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Exploration of the Implementation of Music Therapy into the Health Services: Lituanian Experience
Integration of music therapy into medical treatment facilities is very uneven in different countries. Scientific evidence of successful examples and sharing of good practices between countries is essential for the further development of music therapy and the improvement of the quality of complex medical services. The goal of this study was to analyse the situation of music therapy implementation into the health services in Lithuania. Analysis of historical background, legislation and overview on music therapy training has been made. Music therapy in Lithuania has gone through more than thirty years of development. Acqaintance and acceptance of music therapy as a relevant and fruitful component to the complexity of the existing medical services was long but successful process. Overview of current initiatives and achievements of the implementation of music therapy into clinical practice and research has shown promissing positive results in developmental pediatrics, psychiatry, special education, neurology, neonatology, oncology, somatic and preventive medicine, rehabilitation. The Music Therapy Master program in Lithuania is being implemented. Possibilities to use music therapy as an inovative service and resourse in various medical settings are in the process of the rapid growth. Collaboration involving music therapists in interdisciplinary teams would help to achieve a comprehensive, versatile patient-centered and health-centered complex service.
It is customary to talk about music therapy as a new profession. This is not entirely true, since music therapy has a long and rich history. Music has been used for centuries to lift the mood, calm soothe the body or spiritual pain, foster cognitive and motor development 1, 2. According to contemporary music therapy definitions used by the World Federation of Music Therapy and by professional organizations across the world, music therapy is described as an established allied health care profession that entailes a therapeutic relationship between a patient and certified music therapist. Nowadays, treatment techniques are designed to achieve functional changes in mood, brain and behavior. This is usually a pleasant therapeutic intervention for patients of all ages and with various health problems.
Music therapy in medical literature is widely reported as an effective complementary service in the following areas: adult psychiatry, especially in the treatment of depression, eating disorders, personality disorders; children and adolescent psychiatry in reducing emotional and behavioral disorders; neurology, restoring brain functions after stroke and other injuries; rehabilitation and nursing of elderly people with Alzheimer‘s and related dementias, with Parkinson‘s disease; children with autism; preborn babies; psychosocial oncology and other fields 3, 4, 5, 6, 7, 8. This shows a substantial progress in the establishment of music therapy service and research strategies for clinical work. However, appropriate understanding of the possibilities of music therapy and its integration into medical treatment institutions is very uneven in different countries. This is why scientific evidence of success cases and sharing of good practices between countries are essential for further development of music therapy and improvement of the quality of complex medical services in todays world. Recognition of music therapy and the way of its appreciation has had its own history, which was different in each country, therefore it is important to collect data, describe and study the vast possibilities of music therapy applications.
The goal of this study is to analyse the situation of music therapy implementation into the health services in Lithuania.
1. Collection of the historical data and description of the development of music therapy in the country.
2. Analysis of legislation of arts therapies.
3. Overview on music therapy training.
4. Statistical data about the number of music therapists in Lithuania.
5. Overview of current initiatives and achievements of the implementation of music therapy into clinical practice and research.
In the late 1970’s till 1990’s the early pioneers of music therapy started the practice in the health resort town Druskininkai. They carried out services in music therapy rooms set up in the sanatoriums and investigated the effects of music in treating psychosomatic diseases. The research data provided the basis for a first doctoral thesis on music therapy in Lithuania 10. Numbers of professionals interested in music therapy and its applications are gradually increasesing in the country.
The Re-Establishment of the State of Lithuania (1990) and the law on Social Integration of Disabled (1991) made way for the development of music therapy in educational contexts. The Lithuanian Centre of Alternative Arts Education was established in 1992. There were quite a few initiatives taken by the centre’s founder prof. Albertas Piliciauskas. First of them was the establishment of music classes, which were held in the country’s big cities, named “Credo” for children and adults with disabilities 11. Second, he initiated the start of a doctorate program with a target to investigate arts for handicapped at Vilnius Pedagogical University 12, 13, 14, 15.
