Chapter 1

What is Music, Health, and Wellbeing and Why is it Important? Raymond MacDonald, Gunter Kreutz, and Laura Mitchell

The origins of Music, Health, and Wellbeing The great saxophonist Charlie Parker once proclaimed ‘if you don’t live it, it won’t come out of your horn’. This quote has often been used to explain the hedonistic lifestyle of many jazz greats; however, it also signals the reciprocal and inextricable relationship between music and wider social, cultural, and psychological variables. This link is complex and multifaceted and is undoubtedly a central component of why music has been implicated as a therapeutic agent in vast swathes of contemporary research studies. Music is always about more than just acoustic events or notes on a page. Moreover, music’s universal and timeless potential to influence how we feel and think lies at the heart of our motivation to produce this edited volume. Music has been imbued with curative, therapeutic, and other medical value throughout history. Musicians, therapists, philosophers, as well as other artists and scholars alike have documented its physical, mental, and social effects in treatises from as early as 4000 BC to the present (Spintge and Droh 1992). Clearly, the relationship between music, health, and wellbeing is complex and involves numerous facets and challenges. To begin with, there is considerable debate on all three of the key terms in the title of this volume. Leaving aside the intricacies of etymology and translation in various languages, one significant challenge is the establishment of causal links between musical activities on the one hand and specific individual health and wellbeing benefits on the other. This book is conceived to accept this challenge by means of building evidence-bases in different areas of music and health research and we hope that this collection of chapters will further our understanding of music as a part of both human nature and human culture. The integration of different academic disciplines presented throughout this text reflects recent developments in music research where multidisciplinary approaches are viewed as vital to the development of our understanding of musical behaviour. It is also important to note that the profession of music therapy dates back to the early twentieth centenary and music therapists have been researching and delivering therapeutic interventions across a vast range of clinical settings for a considerable amount of time (Bunt and Hoskyns, 2002). Moreover, interest in the social psychology of music and evolutionary origins of music have emerged as key themes in music psychology research. Consequently, the effects of musical activities on individuals in both clinical and non-clinical settings are now being studied. These approaches place emphasis on variables including psychological, physiological, cultural and behavioural effects which may have implications for health and wellbeing. In brief, music therapy and music psychology research complement each other while maintaining traditions that are specific to each of these areas. Research into the relationship between music, health, and wellbeing necessitates novel approaches from right across the academic spectrum, including arts and humanities as well as the

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social and natural sciences (Pothoulaki et al. in press). From engineers endeavouring to develop new technology to help individuals with physical disabilities explore their creativity, to music graduates seeking to use their skills and training within a community music context, through to surgeons playing recorded music for patients in hospital to alleviate pain and anxiety. Musical activities and responses are also considered as potent preventative measures to enhance psychophysiological wellbeing reaching into almost every aspect of life. What is understood now as a multidisciplinary interest in the relationship between music, health, and wellbeing has captured the public’s imagination as well as sparking a wealth of academic research (Cassidy and MacDonald 2010). Witness the huge growth in community singing. Singing is now viewed as being more accessible than in previous times, and many community singing groups explicitly state that the health benefits of community singing are a primary reason for participation (Clift, Chapter 9). One reason for this growing recognition of the potential benefits of music interventions in the general population, irrespective of the individual level of musical training, is the considerable advance in research that investigates the benefits of music on various health measures (Wosch and Wigram 2007). Indeed, in recent years there have been an increasing number of studies that investigate the relationship between music, wellbeing, and health. Importantly, this heightened interest is influenced by developments in research methodologies (qualitative and quantitative) in many contexts including laboratory, clinical, educational, and community settings. The current book presents many of these contexts and research designs.

