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Scientific Perspectives on Music Therapy

THOMAS HILLECKE, ANNE NICKEL, AND HANS VOLKER BOLAY


German Center for Music Therapy Research, and Outpatient Department,
University of Applied Sciences Heidelberg, D-68123 Heidelberg, Germany

ABSTRACT: What needs to be done on the long road to evidence-based music


therapy? First of all, an adequate research strategy is required. For this pur-
pose the general methodology for therapy research should be adopted. Addi-
tionally, music therapy needs a variety of methods of allied fields to contribute
scientific findings, including mathematics, natural sciences, behavioral and
social sciences, as well as the arts. Pluralism seems necessary as well as inevi-
table. At least two major research problems can be identified, however, that
make the path stony: the problem of specificity and the problem of eclecticism.
Neuroscientific research in music is giving rise to new ideas, perspectives, and
methods; they seem to be promising prospects for a possible contribution to a
theoretical and empirical scientific foundation for music therapy. Despite the
huge heterogeneity of theoretical approaches in music therapy, an integrative
model of working ingredients in music therapy is useful as a starting point for
empirical studies in order to question what specifically works in music therapy.
For this purpose, a heuristic model, consisting of five music therapy working
factors (attention modulation, emotion modulation, cognition modulation,
behavior modulation, and communication modulation) has been developed by
the Center for Music Therapy Research (Viktor Dulger Institute) in Heidel-
berg. Evidence shows the effectiveness of music therapy for treating certain
diseases, but the question of what it is in music therapy that works remains
largely unanswered. The authors conclude with some questions to neuroscien-
tists, which we hope may help elucidate relevant aspects of a possible link be-
tween the two disciplines.

KEYWORDS: music therapy; therapy research; multidisciplinary approach;


pluralistic point of view; working ingredients

INTRODUCTION

Music therapy and music therapy research currently represent heterogeneous but
growing fields. In their clinical work, music therapists experience music as an effec-
tive tool in the treatment of various illnesses. Despite this clinical observation, it is
necessary in modern societies and current health care systems to prove the effective-
ness and efficacy of psychological as well as medical treatments. Therefore one of the
major efforts in current music therapy research is to study effectiveness and efficacy
of defined interventions for certain diseases. However, even if the corpus of outcome

Address for correspondence: Prof. Dr. Thomas Hillecke, German Center for Music Therapy
Research, University of Applied Sciences Heidelberg, Outpatient Department, Maaßstraße 26,
D-68123 Heidelberg, Germany. Voice: +49-6221-4154; fax: +49-6221-4152.
thomas.hillecke@fh-heidelberg.de

Ann. N.Y. Acad. Sci. 1060: 271–282 (2005). © 2005 New York Academy of Sciences.
doi: 10.1196/annals.1360.020

271
272 ANNALS NEW YORK ACADEMY OF SCIENCES

studies in music therapy were extensive and positive enough, the question would still
remain about what it is in music therapy that works. There is an urgent need for the
application of empirical research methods to studying the ingredients of music ther-
apy. This application is needed especially because of the heterogeneous and often in-
commensurable theories music therapists use to describe and explain their work. One
consequence of this is that communication between music therapy centers nationally
as well as internationally can be described as, at best, unsatisfactory.
The different approaches also offer advantages in an evolutionary and epistemo-
logical sense. They reflect the broad way to study and explain relevant aspects as
well as the complexity of music therapy work. However—as Darwin said—only the
fittest survive. These different approaches reveal that music is associated with many
biological, psychological, and sociocultural phenomena in human life. Therefore a
single explanation, such as a great unifying music therapy theory, seems nothing
more than a utopian vision. The major disadvantage of theoretical heterogeneity
makes the study of working ingredients of music therapy more difficult and a
theoretical agreement among representatives of the field unlikely. Concerning these
aspects one can conclude that knowledge of working factors is far from evidence
based, whereas the field of outcome studies is growing, supporting the clinical expe-
rience of music therapists and allied professions that music represents a useful tool
in the treatment of different mental and somatic diseases.1–10

