The impact of music therapy versus music medicine on psychological outcomes and pain in cancer patients: a mixed methods study Joke Bradt &Noah… [607227]

ORIGINAL ARTICLE
The impact of music therapy versus music medicine
on psychological outcomes and pain in cancer patients:
a mixed methods study
Joke Bradt &Noah Potvin &Amy Kesslick &
Minjung Shim &Donna Radl &Emily Schriver &
Edward J. Gracely &Lydia T. Komarnicky-Kocher
Received: 2 August 2014 /Accepted: 6 October 2014 /Published online: 17 October 2014
#Springer-Verlag Berlin Heidelberg 2014
Abstract
Purpose The purpose of this study was to compare the impact
of music therapy (MT) versus music medicine (MM) inter-ventions on psychological outcomes and pain in cancer pa-
tients and to enhance understanding of patients ’experiences
of these two types of music interventions.
Methods This study employed a mixed methods intervention
design in which qualitative data were embedded within a
randomized cross-over trial. Thirty-one adult cancer patientsparticipated in two sessions that involved interactive music
making with a music therapist (MT) and two sessions in which
they listened to pre-recorded music without the presence of atherapist (MM). Before and after each session, participants
reported on their mood, anxiety, relaxation, and pain by means
of visual analogue and numeric rating scales. Thirty partici-pants completed an exit interview.
Results The quantitative data suggest that both interventions
were equally effective in enhancing target outcomes.
However, 77.4 % of participants expressed a preference forMT sessions. The qualitative data indicate that music im-
proves symptom management, embodies hope for survival,and helps connect to a pre-illness self, but may also access
memories of loss and trauma. MT sessions helped participants
tap into inner resources such as playfulness and creativity.Interactive music making also allowed for emotional expres-
sion. Some participants preferred the familiarity and predict-
ability of listening to pre-recorded music.
Conclusions The findings of this study advocate for the use of
music in cancer care. Treatment benefits may depend on
patient characteristics such as outlook on life and readiness
to explore emotions related to the cancer experience.
Keywords Music therapy .Cancer .Symptom management .
Mixed methods research
Introduction
Music interventions have been used to address a variety of
symptoms in cancer patients including anxiety [ 1,2], stress
during chemotherapy or radiation therapy [ 3,4], mood distur-
bance [ 5], and pain [ 6]. The use of music in cancer care can be
situated along a continuum of care, namely from music listening
initiated by patients, to music medicine (pre-recorded music
offered by medical personnel for symptom management) and
to music therapy (the psychotherapeutic use of music). Several
authors have argued for a clear distinction between these areas ofpractice when researching the e fficacy of music interventions
[7–9]. Whereas music medicine (MM) does not involve a sys-
tematic therapeutic process, music therapy (MT) requires thepresence of such a process developed between the client and a
trained music therapist through personally tailored music expe-
riences including listening to live, improvised, or pre-recordedJ. Bradt (*):N. Potvin :M. Shim :D. Radl
Department of Creative Arts Therapies, School of Nursing and
Health Professions, Drexel University, 1601 Cherry Street,
Philadelphia, PA 19102, USAe-mail: [anonimizat]
A. Kesslick:L. T. Komarnicky-Kocher
College of Medicine, Drexel University, 216 North Broad Street,Philadelphia, PA 19102, USA
E. Schriver
Department of Epidemiology and Biostatistics, School of PublicHealth, Drexel University, 3215 Market Street, Philadelphia,
PA 19104, USA
E. J. Gracely
Department of Family, Community and Preventive Medicine,
College of Medicine, Drexel University, 2900 Queen Lane,
Philadelphia, PA 19129, USASupport Care Cancer (2015) 23:1261 –1271
DOI 10.1007/s00520-014-2478-7

music; playing music instrument s; improvising music; and com-
posing music [ 7,8].
We situate the use of music for symptom management
within a biopsychosocial framework. On a neurophysiological
level, listening to music may reduce anxiety through suppres-
sive action on the sympathetic nervous system [ 10].