Why music? What are, if any, the special reasons to consider music in contexts of wellbeing and health? Many authors in this volume rightfully address the lack of coherence of research in this field. The diversity of approaches and findings, the heterogeneity of methods, participants, outcomes, and interpretations of findings which are reflected in this text may be serious obstacles in theory building and could well compromise progress in the field. But by the same token, this heterogeneity of research is also indicative of an undercurrent suggesting broad support of basic ideas, which run throughout the chapters. The fact that music is implicated in so many different types of interventions relating to health and wellbeing underscores the belief that being moved or touched by music cannot be held purely as a metaphor, which renders music as mere embellishment of our daily lives. Presented below are a number of possible reasons as to why music could produce these beneficial effects.

Music is ubiquitous Now more than at any other time in history, music is pervasive. The technological revolution that has taken place in terms of music listening means that we can now listen to our own musical choices 24 hours a day. Cheap, discreet, and easily operated digital music devices with large storage capacities facilitate selecting music to accompany household chores, driving, a romantic meal, a bus journey, shopping, a long walk, etc. Indeed, these devices are so discreet that we can, in effect, listen to our own music in virtually every context imaginable.

Music is emotional There is no doubt that music affects our emotions (Juslin and Sloboda 2010). When selecting music to listen to in any particular situation we make a number of sophisticated and highly nuanced psychological assessments in an instant. This type of assessment may include questions such as: how do I feel right now? How do I want to feel in five minutes or one hour and what music will help me achieve this goal? Which music suits me for this very moment, or a certain

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period of time? Is anybody else listening and what will they think? Within and beyond these assessments we also make very specific musical decisions about how particular pieces will change the environment and the psychological states of other individuals around us. This capacity of music to affect our mood and emotions may be one of the key features that facilitate musical activities producing positive effects.

Music is engaging When we play or listen to music we are involved in various different levels of processing. A number of chapters within the book demonstrate to what extent engaging in music may produce positive neurological effects in the brain. Indeed it has been suggested that music can influence the plasticity of the brain in specific ways, which can translate into changes, for example, of the human motor system (LaGasse and Thaut, Chapter 12).

Music is distracting When we are listening to, or playing music we can be distracted from aspects of our lives that are distressing: a painful stimulus, a very emotional event. Certainly there is evidence that music can distract the listener and performer in many ways, e.g. possibly through the immersive state of ‘flow’ (Csíkszentmihályi 1996), and in doing so can provide health benefits.

Music is physical In addition to the entwined relationship of music and dance, musical performance can be physically demanding. Drummers, for example, are required to have high levels of stamina, coordination, and dexterity across all four limbs. Specifically in a health context, coupling music with physiotherapy can help stroke patients undertake rehabilitation exercises that may facilitate development in arm and leg function more quickly (van Wijck et al. in press).

Music is ambiguous Another reason why music can evoke such strong emotions is that music is ambiguous in meaning. Regardless of what specific emotion a composer attempts to imbue a piece of music with, or no matter what specific emotion a performer wants to convey in any given performance, as listeners we filter everything we hear though our own listening histories, experiences, and preferences. We are therefore free to interpret what we hear in an infinite number of ways (Mitchell and MacDonald 2011). While there is a significant amount of research investigating the effects of specific structural parameters upon musical communication, it is clear that preference and structure interact in a number of sophisticated ways to produce meaning for the listener (Knox et al. in press).

Music is social Music, by its very nature, is a social activity. Indeed it may be possible to define music through its social function, i.e. any sound, action, or silence can be termed ‘music’ if the social context labels it as such. The social functions of music are numerous and vastly important to society, linking people whether one-to-one, in large gatherings, or connecting through technology.

Music is communicative One of the primary functions of music is to communicate (Miell et al. 2005). Indeed, music can be viewed as a fundamental channel of communication, providing a means by which emotions and ideas can be expressed, communicated, and shared, both locally and globally, even when communicating by language may be impossible (Hargreaves et al. 2005). Taking the specific

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example of investigating the link between music and health, the profession of music therapy is predicated upon a deep and sophisticated understanding of the process of musical communication. In order to develop a trusting and effective clinical relationship, a music therapist must utilize this knowledge of musical communication to produce positive effects for clients. The communicative potential of music is undoubtedly linked to its therapeutic potential.