MUSIC THERAPY RESEARCH STRATEGIES

The combination of the two terms music and therapy implies the application of
both music research and therapy research methods. One possibility is to use therapy
research methodology in music therapy. This perspective opens the door to different
research designs to study specific questions and draw respective conclusions.
TABLE 1 distinguishes basic research, single-case research, group research, and
reviews.
For example, the description of phenomena as well as experimental research can
help to identify relevant aspects of music therapy. It often leads to new ideas of
interventions and underlying mechanisms of music as a therapeutic means. The
observation and clear description of a phenomenon is very important for all scientific
work. It represents one first step to reducing complexity and to enhancing objectivity
(understood as intersubjectivity), also for music therapy.
Single-case research facilitates the understanding of relevant phenomena in a de-
fined therapy process. With single-case course studies we comprehend the process
of change of clients or patients with regard to the complexity of music therapy.
Especially in this area, qualitative and quantitative designs complement each other.
Nowadays the field of single-case studies with a different purpose is growing. The
goal is to guarantee process quality and probably external validity of a given inter-
vention. One important project of the German Center for Music Therapy Research
was to develop a quality assurance system for the Music Therapy Outpatient Depart-
ment of the University of Applied Sciences, Heidelberg,11 which is unique in the
music therapy field. Every therapy in this department is videotaped and evaluated for
clinical significance.12,13
HILLECKE et al.: PERSPECTIVES ON MUSIC THERAPY 273

TABLE 1. Therapy research strategies


Type Design Conclusions

Basic Description of phenomena Identification of relevant aspects


research (generation of hypotheses)
Experimental research on psychological Identification of relevant aspects
and physiological effects of music (explanation of effects)

Single-case Descriptive case studies Understanding of specific relevant


research aspects (generation of hypotheses)
Qualitative single-case course studies Understanding of specific process
aspects (generation of hypotheses)
Quantitative single-case course studies Objective illustration of specific pro-
cess aspects (generation of
hypotheses)
Comparative case studies Identification of similarities and dif-
ferences (generation of hypotheses)
Single-case studies as a measure of Inspection of process and outcome
quality assurance standards

Group Descriptive qualitative research on Identification of different effects by


research group comparisons different interventions in compara-
ble patient groups. Identification of
differences between different patient
groups in comparable interventions
(generation of hypotheses).
Effectiveness (efficacy) research Identification of change during the
• pre–post comparison therapeutic process (post hoc)
• controlled course analysis Identification of change by the thera-
• randomized comparisons with peutic process (propter hoc)
waitlist controls (hypotheses testing)
• randomized comparisons with
alternative treated group
Follow-up effectiveness (efficacy) Identification of stable change after
research the therapeutic process (post hoc).
• uncontrolled Identification of stable change by the
• controlled therapeutic process (propter hoc)
• randomized (hypotheses testing)
Research on working factors (micro- Identification of working ingredients
analysis, event research, comparison (generation of hypotheses, hypothe-
of different treatment conditions) sis testing, and explanation of
effects)
Multicenter studies Identification of differences and simi-
larities by different institutional
frameworks

Reviews Studies of literature Identification of relevant literature


(generation of hypotheses and
theories)
Metanalysis Comprehensive presentation of
empirical studies (testing of
hypotheses and theories)
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Most common are group research designs. These designs are of great value in
every clinical research area. Different group research designs can have various in-
tentions. The main interest is to test outcome and to find out what works. Effective-
ness studies and efficacy studies are the main work of the German Center of Music
Therapy Research. With these designs the outcome of music therapy in the field of
chronic nonmalignant pain (1), children with migraines (2), tinnitus (3), and heart
catheter examinations (4) was tested. The results show clinically significant positive
change in the first three areas and poor effects in the last one. In an ongoing multi-
center study, the outcome of neurological music therapy (NMT) for hemiparetic
stroke patients is being tested in collaboration with the Center for Biomedical
Research in Music of Colorado State University.
Another growing field is the review method. This method offers two major
possibilities. One is to study the literature by summarizing contents. This is a neces-
sary tool to comprehend the state of the art. Since the 1950s, researchers have carried
out what is called metanalysis. This is a debatable review integrating and combining
statistical results. In the field of music therapy, metanalytical studies have existed
since 1986.7 Currently quite a few of them reflect the effect sizes of music therapy
in different clinical fields.1–5,7–10
This systematology (TABLE 1) highlights the important and growing role neuro-
science can play in music therapy research. Neurocognitive research has the poten-
tial as a basic research approach to identify and explain relevant effects of music in
therapy by the use of experimental research designs and neurophysiological investi-
gation methods. It is also a useful tool to identify working ingredients, to generate
new hypotheses, and especially to test and explain the correlation between music
therapeutic intervention techniques and empirically observed outcome.

