Receptive music therapy and music medicine

1. Introduction

Version followed: two related practices kept apart. (a) Music medicine as Ralph Spintge built it at the Sportklinik / Krankenhaus für Sportverletzte Hellersen (Lüdenscheid, Germany): "anxiolytic music" played through headphones before and during painful or operative procedures. (b) Receptive music therapy as set out by Grocke & Wigram (2007, Receptive Methods in Music Therapy), with music-and-imagery formats from Wärja & Bonde (2014). The boundary between them follows the Cochrane definitions used by Bradt, Dileo and colleagues. [source: Pharmazeutische Zeitung 1997; Thieme abstract; UBC Press TOC; Wärja & Bonde 2014; Cochrane CD006911 PLS]

Music medicine: patients "simply listen to pre-recorded music that is offered by a medical professional". There is no therapist-led process. [source: Cochrane CD006911 PLS]
Music therapy: "requires the implementation of a music intervention by a trained music therapist", within a therapeutic process that adapts the music to the individual. [source: Cochrane CD006911 PLS; Bradt, Dileo & Shim 2013 PLS]
Dileo's distinction: Cheryl Dileo set out this distinction and "levels of practice" in a 1999 chapter, Introduction to music therapy and medicine: definitions, theoretical orientations and levels of practice. That chapter is cited by Wheeler et al. 2019, but it is not drawn on in this guide. [uncertain]

How change is thought to happen.

Music medicine (Spintge): Spintge's working idea is physiological. Anxiety and pain are said to reduce the variability of body rhythms, and music whose rhythm variability resembles a relaxed physiological state is meant to calm the autonomic nervous system. This is meant to lower muscle tone and inner tension, raise the pain threshold, and reduce how much sedative and analgesic is needed. These are Spintge's hypotheses and claims as reported in the trade press, not established mechanisms. [source: Pharmazeutische Zeitung 1997]
Receptive music therapy: music works through the client's relationship with the therapist and with the music. It is used to relax, to evoke imagery, memories and feeling, and to open these up for reflection, with the therapist choosing and pacing the music. [source: Wärja & Bonde 2014; Bryk, CareSearch] [synthesis for the general summary]

Evidence status, as the sources state it.

Preoperative anxiety: Bradt, Dileo & Shim (2013, Cochrane CD006908) pooled 26 trials (2,051 participants), all using pre-recorded music. Music listening may reduce preoperative anxiety: about 5.7 points lower on the STAI-S than standard care. Most trials were at high risk of bias.
Cancer: Bradt et al. (2021, CD006911.pub4) rated the evidence for adults with cancer as low to very low certainty. Benefits were more consistent for music therapy than for music medicine. Quality-of-life and fatigue benefits were seen for music therapy but not for music medicine.
Adjunct only: both are adjuncts within medical care and never replace anaesthesia, analgesia or medical treatment. [source: Cochrane PLS pages]

Professional frame (for the psychotherapist).

What you can offer: music medicine (supported listening to recorded music) is not a regulated profession. In Spintge's model it is offered by medical and nursing staff, and a psychotherapist can offer it inside their own scope.
What needs a music therapist: receptive music therapy needs a qualified music therapist. Examples are UK HCPC registration (BAMT is the professional body) or US MT-BC through CBMT (AMTA is the professional body), or the national equivalent.
What needs specialist training: Guided Imagery and Music (Bonny Method) needs additional AMI-endorsed training. Vibroacoustic therapy needs device-specific training within a medical team.
Do not: use music-evoked altered states, Bonny Method programmes, or vibroacoustic devices without that training. Refer instead, or co-work with a music therapist. [synthesis; credentials uncertain]

2. Framework

Neither tradition publishes one phased manual. Below are the session structures the sources describe, plus a working sequence (marked) for a psychotherapist.