Music affects behaviour There is now a considerable amount of research highlighting how music affects our behaviour in very deep and sophisticated ways (North and Hargreaves 2008). Whether in a personal, social, consumer, educational, or motivational context there is clear and unequivocal evidence that music affects behaviour. This capacity of music to affect our behaviour has been harnessed in numerous contexts to change behaviours in beneficial ways (Hallam and MacDonald 2008).

Music affects identities There is no doubt that music also has an important part to play in our constantly evolving and socially negotiated identities (MacDonald et al. 2002). There is evidence that music listening is the most important recreational activity for young people, influencing clothing preferences, magazines read, places to socialize, and even friendship groups (Zillman and Gan 1997). For many young people, music is key to how they orient themselves in their lives and their music tastes are often employed as a ‘badge of identity’ or way of signalling to the world key aspects of their personality (Hargreaves and North 1997).

What is health? One of the most widely discussed contemporary definitions of health from the World Health Organization (WHO) reveals it as ‘a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity’. This definition embraces, although indirectly, a salutogenetic approach to health (e.g. Antonovsky 1987). This perspective suggests that every individual can activate intrinsic and personal psychological resources that can help to cope with illness without relying exclusively on extrinsic support to overcome health problems. Therefore health is, to some extent, in our own hands rather than being granted from any health system surrounding us. Moreover, health practices are rooted in everyday activities and many of those are related to the arts and culture. One important consequence of this view is that the term ‘wellbeing’ has now become an integral part of health. In other words, what matters is not only how poorly we feel, but it is of no less importance how well we feel and which cultural resources are available to sustain and develop our sense of coherence. Some commentators, however, have suggested that the WHO definition of health also has some pitfalls. For example, it falls short of suggesting the critical importance of economic resources that are available to individuals and the society in which they live. Also, it does not address specific cultural activities as prominent resources. In numerous strands of research following the WHO and other definitions and models of health, there is significant focus on nutrition, physical activities, and environmental conditions. These are certainly major influences on individual health in the most direct sense. However, it is still surprising that the value of cultural and arts practices are, by and large, absent from any key discussions surrounding health and health promotion. In summary, approaches to health and wellbeing place different emphasis on the extent to which individuals can influence their own health condition. There is evidence to show that music is an intrinsic and important part of human development. Thus, it needs to be considered as a universal resource, from which implications for health and wellbeing emerge.

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Given this broad definition of health that stresses wellbeing in all its manifestations, and given the various qualities of music outlined above, it is perhaps not surprising that there has been an upsurge in interest in the relationship between arts in general and specifically music and health. Various countries have instigated national bodies to investigate the relationship between the arts and healthcare, for example, The Arts and Health (Australia), The Society for the Arts in Healthcare (USA), and Artful (Scotland). There are also a number of dedicated international journals such as Arts and Health: An International Journal for Research, Policy and Practice.

How is the relationship between music and health assessed? A specific aim of this book is to overview the multitudinous ways in which the relationship between music and health is assessed. One way of conceptualizing these approaches is to classify different research methodologies as either qualitative or quantitative. Quantitative methodologies include physiological and neurological measures, observation of behaviour, and assessment of task performance, self-report questionnaires, and the use of rating scales. In contrast, qualitative methodologies include focus groups, interviews, real-life interactions, and web-based resources. This work can include informal situations such as investigating music listening in everyday life or experimental contexts where the effects of music are investigated in more controlled environments. A key point here is that the relationships between outcome measures assessed by these various techniques and ‘music’ are complex, and developing causal links is a fundamental challenge for this area of study. In particular there is a need to develop ‘evidence-based practice’, a concept which, as Wigram and Gold discuss in Chapter 13, must be defined broadly and with subtle consideration for the different epistemologies that underlie each approach to ‘evidence’. Along with this heightened interest in music, health, and wellbeing there is significant spurious postulating about the benefits of music. Therefore, one challenge for researchers is to sensitively evaluate the evidence available in this area where there are a multitude of approaches and many different epistemologies. Our contention, which we hope that this book helps demonstrate, is that when music is utilized in knowledgeable ways, evidence suggests it can have positive effects.

