between humans is nothing new to many of us. For centuries music has held a prominent and crucial role within human existence. Across many decades and multiple theoretical fields, researchers and practitioners have examined and explored the complex phenomena of music and its strong association with human intimacy and connection. Zander’s words above, recorded during an interview as part of my doctoral research, appear to describe the powerful way that singing in the neonatal intensive care unit (NICU) connects and supports a deep and intimate bond with his baby, achieved exclusively through a musical process. Intimate connections through music and the relation of music to the very beginnings of human life frame the very core of Malloch and Trevarthen’s theory of communicative musicality (Malloch, 2000; Malloch & Trevarthen, 2010b).

This paper will discuss shared musical moments in fostering intimacy, illustrated through the musical experiences of two parents and their hospitalised infants. These case vignettes are taken from my doctoral research exploring parents’ experiences and perceptions of singing and using their voice with their preterm baby in a neonatal unit (NU) (McLean, 2016) that acts as a foundation for this paper. This qualitative, exploratory study explored the lived experience of nine parents in a NU who had also experienced music therapy services with their baby during their hospital admission. I conducted in-depth interviews with each of the nine parents, using strategies from interpretative phenomenological analysis (Smith, Flowers, & Larkin, 2009) to understand and interpret their experiences. The principles of communicative musicality theory will be highlighted throughout the paper, calling for a greater acknowledgement of the parents experience to better understand and examine the role of music in fostering intimacy and connection through early musical moments.

The concept of intimacy within academic and popular culture is multifaceted and complex. Marar (2014) described an elusiveness and subtlety of the concept that makes it challenging to define. For the purposes of this paper, intimacy will be understood through the contemporary lens of the Merriam-Webster’s Online Dictionary:

  1. a state marked by emotional closeness
  2. a quality suggesting closeness or warmth
  3. something that is very personal or private

The term musical moments is also relevant to this discussion of fostering intimacy through musical beginnings. I have used the term musical moments to refer to shared instances or exchanges occurring between a parent and their baby that are musical in nature. This understanding of musical is grounded in Malloch & Trevarthen’s (2010b) inclusive view of musicality being an innate capacity of all humans to communicate and connect that moves away from the more conventional view of musicality as something only held by trained or naturally talented musicians. These moments are considered musical through not only traditional exchanges such as instrument playing or singing together but also through more subtle musical exchanges including humming or shared body movements that frame early parent- infant interactions of connection. These interactions can involve the musical elements of pulse, rhythm and shared timing as described in the theory of communicative musicality.

Musical Intimacy for the Hospitalised Infant and Parent

Adult-infant musical companionship has been examined and discussed across multiple fields of infant research and practice, with numerous studies documenting an infant’s musical development and sophisticated musical perception and abilities (H. Papousek, 1996; Trehub, 2001; Trehub & Degé, 2015; Trevarthen, 2001a, 2002). Studies have also explored the role of the parent or caregiver in nurturing their infant’s engagement in and capacity for music (M. Papousek, 1996; Trehub, Ghazban, & Corbeil, 2015; Trevarthen & Malloch, 2002) and the use of music to provide for the needs of the baby through musical parenting practices (Custodero & Johnson-Green, 2003, 2008).

When examining parent infant interactions, research has shown that musical exchanges allow the infant and parent a way to express and share feeling states with one another that are crucial to the development of the parent and infant relationship (Milligan, Atkinson, Trehub, Benoit, & Poulton, 2003; Rock, Trainor, & Addison, 1999; Trevarthen, 2001a, 2001b). Zeedyk (2006) argued that the inclusion of imitation as a strategy within these interactions is particularly powerful for facilitating intimacy “in which both infant and adult are actively engaging in an emotionally endowed, communicative exchange” (p. 332). This ability and desire to be aware of, and responsive to, another’s feeling state has been defined by Stern (1985) in his early writings as affect attunement. Trevarthen (2001a) expanded on this view of sharing experience and emotional states through the notion of an infant’s innate intersubjectivity. Both these theoretical understandings illuminate the emotional potency and sophistication of early interactions. Malloch’s early research (2000; 2010a) identified the musical parameters of pulse, quality, and time as foundational to this theory, forming the basis of all communication at the beginnings of life, and through this musical exchange, the parent and infant are able to communicate and connect on an intimate level.