A. Music medicine episode (procedure-linked)

Offer and consent. Offer music as an option, not an order. Note the patient's preferences and any music they dislike or that carries bad associations. [synthesis; screening from Murakami 2021]
Selection. Let the patient choose, or offer a curated selection. Sedative features are recommended: no lyrics, slow tempo of about 60–80 beats per minute, no percussion, a steady melody. Spintge chose music by its rhythm variability and built special programmes for unpleasant interventions such as nerve blocks. [source: ASRA, Graff 2018; Pharmazeutische Zeitung 1997]
Set-up. Use headphones, not music played aloud in the theatre. Use the patient's own device or a hospital player. In the Erasmus MC IMPROVE implementation study the volume was capped by a lock on the device. [source: ASRA 2018; IMPROVE NL-OMON23299; Pharmazeutische Zeitung 1997]
Pre-procedure listening. Spintge reported calming after about ten minutes. Total duration is not specified in the sources. [source: Pharmazeutische Zeitung 1997]
Intra-procedure listening under regional anaesthesia or sedation. It may also help at induction and emergence. Evidence under general anaesthesia is limited. [source: ASRA 2018]
Post-procedure listening. IMPROVE advised at least 30 minutes twice a day from postoperative day 1 until discharge. [source: IMPROVE]
Review. Ask the patient's rating of anxiety and pain, check for adverse responses, and adjust the music. [synthesis]

Moving between steps follows the clinical pathway: pre-op, then theatre, then ward. Stop or change the music whenever the patient asks or shows distress. [synthesis; Murakami 2021]

B. Receptive music therapy course

Referral and assessment. Assess issues, patterns, needs, music history and preferences, and associations, including trauma links and seizure history. Agree the purpose: for relaxation, for example sleep, energy or mental clarity. [source: Bryk, CareSearch; Murakami 2021]
Method choice. Choose from relaxation, imagery, song-lyric discussion, reminiscence and life review, perceptual listening, collage, vibroacoustic work, or movement to music. Match it to the client's ego strength, affect tolerance and stabilisation needs. [source: UBC Press TOC; Wärja & Bonde 2014]
Session sequence (common shape):
- verbal check-in and focus;
- induction or settling;
- listening;
- return to alertness;
- processing through talk or art. [source: Wärja & Bonde 2014; Bryk]
Review and ending. [synthesis]

Typical formats:

Format	Session length	Listening	Course
Bonny Method of GIM (individual)	90–120 min	30–40 min programme	not stated
KMR brief music journeys	about 60 min	single pieces of 2–6 min	not stated
Group Music and Imagery (GrpMI), 2–4 people	90 min	one 4–12 min piece	8–10 weekly sessions
Music-assisted relaxation	agreed with the client	not stated	live sessions, then a recorded track used until needs resolve

[source: Wärja & Bonde 2014; Bryk]

Criteria for moving on:

Stabilise before challenging work. In trauma work, start with stabilisation and resource-building. Move from supportive music to mixed and then challenging music only once alliance, ego strength and affect tolerance are established. [source: Wärja & Bonde 2014]
Group entry criteria. GrpMI used a minimum GAF score of 41 and a trial listening to one piece as entry criteria. [source: Wärja & Bonde 2014]

3. Guiding principles

Music medicine and music therapy are different interventions. Name which one you are offering, and do not call playlist listening "music therapy". [source: Cochrane PLS; ASRA 2018]
Adjunct, never replacement. Music sits alongside anaesthesia, analgesia and medical care, and never delays them. [source: Cochrane CD006908 PLS]
The patient chooses and controls. Offer choice of music and control of stop and volume. Imposed or censored music can harm. [source: ASRA 2018; Murakami 2021]
Match the music to the state. Use sedative features for anxiety: slow, no lyrics, predictable. Spintge's rationale is rhythm variability. [source: ASRA 2018; Pharmazeutische Zeitung 1997]
The iso-principle and supportive versus challenging music. Choose music that meets the client's current mood and capacity. Use supportive music for exhausted or fragile clients, and challenging music only when they are ready. [source: Wärja & Bonde 2014]
Screen associations first. Ask about songs, genres or sounds linked to trauma, substance use or loss before you play anything. [source: Murakami 2021]
Monitor continuously and stop quickly. Watch for behavioural, verbal and artistic signs of distress, ask about the experience, and stop or change the music at once if needed. [source: Murakami 2021]
Protect hearing. Headphone exposure should stay within the WHO-ITU allowance: 80 dB for 40 hours a week for adults, 75 dB for children. Use volume limits. [source: WHO-ITU 2019]
Use headphones in shared clinical spaces. This means headphones, not music played aloud in theatre, so the patient's choice does not become everyone's noise. [source: ASRA 2018]
Process what the music evokes. In music therapy the listening is followed by verbal or artistic reflection. [source: Wärja & Bonde 2014; Bryk]
Stay within your training. Bonny Method, altered-state imagery and vibroacoustic devices belong to trained practitioners. [synthesis]
Be culturally humble. Musical meaning is personal and cultural, so ask about it rather than assume. [synthesis; Murakami 2021 on cultural ties]

