JOINT COMMITTEE ON ARTS, SPORT, TOURISM, COMMUNITY, RURAL AND GAELTACHT AFFAIRS debate -
Tuesday, 11 Apr 2006

Music Therapy: Presentation.

Chairman

In January, I put forward the idea of the preparation of a report on music therapy. It seems that music therapy has a major role to play in the treatment of illnesses that affect young people and the elderly and that range from autism to children's inability to concentrate, even in the classroom, and other such issues. I sent 240 questionnaires to various acute, district, national and other hospitals and received 90 responses. The information they contain is interesting. Arising from this initiative, I met Professor Jane Edwards who is in charge of the music therapy in the University of Limerick. That is the progress that has been made to date.

I welcome Dr. Jane Edwards from the Irish World Academy of Music and Dance at the University of Limerick. She is an expert in the field of music therapy, an issue that is close to my heart. I am trying to eke out enough information to impress upon the Department of Health and Children, in particular, that music therapy is as important as speech therapy and occupational therapy. Music therapy has a role to play and is internationally recognised as an important part of any medical intervention. I invite Dr. Edwards to make her presentation, following which we will take questions from members.

Dr. Jane Edwards

I thank the Chairman for the invitation to address the committee on music therapy. As the course director, since 1999, for the only music therapy training available in Ireland, I have a particular interest in ensuring that music therapy is recognised as a means by which services to people in a range of health and care contexts can be optimised and enhanced in this country. I am delighted the committee asked me to make a presentation and I would particularly like to mention how appreciative I am, along with my music therapy colleagues, of the contribution the Chairman, Deputy Keaveney, has made to the understanding and promotion of the professional practice of music therapy in Ireland.

I wish to make some comments about the general importance of the arts in health and the specialist role of the music therapist in service delivery. The arts invite us to explore our identity as individuals, within communities and as a wider society. The arts engage, challenge, teach and inspire us. At the heart of all the arts lies the work of the human imagination. The arts reflect our history, our identities and ourselves. People with compromised health and reduced abilities have the right to exercise and experience the breadth of their imaginative potential through access to the arts. We should not be obliged to ask what is the work of the imagination for but rather how can we maximise the potential of every citizen to use his or her imagination to its fullest.

There is a vibrant arts health movement in Ireland that is exemplified in the employment of arts officers in hospitals, the funding of arts health programmes through the Arts Council and the development of community initiatives and arts in health through such organisations as Music Network. At the same time, the creative arts therapy professions have been building their expertise and profile here. There is an association for creative arts therapists, formed in 1992, and for a number of years specialist postgraduate qualifications have been available at third level in music therapy, art therapy and drama therapy.

Music therapists work as members of multidisciplinary teams, in a range of health and education settings, to identify, address and ameliorate needs in psycho-social, emotional, developmental and cognitive domains. At the heart of our work is the process of imagining and creating change through the medium of music for the benefit of clients. For the past 13 years, in my work as an educator of qualified music therapists, I have facilitated future professionals in the creative arts therapy and profession of music therapy to develop skills in the assessment of clients needs, the delivery of effective programmes to meet these needs, the evaluation of the extent to which needs were met through music therapy, and skills in reporting clinical outcomes of music therapy work.

I now wish to comment on the music therapy profession in Ireland. For a number of reasons it is difficult to provide exact information about the professional profile of qualified music therapists in Ireland. However, it can be noted that 46 qualified music therapists are members of the all-Ireland music therapy e-mail discussion group. There have been 20 graduates of the MA in music therapy at the Irish World Academy of Music and Dance since the two year masters programme commenced in 1998. A further nine students will complete the programme in the middle of this year.

A broader picture cannot be given since, as there is currently no award designation, music therapists are often employed under other occupational titles. I would argue that this seriously limits the development potential of music therapy here in Ireland. When a music therapist leaves a job the post can often revert to the general pool of posts in the facility or service. Since there is no professional registration available, there is no way to ensure that people who are called music therapists have appropriate qualifications to practise. Very few music therapy jobs are offered full-time; most opportunities are through sessional or part-time work.

There is currently one music therapy post available where the pay is so low that no one will apply for it. Therefore, it has remained vacant for several years in spite of having had a qualified professional working previously in demonstrating the effectiveness of the role. It is arguably a situation where these highly trained professionals cannot afford to work as music therapists.