For a hospitalised, premature infant requiring intensive medical care, both the infant and their family are faced with multiple challenges in opportunities for attuned interaction and the development of a healthy parent infant relationship (Udry-Jørgensen et al., 2011). Prenatal attachment processes forming between a parent and their baby during the prenatal period are at risk in the context of a high-risk pregnancy and premature birth experience (Pisoni et al., 2016). Studies have highlighted specific relational threats for the infant and parent including the neurodevelopmental immaturity of preterm infants and related avoidance behaviors during interaction (Brisch, Bechringer, Betzler, & Heinemann, 2003; Newnham, Milgrom, & Skouteris, 2009). Parental trauma has also been documented as affecting a parent’s representation of their infant and related capacity for responsive and attuned engagement with their hospitalised baby (Keren, Feldman, Eidelman, Sirota, & Lester, 2003; Korja et al., 2010 ). Furthermore, previous research on the parenting experience in a NICU has revealed themes of parental distress, depression, lack of control, separation, adapting to risk, oscillation between hope and hopelessness, feelings of exclusion and inclusion, and preserving the family (Obeidat, Bond, & Callister, 2009; Swartz, 2005) as major challenges facing parents of a premature and hospitalised infant.

Music Therapy and Communicative Musicality: Representing the Parents Experience

When exploring intimate processes between parents and their infants, it seems important to consider the parent’s experience of such moments with their baby more closely. A growth in studies examining the applications of communicative musicality theory across a wider variety of clinical and social landscapes has culminated in Malloch & Trevarthen’s seminal text (2010a). Despite this, there remain limited studies that explore the qualitative experience and perspective of this musical exchange through the voice of the parent. From a contemporary music, health and well-being perspective, research methods that “facilitate the exploration of the subjective and phenomenological aspects of musical experience” are needed and “ it is these very individual aspects of musical life that lie at the heart of why music has powerful beneficial effects upon health” (Macdonald, 2013, p. 11).

In the discipline of music therapy, the theory of communicative musicality has provided a comprehensive and influential theoretical grounding for research and practice across multiple practice fields (Edwards, 2014; Pavlicevic & Ansdell, 2009; Robarts, 2010; Wigram & Elefant, 2010). Malloch & Trevarthen (2000) concurred, stating that “music therapy is based in the life- long human trait of creating companionship with another by structuring expressive time together” (p. 14). However, Pavlicevic & Andsell (2009) called for additional theoretical grounding beyond communicative musicality theory to ensure that a more “culture- centred, context- sensitive and reflexive orientation….”(p. 358) is created. This argument is relevant when working closely with families and taking into account each family’s unique cultural system and the influence of context on shared musical moments (Loewy, 2015; McLean, 2016; Shoemark & Dearn, 2008; Shoemark, Hanson-Abromeit, & Stewart, 2015).

Two key music therapy studies have applied communicative musicality theory to clinical practice with premature and hospitalised infants in a NICU. Malloch, Shoemark, Črnčec, and colleagues (2012), conducted an interventional study measuring the effect of live, contingent singing from a music therapist, for late pre-term and full-term infants in a NICU. This study explicitly acknowledged the principles of communicative musicality and the relevance of this theory in working as a music therapist with hospitalised infants in a NICU setting. Similarly, Haslbeck’s (2014) study of music therapy with premature infants in a NICU utilised communicative musicality theory to interpret the potential of a music therapist’s role in uncovering a preterm infant’s communicative musicality capacities, drawing heavily on acoustic analyses of audio recorded interactions between the therapist and infant. Both these studies highlight the synergy between music therapy practices with hospitalised infants and communicative musicality principals, providing valuable insights for music therapists and other health professionals in supporting hospitalised infants through musical interactions. What is not explored within these studies is the parent’s role and perspective and how music therapists and other professionals can foster and support opportunities for these shared musical moments to occur in such complex scenarios.

We are missing a piece of the communicative musicality puzzle when it comes to more deeply exploring a parent’s musical role with their baby in such complex settings. While the communicative component of this theory assumes a shared musical exchange is at play between an infant and parent, limited discussion explores the parent’s perspective and role within these intimate musical moments with their acutely unwell baby. The conditions and variables that surround these musical moments require further exploration.

Musical Moments Leading to Fostered Intimacy for the Hospitalised Infant and their Parent

My background as a music therapy clinician and researcher with hospitalised infants and their families provides a clinical lens for exploring the applications of communicative musicality theory in the context of a neonatal hospital setting. The following case vignettes involve the stories of two parents who participated in this research. For the purposes of this paper, some of the main themes that emerged from these parents’ interviews will be presented, illuminating the way in which shared musical moments with their baby fostered a sense of intimacy.