Additionally, its pain-reducing and mood-enhancing effects
have been attributed to amygdala mediation [ 11,12].
Cognitively, music helps patients focus their attention awayfrom stressful events to something pleasant and soothing.
Moreover, music listening may activate imagery, offering a
temporarily escape from the reality of cancer diagnosis andtreatment. Importantly, music pro vides patients with an aesthet-
ic experience that can offer comfort and peace during times of
distress. Psychosocially, interactive music making within atherapeutic relationship provides a deeply humanizing and
validating experience for the pa tient. These experiences offer
opportunities to explore and process emotions in a creativeprocess unique from other ther apeutic disciplin es and facilitate
meaning making through music-evoked reflections [ 7].
Results of a Cochrane systematic review on the use of
music interventions with cancer patients indicate that music
interventions may have beneficial effects on anxiety, pain,
mood, quality of life, and physiological responses [ 7]. The
review authors concluded that more randomized controlled
trials (RCTs) are needed to directly compare the effectivenessof MM versus MT interventions with cancer patients so that
the impact and clinical role of each can be better understood.
The current study was in direct response to this recommenda-tion, namely to (1) compare the impact of MT versus MM
interventions on psychological outcomes and pain in cancer
patients and (2) enhance understanding of patients ’differen-
tial experiences of these two types of interventions.
Methods
Design
We firmly believe that research methodology should be driven
by research questions rather than by an a priori stance regard-
ing superiority of research method. Therefore, we adhere to
pragmatism as our philosophical stance [ 13]. We used a mixed
methods research approach in which both quantitative and
qualitative data are gathered and integrated, resulting in inter-
pretations that are grounded in the combined strengths of bothdata sets [ 14]. Specifically, we employed a mixed methods
intervention design in which qualitative data (i.e., semi-
structured exit interviews) were embedded within an RCT[15]. The purpose of the interviews was to (a) bring greater
understanding of cancer patients ’experience of music inter-
ventions and (b) give participants the opportunity to share intheir own words the impact of the interventions on their well-
being.
This study was approved by an Institutional Review Board,
and informed consent was obtained from all participants.
Thirty-one participants completed two MT sessions and two
MM sessions within a 2-week timeframe. Using a list ofrandom numbers, participants were randomized to one of
two treatment sequences consisting of two MT sessions
followed by two MM sessions or vice versa. The use ofsequentially numbered, opaque, sealed envelopes ensured
allocation concealment.
Participants
Thirty-one adult cancer patients at an urban hospital were
recruited between August 2012 and June 2013. Patients were
eligible if they were currently receiving inpatient or outpatientcancer treatment; were proficient in English; and did not have
a cognitive impairment, psychotic disorder, or hearing impair-
ment. The mean age was 53.8 years and 67.7 % were female.Demographic characteristics are summarized in Table 1.
As this was considered a pilot study, no a priori sample size
was computed. Instead, we anticipated that this study wouldprovide standard deviation estimates to guide future large-
scale trials (see Fig. 1for participant flow).
Interventions
Music therapy MT sessions were provided by a board-
certified music therapist and lasted 30 to 45 min each. The
aim of the sessions was to help patients manage stress, mood,
and pain and to provide psychosocial support. After a briefdiscussion about current concerns, the music therapist offered
live music based on patient needs. She invited participants to
sing and/or play an instrument (e.g., xylophone and small
percussion instruments) along to a familiar song or improvised
melody. These experiences were followed by additional
songs, co-created instrumental or vocal improvisations, song-writing, or music-guided breathing exercises. The therapist
provided ample opportunity for verbal processing of emotions
and thoughts evoked by the music.
Music medicine At the start of the study, participants were
asked to list their music preferences on a demographic infor-
mation sheet. Based on this information, we created individ-
ualized playlists. The music therapist met with each partici-pant at the start of the MM session to deliver an iPod with the
patient ’s playlist. The music therapist made sure the patient
was able to operate the iPod, but no further assessment tookplace. Participants were asked not to engage in other activities
while the music played. The music therapist then left the
room. MM sessions lasted 30 –45 min.1262 Support Care Cancer (2015) 23:1261 –1271

We minimized expectation effects of participants through-
out the study by referring to both treatment conditions as
music sessions rather than referring to one intervention asmusic therapy.