I now wish to comment on the current lack of parity between working pay and conditions of qualified music therapists in Ireland and other English-speaking countries, most notably the United Kingdom. In other English-speaking countries, such as Australia, New Zealand, the United Kingdom and the United States, award conditions and professional recognition are available for qualified music therapists. In the United Kingdom, qualified music therapists are registered with the Health Professions Council. Since 1999, they have been registered under the occupational designation of "arts therapists". They share this designation with drama therapists and art therapists. This registration protects the occupational titles drama therapist, music therapist, art therapist and art psychotherapist. At the same time well established award conditions for qualified music therapists allow health services to decide to create or maintain posts and develop services to which music therapists can contribute their professional expertise.

In Ireland, it is heartening that Vision for Change, a recently published report by the expert group on mental health policy, mentions the use of creative therapies several times. However, there is no strategy as yet to indicate how service providers within the HSE can employ creative therapy experts, or even what that description needs since there is no such job title officially in the health service.

Recently, the European music therapy confederation was recognised as an official professional body in Brussels. This allows the confederation to develop a procedure for registration of music therapists throughout Europe. This could result in the anomalous situation where a professional may have a therapy qualification that is recognised Europe-wide but cannot be employed in this occupational title in the Republic of Ireland.

Current findings of local and international research show the value of music therapy for people of all ages receiving special education and health care services. Music therapy is an evidence-based profession. This means that the actions for therapists to address needs of patients or clients are based on published reports from expert clinicians as well as published findings from research studies. Where there is none, the therapist seeks to develop knowledge through description and evaluation in the first instance, leading ultimately to research studies. There are many hundreds of research studies to show that music therapy has a positive effect for many psychiatric, developmental and medical conditions.

Recently the Irish World Academy of Music and Dance at the University of Limerick received funding from the Health Service Executive mid-western area to investigate the effects of music therapy and art therapy on the agitation behaviour of patients in a specialist continuing care unit of the Limerick mental health services for older people. All the patients had a form of dementia. At the end of a 28-week period, agitation was significantly decreased for the participants and, therefore, the quality of life of these residents improved. This decrease in agitation was not only statistically verified but could be described as meaning some patients changed from demonstrating agitated behaviours such as calling out several times an hour to calling out only once or twice per day.

In March 2006, a short paper entitled Music Therapy in the Treatment and Management of Mental Disorders was published in the Irish Journal of Psychological Medicine. The paper, which presents a number of research studies that provide evidence for a clinical role for music therapy in the management of symptoms of mental disorders, was circulated to members. This is more than living in hope that participation will be enjoyed by patients. Instead, it is the quantified and proven benefit of music interaction provided in therapeutic service by a highly trained professional.

Support is requested from the committee for recognition of the distinct role of the arts worker qualified in the professional field of music therapy and further support is sought to have this role negotiated and defined as a professional title within the education and health sectors in Ireland. Music therapy requires validation as an occupational title within health and education services in Ireland. The profession of music therapy needs recognition through the process of registration of the profession. This will ensure people employed as music therapists can deliver accountable and effective services to vulnerable groups such as those in aged care services, survivors of sexual abuse, adults with intellectual disability and other community members who require services from properly accountable, trained advocates.

It is extraordinary that music therapy has such a developed role, for example, in the UK. However, no distinction is made in Ireland in a health or education setting between the work of a musical volunteer, a professional arts performer and a qualified music therapist. Every day our work is cut out for us defining our role, responding to misconceptions about our work and identity and working for positive change, not only for our professional future but also for the benefit of patients and families for whom this expert service is warranted. I seek the support of the committee for the proper recognition of the profession of music therapy in Ireland and I thank the Chairman for the invitation to make a presentation.

Chairman

I thank Dr. Edwards for an interesting presentation on this issue. She stressed that music therapy, community music and so on are not the same. An American intern issued the invitation to the group on my behalf and she mistakenly used the term "musical therapy" rather than "music therapy". I was, therefore, interested in Dr. Edwards's reaction and she clearly defined the difference between both. This is related to the Health and Social Care Professionals Act which was passed by the Dáil recently. A strong debate was held on the difference between physiotherapy and physical therapy as one must have a degree to practise the former while the latter can be practised following a six-week evening course. My eyes were opened in this regard.

Dr. Edwards has highlighted the main needs as professional registration, a strategy to define creative thinking and a strategy to employ creative therapists. It is easy to associate music therapy with dementia, Alzheimer's disease and so on. Could she expand on her work with children and the impact of music therapy on them?