Zander & Evan’s Musical Beginnings

Zander was a first time father to his son Evan who was born prematurely at 27 weeks gestation and spent over 3 months in the NICU and special care nursery. Evan required intensive medical intervention to support his physical stability, growth, and development across an extended period of time. Evan’s parents visited the hospital every day to be close to their new baby despite the multiple physical and medical barriers that met them in the NICU. As Evan’s condition slowly stabilised, Zander and his wife Simone enjoyed regular kangaroo care with Evan beside his isolette. Kangaroo care is the act of skin-to-skin contact between parent and infant with the infant positioned on the chest of the parent or caregiver (Moore, 2015).

I met Evan and his parents in the NICU 6 weeks later when they were still requiring intensive care support. Zander and Simone attended a parent support group I was running focused on a parent’s use of voice and singing with their preterm baby. After the group, Zander and Simone approached me to seek additional advice and guidance around using their voice to create a connection with their baby. Zander and Simone expressed their own anxiety about Evan’s health and described the busy and noisy environment of the NICU as making it extremely challenging to know where to start with sharing such time with Evan.

Weekly music therapy sessions then commenced with Evan and his parents with a focus on supporting Zander and Simone’s opportunities to engage in intimate musical moments with their baby. Zander had a strong relationship with music, playing guitar, singing, and composing music in a band across many years. He expressed his desire to actively engage in musical moments with his baby but felt overwhelmed and unsure of how to make this happen in the NICU environment. Music therapy sessions involved facilitating Zander’s musical interactions with his baby during Simone’s cuddles with Evan. This involved close communication and collaboration with staff and Evan’s parents to discuss the role of music and sound for Evan and his family based on their baby’s developmental age, medical condition, and the physical conditions of the NICU environment. Zander chose several familiar and emotionally significant songs that he wished to share with Evan and that he felt comfortable to play on guitar and sing. My role involved supporting Evan’s parents to engage in this musical process in a safely structured and contingent way, facilitating opportunities for positive moments of connection with their baby and supporting Zander and Simone’s active parental role in the hospital setting.

The following section of the vignette presents a narrative that emerged from Zander’s interview as part of my doctoral research study. This interview took place after Zander had been in the NICU with Evan for just over 2 months and had been engaging in music therapy sessions.

When discussing Zander’s experience of engaging in musical moments with his baby in the NICU, he described his strong existing relationship with music as influencing his desire to use music with Evan and be a “musical dad” for his new son. Zander described his experience of playing the guitar and singing to Evan in the NICU as “momentous” yet painfully bittersweet at times due to the transient nature of the musical exchange and how quickly a powerful moment of connection through the music would pass.

Well it's- the- the feedback you get is really fragile and hard to- you can't hold onto it, it is something that happens and you- you just want- because of the situation that we are in, you just want something to cling to.

Zander also described these musical interactions shared with Evan as emotionally “supercharged” moments in contrast to the dire circumstances of the NICU and Evan’s medical state. The emotional potency of these musical processes with his baby were at times overwhelming for Zander.

Yeah, it is crap there is no- there is no sugar coating it- this is shit, this is really shit! […] but the flip side of that is the experiences that you do have, like when I am singing to him, is just- super- charged beyond belief! […] It is almost too much.

Zander experienced intense moments of intimate connection with Evan through these shared musical processes. When Evan offered Zander a response during the musical dialogue through eye contact or a head turn towards Zander this was perceived as a “two way” conversation occurring between father and son through the music.

Cause it is you know, one thing for him to be sort of sitting there looking at you, but then a bit of- sound gives you that engagement and that activity with him and so it creates a- creates an intimacy […] yeah and there is an exchange in that. It is not a 'one way street'.

Zander also described the importance of singing and guitar playing with Evan as an exclusive, personal and intimate experience for himself, his baby and wife in the NICU.

It is a really um, it is an intimate experience for me […] it is not something that I want to share exactly, if other people like the guitar playing that is great but don't talk to me while I am doing it, just let me get on with it, this is about me and Evan.

Zander’s experience of using music through playing the guitar and singing familiar songs to his baby presents us with a clear insight into the connection between musical experiences and achieving a sense of shared intimacy with his baby in the NICU. Zander’s reflections speak to several underlying parameters of communicative musicality theory. His descriptions of time passing transiently during musical moments with Evan relate to Malloch’s (2000) notion of narrative through music and the musical ways we interact with others through time. Zander also explicitly refers to the potency of Evan’s response to his musical offerings which he experienced as a “two-way conversation” with his baby through the music, highlighting a sense of communication and “shared sympathy and situated meaning” with his baby (Malloch & Trevarthen, 2010b, p. 4). The powerful and emotional experience of singing and playing guitar to his baby shines through in his stories and he explicitly refers to the “intimate experience” of these musical moments with Evan in the NU.