Measures and data collectionMood, anxiety, and relaxation were measured with a visual
analogue scale (V AS), a 100-mm line; the length of whichrepresents a continuum of an experience such as mood. Pain
intensity was measured by means of an 11-point numeric
rating scale (0 –10) [16].
All participants were invited to participate in an audio-
recorded semi-structured, open-ended exit interview.
Interview questions focused on the participants ’experiencesof the music sessions in general and about their differential
experiences of the MT and MM sessions. Participants were
also asked which of these they would like to receive for futuretreatments. A blinded outcome assessor collected the quanti-
tative outcome data immediately before and after each music
session. After the final session, the outcome assessor conduct-ed the exit interview.
Data analysis
Quantitative analysis Data were entered into RedCap [ 17]
and exported to SAS/STAT® software for analysis. Average
pre- and posttest scores were computed for the two sessions ofeach treatment condition. We utilized these averages for com-
parisons within and between conditions. In the event of
skewed data, Wilcoxon rank sum tests were used to test thewithin-condition differences. Otherwise, paired ttests were
used. Paired ttests on the difference scores were used to test
for between-condition differences.
Qualitative analysis The interviews were transcribed verbatim
and reviewed for accuracy. The transcripts were imported intoMAXQDA 11 [ 18] and analyzed by two coders (NP, JB) using
theoretical thematic analysis procedures as outlined by Braun
and Clarke [ 19]. Theoretical thematic analysis is aimed at iden-
t i f y i n ga n da n a l y z i n gp a t t e r n sd r i v e nb ya nap r i o r it h e o r e t i c a l
framework or specific research questions. The coding was guid-
ed by the following research questions: (1) What do participantsreport as treatment benefits or harms? and (2) How do they
describe their (differential) experiences of the two types of music
interventions? Themes were identified using a semantic approach[19] in which themes are derived from “the explicit meaning of
the data and the analyst is not looking for anything beyond what
a participant has said ”[19] (p. 84).
Integration of data sets After completion of the quantitative
and qualitative data analysis, the two data sets were comparedto examine (dis)congruence of the findings. In addition, we
created a joint display [ 15] of quantitative and qualitative
findings to examine differential experiences of participantswhose quantitative data profile indicated much greater bene-
fits in MT than in MM or vice versa.
Results
Quantitative results
The quantitative data indicate that the MT and MM sessions
were equally effective in improving anxiety, mood, relaxation,
and pain. There was no statistically significant difference
between the conditions for these outcomes (Table 2).Table 1 Participant characteristics ( n=31)
N(%)
Age (M±SD, range) 53.8±13.84, 32 –88 years
Gender
Female 21 (67.7)
Ethnicity
Black 23 (74.2)Caucasian 6 (19.4)Asian 1 (3.2)Other 1 (3.2)
Marital
Married 7 (22.6)Non-married 10 (32.3)Widower/widow 6 (19.4)Divorced/separated 5 (16.1)Other 3 (9.6)
Education
High school or less 24 (77.4)College/university 7 (22.6)
Type of cancer
Breast 6 (19.4)Gastrointestinal 3 (9.7)Gynecological 3 (9.7)Head and neck 3 (9.7)Hematologic 7 (22.6)Lung 4 (12.9)Other 5 (16)
Recurrence of cancer
No (first time) 22 (71)Yes (second time or more) 8 (25.8)Not reported 1 (3.2)
Patient type
Outpatient 22 (71)Inpatient 9 (29)Support Care Cancer (2015) 23:1261 –1271 1263

The majority of the participants (77.4 %) expressed a
preference for receiving MT sessions for the remainder oftheir cancer treatment or future treatments. Figure 2depicts
participants ’treatment preference alongside reasons for pref-
erence as gleaned from the qualitative data.Qualitative results
Thirty participants completed the interviews. The qualitative
analysis resulted in eight key themes organized into two
clusters:Fig. 1 Participant flow chart1264 Support Care Cancer (2015) 23:1261 –1271

1.Common themes: Themes related to treatment benefits
experienced across the treatment interventions.