We spend much money in primary schools on interventions in respect of ADD, ADHD, fragile X syndrome, dyslexia, dyspraxia, etc. Does music therapy have a role to play at the pre-emptive stage in this regard? If we spent more money on developing music therapy for those under six years of age, would we need to spend less on therapy for those over six?

Dr. Edwards

That is a major question. Music therapies increasingly work at younger ages, even to the point where we have a number of services for mother-infant and parent-infant interactions. I am from Australia and have lived here for seven years. Before I came, I was funded by the Australian Government to offer a ten-week music therapy programme, Sing and Grow, to many vulnerable families throughout Australia. That programme remains in place.

We have copied the programme in Ireland — here it is called Suantrai — but it is only on offer in Limerick at present. It is aimed at mothers and infants, but is currently confined to the refugee and asylum seeker community in the Limerick area because of the type of funding we receive. The work tries to offset for vulnerable parents what might happen if they do not bond with their children. We use music with infants, particularly face-to-face play, because that is often what is missing if the mother is depressed or distracted. Gross motor play or rough play is often well established. Face-to-face interaction gives parents the feeling of being in love with their baby through the step of staring deeply into their eyes. We use songs that encourage this interaction at an early stage of the infant's or young child's development.

We do not know yet whether music therapy has a special role to play in outcomes for this cohort. However, our attendance rates are very high compared to similar programmes for parents-infants. This may be because parents make the association through the media that music is good for their children and this motivates them to become involved with our programme. Research has shown that regardless of the intervention offered to a vulnerable parent and child, they will, if they can access the service, achieve a positive outcome.

In terms of special education, there is good evidence to show that music therapy sessions, where targeted and warranted for particular children, can help with pre-academic skills such as turn-taking and paying attention. Skills such as these and knowing to look at the person who is speaking can be difficult for children with learning difficulties. Music therapy involves much drilling in this area and uses musical interaction centred around "my turn" and "your turn". It is not too strict, but teaches the basics of reciprocity and the give and take of social interaction that, for those children, is often impoverished.

Deputy O’Shea

I welcome Dr. Edwards and thank her for her presentation. I am a teacher and find a resonance in what she says. My local hospital, Waterford Regional Hospital, has a healing arts trust. Something tangible has a greater impact on people and I believe that having paintings hung throughout the hospital improves the environment and contributes to patient recovery. As a teacher, I know that environment is very important for children. If the environment is stimulating, children perform better.

Dr. Edwards referred to music therapy as it applies to those with special needs. I recall some years ago seeing children who were profoundly intellectually disabled working with their teacher. I recollect her qualification was in music and she was using music. I was convinced that what she was doing was having a soothing and comforting effect and therefore what Dr. Edwards is saying has a certain resonance for me. I note her concerns about the definition of professional registration. It is obvious she regards this music therapy as having a different role in the area of medicine in general but also in education.

How does Dr. Edwards envisage programmes of music therapy being structured within the normal school situation for children with learning disabilities or other problems? The primary school system is such that effectively one teacher teaches all subjects. Should there be a component in teacher training to include music therapy or is it more effective and efficient to have professionals available to a number of schools or classes? What would be the best model?

I am not quite sure how music therapy could be provided in hospitals. Would it mean that background music would be available for those who want it or would there be a targeted approach to different groups of patients? General hospitals cater for surgical, medical and psychiatric patients. It is the case that one size will not fit all. I know from experience that the arts play a positive role in the healing process. It would be necessary to determine the level of inputs necessary to bring out positive effects for patients. There is much to be learned about the effects of the use of therapies in medicine. I am open to what Dr. Edwards has said in her presentation which has been interesting and stimulating. There is merit in developing the processes she has described.

Dr. Edwards

Deputy O'Shea asked two questions, one being about the model of implementation for music therapy in special education or in general education settings and the second question was about music therapy in hospitals. I will deal with the second question first.

I worked for seven years at the Royal Children's Hospital in Brisbane and I gained my PhD from the faculty of medicine, the department of paediatrics and child health at that hospital. I am expert in working in a medical context with children in pain, in need of rehabilitation and in need of psycho-social care. For children who are hospitalised, psycho-social care is perhaps the most challenging area. There are psychological and social consequences of injury or illness and of having to leave home and be in hospital for long periods of time or having frequent disruptions to home and school life because of coming into hospital.