Annabelle and Harriet and Winnie’s Musical Beginnings

Annabelle was a first time mother to identical twin daughters Harriet and Winnie who were born prematurely at 28 weeks gestation and spent over 2 months in the NICU and special care nursery. The twins both required intensive medical support to ensure their medical stability in the early weeks, followed by a long period of time in the special care nursery to support their growth and development through the establishment of feeding across later weeks. I met Annabelle during a parent support group that I was facilitating with the social worker in the NICU focused on an infant’s auditory development and the role of parental voice and singing for infants in a NICU and nursery setting. Annabelle actively contributed to the group discussion on her experience of using her voice to connect with her daughters. She described herself as someone who had a strong connection to all types of music, listening to a variety of music at home and in the car. Annabelle had intentionally accessed classical music during her pregnancy to relax and promote a calm state. After the parent group Annabelle consented to taking part in the research study, engaging in an interview where she described her experiences and perceptions of singing and using her voice with her twin daughters.

The following section of the vignette presents a narrative that emerged from Annabelle’s interview. This interview took place after Annabelle had been in the NICU with Harriet and Winnie for over 6 weeks and both daughters were still requiring time in the nursery to support their respiratory needs and continued growth. The powerful physicality of musical moments in fostering intimacy with her daughters is illuminated in Annabelle’s narrative.

Annabelle described the role of humming and singing to connect with her daughters in the NICU. At times, this was the only way Annabelle felt able to bond with her babies and “touch” them with her familiar voice when multiple physical barriers were present.

I am the number one voice that they recognise from in utero and so I just wanted to give them that familiarity of Mum's voice […] My touch wasn't giving them that because I couldn't touch them when whilst they were inside me- it was my voice. My voice was the only connection that we had from now and in utero […] so I had to use that as much as I could to- to keep that relationship there. So whilst they were in an untouchable bubble, so to speak, I could touch them with my voice.

Annabelle described the powerful physicality of using her voice to hum to her daughters during kangaroo cuddles together, which supported a stronger sense of connection and closeness between them in the NICU.

It was only upon choosing to hum over singing that I felt more of the vibration in my chest and I just thought that surely that is going to be quite positive for the girls that they are going to really feel that vibration when I hum […] I could feel it because- they were on me- I could feel that vibration between the two of us.

Annabelle also described the importance of the exclusiveness of shared musical moments with her daughters in the NICU. This was experienced as a private time for Annabelle that was solely focused on sharing intimate interactions together with her daughters.

It's about my girls and I, not about anybody else […] it’s not about anybody else but the three of us.

Similar to Zander’s reflections, the emotional power of these musical moments with her daughters were at times an overwhelming experience for Annabelle in the NICU.

Sometimes when I would be singing, you know, humming was different because you could sort of hum through a bit of a- a crack where singing, I would just have to stop because I would just- tearing up too much and, I am like, ' I just have to stop, I just have to stop', I couldn't push through a song when I was crying, you know.

Annabelle’s experience of humming and singing with her twin daughters highlighted the role of these musical moments in fostering feelings of intimacy and closeness with her babies. Annabelle described the physicality of these musical moments shared with her daughters in supporting her feelings of connection and closeness with them through the vibrations of her voice. This multi-modal experience of shared musical moments aligns with Malloch & Trevarthen’s (2010b) understanding of musicality as a way “to share purposes and meanings through touch, sight and sound” (p. 9).

The emotional potentials of music also emerged from Annabelle’s interview, illuminating the potency of singing interactions for Annabelle. Malloch described musical companionship as “the vehicle that carries emotion from one to the other” (2000, p. 48). Annabelle’s words shed some light on the emotional complexity of a parent’s musical experience with their baby in a NICU and the need to acknowledge this when working to support parent’s to share in intimate musical companionship with their baby. While the sharing of emotional states between an infant and their caregiver is acknowledged as a vital component of wellbeing and development for the infant and caregiver’s relationship, (Balbernie, 2007; Stern, 1985; Trevarthen, 2001b) sensitive consideration of the emotional power of music for some parents in this context needs to be addressed to ensure parents are appropriately supported to identify and process such emotional moments experienced through music.