4. Intervention inventory

The inventory has two parts. Part A covers music medicine procedures. Part B covers receptive music therapy methods, named as Grocke & Wigram (2007) list them, plus the music-and-imagery formats in Wärja & Bonde (2014).

Important caveat: the chapters of Grocke & Wigram are not drawn on (only the table of contents and the publisher's description). Wherever the steps for a Part B method are not from a source, they are marked [synthesis] and may differ from the book's protocols. [uncertain]

Part A: Music medicine

A1. Music preference and association screen

Purpose: find music that soothes this person, and music to avoid, before any listening. Use it at first contact, before every music medicine or receptive intervention. [source: Murakami 2021; ASRA 2018]
Steps:
1. Ask what music the person likes, what they dislike, and what they listen to when stressed.
2. Ask directly whether any songs, artists, genres or sounds remind them of a bad time. Examples are trauma, substance use or a loss.
3. Ask about hearing problems, hearing aids or implants, tinnitus, sound sensitivity, and any seizures triggered by music.
4. Ask about cultural or religious meanings of music, and any music they would not want in this setting.
5. Record a short "use / avoid" list in the notes. [synthesis built on Murakami 2021]
Example language (illustrative): "Some music settles people and some brings back things they'd rather not feel right now. Is there anything you'd like me to steer clear of?"
Watch for:
- a hesitant or emotional reaction to a genre: explore it gently and add it to the "avoid" list;
- musicogenic seizure history, which is a contraindication for that music and needs medical advice. [source: Murakami 2021]

A2. Selecting or assembling the anxiolytic programme

Purpose: provide music with sedative properties for procedures. [source: ASRA 2018; Pharmazeutische Zeitung 1997]
Steps:
1. Offer the patient's own music, or a short curated set to choose from. ASRA suggests classical, smooth jazz or soothing sounds.
2. For sedative aims, favour:
  - no lyrics;
  - a tempo of about 60–80 beats per minute;
  - no percussion;
  - a steady melody;
  - predictable dynamics.
3. For painful procedures, Spintge used purpose-built programmes chosen by rhythm variability. Those programmes are not available in the sources, so do not claim to reproduce them. [uncertain]
4. Make the programme at least as long as the expected wait plus the procedure, without abrupt changes. [synthesis]
Example language (illustrative): "Would you rather bring your own music, or pick from a few calm instrumental playlists we have?"
Watch for: music the patient finds boring or irritating, which works against the aim. Patient preference generally overrides tempo rules. [synthesis]

A3. Pre-procedure anxiolytic listening

Purpose: reduce preoperative or pre-procedural anxiety, alongside standard care. [source: Bradt, Dileo & Shim 2013 PLS; ASRA 2018]
Steps:
1. Confirm consent and the chosen music.
2. Fit the headphones and set the volume low enough that the patient can still hear staff speaking. Lock or cap the volume if the device allows.
3. Tell the staff team the patient is listening, and agree a signal such as a touch on the shoulder before speaking.
4. Start the music in the holding area. Spintge reported calming after about ten minutes. [source: Pharmazeutische Zeitung 1997]
5. Offer a simple focus, such as noticing the breath or the melody, without making it a task.
6. Check comfort after a few minutes. [steps 1–3, 5 and 6 are synthesis]
Example language (illustrative): "Let the music do the work. You don't need to concentrate on anything. If you want it louder, softer or off, just tell us."
Watch for:
- slower breathing, lower shoulders and less fidgeting: signs it is working;
- restlessness, tears, or the patient taking the headphones off: stop and ask what is happening;
- the patient's anxiety rating before and after, recorded on whatever scale the service uses.