I worked on a referral system. As I was the first music therapist at the hospital, I needed to become familiar with the staff and educate them, as they did me. In the beginning I saw many children based on the perception of staff that they needed cheering up or some activity. As I worked through a number of years in my programme, I found that I could help the staff to understand that the types of children who would really benefit from music therapy were children who had difficulties such as coping with hospitalisation by not speaking or by not eating. I began to work very closely with staff to target those children much earlier. We tried to work with them before the behaviour had continued for four days. We could show, not from my own work or research but from international research, that where children could be prevented from engaging in such behaviour, their outcomes were much better both in school and in their readjustment to family life.

I worked closely in the burns unit over many years with a large number of children who had severe burn injuries and in pain management for those undergoing painful procedures. Although they have pharmacological help, they can often become quite distressed because the procedures are lengthy — I will not go into detail.

I work with children before, during and after procedures and with those who have difficulty sleeping. Sometimes when one can resolve a sleep issue for children, one resolves many other complications. Those are my comments on my experience of working in a paediatric hospital and completing several research studies in the children's hospital in Brisbane. At one point, when I left the city, they employed four music therapists there.

At the Crumlin children's hospital, there are two music therapists in the department. Regarding infant mediation in an educational context, music therapists are most closely aligned with allied health professionals, occupational therapists and speech and language therapists. Usually, when we enter a school or educational setting, our processes of engaging with staff and those children referred to us are similar. Like the other professionals, we usually have targeted interventions whereby we work with the child one to one or in a group. We might also have strategies for the classroom that we help the teacher to use so that he or she can maximise the child's participation, particularly in musical interaction. Sometimes we notice ways in which the child responds that teachers might use effectively when we are not present.

Senator Ó Murchú

I too thank Dr. Edwards for a very informative presentation and compliment the University of Limerick on its very innovative work. I can see from her presentation how necessary it is to spread knowledge and awareness of the benefits of music therapy throughout the broader education system and community.

I have had several personal experiences of the effect of music on young people with mental disorders. I remember one young man who attended a function that we run five nights a week. We have visitors, and he has attended for several years, allowing me to see the improvement. He learned a few tunes on the piano accordion, and he also had a single song, "Lovely Rose of Clare". He would dance a few steps, not necessarily fully in time. However, he was centre-stage and he was good and entertaining. That was the important thing; it was not a matter of patronising him. One could see from body language alone how he responded. He received a tumultuous round of applause, and I could not imagine any medical drug having the same effect.

How does one highlight that more and create greater awareness in the university system? How can we integrate Dr. Edwards's progress, knowledge and success into the community? What I mentioned happened in the community, and I can think of several other cases like it. Recently I was particularly fascinated, but not surprised, by a story that Dr. Edwards may have read in the newspapers. The British have now discovered that harp music has a very important effect on people in hospitals, so much so that in some they have introduced harp music to the operating theatre. Many people will have been aware of the soothing, therapeutic effect of such music but perhaps have never really focused on it or seen how we might acknowledge it. Did Dr. Edwards find anything particularly distinctive about the harp over other types of music? I was not surprised at that study because I possibly could have said it about other instruments. Nonetheless, in Britain the harp is the instrument on which the focus is being placed.

Dr. Edwards has been involved since 1998-99, which is quite a good period of exposure to this area. Has she seen any indication of an awareness within the educational system throughout the country? Generally, matters that operate within a university system are categorised or compartmentalised. They find their own interaction with the real world afterwards. Given the importance of this and the fact we are somewhat late in realising it, is there any way to expedite the relationship between the medical services, the community and the university? It is not a matter of just providing the qualification but speeding up matters, because it obvious that there is something special here, as has been proven, and that it is working. The big question is how long it will take to have it in place universally in the community. Can Dr. Edwards see a way in which the university might interact even more directly with the other partners in this area, particularly the community?

I compliment Dr. Edwards on her work. I found her presentation definitive. We often approach these areas the way some people look on alternative medicine in that they are not sure whether it works. I have no doubt it does work. Can Dr. Edwards say whether it has been measured on a broad basis that is sufficiently convincing to ensure that the powers that be and all people involved treat it in a much more urgent manner? Even if it is not proven in black and white, we all have experienced the fact that it works. It is important to disseminate this awareness more quickly into the greater world.

Chairman

Perhaps Dr. Edwards could differentiate between the music therapist, that is, the person who has an interest in music and someone with a professional qualification in music who is not a therapist.

Dr. Edwards

Perhaps I will comment on the differentiation between professionals. Senator Ó Murchú asked me, too, about how we could educate more people into using music effectively with a range of people who might have additional needs. I have a commitment to that, as does the University of Limerick's Irish World Academy of Music and Dance. Every semester I teach the special education students at Mary Immaculate College. Sometimes there are 20 or 50 special education and special needs teachers as well. I try to teach them about how they might refer to a music therapist, and also how they might use music, themselves, in some ways that might be more effective than others.

