Music Therapy on the High Note
By Amber Beggins

The script:
(You’re listening to the High Note, a podcast by Amber Beggins. This episode is sponsored by Bord Pickup Trucks, for all your uneventful trucking needs.)

Good morning, afternoon, or evening, and welcome to the High Note. I’m your host, Amber Beggins, and thanks for tuning in! So, you can learn a lot about a person from the music they listen to. Many of us have that “comfort” song, album, or artist that entrances a part of us that’s hard to describe, and I think there’s a lot of vulnerability and identity in that. Take a moment to consider what that is for you and how it connects to your life or experiences. Personally, my comfort music comes from this rap duo by the name of $uicideboy$, with dollar signs instead of S’s. Maybe that name is enough on its own to make you cringe but hear me out. They’re cousins who both come from backgrounds of heavy addiction, especially to opioids. Even with all the hardships that brings, they’ve stuck together and for the last ten years, prolifically released music that’s brutally honest about their struggles with mental health and substance use. And for the last few years, they’re both sober. I find it so inspiring that they’ve achieved long term recovery and are continuing pursue even greater success than when they were using. I also think this speaks to the extraordinary, and largely untapped potential for music to help people struggling from substance use disorder.

Just so we’re on the same page, substance use disorder is the condition associated with uncontrolled use of one or more substances – that is, drugs – despite harmful consequences. It’s an ever-growing problem in the United States and worldwide, with more and more people meeting the criteria for substance use disorders over time, and as the risks associated with the unregulated illicit drug supply continue to increase in severity. It’s also a notoriously difficult disorder to treat with extremely high rates of relapse among recovering users across the board. As a result, there’s a growing movement among substance users, their loved ones, professionals, and society at large that’s questioning the strictly abstinence-based approaches that have dominated recovery for so long, and it’s called harm reduction. Harm reduction is built on the philosophy that treatment should focus on minimizing the harmful effects of substance use and high-risk behavior rather than eliminating them entirely, at least in the beginning. It lets clients work toward change incrementally and at their own pace, which many argue is essential to setting them up for lasting recovery. In this episode, we’re going to look at one specific harm reduction-based intervention called music therapy. It’s an established practice in which clients listen to, analyze, compose, and/or perform music in pursuit of various treatment goals.

Music therapy is a promising form of substance use disorder treatment that may reduce harm by redirecting energy toward non-substance-related activities with uniquely tangible results. Yet, most aren’t aware of it or can’t access it, largely due to a lack of education and concrete information. Expanding access by embracing music therapy in the short term could help us learn much more about its efficacy and how it works but will require a shift in the entire conversation on mental health treatment.

But first, let’s back up for a second and consider what exactly music therapy is and why it’s worth exploring in the first place. The basic premise is that music is such a universal experience that we can use it to encourage engagement in treatment. That might look like listening to music as a group and discussing the lyrics, playing instruments, or writing and sharing original music. Music is extremely versatile, and that’s one of the things that makes this therapy so unique. Think about all the ways that music shows up in your life. Do you listen to music for relaxation, or as an emotional outlet when you’re sad, anxious, or angry? Do you spend time with others at concerts or nightclubs? Maybe you find joy and community by playing an instrument or tell your own story by composing original pieces. The goals addressed in music therapy are about as varied as the ways we use music outside of a clinic. For example, licenced music therapist Claire Ghetti explains in a 2004 article that substance use councilors may use music therapy to establish trust in treatment and group cohesion, promote accountability and self-awareness, encourage reflection on both harmful and helpful aspects of substance use, develop self-esteem through validation of identities separate from addiction, and affirm internal motivations, priorities, and healthy coping mechanisms. These are all worthy accomplishments in a substance use treatment setting, but the full value of music therapy extends into a broader social framework centered around harm reduction. Where reducing harm is concerned, it’s always important to consider treatments that don’t strictly require complete abstinence, but music therapy offers more than that. As an expressive therapy, where clients are supposed to draw on their own experiences and connect them to treatment, music therapy is kind of required to be nonjudgemental. Consequently, it can be a remarkably powerful community-building exercise. These kinds of vulnerable group activities that build deep connections are very important in treating addiction, which is a condition that thrives on isolation. Additionally, the variety of music that exists lends itself to cultural and personal relevance in participants’ lives. In a supportive setting, music is something that just about anyone can engage with, which means that there’s a low threshold to accessing treatment. These components all help set up the greatest number of clients to achieve the greatest amount of success, which is exactly what harm reduction is all about.