The Lithuanian Association of Educational Music Therapy was established in 1997. The organization aimed to unite musicians and music pedagogues, who pioneered in educational settings working with special needs children. Another important goal of the organization was training of music therapy skills. The first training phase was focused on Nordoff-Robbins approach. In 1999 – 2000 and later during 2003 - 2017 the Association launched courses given by renowned music therapists from Europe and USA. In 1997 a working relationship was established with the Norwegian music therapists, mainly with prof. Brynjulf Stige, the head of music therapy programme in Sandane. A cooperation agreement between Vilnius Pedagogical University and Sogn og Fjordane University College was signed in 1998. This resulted in seven Lithuanians graduating with a degree in music therapy in Norway, while one of the colleagues graduated from Augsburg University in Germany. This led to a jumpstart in the activities of music therapy in Lithuania 11.
From 2002 onward, Lithuanian Association of Educational Music Therapy has been involved in projects. In 2002 – 2003 it implemented PHARE 2000 ACCESS project “Social-interactive model: integration in partnership of musical activities with cerebral palsy teenage”. In 2004 – 2005, it carried out Geneva Initiative in Psychiatry project “Artistic self-expression of persons with severe mental problems”. Lastly, in 2011-2013, the Association participated in the European Social Fund project on implementation of art therapy and music therapy models in schools.
In years 2008, 2010, 2014, 2016 international music therapy conferences were organized in Lithuania. The field of music therapy services and research has expanded, so in 2011 The Lithuanian Association of Educational Music Therapy has been renamed to Lithuanian Music Therapy Association, and in 2013 the Association opened Music Therapy Service Center in Vilnius.
Nowadays, music therapy services are integrated in most of the mental health institutions in Lithuania 16. Also, neonatology, neurology, oncology and rehabilitation clinics are showing increased interest in music therapy service and research 17, 18.
For a long time the development of music therapy was limited because music therapy as a service and the profession was not officially recognized in Lithuania. For a decade members of the Lithuanian Music Therapy Association have been working towards legal recognition of music therapy profession. The first interdepartmental working group of the Lithuanian Parliament started in 2005 and raised the questions of music therapists’ education and services. However, after the change of political powers in the parliament and the ministries, the work was halted. In 2009, second interdepartmental working group named “Arts for Health” continued the work. In this stage it managed to prepare recommendations regarding the regulations of services as well as study programmes for art therapists and music therapists. Example was taken from the British Health Professions Council’s “Standards of Proficiency Arts Therapists“. In 2011 Lithuanian Ministry of Health released a draft law on legalization of the activities of arts therapists. An “Orderfor professional qualification requirements of arts therapists” has been signed by the Lithuanian Minister of Health in October 2014 while came into force in May 2015. Finaly, the main document legitimizing and regulating the profession of music therapy, i.e. a law “Arts therapists operational requirements“ will come in to force in May 2018.
The issue of music therapists’ education has been raised since the 2000s. In 2004 the Specialization in Arts Therapies (40 ECTS) within Social Work Master's degree program was established at the Vilnius Pedagogical University.
In 2011 the optional program “Introduction to Music Therapy” (60 ECTS) started at Lithuanian Academy of Music and Theatre within Bachelor of Music degree program. However, in 2013, the program was halted due to financial constrictions. In 2014 a program "Music and Health: An Introduction to Music Therapy" (40 ECTS) designed for musicians, physicians, teachers, psychologists, social workers who want to use the music / music therapy elements within a frame of their professions was approved at Lithuanian Academy of Music and Theatre Competency Training Centre.
A Joint Music Therapy Master's program (120 ECTS, 2 years) prepared during 2013-2014 was accredited and started in 2015. Joint partners are Vilnius University Faculty of Medicine and the Lithuanian Academy of Music and Theatre Faculty of Music. Qualification degree awarded for the graduates is master in health sciences.Additional entry requirements entering the Music Therapy Master's program: “Music and Health" program’s study module "Health Basics" (12 ECTS) compulsory for musicians, and study module "Music Basics" (6 ECTS) compulsory for health care professionals.