Conceptual framework One of the main reasons for wanting to bring together a collection of chapters such as those in the present volume is to attempt to integrate a number of related disciplines that all utilize music for reasons of positive outcome. Figure 1.1 displays one possible way of integrating these related approaches. The area with the most explicit remit and longest history relating to health and wellbeing is music therapy, and there are a number of chapters that utilize a music therapy approach. Music therapy can be defined in a number of ways but fundamental to all approaches is an emphasis on the therapeutic relationship between the client and the therapist, using music as a primary means of establishing and maintaining this relationship and producing positive benefit for the client. Another group of chapters within this volume originate from a music education perspective. There is considerable interest in the possibility that music education can produce benefits in other areas for participants, for example, the question of whether attending piano lessons improves pupils’ maths ability or if violin lessons enhance general cognitive capacities. The key point here is that these interventions are not primarily aimed at wider psychological benefits. The purpose of a piano lesson is to improve piano skills; but there may be secondary benefits for participants relating to health and wellbeing and it is these psychological benefits of music education that

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Music education

Everyday uses of music

Music therapy

Community music

Fig. 1.1 Conceptual framework for music, health, and wellbeing.

overlap with music therapy. Additionally, in Chapter 21, Ockelford outlines how music education for individuals with special needs can also have beneficial effects on wider psychological variables. This type of work is another overlap between music therapy and music education. A more recent field of study is community music, which can be defined as organized music interventions that take place outside of formal education contexts. One of the most popular of these is community singing, but there are many different types of community music interventions, often with educational objectives; running music lessons in community centres where groups get together to perform pop music is a good example of an intervention that allows people to develop their creativity through music but also to develop instrumental skills. These community interventions will sometimes have therapeutic objectives as secondary goals, such as the running of music classes in a psychiatric hospital where patients can develop percussion skills. Here the emphasis is on the development of specific skills but the intervention (which is social, enjoyable, and rewarding) may afford the participants other non-musical benefits, illustrating how community music overlaps with both music education and music therapy. The fourth subsection in the Venn diagram in Figure 1.1 is ‘everyday uses of music’. While this is not a distinct field of practice and there are a number of professional practitioners developing interventions within an ‘everyday uses of music context’, there is considerable interest in the effects of listening to music in real-world informal settings. For example, does listening to preferred music while driving enhance mood and can music listening while doing housework reduce feelings of pain and anxiety? Once again these musical situations are not explicitly clinical or therapeutic but there is significant interest in these contexts in terms of how they can positively affect health and wellbeing.

Structure of the book This book presents issues for researchers and practitioners across a variety of fields including music, therapy, public health, and medicine. It does this by bringing together a range of chapters to provide a multidisciplinary and pluralistic account of recent research advances and applications in both clinical and non-clinical contexts. Some of the areas explored include: the nature of