FIGURE 1. Music therapy (research): a multidisciplinary field.


HILLECKE et al.: PERSPECTIVES ON MUSIC THERAPY 275

THE NECESSITY OF PLURALISM IN MUSIC THERAPY

Music therapy is a multidisciplinary field in which the researchers can learn from
others. The field overlaps with a wide spectrum of scientific areas, including math-
ematics, natural sciences, behavioral and social sciences, as well as the arts (FIG. 1).
The word music stands for a multiplicity of human events that are difficult to analyze
from a reductionist point of view. Therefore the study of music and music therapy
needs to be multidisciplinary as well as theoretically and scientifically pluralistic.
Some examples may illustrate this requirement: (1) Physics may be a useful tool
to study psychophysical aspects of music as acoustical phenomena. It describes
physical aspects of music, such as sound waves, volume, and acoustic pressure.
(2) Biological and biomedical aspects are relevant in understanding how music is
processed by the nervous system and how its effects reach other organic structures
of the body. Biological background is necessary for the explanation of how music
leads to physiological changes. From this point of view music as a personal experi-
ence is a result of physiological information processing. (3) Psychotherapy research
is currently a very systematic research field (see above). (4) Also psychology with
psychological experiments and psychological diagnostics, such as questionnaires
and tests, including the paradigm of cognition, are very important tools in analyzing
what happens in music therapy. Music psychology is mainly very important to un-
derstanding how music influences behavior and experience. (5) Sociological as well
as ethnological aspects play an important role in music therapy research. For exam-
ple, do the social and ethnic backgrounds play important roles in the reaction of
patients to music therapy interventions? It could also be asked whether music ther-
apy is a development of industrialized Western culture, or does it exist in (all) other
cultures? What are the differences in music therapy interventions among these cul-
tures? (6) Another relevant aspect is musicology. This field, for example, contributes
different possibilities for describing music in symbols and interpreting music as art
and creativity.