2.Unique themes: Themes that were unique to MT or to
MM sessions.
The themes are discussed below and presented in Table 3,
with example quotes.
Common themes across treatment interventions The qualita-
tive data suggest that engagement in MT and MM sessions
was both beneficial for symptom management ( Theme 1 ). The
music enabled participants to escape from stress in general
and from worries related to the cancer diagnosis and treatment
specifically. Experiencing music as relaxing, peaceful, andsoothing was the most commonly stated benefit. Participants
furthermore commented that engaging in music was fun and
lifted their mood. Noteworthy is that many participants appre-ciated the playfulness of interactive music making
(musicking) and “feeling like a child again ”in the MT
sessions.
Many references were made to memories elicited by music
(Theme 2 ), including childhood memories of carefree times.
Music also facilitated connection to the pre-illness self. Music
experiences were meaningful because they helped participants
bridge the past (Who was I?), present (Who am I now?), andfuture (Who will I be? Will I survive?). However, for someparticipants, music evoked intense memories of loss and
trauma.
Numerous references were made to the fact that music
offers hope for the future and inspiration to move forward
(Theme 3 ). When confronted with a diagnosis of cancer,
people need hope and reassurance. The beauty of music stands
in sharp contrast to the hopelessness that a diagnosis of cancer
may bring as illustrated by the following participant quote:“When the doctor first tells you that you have a cancer you
feel like tomorrow is your last day, but the music makes you
feel like there ’s a future. ”
Themes unique to music therapy sessions Many participants
commented on the importance of the presence of the musictherapist ( Theme 4 ). This presence added a valuable dimen-
sion to the music experience, namely one of feeling cared for
and supported. In addition, several participants stated that theyexperienced the live music quite differently: “It felt like some
of the music when she would play, I could feel it in me, like
something like rush right through me like a good vibe rightthrough my body. ”Participants who expressed a preference
for MT for future treatments identified the musicking and the
music therapist ’s empathy and support as main reasons
(Fig. 2).
A large number of comments spoke of the importance of
creativity. One participant, in particular, provided a beautiful
metaphor for the creative process: “When I had to par-
ticipate with the xylophone thing …that made me feel
good. You know, like a rush …like if you see a flow-
er…and the flower is blooming and then you go and
again and it keeps blooming and blooming until itblooms all the way. Like that. ”
Finally, participants valued the opportunity to release emo-
tions not usually expressed as reflected in this quote by a maleparticipant: “I remember one time when I was upset and I
didn’t really know Amy that well and I opened up to her and I
cried. That is not easy for me to do around someone I know,let alone someone I ’m just meeting …Because, you know, the
macho myth, man are not supposed to cry and all that ”.M u s i c ,
coupled with the therapeutic relationship, made it safe for
these emotions to surface and be explored.Table 2 Comparison of mean difference scores between treatment conditions
Music therapy ( n=31) Music medicine ( n=31)
Pre- Post- p Pre- Post- p Mean differenceap
Mood 57.6±22.5 84.5±11.7 <0.0001 58.4±23.5 80.7±13 <0.0001 −4.5±20.3 0.23
Anxiety 30.1±22.3 15±16.5 0.0002 31.6±23.1 18.2±16.3 <0.0001 1.8±20.8 0.64Relaxation 55±24.1 83.8±11.3 <0.0001 55±21.3 80.6±13 <0.0001 −2.9±21.5 0.46
Pain 3.6±2.7 2.7±2.1 0.0004 3.8±2.6 2.7±2.2 <0.0001 −0.2±1.4 0.42
a(MM post –pre)–(MT post –pre). For mood and relaxation, negative values indicate more beneficial change in MT; for anxiety and pain, negative values
indicate more beneficial change in MM
0%10%20%30%40%50%60%70%80%90%100%
Music Therapy Music MedicineFeeling cared for
Musicking
Creativity
Emotional expression
& processing
Preference for original
recordings and familiar music
Fear for playing instruments
Fig. 2 Treatment preference and associated reasonsSupport Care Cancer (2015) 23:1261 –1271 1265

Table 3 Themes from qualitative data
Theme and definition Categories and definitions Example quotes
Common themes across music therapy and music medicine sessions
Theme 1 Symptom Management :L i s t e n i n gt o
music and musicking improve patients ’stress,
pain and mood.Escape : Music provides a mental escape from
concerns related to cancer diagnosis and
treatment and other day-to-day worries.It made me forget about my treatment, you
know? The treatment, the pain and it just had
me feel like I was floating on a cloud.