A4. Intra-procedural listening (regional anaesthesia, sedation, painful procedures)

Purpose: comfort and masking of theatre noise. It may reduce sedative or analgesic use. Spintge used it during procedures such as nerve blocks. [source: ASRA 2018; Pharmazeutische Zeitung 1997]
Steps:
1. Continue the pre-procedure programme through headphones, never aloud in theatre.
2. Clinicians keep full control of verbal communication: lower the volume or lift one ear cup for instructions.
3. Restart or change the music on request. [source for headphones: ASRA 2018; others synthesis]
Example language (illustrative): "We'll tap your arm if we need you. Otherwise just stay with the music."
Watch for: the patient missing instructions, and any music-evoked distress. Never reduce monitoring or analgesia because the patient "has music". [synthesis]

A5. Induction and emergence listening

Purpose: keep the patient relaxed and mask conversation and alarm noise at the start and end of anaesthesia. Evidence that music reduces anaesthetic requirements under general anaesthesia is limited. [source: ASRA 2018]
Steps:
1. Agree with the anaesthetic team beforehand.
2. Play the patient's chosen calm music through headphones at induction.
3. Resume it in recovery if the patient wishes. [synthesis]
Example language (illustrative): "Your music will be on as you drift off, and we can put it back on when you wake."
Watch for: disorientation on waking, and patients who find unexpected music confusing. Ask before resuming. [synthesis]

A6. Postoperative ward listening schedule

Purpose: reduce postoperative anxiety and pain and support recovery. [source: IMPROVE NL-OMON23299; ASRA 2018]
Steps (IMPROVE version):
1. Use headphones on a device with the volume locked.
2. Listen for at least 30 minutes twice a day, from postoperative day 1 until discharge.
3. Participation is voluntary and based on consent. [source: IMPROVE]
Additional steps [synthesis]:
- link the sessions to routines such as after observations or before mobilising;
- keep a simple log;
- review use on the ward round.
Example language (illustrative): "Two half-hour music breaks a day: maybe one mid-morning and one before you settle for the night?"
Watch for:
- non-use (see section 5);
- noise complaints from neighbours: check the headphones;
- infection-control rules for shared headphones (follow local policy). [synthesis]

A7. Pain-procedure programme (Spintge's Hellersen model)

Purpose: music before a pain-therapy session to reduce muscle tone and inner tension and raise the pain threshold, and music during unpleasant interventions such as nerve blocks. [source: Pharmazeutische Zeitung 1997; Thieme abstract]
Steps:
1. Fit headphones before the session and play the programme during the waiting period.
2. Continue during the intervention.
3. Ask about the pain experience afterwards. [source: Pharmazeutische Zeitung 1997]
Example language (illustrative): "This music is here to help your muscles let go before we start."
Watch for: Spintge's claim that sedative and analgesic needs fall by up to 50% comes from a 1997 press report of his talk. Do not change any prescribed medication on that basis; that is the medical team's decision. [source: Pharmazeutische Zeitung 1997; synthesis]

Part B: Receptive music therapy

These methods are delivered by music therapists. A psychotherapist may use B1, B5 and B6 in a simple, non-altered-state form. B3, B4, B9 and B11 need music therapy or specialist imagery or device training. [synthesis]

B1. Music-assisted relaxation for adults (live induction plus recorded track)