The Senator also asked me about expediting more quickly this operational differentiation between music therapy as something effective that a qualified person can employ for clinical gain. That is a difficult question because in my experience it involves both legislation and the political will to create a category by which music therapists can be employed, whether creative art therapists or, as in some countries, where this comes under the umbrella of allied help. This means a facility could choose whether it wanted a music therapist, an occupational therapist or speech and language therapist, depending on their departmental needs or the judgment of a social worker.

Chairman

Would Dr. Edwards consider that the music therapist would be of the same level of need as the occupational therapist or the speech therapist?

Dr. Edwards

That is the case in the United Kingdom, Australia and New Zealand. For example, with regard to the two new graduate entry courses in speech and language therapy and occupational therapy at the University of Limerick, I wrote the bid which was sent to the Department of Health and Children and the HEA. That bid was successful and, when the new places were opened up, the University of Limerick was the only university to get all three disciplines — physiotherapy, occupational therapy and speech and language therapy. The courses are based on the MA in music therapy that is taught at the Irish World Academy of Music and Dance.

Senator Feeney

I commend Dr. Edwards on a fine presentation and congratulate her on achieving publication in the Irish Journal of Psychiatry. What type of feedback has Dr. Edwards received with regard to music therapy from those in the world of medicine, particularly doctors?

Dr. Edwards stated that music therapy is an evidence-based profession. I am a member of the Joint Committee for Health and Children, which is regularly informed that best medicine and best practice must be evidence based. It is more difficult, as Senator Ó Murchú noted, to have evidence-based medicine than to have evidence-based music. I have four children. If my son is in bad form, he picks up his guitar; when he is in good form, he does the same. Playing guitar will alter his mood, depending on what he needs. That is something which is evidence-based.

How does Dr. Edwards see her position with regard to the HSE and medicine in Ireland? She referred to the fact there are few music therapists and that there is no registration system, with the result that it is difficult to differentiate qualified from unqualified practitioners. While someone in her position must remain tight-lipped in this regard, she must be annoyed and frustrated that people with no qualifications can call themselves music therapists. Does registration come under the Department of Education and Science or otherwise?

Dr. Edwards

The Senator inquired about feedback from doctors. Whenever I have the opportunity to discuss my background and experience and what the students are learning in the programme, I receive a much more positive reception than might be imagined. The most common response is that music therapy is seen as a luxury. It is associated with entertainment and there is an idea that it is the icing on the cake. In that context, I suggest that the icing can sometimes be the best part and that children sometimes only eat the icing. Perhaps we could consider ways of broadening our perception of what the health services should do and of what they should bring to a field such as music therapy.

I referred to the expert mental health group and its report, A Vision for Change. I was heartened to note that creative therapists were referred to in the report. However, there was no specific designation of music therapist, art therapist or drama therapist in the document. In a sense, "creative therapist" is a term without meaning. One could be any type of therapist and be quite a creative person. We have quite a way to go with regard to bedding down the terminology of what we mean by music therapy.

Many of us use music in different ways and the Senator referred to her son picking up his guitar. I want to encourage people to use music in a range of ways in a health care context. However, when practitioners call their work music therapy, they must be qualified to provide such therapy because patients, their families and the health service should know that the practitioner is accountable for the service on offer. This is especially important when working with young children, infants and people who have been traumatised, whether it is because they are refugees and have had experience as asylum seekers prior to arriving in Ireland or they are adult or child survivors of sexual abuse.

Senator Ó Murchú asked about music therapy being an evidence-based profession and pointed out that in this committee, best practice is underpinned by evidence. There are different ways to provide evidence, such as expert opinion, controlled trials which evaluate effectiveness, randomised controlled trials — the committee would be surprised how many studies fulfil the criteria for a randomised controlled trial — and meta-analyses, in which all the studies are pooled together. In music therapy, meta-analyses are emerging and I have reported on a number of them in my paper in the aforementioned journal and today's report.

The practicality of how to derive a designation within the Health Service Executive in order that music therapists can be employed is key to the profession moving forward. I have been heartened by the committee's comments which pointed out that music is enjoyed, loved and now shown to be efficacious therapeutically. We are at a stage where we must start considering how to optimise and maximise these elements. Senator Feeney asked about the registration of music therapists. We want parity with the other allied health professions, namely, those registered through the recent decision of the Parliament.