Beyond these more general benefits, I’d also like to touch on a specific aspect of music therapy that I don’t see talked about much, in music therapy or other treatment circles, and that is the creation of a final product. We hear a lot about how connection and honest self-exploration are key tenets of harm reduction, but I think there’s something to be said about the effects on quality of life that come with developing tangible skills and creations. In a 2019 cohort study of patients in treatment for co-occurring substance use and mental health disorders, the authors Kirkland et al. review observations of positive treatment outcomes among clients who don’t just compose and perform, but also record as part of music therapy. They argue that recording offers unique opportunities for developing self-esteem, confidence, agency, and technical skills which persist beyond the conclusion of treatment. Of the clients surveyed, the authors found that a majority consider the creation of a final product among the most valuable parts of their treatment with music therapy. This makes a lot of sense to me. I mean, I can appreciate the sentiment behind, “it’s about the journey, not the destination,” but isn’t it nice to look around and see that you’ve made it somewhere new? Otherwise, we’d all be perfectly content just running around in circles. That’s not to say that more conventional forms of therapy don’t get us anywhere – but my point is, treatment can often feel like an uphill battle with little to show for it, especially when you’re so accustomed to instant gratification. I find it very difficult to gauge how far I’ve come by trying to remember what I said in a meeting months ago and comparing it to what I said today. Alternatively, recording musical performances and compositions provides tangible material for me to reflect on as well as reminders of my abilities and progress. For those who develop enough confidence to do so, recordings can also be shared and celebrated with others, and even monetized in the long-term, serving as lasting tools for sustaining self-exploration, community, and quality of life.

While this might all sound fine and dandy, music therapy is still a relatively obscure modality, especially in the field of recovery. According to Dr. Amy Clements-Cortés in a 2018 article, music therapy is offered at less than 15% of American substance use treatment facilities. You might be wondering, if music therapy can be so helpful, why isn’t it more available? Well, the consensus seems to point to issues in education and research. Psychiatry overall is a field dominated by evidence-based practices. These are specific forms of treatment backed by extensive bases of research in support of their efficacy, with favor for data obtained through randomized controlled trials. This is considered the highest quality, most irrefutable data, and there isn’t much research on music therapy that uses it. In a 2010 meta-analysis, Dr. Michael Silverman found that less than 20% of 52 studies surveyed consisted of randomized controlled trials. This is a problem because it means that most of the research on music therapy isn’t confidently considered verifiable or more beneficial than harmful. Moreover, the difficulty of securing resources to conduct more research constitutes a high barrier to expanding this literature base and effectively keeps music therapy gridlocked.

There’s another similar obstacle in the way, namely a lack of education. I interviewed a music therapist at Northpoint Recovery Colorado, and when asked why she thinks music therapy isn’t more widespread, she pointed to education. “I would like people to know what music therapy is. That it’s not just, like, playing a song — it’s a lot deeper than that.” She sees expressive therapies in general as overlooked and underutilized. To investigate this further, I administered a survey via Reddit to gauge peoples’ familiarity with and opinions of music therapy. Indeed, out of a couple dozen responses, only one respondent answered that they know something about how music therapy works beyond just having heard of it, even though all participants answered that music is at least somewhat important in their lives and most expressed interest in trying music therapy. So, while demand is definitely there, there’s still a lot of unsureness and apprehension to really give it a shot. She explained to me that this tentativeness exists among clinicians and clients alike. She said this with regard to clients: “Some of the comments I get are like, ‘well, you know, I saw in the schedule that we have music therapy and initially I thought that was going to be really stupid, like it was going to be a waste of time.’” What I find really interesting about this is that most of these clients end up enjoying the therapy a little bit later regardless of their initial hesitations. Again, just about anyone can gain some kind of benefit from it – they just have to give it a chance and learn what it’s really about.