Purpose: reduce anxiety and support sleep, energy or clarity. Used with palliative patients and other anxious adults. [source: Bryk, CareSearch; Grocke & Wigram ch. 4 title]
Steps (Bryk's procedure):
1. Assess. Assess issues, patterns and needs, then agree the purpose of the relaxation and the session length.
2. Settle. Help the client find a quiet, comfortable place to sit or lie, with physical support. Acknowledge distractions rather than trying to remove them all.
3. Choose and test the music. Choose recorded music to fit the client's needs; the therapist often uses pieces unfamiliar to the client, to keep attention on the spoken induction. Test speaker position and volume.
4. Spoken induction over the music:
  - settle the body;
  - focus on the breath;
  - body scan;
  - imagery of a safe, comfortable space;
  - an affirmation or mantra;
  - an "outro" back to alertness.
5. Debrief. The client reflects and asks questions, and is encouraged to practise.
6. Refine. Refine the music across sessions from feedback, then make a smooth recorded track in an accessible format for home use until needs resolve.
Example language (illustrative): "Let the chair hold your weight… notice the next breath out… when you're ready, bring to mind a place where you feel safe and comfortable."
Watch for:
- feedback on which pieces jarred;
- sleepiness, which is fine if the goal is sleep;
- breath-focus or body-scan cues that raise panic in trauma survivors: switch to an external focus such as the melody or a sound in the room. [synthesis]

B2. Relaxation with music for children and adolescents

Purpose: age-adapted relaxation. The method is named in Grocke & Wigram ch. 3; its contents are not drawn on. [uncertain]
Steps [synthesis]:
1. Get parent or carer consent and the child's assent.
2. Use short segments of 3–5 minutes.
3. Use concrete imagery the child helps choose, such as a favourite place or animal.
4. Give movement-based release before stillness, for example "squeeze and let go".
5. Allow eyes open.
6. Involve a carer for home practice.
7. Use the WHO-ITU children's listening mode (75 dB) for headphones. [source for 75 dB: WHO-ITU 2019]
Example language (illustrative): "Let's make your arms floppy like spaghetti while the music plays."
Watch for: overstimulation (complex music or certain timbres can overwhelm children with sensory regulation difficulties). Stop if it appears. Follow safeguarding duties if a disclosure occurs. [source: Murakami 2021; safeguarding: synthesis]

B3. Visualisation and imagery with music

Purpose: evoke imagery, feeling and memory for exploration. It is named in Grocke & Wigram ch. 5. The sources describe the KMR brief-music-journey format, and this entry follows it. [source: Wärja & Bonde 2014]
Steps (KMR as described by Wärja & Bonde):
1. Hold a session of about 60 minutes.
2. Use verbal dialogue to find a focus.
3. The client reclines, eyes open or closed.
4. Play one short piece (2–6 minutes), chosen by the therapist from the "supportive" fields of the taxonomy and matched to the client's speech and affect regulation.
5. The listening is unguided, and the therapist listens alongside.
6. Follow with art-making, then verbal reflection.
Example language (illustrative): "Just notice whatever comes as the music plays: images, feelings, nothing at all. Afterwards we'll draw and talk about it."
Watch for:
- negative or intrusive imagery, which can cause harm (Abbott 2005, as cited by Murakami 2021);
- imagery that turns frightening: open the eyes, orient to the room, and switch to a familiar, positively associated piece or to breathing guidance. [source: Murakami 2021]

B4. Group Music and Imagery (GrpMI)

Purpose: short-term group work on current needs, including stabilisation in trauma. [source: Wärja & Bonde 2014]
Steps:
1. Screen. Use a trial listening to one piece, sitting up with no relaxation induction and eyes closed if comfortable. Wärja & Bonde report a minimum GAF score of 41.
2. Group set-up. Two to four participants; eight to ten weekly sessions of 90 minutes.
3. Dialogue. Each session opens with 45–60 minutes of verbal dialogue on current needs.
4. Induction. A short relaxation induction.
5. Listening. One classical piece of 4–12 minutes, chosen by the therapist with a mixed intensity profile; listening is unguided.
6. Drawing. Each person draws an individual mandala in silence.
7. Closing. A short group discussion of the experiences and drawings.
Example language (illustrative): "When the music ends, take the paper and let colour and shape say something about what you heard, without talking yet."
Watch for:
- members flooded by the shared piece;
- one member's material dominating the group.
- Keep the piece supportive early in the series. [source: Wärja & Bonde 2014 for supportive-first; the rest is synthesis]