PROBLEMATIC ASPECTS OF APPLYING THERAPY RESEARCH


TO MUSIC THERAPY

The first problem, of relevance for music therapy, especially in the treatment of
psychological disorders, can be called the specificity problem and is a result of more
than 50 years of psychotherapy research. Psychotherapy theorists have often been
frustrated by this problem and therefore mainly ignored it. This problem was first
formulated by the psychiatrist Jerome D. Frank14 and empirically first observed by
the psychoanalyst Lester Luborsky.15 It is labeled “the dodo bird verdict” because
the dodo bird says to Alice in Wonderland: “Everybody has won and all must have
prizes.” Its consequences are best summarized by Michael Lambert,16 who came to
the conclusion that extratherapeutic aspects determine 40%, therapeutic relationship
30%, expectancy and placebo effects 15%, and specific therapeutic techniques 15%
of the observed outcome variance in psychotherapy studies. This reveals that unspe-
cific factors play a major role, and specific therapeutic techniques seem to be almost
negligible.
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The dodo bird verdict characterizes empirical results of outcome studies and
comparative studies.
• The differences in outcome between various approaches, such as depth-ori-
ented psychotherapy, humanistic therapy, behavior therapy, and cognitive
therapy can almost be ignored. All of them produce comparable effects.
• One consequence is the evidence-based assumption that common factors—as
ingredients that are shared by all these approaches—are of much more signif-
icance than specific factors, which reflect the specific assumptions of these
different theoretical approaches.
For music therapy as a treatment of psychological disorders, the problem leads to
the serious question of whether the observed outcome of clinical studies depends on
music as the specific ingredient, or on common factors. The only possibility for cop-
ing with that challenge is to use comparative therapy studies or working factor stud-
ies, which correlate music therapy techniques to observed outcome.
The second problem is of more practical relevance. It can be called the eclectic
problem. It points out that traditional theoretical frameworks are often obviously not
satisfying for music therapy clinicians. This is also comparable to the situation re-
garding psychotherapy. An extensive corpus of modalities and treatment theories ex-
ist in the music therapy world. Some of them are psychoanalytic music therapy,17
humanistic music therapy,18 behavioral music therapy,19,20 Nordoff-Robins music
therapy,21 and music medicine.22 Often music therapists refer to one of them as the-
oretical background; nevertheless these traditional approaches can be considered as
more or less belief systems. In clinical reality most of the music therapists mix tech-
niques and theories, creating their own blend and personal music therapy theory. Ad-
ditionally they also combine music therapy with other therapeutic modalities. To
handle this eclecticism problem, the development of treatment manuals, including
defined musical interventions, is a promising possibility. The best way, however,
would be to develop theories that are testable as well as practical, and that would
contain empirical knowledge of etiology, pathology, working factors, and expected
outcome. These theories should then be tested by clearly defined and suitable empir-
ical methods. If falsification is the outcome, they should be dropped. Unfortunately
the philosophy of falsification23 is currently not common enough in the field of
music therapy. Therefore epistemology should be more emphasized in music therapy
training programs.
The question that we are asking is whether neuroscience or neurocognitive
approaches constitute new upcoming paradigms for the music therapy field. Since
the publication of The Structure of Scientific Revolutions,24 the idea of a scientific
paradigm shift is often used to proclaim new perspectives. However, for a new sci-
entific paradigm to exist as a result of a scientific revolution, an old paradigm is
necessary. The situation in the field of music therapy is very different. There is a lack
of specific evidence-based theories on the one hand, and there is therapeutic eclec-
ticism in practical music therapy work on the other. The situation may rather be de-
scribed as a continuous search for adequate theoretical frameworks that help
practitioners in their everyday work. The transference of theories from other disci-
plines, especially psychology, was and is predominant (for example, psychodynamic
music therapy, humanistic music therapy, behavioral music therapy, and cognitive
music therapy). A music-specific therapeutic paradigm itself does not exist. If a par-
HILLECKE et al.: PERSPECTIVES ON MUSIC THERAPY 277

adigm changes, it concerns basic research areas (such as physics), in general, not ap-
plied sciences, like music therapy or medicine. If the upcoming or current paradigm
(or scientific matrix) of medicine or psychology is naturalism containing neurocog-
nition, it would be better to ask what music therapy can learn from that current per-
spective. In psychotherapy research, different developments can be detected. Pure
naturalism in this field has been analyzed and fundamentally criticized by Slife.25
This author points out the limitations of a naturalistic point of view. Naturalism, like
other theoretical frameworks, is based on implicit and often unexamined assump-
tions. In the case of naturalism these are the following:
• Objectivism: The objective world of therapy occurs outside our subjectivity,
and thus in a value-free world without meaning and morality. Alternatively,
music therapeutic relationships occur between (two or more) subjects, who
interpret musical experiences individually and by interaction.
• Materialism: Matter is what is important and sufficient for understanding.
Hence, nonobservational constructs are operationalized, and psychotherapy is
increasingly biologized. Alternatively, social contexts are of significance in
music therapy settings. Especially psychological disorders and symptoms, as
well as reactions to music, are often culture bound and cannot be understood
as mere biological phenomena.
• Hedonism: All living things seek pleasure and avoid pain, with all higher ani-
mals ultimately concerned with benefits to the self (well-being as major out-
come). Alternatively, outcome may include other different values, such as
altruism. Musical experiences that moderate change can initially be emotion-
ally disturbing and may not always lead to pleasure.
• Atomism: The natural world comprises self-contained atoms, each with
unique properties and qualities contained therein. Therefore the individual is
of relevance. Alternatively, the relevant focus of music therapy could also be
on a family or other social groups.
• Universalism: The most fundamental things are the things that do not change.
This ideal is a matching of diagnostic and treatment “universals.” Alterna-
tively, every music therapy may be described as a unique phenomenon that
cannot be repeated or experienced by unique human beings.
To do justice to the complex matter of music therapy, different research approach-
es, such as quantitative, qualitative, biological, psychological, or sociological are
necessary. Despite the complexity of music therapy it is probably better to work with
specific microtheories, and specific operational hypotheses as often used in current
medicine and psychotherapy (research).26 These specific theories should be tested
using adequate and modern scientific methods, techniques, and approaches. Neuro-
physiological investigation methods represent especially important new tools that
are relevant in music therapy research and should be integrated into the pluralistic
corpus of significant music therapy research methods.
In addition to the two problems characterized above, others exist. One is the gap
between theory, research, and practice. Here the main question is whether general
objectivistic theories and empirical results are adequate for music therapy research.
In empirical studies there is a strong emphasis on homogeneity of groups and inter-
ventions, but the clinical work often consists of heterogeneous single cases.
278 ANNALS NEW YORK ACADEMY OF SCIENCES