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the scientific evidence to support the relationship between music and health; the current views from different disciplines on empirical observations and methodological issues concerning the effects of musical interventions on health-related variables; the mechanisms which drive these effects and how they can be utilized for building robust theoretical frameworks. While covering a wide range of diverse yet complementary areas, there is a definite focus on evidence-based approaches as well as critical reviews of recent published research. One innovative and important aspect of this book is that research from the contrasting but related disciplines of music therapy, community music, and music education is presented and synthesized. This strategy aims to ensure that closely-related strands of research in different disciplines are brought together. The book is structured in five sections with each section delineating one particular approach to music health and wellbeing. Section 1 provides an introductory context by presenting neurological (Chapter 2, Altenmüller and Schlaug) and cultural (Chapter 3, Elliot and Silverman) overviews relating to music health and wellbeing. The significant contribution made by the music therapy profession to music, health, and wellbeing is also signalled here in Chapter 4 (Trondalen and Ole Bonde). Section 2 covers issues in community music and public health. The growing recognition of community music as an important musical activity is very much in keeping with current thinking that supports the integration of social, educational, medical, and therapeutic practices. In this section there is discussion around the different approaches that provide evidence of the relationship between music-making and potential positive effects on public health. Chapter 5 (Daykin) discusses the role of music in the development of healthy communities while Murray and Lamont (Chapter 6) investigate community music across a range of contexts. Two Chapters, 7 (Ruud) and 8 (Ansdell and DeNora), present a relatively new approach to music therapy that explicitly recognizes the importance of community music. Community music therapy has a prominent position within the text, as this approach is a significant attempt to investigate clinical practice within a community context that is very much in keeping with the aims of the book. Another term that appears in these chapters and across a number of other chapters in the book is ‘health musicking’; a term that is highly relevant here as it relates to musical activities across a range of contexts that have implications for health. Chapter 9 by Clift provides a summary of his empirical and practical work in the area of psychological effects of group singing while Chapter 10 (Quiroga Murcia and Kreutz) and Chapter 11 (Davidson and Emberly) explore the relationship between dancing and music within a heath context. In Section 3, the relationship between music and health is investigated in clinical and therapeutic contexts. This section again takes into account both biological (Chapter 12 by LaGasse and Thaut) and cultural perspectives (Chapter 14 by Stige, and Chapter 15 by Pavlicevic). Some of the chapters within the book have relevance across a number of sections. For example, Chapter 14 also relates to section 2. Wigram and Gold reflect on the continued need for case studies and indepth qualitative methods as well as quantitative assessment within quasi-experimental and experimental research paradigms in Chapter 13. Chapters 17–20 include clinical and experimental examples of how music can be used to alleviate pain and anxiety, with a key theme of the relationship between musical preference and musical structure. The final chapters in this section highlight the important dichotomy of music listening and musical participation. Section 4 focuses on educational contexts and the widely-discussed relationship between music education and psychological and social benefits. This section examines the notion that musical participation (both listening and performing) and musical skill development may influence mental and physical wellbeing in a variety of educational settings across different social environments and music cultures. The relationship between music education and music therapy is discussed in

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Chapter 21 (Ockelford) and 26 (Ockleford and Markou). Musicians’ health, with some emphasis on health prevention in contemporary music conservatory education, is discussed in Chapter 24 by Ginsborg, Spahn, and Williamon while music education across the life span is examined in Chapter 25 by Gembris. Section 5 looks at everyday uses of music related to health and wellbeing and presents chapters dealing with the positive effect of music listening in non-clinical everyday contexts. Västfjäll, Juslin, and Hartig (Chapter 27) highlight the importance of music’s capacity to provoke strong emotional responses in listeners as a possible key component relating to health and wellbeing while Koelsch and Stegemann (Chapter 29) discuss neurological effects of musical activities and their therapeutic implications. Theorell and Kreutz (Chapter 28) summarize epidemiological work around music and health, a scarcely developed, but highly fertile field of future research. Kreutz, Quiroga Murcia, and Bongard (Chapter 30) summarize psychoneuroendocrine research on music to provide some ground for further exploration. Cross-cultural approaches to music and health are presented by Saarikallio in Chapter 31. Hallam reviews the very important issue of the possible positive effects of background music in Chapter 32, and this final section also contains two chapters discussing the possible deleterious effects of music listening. In summary, aligned with the explosion of interest in the relationship between music and health are considerable advances in the quality and quantity of research investigating the ways in which music and health are related. The text attempts to be innovative in the way in which it brings together research from a wide variety of academic and applied backgrounds to add to our understanding of the many ways in which music and health are related. The book provides an opportunity for such interdisciplinary critiques and for a wide-ranging consideration of the processes and outcomes of musical participation as it relates to health and wellbeing. While any book about music about is ultimately trying to translate into words a process where the fundamental characteristics are non-verbal, the attempt to try and understand more fully the process and outcomes of musical engagement is of vital importance. This is particularly crucial if we are to further our knowledge about the beneficial effects of music. Of course music is not an ultimate panacea, a magic bullet that can cure all ills, but there is a growing body of evidence suggesting that when utilized in knowledgeable ways music can have significant positive effects upon our health and wellbeing. Victor Hugo’s observation that ‘music expresses that which cannot be put into words and cannot remain silent’ highlights both the power of music and the paradox of trying to write about music (Hugo 1864). Regardless of this paradox there is much to be gained from attempting to translate into words the crucial relationship that exists between music and health improvements. In times of socio-economic turmoil, questions as to how to respond to the vast challenges of demographic change have remained unanswered. We believe there is a clear need to bring back more culture and humanity into medical systems, which have replaced doctors, nurses and patients by providers, customers and clients (Hartzband & Groopman, 2011). In conclusion, the creative potentials of music and art are needed more than ever.