Both Annabelle and Zander’s stories illustrate different ways of being musical with babies in a NICU, from playing guitar or singing a song through to more understated musical uses of the voice to hum or chat to their baby. While these musical behaviours vary from the conventional through to the subtle, they are understood as being musical in nature through the lens of communicative musicality theory. “We use the term 'musicality' to distinguish the underlying forms and qualities of expression in time that characterise and give meaning to all kinds of music - sung, or performed on instruments” (Malloch & Trevarthen, 2000, p. 13). Through Zander’s guitar playing for Evan or Annabelle’s humming to her twins during a cuddle, a shared seeking of companionship and a “communicative will” (Malloch & Trevarthen, 2000, p. 13) existed through such musical behaviours. Figure 1 represents Zander and Annabelle’s experiences of sharing musical moments with their baby in the NICU and the multiple ways that musical moments fostered intimacy for these parents and their babies.

Multiple ways musical moments fostered intimacy for Zander and Annabelle and their babies in the NICU
Figure 1. Multiple ways musical moments fostered intimacy for Zander and Annabelle and their babies in the NICU. [view full size image]

These parents’ musical stories strongly speak to each of these facets of intimacy that make human connections possible. Moreover, Zander’s experience of musical moments with Evan as transient and fleeting in nature mirror Marar’s (2014) discussion on the elusiveness and subtlety of intimacy as a concept.

Grounding Communicative Musicality Theory in Context and Culture

Parents of a hospitalised infant in an intensive medical setting are surrounded by a range of conditions specific to the NICU context that shape their experience of and engagement in music. As Zander and Annabelle described, this influenced how they accessed their voice or an instrument to share in musical moments with their baby. The role of music to connect, nurture or communicate with their baby and the powerfully emotional and at times overwhelming moments of intimacy that these musical moments evoked were shaped by context. The music therapist’s role in supporting the facilitation of these musical moments for Zander and Annabelle within the context of the NICU is introduced briefly through the case vignettes and provides a small insight into the value of partnering with parents to support early musical beginnings for the hospitalised infant and their family. Furthermore, Zander and Annabelle’s existing relationships with music had an influence on the way they individually engaged in musical moments with their babies. Zander’s existing musical history of playing guitar and singing in a band strongly influenced his desire to use music through guitar and singing as a way to share in intimate moments of connection with his baby. While Annabelle’s use of her voice through humming and singing with her twin daughters was nested in her own existing relationship with music.

The parent’s perspective provides us with an opportunity to further consider the context and culture of musical beginnings that remains underprivileged within the application of communicative musicality theory in practice and research. This paper argues for greater acknowledgement of the individual influences that shape human’s engagement in musical moments when applying communicative musicality principles to practice. The technically measurable and tangible behaviours and patterns occurring during early musical exchanges have been identified through this comprehensive theory. However, we are left wondering about the many other influences within the culture and context of the infant and parent that play a role in how musical moments unfold and how and why music foster’s intimacy in the very beginnings of life. The complexity of music as a social and intimate process shared between humans demands the exploration of individual circumstances and cultural values, attitudes and beliefs if we are to more deeply understand how we can best foster intimacy through music.


This paper has illuminated the powerful role of shared musical moments in fostering intimacy for parents and their hospitalised infant in a NICU. Grounded in Malloch & Trevarthen’s (2010a) theory of communicative musicality, a critical and contemporary perspective on this fundamental theory underpinning early musical interactions for the hospitalised infant and parent has been shared. Through greater representation and exploration of parents’ active musical roles with their baby, grounded in the cultural context of the parent and infant, this paper provides us with a deepened understanding of music’s potential for supporting human connection and shared intimacy in the beginnings of life.

The perspective of the parent has shed light on the way in which a variety of early musical interactions can lead to a parent’s experience of deep human connection and intimacy with their baby in a NICU. Musical moments were perceived by these parents as physically intimate and exclusive and involving a rich emotional exchange with their baby that supported a sense of human connection. In promoting and exploring the relationship between music, health, and well being, this paper has provided a platform for further acknowledging the very powerful role of early musical interactions in fostering intimacy through the experience of the parent. Annabelle will conclude this paper through her own words:

I would hum when they were very, very little. So for the first few cuddles I would just hum and that was always 'Close To You' by the Carpenters […]I think it was just what I started to hum and then I thought, oh the words are perfect you know, that is what I want to be, is close to you! […] I used it very much as a connection to them, you know […] the words of the song were saying exactly what- what I felt.


[1]Please note that these are pseudonyms and not the real names of participants.


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