Awareness of these problems, combined with the epistemological insight that


there is no final conclusion, means that knowledge will advance. In addition to
coincidental findings, insights that happen by chance, inductive generalizations, or
deductive conclusions, keeping an open mind that respects other approaches is espe-
cially important to the growth of a field of applied science like music therapy. There-
fore there is a reasonable chance that music therapy will profit from the quickly
advancing field of neuroscience in music by means of interdisciplinary cooperation
and discussion by experts.

A HEURISTIC WORKING FACTOR MODEL FOR MUSIC


THERAPY AS A THEORETICAL FRAMEWORK

Because of the often unsatisfactory heterogenous theoretical situation in music


therapy, the team at the University of Applied Science in Heidelberg has started to
develop a specific model for the most effective ingredients in the field of music ther-
apy. One provisional result is a heuristic model of working factors. The emphasis in
this model is on a systematic collection of such ingredients seen as significant in
music therapeutic work. It focuses on pragmatic therapeutic aspects and should be
more specific if applied in special clinical fields (e.g., a therapy manual). Currently
it consists of five factors.
(1) The first is called attention modulation or the attentiveness factor: The
basic assumption is that music as an auditive quality has the power to
attract attention (more than other sensual modalities). This factor includes
phenomena associated with musical experience, like distraction, the relax-
ational use of music, and the so-called anxiolytic or algolytic effect that
often is discussed in music medicine.16 This musical ingredient is com-
monly used as an auditive signal for waking up (alarm clock effect). Addi-
tionally, many people use music for distraction from stressful events in
everyday life. An impressive example for the power of auditive experi-
ences to attract attention is the tinnitus experience. Patients suffering from
such symptoms are often unable to concentrate on other sensory stimuli.27
Attention modulation is supported by the phylogenetic function of audition
as an early warning system. Anesthesiological studies of Schwender28 and
others imply that the auditive system is the sensory system that switches
off last. A typical clinical use of that working factor is pain therapy, and it
is very useful in music therapy with autistic and ADHS children.
(2) The second ingredient is called emotion modulation or the emotional fac-
tor: The basic assumption is that music (more than other human experi-
ences) has the power to modulate emotions. Not only basic but also
complex emotions, like national sentiments, can be stimulated by music.
This factor is most relevant in active music therapy and includes direct
emotional activation as well as the recall of emotional events associated
with musical and auditive experiences. Emotion modulation is discussed in
nearly all music therapy approaches, but empirical knowledge is still rather
limited.29 Emotion modulation is often a component in film music or love
HILLECKE et al.: PERSPECTIVES ON MUSIC THERAPY 279