Senator Feeney

Is Dr. Edwards referring to the Health and Social Care Professionals Act 2005?

Dr. Edwards

Yes.

Deputy Kelly

I welcome Dr. Edwards who is said to be a great woman. I see her smiling at that comment. What is music therapy? What is actually done? Will Dr. Edwards describe an average day in the life of a music therapist? Do the therapists or the patients play? What and how many instruments are used?

Chairman

Does anyone play?

Deputy Kelly

Can we all join in? Is any instrument favoured over others? What is the distinction between music therapy and community music? From Dr. Edwards's research, what is the state of music therapy in Ireland's health care system? Many of the medical facilities the committee has contacted have a form of community music. What benefits could they receive by installing a professional music therapy programme in their institutions, hospitals, nursing homes and so on? Has Dr. Edwards carried out controlled experiments on the benefits of music therapy for individual patients?

Dr. Edwards specialises in the effects of music therapy on children but it appears that most of the institutions throughout Ireland do not link music therapy and children and define the former as a therapy used in geriatric units for patients suffering dementia or Alzheimer's disease. How does Dr. Edwards propose to raise the awareness of the programme's use in paediatric facilities?

What could Dr. Edwards tell institutions with limited funding that need to allocate their resources based on the most beneficial treatments, such as speech and occupational therapy? How much would a medical facility need to invest in equipment, staff and supplies to implement a music therapy programme? If I run a children's or geriatric hospital and decide to consult Dr. Edwards as my adviser, what would it cost to set up such a programme? Most people we contacted suggested music therapy would be of no benefit in general hospitals because patients stay for a short time. Is this correct? Some claim that therapists are not licensed. Is it vital that therapists be qualified with a university degree? Many people have taken career breaks or retired from the showband scene and play music in nursing homes. The musicians are delighted because they get to bed at 4 p.m. instead of 4 a.m.

How can we increase interest in music therapy at university level? What does a typical music therapy session consist of and how long does it last? Can Dr. Edwards prove that music therapy is a healing process? Some believe that everything heals and those who are selling a product or service always suggest it will heal. It is all in the mind. People will believe anything. What is the future of music therapy? Does Dr. Edwards believe music therapy will become a major industry? Perhaps I will provide a session afterwards.

Senator Feeney

Can Deputy Kelly play an instrument?

Deputy Kelly

I am not prepared to discuss that but I will speak to the good doctor later. How can we educate people about music therapy so that they can choose it as a treatment? Can Dr. Edwards provide examples of music therapy in action?

Chairman

The Deputy did not ask too many questions. Dr. Edwards can duck and dive.

Deputy Kelly

I only ask questions that Dr. Edwards will be able to answer.

Dr. Edwards

I hope Deputy Kelly is able to remember them. I will begin by responding to the penultimate question, on whether I believe music therapy is the next big thing. It does not need to be the next big thing, nor do we need a large number of music therapists. Where music therapy is provided it should be by those with appropriate qualifications and competence to engage with people who are vulnerable.

A number of members asked about the average day in music therapy. Music therapists receive referrals after a clinical need has been identified. The client will be referred to the music therapist or will join a group with needs to be addressed. The music therapist uses a number of methods. The primary one is musical improvisation, creating music in the moment. Sometimes this is recorded, played back and reflected on by the group or individual. Instruments are left in a room and the patient or group comes into the room and begins to play music with the therapist. It may begin quietly or energetically and enthusiastically. A theme may be chosen or some encouragement may be needed. A therapist may ask someone to demonstrate how an instrument is played. The individual will choose the instrument, put it on the lap and play it.

In Australia I worked on a programme for survivors of torture and trauma from the former Yugoslavia. In that group I worked through interpreters and began with a simple interaction, asking the members of the group to try out and choose an instrument and play it as loudly as possible and as softly as possible. I then asked them to play the instrument one by one. Before the session began the interpreters had explained that these were hard men and the interpreters did not believe this exercise could be done. I thought, why not just try and see what happens? We went around the room and everybody played their instrument, and then I asked each person what it was like to do so. One man began to speak, and because I could not understand him the interpreter had to interpret. He made a brave comment. The interpreter indicated that the man was wishing that his wife could see him playing this beautiful instrument as he thought she would fall in love with him again.

Chairman

Dr. Edwards is telling the wrong person.