Graduates of the Joint Music Therapy Master's program are able to: implement music therapy programmes for various client groups in health care, social and special education institutions, as well as within various sociocultural environments; independently solve professional problems within an ever changing context and take responsibility for the results of their activities; engage in scientific research activity, i.e. develop new ideas, participate in interdisciplinary research, develop current methods of music therapy and create new ones.
The study programme is unique in Lithuania in providing education in music therapy. It is a joint study programme combining interdisciplinary knowledge and skills while assimilating the experience of Medical faculty of Vilnius University and Music faculty of Lithuanian Academy of Music and Theatre as well as the experience of the health institutions where students perform practice, vital for becoming a highly qualified music therapist. The high motivation of students, their initiatives to integrate music therapy in health care and investigate the process and outcomes led them to successfully defended first 7 master's thesis in June 2017.
According to the Official Statistics Portal data in 2017, the resident population in Lithuania was 2812.713 9. Presently there are 15 professionally trained music therapists and 22 pioneers in music therapy recognized by the Lithuanian Music Therapy Association, who have gained experience in their many years of practice. That shows that the ratio is 0,001 therapist to 100.000 inhabitans. However, the number of music therapists is still small and the need for qualified specialists is increasing because of the wide possibilities of applying music therapy, both in work with children as well as with adults, in various medical, educational, and social spheres. Currently there is a shortage of both workplaces in institutions as well as music therapy specialists, especially in smaller towns and countryside. Therefore, majority of music therapy initiatives take place through various short-term projects in municipality owned medical, education, or social institutions, applying music therapy and musical therapy elements, and involving volunteer musicians and others interested in music therapy. There is a growing number of professionals working in this area. In addition, interest of public and medical communities is increasing over time.
Positive influence of lullabies on a child, singing mother, family evening cosiness was more sensed than explored and was passed on from one generation to other. Scientifically influence of lullabies is not widely studied, only a few scientific articles on music therapy for small children were found during literature overview. It is important to consider methods for putting a child to sleep and follow up lullaby singing and how it influences a child and family. In order to review lullaby singing for preschool children in Lithuania, a survey has been done, using questionnaire specially developed for this purpose 19. 208 parents have completed the survey. According to the data, lullabies were listened to 73,56% of families; no statistically significant difference between gender of parents, family structure and musical education background of respondents was found. In families of parents, who had heard lullabies in their childhood, children heard lullabies more often (p<0,05). Majority (83%) of parents stated that thay sing live themselves, 19,61% tend to choose records. Main reasons for not singing lullabies in the family – lack of knowledge (9,87%) and distrust of musical abilities(4,6%). Traditional and lullabies of own creation were the most popular option. Asked why they sing lullabies, parents mostly pointed out that they were beneficial to emotional health of a child (51,63%), the child fell asleep quicker (49,67%), family bonds grow stronger (41,18%) Respondents have positive attitude to importance of lullabies, especially as a tool for getting children to sleep and maintaining proper emotional health of children.
The effect of lullabies on heart rate, oxygen saturation and behavioral state of preterm infants (up to 32 weeks‘ postmenstrual age) was investigated 17. The research showed that heart rate decreases significantly during live and recorded lullabies sessions after intervention compared with HR before and during intervention and during no intervention session, behavioural status of preterm infants changes significantly (a deeper sleep) during the live lullabies session after intervention compared with behavioral status before and during intervention and during no intervention session. live lullabies have a greater soothing effect on a preterm neonate compared with recorded ones at 15th minute after intervention and their effect on heart rate is observed sooner than in recorded lullabies. The effect of lullabies on oxyden suturation was not significant.
The research on the peculiarities of a depressed patients’ musical improvisation showed some features of depression and the appropriateness of the improvisation assessment methods MIDI and IAP 20. The data revealed that the pitch of notes in improvisation by depression patients group were significantly lower than the controls, and other musical parameters such as the amount of notes, velocity of notes, duration of notes were tendentious lower than the controls. MIDI analysis is completed fast, it is more informative and objective, IAP assessment method apparently demands more time, diligent and deep work, but shows more aspects used in clinical work.