songs. Neuroscientific research indicates that music is processed in the


emotional brain (e.g., limbic system, gyrus cinguli, and the paralymbic
cortical regions), and highly dissonant music tends to be unpleasant. In
recent years research has been conducted on the so-called thrill or chill
effect, which is an emotional and physiological reaction to music often
associated with getting goose pimples.30–32 Emotion modulation is com-
mon, especially in the psychotherapeutic use of music to directly evoke
emotions, to recall emotional memories, and to learn more flexible emo-
tional reactions.33,34 It is very important to study the emotion modulation
potential of music precisely because most psychological disorders and
mental illnesses can also be described as emotional disturbances. Eliciting
emotions by music may be a relevant topic and useful tool in the future
treatment of these emotional disorders.
(3) The third factor is called the cognition modulation or cognitive factor: The
basic assumption is that music represents a neurocognitve capacity. Music
is produced by the human brain. The neuronal processing of music as well
as its complexity is comparable to speech.35,36 Therefore it is obvious that
understanding music means thinking and creating (subjective) significance
and experience. This factor implies subjective and cultural meanings for
music as well as psychological, cognitive associations connected with spe-
cific musical experiences. In the same way the evocation of synaesthetic
experiences is often used in music therapy. Musically induced visual imag-
ery contributes to that factor as well as musical imagery itself.29 Music
always has a subjective meaning for humans. It is often observed that sub-
cultures define themselves by specific musical styles, which are coded as
some kind of group-specific language. Additionally music is used to alter
states of consciousness in different native cultures.37 Music is also known
to facilitate recall of episodic memories.38 Cognition modulation is clini-
cally used to change subjective cognitions and meaning patterns, and is
also important in music guided imagery techniques.39,40 Some music ther-
apists use music to induce a hypnotic trance and to alter states of con-
sciousness.41
(4) The fourth factor is called behavior modulation or motoric behavioral fac-
tor: The basic assumption is that music represents a useful possibility to
evoke and condition behavior, such as movement patterns, without the
necessity of conscious will. The association of music and dance is well
known. Marching songs are common, and the military offers a great variety
of military marches. Neuroscientists, like the team of Michael Thaut, point
out that rhythmic stimulation influences timing processes in the frontal
brain and associated neural structures (neurologic music therapy, NMT).
This factor is used therapeutically in gait rehabilitation of stroke patients
and in the treatment of movement problems, for example, in Parkinson
patients.42,43 Music and auditive stimulation—known since the time of
Pavlov—is a useful tool in behavioral conditioning in general. The analysis
of the behavioral component of patients’ performing music is of central
interest in active music therapy and important in facilitating the learning of
new behaviors. It is used as a theoretical framework in behavioral music
therapy.44,45
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(5) The fifth and last factor we call communication modulation or interper-
sonal factor: The basic assumption is that psychotherapeutic music therapy
represents a complex paradigm of nonverbal communication.46 This factor
should be more emphasized in the future. It is often pointed out that music
therapy uses nonverbal interpersonal interaction, but there is still little
empirical knowledge of the patient–therapist interaction in music therapy
settings. This phenomenon can be observed as a kind of community-build-
ing effect of music, for example, songs and music of sport fans, or music at
the campfire. Many cultures use music to evoke the communal spirit and to
enhance group cohesion. Humans use music to communicate simulta-
neously and not alternately, as in verbal dialogue. Improvisational music
activities in therapeutic contexts are expecially seen as a form of nonverbal
communication. Communication modulation is often used in a clinical set-
ting for the learning of interpersonal competencies, especially in group
music therapy. The reality of many music therapy interventions (active
music therapy) is realized when therapist and patient are sharing a joint
music activity and experience.

CONCLUSION

We conclude that music therapy does not need a new paradigm but may profit
from new research methods. In clinical observation the therapeutic use of music
often seems adequate and beneficial, but the empirical knowledge in our field is rare
and limited, yet growing. If we want music therapy to have a more respected and
defined role in modern health care systems, enhanced efforts will be needed. Neuro-
scientific research can help to support the long road toward evidence-based music
therapy. We have started to walk this road, but the end is still not in sight. In conclu-
sion, we pose several questions for neuroscientists:
• Do specific neurocognitive theories have the potential to explain the connec-
tions between music therapy interventions and the pathophysiology of mental
and somatic diseases?
• Are specific neurocognitive theories and methods relevant for the explanation
of observed short-term effects of music therapy interventions?
• Are neurocognitive theories and methods relevant for the explanation of
observed positive outcome of effectiveness studies in music therapy (long-
term effects)?
• Do neurocognitive theories and methods deliver new intervention strategies
and techniques for music therapy?
• Do neurocognitive theories and methods help us to get a clearer view of possi-
ble working factors in music therapy?
[Competing interests: The authors declare that they have no competing financial
interests.]
HILLECKE et al.: PERSPECTIVES ON MUSIC THERAPY 281