B5. Song lyric discussion

Purpose: use a song's words as a bridge to the client's own themes. Named in Grocke & Wigram ch. 6; contents not drawn on. [uncertain]
Steps [synthesis]:
1. The client or therapist chooses a song; client choice is preferred.
2. Provide the lyrics if helpful (do not distribute copyrighted lyric sheets beyond fair use; follow local rules).
3. Listen together.
4. Ask open questions: which line stood out, who the singer is speaking to, what the client would say back.
5. Link the discussion to the treatment goals.
6. Close with a grounding piece if the song stirred grief.
Example language (illustrative): "Which line stayed with you? … If you could write the next verse, what would it say?"
Watch for:
- rumination: repeatedly replaying sad songs can deepen low mood (Garrido et al. 2017, as cited by Murakami 2021);
- songs tied to substance use, which can cue craving (Short & Dingle 2016, as cited by Murakami 2021).

B6. Reminiscence and life review with music

Purpose: use music from key life periods to recall and integrate memories. Used with older adults, in dementia care and in palliative care. Named in Grocke & Wigram ch. 6; contents not drawn on. [uncertain]
Steps [synthesis]:
1. Build a timeline of meaningful music by decade or life stage, with family help if needed.
2. Each session, play one or two pieces from one period.
3. Invite the memories, places and people they bring up.
4. Gather these into a life-story product, such as a playlist with notes.
5. Close with a piece the person finds comforting.
Example language (illustrative): "What was happening in your life when this song was around?"
Watch for: music tied to a negative life event can produce distress (Gattino 2015, as cited by Murakami 2021). Have a stop agreement.

B7. Perceptual listening (intellectual disability) and music appreciation (adults)

Purpose: build attention, auditory discrimination and enjoyment, or aesthetic engagement. Named in Grocke & Wigram ch. 7; contents not drawn on. [uncertain]
Steps [synthesis]:
1. Play short excerpts with one clear feature to notice, such as an instrument, loud versus soft, or fast versus slow.
2. Invite a response by pointing, gesture, picture card or words.
3. Gradually increase complexity.
4. For music appreciation, explore the piece's background and the listener's response.
Example language (illustrative): "Show me when you hear the drum."
Watch for: sensory overload. Use lower volume and simpler textures. [source: Murakami 2021]

B8. Music and collage

Purpose: combine listening with image selection to externalise feelings and themes. Named in Grocke & Wigram ch. 8; contents not drawn on. [uncertain]
Steps [synthesis]:
1. Play a chosen piece while the client selects and arranges magazine images or materials.
2. Use safe materials: blunt scissors and non-toxic glue.
3. Title the collage.
4. Discuss links between the music, the images and the client's life.
Example language (illustrative): "As the music plays, pick any images that catch you; don't think too hard about why."
Watch for: the collage is not diagnostic evidence of anything. Discuss the client's own meanings only. [synthesis]

B9. Vibroacoustic therapy (medical adjunct)

Purpose: low-frequency sound vibration delivered through a bed or chair, combined with music. Named in Grocke & Wigram ch. 9; contents not drawn on. [uncertain]
What a psychotherapist should know:
- Do not use without device-specific training within a medical or rehabilitation team.
- Follow the manufacturer's contraindications.
- Do not present it as a treatment for physical disease. [synthesis]

B10. Movement to music

Purpose: receptive listening that invites movement, for activation, body awareness and expression. Named in Grocke & Wigram ch. 10; contents not drawn on. [uncertain]
Steps [synthesis]:
1. Clear the space.
2. Offer seated alternatives.
3. Start with small movements to steady music.
4. Build rest breaks into the session.
5. No touch without explicit consent.
Example language (illustrative): "Let your hands follow the music, as big or as small as feels right."
Watch for: falls and fatigue. Murakami notes that movement activities without rest breaks may cause injury. [source: Murakami 2021]