The research on music therapy effect on adult oncological patients’ emotional state and anxiety during the preoperative period led to conclusions that after the music therapy, general anxiety and depression levels decreased by an average 3.1 times, distress level decreased by 3.6 times, improved mood, decreased patient suffering from stress, anxiety, depression, fear, sadness, anger, apathy 21.
Music therapy for families was also introduced with the research aim to determine music therapy’s influence on communication in families that have children with cerebral palsy. Study results revealed a positive influence on parent – child emotional bind, child development and communication abilities. Parents who participated in music therapy sessions proved that active musical activity provoke parents and children for emotional exchange and interaction, provide meaningful and supportive experience 22.
Research on the application of music therapy in pediatrics has been performed with preborn babys and their mothers with the aim to evaluate the influence of music therapy over the stress mothers and their premature babies experience. At the start of the research a majority of babies have been characterized by possessing the following stress-inherent signs: fan-stretched fingers, yawning, hiccups and contractions, legs extension, wincing. At the end of the research a level of the stress undergone by all the babies has decreased. Yawning as a stress indicator of the nervous system has changed the least. It has been observed in almost half of the babies researched, irrespective of music therapy. Mothers who have participated actively in music therapy and spontaneously sung to their babies have built up a higher degree of self-confidence and been able to easily establish a connection with their babies. At the end of the research a level of the stress experienced by all the mothers surveyed in the study has diminished slightly or to an average 23.
The findings of the research work “The Effects of Music Therapy on Psychomotor Development of Infants Growing at the Residence for Infants with Developmental Disorders” demonstrated that active music therapy is an efficient mean of harmonizing the psychomotor development of infants with developmental disorders 24. Data revealed that the averages of the estimates of psychomotor development of the infants to whom an active music therapy has been applied have increased considerably. At the end of the research statistically significant disparities between the estimates of experimental and control groups in every researched area of functioning have been determined. The biggest discrepancy has been observed in the area of social skills, while the smallest – in the area of expressive language.
The benefit of music therapy in Rett syndrome cases has also been studied 25. Rett syndrome is a rare genetic girls’ disease. Individuals with this syndrome experience a full range of the most complex health problems that are terribly complicated and influenced the development of communication, learning, mobility, and, in general, the whole life. However, particularly outstanding feature of Rett syndrome is a little damage of two major senses: hearing and vision. The results of the investigation turn out that music therapy is indicated for variety of health needs for individuals with a Rett syndrome, but it can be particularly effective to enhance functional hand use, to develop mobility and movement, to improve non-verbal communication, and to let experience joy. Preferred methods in music therapy were improvisational games, and the activities in which girls can choose and reveal their desires; if they have a sufficient time for a response, they respond appropriately to sound or visual stimuli.
Multiple sclerosis is one of the most complicated neurological diseases starting at the age of 18 – 50 years. A study was conducted on the need for music therapy for the psychosocial rehabilitation of these patients 26. The results of questionnaire survey results revealed that 96% of physicians state that emotional problems are the most prominent for multiple sclerosis patients and 64% affirm problems of social life, 80% agree that music therapy would be useful as an instrument of nonmedical treatment. 81% of patients have heard about music therapy application in neurology and 57% express a need for music therapy.
Music therapy and reseach in this field has gone through thirty years of development in Lithuania. Acqaintance and acceptance of music therapy as a relevant and fruitful component to the complexity of the existing medical services was long but successful process. The Music Therapy Master program in Lithuania is being implemented, so more and more qualified music therapists will join the health care system. This will ensure better quality of music therapy services. On the other hand, more and more physicians and other health specialists express a need for a broad variety of new interdisciplinary collaborations. Possibilities to use music therapy as an inovative service and resourse in various medical settings are in the process of the rapid growth. Dissemination of information via professional and general media about sucessful music therapy initiatives and benefits of music therapy implementation are necessary. Collaboration involving music therapists in interdisciplinary teams, collaborative research in Lithuania and with foreign specialists would help to achieve a comprehensive, versatile patient-centered and health-centered complex service.