REFERENCES

1. GOLD, C. et al. 2004. Effects of music therapy for children and adolescents with psy-
chopathology: a meta-analysis. J. Child Psychol. Psychiatry 45: 1054–1063.
2. STANDLEY, J.M. 2002. A meta-analysis of the efficacy of music therapy for premature
infants. J. Pediatr. Nurs. 17: 107–112.
3. STANDLEY, J.M. 1996. A meta-analysis on the effects of music as reinforcement for
education/therapy objectives. J. Res. Music. Edu. 44: 105–133.
4. PELLETIER, C.L. 2004. The effect of music on decreasing arousal due to stress: a meta-
analysis. J. Music. Ther. 41: 192–214.
5. WHIPPLE, J. 2004. Music in intervention for children and adolescents with autism: a
meta-analysis. J. Mus. Ther. 41: 90–106.
6. EVANS, D. 2002. The effectiveness of music as an intervention for hospital patients: a
systematic review. J. Adv. Nurs. 37: 8–18.
7. STANDLEY, J.M. 1986. Music research in medical/dental treatment: meta-analysis and
clinical applications. J. Mus. Ther. 23: 56–122.
8. KOGER, S.M. et al.1999. Is music therapy an effective intervention for dementia? A
meta-analytic review of literature. J. Music. Ther. 36: 2–15.
9. SMEIJSTERS, H. 1997. Musiktherapie bei Alzheimerpatienten. Eine Metaanalyse von
Forschungsergebnissen. Musikther. Umsch. 18: 268–283.
10. STANDLEY, J.M. 1996. A meta-analysis on the effects of music as reinforcement for
education/therapy objectives. J. Res. Mus. Edu. 44: 105–133.
11. WORMIT, A.F. 2003. Qualitätssicherungsinstrumentarien in der Ambulanten Musikthe-
rapie sind möglich! Musiktherapeut. Umsch. 24: 291–292.
12. JACOBSON, N.S. et al. 1984. Psychotherapy outcome research: methods for reporting
variability and evaluating clinical significance. Behav. Ther. 15: 336–352.
13. JACOBSON, N.S. & P. TRUAX. 1991. Clinical significance: a statistical approach to defin-
ing meaningful change in psychotherapy research. J. Consult. Psychol. 59: 12–19.
14. FRANK, J.D. & J.B. FRANK. 1991. Persuasion & Healing: A comparative Study of Psy-
chotherapy. John Hopkins University Press. Baltimore.
15. LUBORSKY, L. et al. 1975. Comparative studies of psychotherapies: is it true that
“everyone has won and all must have prizes?” Arch. Gen. Psychiatry 32: 995–1008.
16. LAMBERT, M.J. 1992. Psychotherapy outcome research: implications for integrative
and eclectic therapists. In Handbook of Psychotherapy Integration. J.C. Norcross &
M.R. Goldfried, Eds.: 94–129. Basic Books. New York.
17. PRIESTLEY, M. 1994. Essays on Analytical Music Therapy. Barcelona Publishers.
Phoenixville, PA.
18. SALAS J. & D. GONZALES. 1991. Like singing with a bird: improvisational music ther-
apy with a blind four-year-old. In Case Studies in Music Therapy. K.E. Brucia, Ed.:
17–27. Barcelona Publishers. Phoenixville, PA.
19. MADSEN, C.K. et al. 1968. A behavioral approach to music therapy. J. Mus. Ther. 5: 69–71.
20. HANSER, S.B. 1983. Music therapy: a behavioral perspective. Behav. Therap. 6: 5–8.
21. NORDOFF, P. & C. ROBBINS. 1975. Music in Special Education. The John Day Com-
pany. New York.
22. SPINTGE, R. & R. DROH. 1992. Musik-Medizin. Gustav Fischer. Stuttgart.
23. POPPER, K. 1994. Logik der Forschung. 45–46. Mohr. Tübingen.
24. KUHN, T.S. 1996. The Structure of Scientific Revolutions. University of Chicago Press.
Chicago.
25. SLIFE, B.D. 2004. Theoretical challenges to therapy practice and research: the con-
straint of naturalism. In Handbook of Psychotherapy and Behavior Change. Bergin &
Garfield, Eds.: 44–83. John Wiley & Sons. New York.
26. LAMBERT, M.J. et al. 2004. Overview, trends, and future issues. In Handbook of Psy-
chotherapy and Behavior Change. Bergin & Garfield, Eds.: 805–821. John Wiley &
Sons. New York.
27. CUNY, C. et al. 2004. Reduced attention shift in response to auditory changes in sub-
jects with tinnitus. Audiol. Neurotol. 9: 294–302.
28. SCHWENDER, D. et al. 1991. Bewusste und unbewusste akustische Wahrnehmung
während der Allgemeinanästhesie. Anaesthesist 40: 583–593.
282 ANNALS NEW YORK ACADEMY OF SCIENCES