It like calm me down. It like take me away from
where I was, put me in another place. Took my
mind from cancer for the moment.
Mood Enhancement : Engagement in music
listening and musicking lifts people ’ss p i r i t s
and provides enjoyment and fun.It lifted my spirit and whatever I was feeling
before, whatever mood I was in before, it justtook it away! It put me in a good mood and putme in a good space and it made me happy.
I was in here dancing, I was singing, I was
praising, I was worshiping, I was crying, I wasjust, (slaps her hands) in here! I was going and
just like having a ball! And you know like, I ’m
still feeling that way …I’m still in that same
mode, I ’m still in that same space.
Peaceful /soothing : Music helps to relax, feel
more peaceful, and reduce anxiety and pain.It calmed me down from the inside.
It also made me forget the pain. You know? It
relaxed me more. It was just more relaxing.
More soothing.
Theme 2 Memories : Music brings back memories
through which participants connect to pre-illness self as well as to loss and trauma. The
music helps to bridge past, present and future.Memories of childhood : Music evokes memories
of a beautiful, carefree childhood.It takes me back to my childhood when
everything was beautiful. Like you know, thesunny days and eating ice cream, sitting on
steps.
Memories of healthy self : Music helps
participants connect to their pre-illness self.When I was thinking of the music, it was more
like looking at my life. You know, the thingsthat I used to do …
Well, in some instances, it took me from my
circumstance …of what I am going through …
it took me back to a more, not a complicatedcancer time.
Memories of loss and trauma : Music has the
potential to evoke memories and feelings of
loss and trauma.I like the music because sometimes it takes me
back…to something that happened, like I
remember about being with my mom and even
the, um, the abuse that I went through (patientstarts to cry).
It also made me think about my husband who
died a year ago from cancer (patient starts to
cry)…We liked to listen to music and just
dance around. He used to like to watch me
dance.
Memories form a bridge across time
:M u s i c
helps to bridge past, present, and future.When I was listening to the music it brought
back memories of different things, good and
bad. And it ’s kind of bridging, making a
connection from my old life to my new life. I
found that very helpful.
The music made me think about my past. It
made me think about my past and my future.
Theme 3 Hope for future : music offers hope and
motivationN/A When the doctor first tells you that you have a
cancer you feel like tomorrow is your last day,
but the music makes you feel like there ’sa
future …makes me feel like now I am going to
see my grandchildren grow up. Especiallywhen she played how great thou art …it gave
me my life back it feels like, you know?
Themes unique to music therapy sessionsTheme 4 Interpersonal connectivity : Participants
value the presence of a music therapist whoIt was really soothing having an actual person
here cause you feel the music more and you get1266 Support Care Cancer (2015) 23:1261 –1271

Table 3 (continued)
Theme and definition Categories and definitions Example quotes
cares for them, provides support through the
music, and engages with them in interactivemusic making.Human connection : Participants value
connecting to a person rather than a playbackdevice.more out of it when someone ’sa c t u a l l yh e r e
playing it for you than listening from a device
I liked the music a lot with Amy because it was a
human connection.
Empathy and support : Participants feel cared for
by the therapist.I just did not feel like a, just the number, so to
speak. It made me feel like she actually cared
about what I was dealing with and she caredabout the effect the music was actually havingon me.
Musicking : Participants enjoyed the music
making and creativity.Well, the session when I listened to music by
myself, I could do that on my own. It was good.