The more I sit with this topic, the more I think that there’s a greater purpose here than just offering more music therapy programs. In fact, I argue that there need to be shifts in the way we talk about the entire field of mental health. For one, I think there’s sometimes this kind of subtle stigma among recovery and mental health circles that work and play are mutually exclusive. I see so many people, myself included, get deeply entrenched in this notion of “no pain, no gain” – and while that mentality certainly has value, I think it becomes easy to brush off more playful things like simply listening to music as somewhat irrelevant to getting better even though they’re often an integral part. This music therapist shared an example with me that, I think, beautifully illustrates the importance of this playfulness. It was from a recent session with her mental health group that involved a game in which players try to avoid dropping an egg. “I had a client come up to me afterwards who said, ‘I felt really bad and self-conscious about dropping the egg, but the group was so positive and supportive. I’ve never had an experience with a group where I haven’t been shamed for making a mistake.’ I think music is a cool, safe way to explore, like yeah, it’s okay to make mistakes; we’ll pick it up and try again.” I think the fact that what might seem like just a silly game, whose main purpose is to facilitate group cohesion, had such a profound impact on this client contains a powerful message: the mere fact that an activity seems playful and fun does not mean it isn’t accomplishing real, important work that has a real, lasting impact. Remembering to, yes, do the hard work, but also take some time to simply enjoy life with those close to us gives treatment a balance that is important to appreciate.

But also, there may be a more radical discussion to be had around the way we decide which practices are worth offering in the first place. I mentioned earlier in the episode that psychiatry favors evidence-based practices, specifically ones that are backed by multiple well-designed, randomized controlled trials. There currently isn’t a lot of data on music therapy that comes from such trials, which means it isn’t considered as “safe” a treatment as something like cognitive behavioral therapy and might explain why it isn’t more popular. Look, the fact that we have this standardized method of scrutinizing data to decide what practices are the most verifiably beneficial is wonderful. Academic rigor is essential in fields like substance use treatment or general psychiatry that deals with peoples’ livelihoods and physiological chemistry. But the bigger picture shows that it’s getting increasingly difficult to meet these very high standards. Far more people are conducting formal research now than when we adopted evidence-based criteria decades ago, and that means obtaining funding and resources is an extraordinarily difficult, time-consuming process. This is especially true for practices like music therapy that are a little more difficult to quantify, even though we have a lot of descriptive evidence to support it. As a result, it could be another couple decades before enough randomized controlled trials have been run to completion to embrace music therapy as truly evidence based. But while so many continue to struggle while relying on traditional treatments, and since the risks associated with music therapy don’t seem any greater, should we really wait to give it a try? I mean, just talking to this music therapist and listening to her stories about clients’ experiences has me utterly convinced that her work has a huge impact on those she works with. Maybe we would see breakthroughs in improving substance use treatment if the field at large would simply hear expressive therapists out.

To recap, we hopefully can see how music therapy is a promising, versatile, and uniquely tangible form of treatment for substance use disorders. Even so, research and education on it still have a ways to go before it catches up to other practices, but we can expedite this process by emphasizing play and reconsidering evidence-based criteria in the conversation on mental health.

Thinking back to your own personal comfort music, how often do you share it with others, or receive someone else’s comfort music? These forms of expression carry so much weight, but many of us don’t really get to fully explore that with others the same way we would in music therapy. So, what can we do to best care for and cultivate such safe spaces for musical connection? How can we show appreciation and educate about expressive therapies? Most of us are intimately familiar with the power of music. When more people learn about how we can harness this power to support so many people in need, we can hopefully do more to support those who use it to save lives. Thanks for tuning in to the High Note; I’m Amber Beggins, and good night, or morning.

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