Dr. Edwards

The Chair appears to be suggesting that it is difficult to get a picture of how music therapists work. That is not the only way. What I often wish to do is wait for the patient or the client to make a response or an interaction. I often do not even make a suggestion. I promise the joint committee that showing up at a child's bedside in a hospital with a guitar is an invitation to play and sing. In my experience, children are very responsive to musical interaction, even those who are not speaking or for some reason are not coping particularly well.

Others methods include song writing. I have written protest songs with children about hospital food or staff, as well as pain. I have written with children love songs to family members, greetings to family members from children in isolation because of infection control, and I sometimes work with song parody. Although I state I work this way, this is the manner in which music therapists work. We take a song, change the words and keep the tune. That is sometimes a very quick way of working with the patient.

Another method is to compose music. I used to work with siblings of children with cancer, and they are a particular group in that the family member is going through a cancer treatment that can sometimes take years. Children are not all the same and they sometimes need extra support and help. I often work with these children by means of a story, with the children creating the story and putting music to it.

The joint committee asked about the instruments used, and I have talked about the guitar and percussion instruments. Sometimes children or adults have learned an instrument and will use that. We sometimes use recorded music and listening, although that is not the main way music therapists would use music. We normally use live music, which can be performed by the therapist, but we usually wait for clients to request, play or improvise something.

I was asked about the difference between music therapy and community music. A masters degree in community music is also offered through the Irish World Academy of Music and Dance at the University of Limerick. Community music operates in quite a different context and with a different objective from music therapy. The music therapist works with the referral system, where we work with clients with a clinical need that is identified. Community musicians and music workers usually go into a community context, be it a halting site, village, hospital or school, with the aim of creating an experience or series of experiences which help the entire community to have an experience of participation, identity, belonging and expression through music.

I have seen many community music projects through the Irish World Academy of Music and Dance. These include projects with the Traveller community and with young people recording songs and putting them on a disc. Music therapy is often very different, and we are not product based. We often do not have a performance at the end, nor do we make a recording that the children take home. We often work in a process of getting to know the client or patient and working specifically to address clinical needs.

The committee asked about clinical studies which I have been involved in. I mentioned in my contribution a year-long study at a 23-bed residential hospital in Limerick where people with dementia are cared for. As these people are being seen in the Limerick mental health service for older persons, they usually have some disturbances that are a result of the dementia. We carried out a pre-test before music and art therapy began and a post-test at the end of a 28-week period. There were significant differences in the patient cohort. To go back to the question of evidence, it can be easy to find statistical significance which does not necessarily mean anything would change clinically. It just means a measure was made that was different enough but in this case 29 behaviours were examined and the only behaviour that did not decrease was the behaviour of wandering. People with dementia often walk around. We do not know whether they are looking for something or it makes them feel more comfortable to be on the move, but we found that all the other behaviours we examined decreased significantly over that period.

I was asked how I would respond if I was asked by the head of a hospital how much it would cost the hospital to have a music therapist. Those costs are determined by the Health Service Executive and not necessarily by me, but hospital managers should consider a music therapist costing the same amount as an occupational therapist. There are costs for instruments and for the maintenance of instruments, for example, if strings or the head of a drum are broken. There are costs also in terms of needing a room where the music therapist can work and so on.

On the question of whether we can then deliver something that shows that is a cost effective therapy, more studies need to be done that can demonstrate how cost effective music therapy is in comparison to other therapies. However, we have good and collaborative relationships with other allied health professionals such as occupational therapists, speech and language therapists and physiotherapists. If a two year old child with burn injuries is asked to lift up his arm and reach out, he will not follow those instructions but if I hold up a tambourine, he will reach out to try to play it. He will stretch out his arms after grafting. I would work closely with other allied health professions. The multidisciplinary teams are what often need to be thought about in service provision rather than playing one allied health professional against another. We work in a team. It is often difficult to see directly that one therapy was more beneficial than another.

Chairman

Dr. Edwards is getting across the message clearly that music is therapeutic but there is a structured approach to music therapy in terms of clinical need. Over the weekend I attended the christening of a baby whose little brother is almost four and cannot understand why this new baby is the centre of attention, a position he used to hold. From what Dr. Edwards is saying, that type of intervention could be helpful, even to help the children express themselves before they are in a position to vocalise how they are feeling. Music therapy has a role in that regard.

Does Dr. Edwards want to comment on whether there is a role for music therapy in the treatment of autism? Our biggest problem is overcoming misconceptions but in the arts the musician is taken for granted regardless of the role he or she plays. We expect the musician who plays in the dance band to sing for children in schools. We often expect the organist to arrive at church services. Music is taken for granted because it is all around us; it is even in the supermarkets. The musician working in a hospital, therefore, should not be any different from the musician going into the schools.