Not that I did not enjoy it. But the session withher, it was about camaraderie! We were
singing, we were laughing. It was the
interchange.
I guess being active makes me feel better and
although I enjoy relaxing and listening to the
music, taking an active part in making the
music was a better part of it for me.
Theme 5 Emotional expression and processing :
Music therapy sessions stimulate expressionand exploration of emotions.Release of emotions : Music enables the
expression of suppressed or repressedemotions.Well it definitely helped with emotions. That is
the key thing. It brought out emotions out ofme that I normally don ’t allow to come out.
Beings though, that I ’m not that emotional kind
of guy, but I guess I am because the musicproves that I am. It really helps me on myemotional level.
Verbal processing of emotions : Participants
appreciate being able to talk with a therapist
about emotions that are evoked by the musicexperiences.It [music therapy] is more like one-on-one and it
is like, we can relate and I can talk about how I
feel and how the music makes me feel …Ic o u l d
easily drift back into my depression but when Iwould have a therapist, I don ’t think I would
drift back into the depression. I would talk
about the depression because I would havesomeone there and we would change the mood
of the music.
Themes unique to music medicine sessions
Theme 6 Aesthetics : Participants prefer pre-
recorded music because of the aesthetics of the
original recordings.Preference for original recording in genera l:
participants may appreciate the original
recording more than the music therapist ’live
performance.I would rather have the pre-recorded music …
The Stevie Wonder music has more beat to it …
and more of a better sound.
Instrumentation : Participants may desire to hear
some of the unique instrumental qualities/
timbres of the original recording.Because the music has like the cordion in it, she
sings and she had that guitar, you know, I prefer
music …with the cordion [patient was referring
to Lawrence Welk ’s accordion music]
Theme 7 Familiarity and Comfort : Participants
prefer their own music that is familiar to them
and prefer the safety of listening to music (in
contrast to active music making).Active music making evokes anxiety 😛 l a y i n g
instruments is unknown territory for some
participants and may evoke anxiety. Singingmay cause frustration.I would choose the music listening …because I
don’t how to play an instrument and I want to
stick to what I know.
What made me mad, and what made me
anxious, angry, was that my voice would not
carry. It felt squeaky the way it was.
Preference for familiar music : Participants prefer
listening to their “own”music as it is familiar
and predictable.My choice of music was more comfortable
T h ep r e – r e c o r d e dm u s i c …It was …music I was
familiar with …music that relaxed me. Music
that would take my mind off of the reason why
I’mh e r e .
Theme 8 Listening to music in solitude : listening
to music in solitude allows for a better focus onthe music without concern of having to interactwith somebody.N/A When she left the room, you can concentrate
more on your music. Concentrate more onwhat you ’re hearing and you can like, put yourSupport Care Cancer (2015) 23:1261 –1271 1267

Themes unique to music medicine sessions A minority of
participants expressed a clear preference for listening to pre-recorded music. Some desired to hear the original recording
rather than the music therapist ’s rendition of the song ( Theme
6) because they wanted to hear specific musical elements (e.g.,
accordion and percussion section). Others felt more comfort-
able listening to pre-recorded music because of familiarity and
because they felt insecure about making music ( Theme 7 ).
Theme 8 , wherein a preference for listening to music alone
was reported, arose from comments from a small number of
participants but provides important guidance to music thera-pists who work in oncology. First, listening to music via
headphones enables a greater focus on the music for some
participants. Second, when a therapist is in the room, there is aspoken or unspoken expectation of interaction. One partici-
pant stated that he felt “watched ”when somebody is in the
room, and this prevented him from truly feeling the music.
Integration of quantitative and qualitative results
The qualitative findings were congruent with the quantitative
results, namely both types of music interventions were effec-
tive for symptom management. Whereas the quantitative re-
sults informed us about the extent of improvements, the
qualitative analysis provided additional information regard-ing: (1) how music may have brought about the improve-
ments, (2) additional benefits experienced by the participants,
and (3) challenges and risks associated with the use of musicinterventions.