References Antonovsky, A. (1987). Unraveling the mystery of health. San Francisco, CA: Jossey-Bass. Bunt, L. and Hoskyns, S. (2002). The Handbook of Music Therapy. London: Routledge. Cassidy, G.G., MacDonald, R.A.R. (2010). The effects of music on time perception and performance of a driving game. Scandinavian Journal of Psychology, 51(6), 455–64. Csíkszentmihályi, M. (1996). Creativity: Flow and the Psychology of Discovery and Invention. New York: Harper Perennial. Hallam, S. and MacDonald, R.A.R. (2008). The effects of music in educational and community settings. In: S. Hallam, J. Sloboda, M. Thault (eds.) The Handbook of Music Psychology, pp. 471–80. Oxford: Oxford University Press.

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Hargreaves, D.J. and North, A. (eds.) The Social Psychology of Music. Oxford: Oxford University Press. Hargreaves, D.J., MacDonald, R.A.R., and Miell, D. (2005). How do people communicate using music. In: D. Miell, R.A.R. MacDonald, and D.J. Hargreaves (eds.) Musical Communication, pp. 1–26. Oxford: Oxford University Press. Hartzband, P. and Groopman, J. (2011). The new language of medicine. New England Journal of Medicine. 365(15), 1372–1373. Hugo, V. (1864). William Shakespeare. London: Hauteville House. Juslin, P.N. and Sloboda, J.A. (eds.) (2010). Handbook of music and emotion: Theory, research, applications. Oxford: Oxford University Press. Knox, D., Beveridge, S., Mitchell, L.B., and MacDonald, R.A.R. (2011). Acoustic analysis and mood classification of pain-relieving music. Journal of the Acoustical Society of America, 130, 1673–82. MacDonald, R.A.R., Miell, D., and Hargreaves, D.J. (eds.) (2002). Musical Identities. Oxford: Oxford University Press. Miell, D., MacDonald, R.A.R., and Hargreaves, D.J. (eds.) (2005). Musical Communication. Oxford: Oxford University Press. Mitchell, H.F. and MacDonald, R.A.R. (2011). Remembering, recognising and describing singers’ sound identities. Journal of New Music Research, 40(1), 75–80. North, A.C. and Hargreaves, D.J. (2008). The Social and Applied Psychology of Music. Oxford: Oxford University Press. Pothoulaki, M., MacDonald, R.A.R., and Flowers, P. (in press). An interpretative phenomenological analysis of an improvisational music therapy program for cancer patients. Journal of Music Therapy. Spintge, R. and Droh, R. (1992). Music Medicine. Saint Louis, MO: MMB. van Wijck, F., Knox, D., Dodds, C., Cassidy, G., Alexander, G., and MacDonald, R. (in press). Making music after stroke: using musical activities to enhance arm function. Annals of the New York Academy of Sciences. Wosch, T. and Wigram, T. (2007). Microanalysis: methods, techniques and applications for clinicians, researchers, educators and students. London: Jessica Kingsley. Zillman, D. and Gan, S. (1997). Musical taste in adolescence. In: D.J. Hargreaves and A. North (eds.) The Social Psychology of Music, pp. 161–87. Oxford: Oxford University Press.

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