B11. Guided Imagery and Music (Bonny Method): refer, do not perform

What it is:
- individual sessions of 90–120 minutes;
- dialogue to find a focus, then an induction into a slightly altered state;
- a 30–40 minute classical music programme, with the client and therapist talking during the listening;
- a bridge back to ordinary consciousness, then drawing and reflection. [source: Wärja & Bonde 2014]
Practice requirement: it requires specialist AMI-endorsed training beyond music therapy. A psychotherapist should refer. [synthesis]

B12. Music selection by taxonomy and the iso-principle

Purpose: choose music that fits the client's capacity. [source: Wärja & Bonde 2014]
Steps:
1. Rate the piece's mood or moods; Wärja & Bonde use Hevner's mood wheel.
2. Place the piece in one of three categories: supportive, mixed supportive-challenging, or challenging.
3. Weigh its features: predictability, form, tempo, dynamics, intensity, and how it opens and ends (including the mood of the first half-minute).
4. Weigh the client's state: alliance, ego strength, attachment, stabilisation needs, current affect and timing.
5. Start where the client is (the iso-principle), then move gradually. [source: Wärja & Bonde 2014; the iso-principle and Summer's "holding" and "stimulating" music are named but not detailed there]
Watch for: challenging music depends on the therapist's verbal support during listening, so do not use it in unaccompanied home listening. [source: Wärja & Bonde 2014; home-listening rule is synthesis]

5. Handling problems

The sources give little guidance on problems. Murakami's (2021) harm model is the main sourced basis. Everything else is marked [synthesis].

Distress, trauma triggers and unwanted memories

Music can cue traumatic memories. Murakami gives the example of an ocean-drum sound for a survivor of sexual abuse. Music can also cue craving (a song linked to past substance use) and distress linked to life events. [source: Murakami 2021]

Response:

Stop or turn down the music at once.
Orient the client to the present: eyes open, name things in the room, feet on the floor.
Offer a familiar, positively associated melody or breathing guidance as a protective element. [source: Murakami 2021]
Add the trigger to the "avoid" list.
Process the episode only when the client is regulated, and decide together whether to return to music. [synthesis]

Prevention: screen associations first (A1), keep pieces short at the start, and use supportive music before challenging music. [source: Murakami 2021; Wärja & Bonde 2014]

Overwhelm or dissociation in imagery work

Signs:

flat or absent responses;
glazed eyes;
losing track of time;
frightening imagery.

Response:

end the listening and bring the client back to alertness;
use grounding;
return to stabilisation and resource-building work before any further imagery. [source: Wärja & Bonde 2014 on stabilisation first; specific steps synthesis]

Altered states of awareness and extended repetition are listed as possible negative effects (Gattino 2015, as cited by Murakami 2021). Do not induce altered states without training. [synthesis]

Music increases anxiety or irritation

Clients rate experiences negatively when the music feels incongruent or uncomfortable (Abbott 2005, as cited by Murakami 2021).

Response:

switch to the patient's own choice, or to silence;
ask what would fit better;
remember that silence or nature sounds are legitimate choices. [synthesis]

Rupture through imposed or censored music

Therapist control of the client's music, or censoring preferred music for non-therapeutic reasons, can harm. [source: Murakami 2021]

Response:

Name it and apologise.
Return control of the music to the client.
Explore what the preferred music means to them.
Take your own reaction (taste, values) to supervision. [source: Murakami 2021 on self-awareness and supervision; the rest is synthesis]

Stuck client: no response or "nothing happens"

Response:

check whether the music is too unfamiliar, too long or too "therapeutic-sounding";
try client-chosen music;
shorten the pieces;
add a concrete focus, such as which instrument they notice;
change the modality of response (drawing instead of talking);
review the goal. Some clients benefit more from music medicine-level listening than from exploratory work. [synthesis]

Non-adherence to ward or home listening

Common barriers:

fatigue;
forgetting;
the device or headphones being uncomfortable;
not seeing the point;
music seen as trivial.