29. ZATORRE, R. 2003. Music and the brain. Ann. N. Y. Acad. Sci. 999: 4–14.
30. PANKSEPP, J. 1995. The emotional sources of “chills” induced by music. Mus. Percep.
13: 171–207.
31. PANKSEPP, J. 2002. Emotional sounds and the brain: the neuro-affective foundations of
musical appreciation. Behav. Processes 60: 133–155.
32. GABRIELSON, A. & W. LINDSTRÖM. 2003. Strong experiences related to music: a
descriptive system. Musicae Scientiae 7: 157–217.
33. BOLAY, H.V. et al. 1998. Musiktherapeutische Handlungsstrategien in der Behandlung
von Schmerzpatienten. Musiktherapeut. Umsch. 19: 268–277.
34. HILLECKE T. & H.V. BOLAY. 2000. Musiktherapie bei chronischen Schmerzen—theore-
tische Grundlagen—das Heidelberger Modell. Anesthesiol. Intensivmed. Not-
fallmed. Schmerzther. 35: 394–400.
35. KOELSCH, S. et al. 2002. Bach speaks: a cortical “language-network” serves the pro-
cessing of music. NeuroImage 17: 956–966.
36. KOELSCH, S. et al. 2000. Musical syntax is processed in the area of Broca: an MEG
study. NeuroImage 11: 56.
37. ROUGET, G. 1985. Music and Trance: A Theory of the Relations between Music and
Possession. The University of Chicago Press. Chicago.
38. SLOBODA, J.A. & P. JUSLIN. 2001. Psychological perspectives on music and emotion. In
Music and Emotion: Theory and Research. P. Juslin & J.A. Sloboda, Eds.: 71–104.
Oxford University Press. Oxford.
39. BONNY, H. 1978. Facilitating G.I.M. Sessions. G.I.M. Monograph, Vol. 1. ICM Books.
Baltimore.
40. BONNY, H. 1989. Sound as symbol: guided imagery and music in clinical practice.
National Association for Music Therapy California Symposium on Clinical Prac-
tices. Music. Ther. Perspect. 6: 7–10.
41. DITTRICH, A. 1987. Bedingungen zur Induktion außergewöhnlicher Bewusstseins-
zustände. In Ethnopsychotherapie. A. Dittrich & C. Scharfetter, Eds.: 7–34. Enke.
Stuttgart.
42. THAUT, M.H. et al. 1997. Rhythmic facilitation of gait training in hemiparetic stroke
rehabilitation. J. Neurol. Sci. 15: 207–212.
43. THAUT, M.H. et al. 1999. The connection between rhythmicity and brain function:
implications for therapy of movement disorders. IEEE. Eng. Med. Biol 18: 101–108.
44. MADSEN, C.K. et al. 1968. A behavioral approach to music therapy. J. Music. Therap.
5: 69–71.
45. HANSER, S.B. 1983. Music therapy: A behavioral perspective. Behav. Therap. 6: 5–8.
46. BOLAY, H.V. 1983. Musiktherapie. In Handbuch der Psychotherapie. R. Corsini, Ed.:
279–754. Psychologie Verlags Union. München.