I had intended asking how we could encourage music therapy to be taken more seriously but Dr. Edwards has answered that question. If we give music therapy the same status as the other therapies, everybody else must come up to that level. I assume Dr. Edwards will agree that the only way to give it that status is to recognise it professionally. Also, if someone wants to be a music therapist, should they have a basic science or nursing degree or can it be either?

Dr. Edwards

The Chairman has made some very good points on issues around misconceptions and how we address those. I would encourage graduates of the programme and other qualified music therapists in Ireland to continue to stress the evidence base for music therapy, the clinical processes involved and the parity with other allied health professionals. The Chairman also asked me about the level of intake into the programme at masters level. We primarily accept people from a music background. They must have high level music skills, usually evidenced through a degree, but we have taken people from other occupational backgrounds relevant to music therapy. A speech and language therapist is about to complete the masters programme and previously a psychologist and social worker completed the degree course. We accept a psychology undergraduate degree as a prerequisite degree but students still need high level music skills. They need to have been studying music for a long time and must be able to demonstrate having worked in different contexts such as having played music in nursing homes or having been called upon in their community to perform their music in public. Their skill levels need to be at that height. There is currently an intake into the programme every two years and we are now moving towards having an intake into to it every year. I hope that will mean we will have more momentum with more people graduating from the programme.

Deputy O’Shea

The Chairman asked about autism and how the therapy may be used with people with autism. I saw a savant young person who had remarkable skills in music and was able to read and play complicated music at four years of age. On the morning he was taken down to meet me, the people in the place he was in said he would play if he wanted to do so. I have never been sure if there was a therapeutic aspect to what was happening in that place. Can music therapy have a significant therapeutic role in treating people with autism?

Dr. Edwards

A number of descriptive studies support a role for music therapy in interacting with children and adults in the autistic spectrum. However, in terms of research findings, we still have more work to do. A large study in this area is currently being conducted. It is a difficult area to research because people diagnosed with autism or conditions such as Asperger's syndrome often are not much like one another. They have special attributes and characteristics and, therefore, are difficult to compare. In the case of the studies carried out sometimes it is not clear whether the changes that took place from the first to the final point of testing are due to music therapy or whether the person might have made those improvements socially in any event. Many music therapists work with children with autism and there are many published studies on this condition, but it is a complex area when we start to examine the important matter of evidence. We are not the only clinicians operating in this area.

Chairman

I intend to visit the music therapy unit in Our Lady's Hospital for Sick Children in Crumlin to observe it in operation. I encourage any or all members of the committee to accompany me on that visit if they are interested. Chris de Burgh opened that unit approximately 12 years ago. I learned that when I happened to be seated beside him at a recent concert. I am glad to hear the unit is still in operation and two therapists are based there.

The interaction we have had today has been helpful in contributing to the preparation of our report. Ultimately, it is clear that music has a role to play in the community and in therapy — they are two different entities. I hope Dr. Edwards will be on standby at the other end of the telephone or computer, in terms of e-mail, if we need to contact her as issues arise as we progress on this matter.

I have been fascinated by the responses I received to the questionnaires issued. Some hospitals that provide music therapy are ecstatic about the benefits of it. While some hospitals that do not provide it are aware that it is beneficial, they are of the view that given that they find it difficult to recruit speech and occupational therapists, why then should they try to recruit music therapists. I liked Dr. Edwards's response to the notion that music therapy is a luxury and the icing on the cake to the effect that the icing can sometimes be the best part and that children sometimes eat only the icing. There seems to be many misconceptions about music therapy, even in the medical field. Hospitals that provide the therapy are excited about its benefits. I hope our report will contribute to increasing the volume of information available on music therapy and to getting across the message of the benefits to be gained from its use.

I suppose I should have declared an interest at the start in that I am a musician by background and studied it for seven years in university. I have spoken to a few musicians who were at college with me. They said that if one was good at performing music one would become a performer, but if one was not good at performing one would become a music teacher. The option of pursuing concepts such as music therapy was not there. One of the roles of this report will be to encourage people in the academic and health sectors into that area. Should it be decided tomorrow that everywhere needs music therapists we would not have enough qualified people to cope.

On that note, I thank Dr. Edwards for her informative contribution. I also thank members of the joint committee for their participation.

The joint committee adjourned at 3.10 p.m. sine die.