Response:

Anchor the sessions to the ward routine. IMPROVE prescribes twice-daily sessions of at least 30 minutes.
Give the patient a simple log.
Make sure the volume-locked device is charged and within reach.
Ask nurses to prompt.
Allow the patient to choose different music.

[source: IMPROVE for the schedule; the rest is synthesis]

Resistance: "music won't help me" or "this is a gimmick"

Response:

present it as an optional adjunct alongside usual care, never a replacement;
share the evidence status honestly: Cochrane reviews found possible benefit with low or very low certainty and high risk of bias;
accept a refusal. [source: Cochrane CD006908 and CD006911 PLS; the rest is synthesis]

Medical-setting difficulties (synthesis unless marked)

Communication loss. The patient cannot hear staff. Agree a touch signal, keep the volume moderate, and lift an ear cup for consent and instructions.
Monitoring and medication. Never reduce monitoring, analgesia or sedation because music is playing. Dose decisions belong to the medical team. [synthesis]
Infection control. Use patient-owned or single-use or cleanable headphones, according to local policy.
Hearing aids and cochlear implants. Check compatibility; streaming or speakers may be needed. Ask the audiology team.
Neonates and infants. Overly complex music can overstimulate. Hiccoughs, grimacing or clenched eyes mean stop (Standley & Walworth 2010, as cited by Murakami 2021). NICU music work is a specialist field: refer.
Musicogenic epilepsy. Music can trigger seizures (Kaplan 2003, as cited by Murakami 2021). Avoid the triggering music and seek neurology advice.

Hearing safety

Volume cap. Keep headphone listening within the WHO-ITU safe-listening allowance: 80 dB for 40 hours a week for adults, 75 dB for children. Use device volume limiting or a locked volume. [source: WHO-ITU 2019; IMPROVE]
Practical rule. The patient should be able to hear a nearby voice over the music. Shorten sessions if they report tinnitus or ear discomfort. [synthesis]

Children and young people

Consent. Get carer consent and the child's own assent, and offer an easy "stop" signal.
Session form. Keep sessions short and concrete, and use the children's volume mode.
Disclosures. Any disclosure during imagery or song discussion is handled under local safeguarding and mandatory-reporting procedures.
Drawings and imagery are not evidence. Never treat imagery or drawings as evidence of abuse.

[synthesis; WHO-ITU 2019 for the 75 dB mode]

Cultural and spiritual meanings

Ask, don't assume. Ask about the religious or cultural significance of particular music, and do not use sacred music as a technique without the client's wish. [synthesis; Murakami 2021 on cultural ties]
Theory is not fact. Spintge's rhythm-variability rationale is his own hypothesis, so present it as such. [source: Pharmazeutische Zeitung 1997]

Scope problems

When to refer. If a client needs ongoing music-evoked emotional processing, imagery or altered-state work, or vibroacoustic treatment, refer to a registered music therapist (or an AMI-trained GIM practitioner).
Keep your own work separate. Keep your own use to supported listening and talking about music. [synthesis]

Sources

Sources:

Books and chapters cited (not drawn on in full):

Grocke, D. & Wigram, T. (2007). Receptive Methods in Music Therapy. Jessica Kingsley. Table of contents and description only.
Dileo, C. (1999). Introduction to music therapy and medicine: Definitions, theoretical orientations and levels of practice. As cited by Wheeler et al. 2019. [uncertain]
Spintge, R. (1993). MusicMedicine: applications, standards, and definitions. In Pratt & Grocke (eds.), MusicMedicine Vol. 3. As listed in the Thieme reference list. [uncertain]
Spintge, R. & Droh, R. (eds.) (1983). Angst, Schmerz, Musik in der Anaesthesie. As listed in the Thieme reference list. [uncertain]
Spintge, R. (2007). Musik im Gesundheitswesen. As listed in the Thieme reference list. [uncertain]

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