We were also interested in exploring if and why certain
patients benefited more from MT than MM sessions or viceversa. To this end, we computed an overall z-score for each
participant to reflect overal l improvement per condition.
Based on these z-scores, we created four typologies [ 15],
namely participants who showed (a) great improvement in
MT but much less or no improvement in MM, (b) great
improvement in MM but much less or no improvement inMT, (c) great improvement in both conditions, and (d) wors-
e n i n gi nb o t hc o n d i t i o n s .T a b l e 4presents the experiences for
participants that fit these typologies. The range of z-scoresrepresents the scores of the four most extreme cases for each
typology. This joint display provides insights into how patientcharacteristics and attitudes may impact treatment benefits.
For example, patients who value the therapeutic relationship
and the creative aspect of musicking appear to benefit morefrom MT sessions than from MM sessions. In contrast, pa-
tients who are apprehensive about playing instruments and
exploring feelings related to cancer may benefit more fromlistening to pre-recorded music.
Discussion
Our findings are congruent with the current literature, namely
that MT and MM interventions have beneficial effects on
anxiety, pain, mood, and level of relaxation in cancer patients[7]. Our quantitative results indicate that, on average, MT and
MM interventions are equally beneficial for symptom man-
agement. However, the qualitative findings and the integrationof the quantitative and qualitative data sets provide a more
nuanced understanding of treatment benefits.
Symptom management is achieved by escaping the reality
of cancer through distraction, imagery, and pleasant memories
elicited by the music. Through its aesthetic qualities, music
furthermore offers comfort and peace during times of distress,lifting people ’s spirit and improving their sense of well-being.
Similar findings were reported in a study exploring adult
cancer patients ’use of music [ 20].
Even though MM interventions typically aim to achieve
symptom management [ 7], our qualitative data suggest that
listening to pre-recorded music frequently goes beyond a mere
reduction of symptoms. First, music helped to bridge pre-
illness identity to present identity and facilitated reflectionon existential issues. Renegotiating one ’s pre-illness identity
and self-narratives in light of the severe “biographical disrup-
tion”caused by cancer is important for experiencing well-
being in face of a life-threatening illness [ 21–23]. Similar to
other studies [ 20,21], the data furthermore suggest that music
gives meaning to people ’s life and embodies hope for survival.Table 3 (continued)
Theme and definition Categories and definitions Example quotes
mind more into it, and it ’s like it relaxes you
more.
When somebody ’s using the headphones, you
can concentrate more. When you ’re using the
headphones, you can sit back and close your
eyes and you can enjoy the music. Ifsomebody ’s in there, then they ’re watching
you, or they ’re doing something physically. So,
I’d rather have it by myself.1268 Support Care Cancer (2015) 23:1261 –1271

Given the existential reflections evoked by music, the pres-
ence of a music therapist may be particularly important.
Several participants specifically commented about the value
of being able to discuss these issues with the music therapist.
Even though listening to pre-recorded music offered health
benefits, most participants expressed a preference for MT
services for future treatments. The therapeutic relationship,interactive music making, and emotional expression were
dominant themes in patients ’narratives about their experi-
ences of the MT sessions, reflecting the importance of humanrelating and empathy in cancer care. Furthermore, musicking
helped patients tap into their inner playfulness and creative
selves. These are important resources that, when strengthened,may facilitate resilience in the face of life ’s challenges [ 24].
The MT sessions also enabled participants to access and
release suppressed and repressed emotions, especially emo-tions related to grief. They relied on the therapist for further
processing of these emotions verbally and/or musically. Music
therapists are trained to go beyond offering verbal support. Forexample, they may musically accompany the patient ’se m o –
tional expression, audibly reflecting the emotions and provid-
ing a safe musical container for continued exploration.
The findings of this study offer important guidance for the
use of music with cancer patients. The results suggest that
music lifts patients ’mood, reduces anxiety, brings peaceful-
ness, and helps to manage pain. This is in line with previous
research demonstrating that the everyday use of music can bean important resource for enhancing one ’s well-being and
sense of empowerment [ 20,25]. However, the mixed methods
analysis suggests that treatment benefits may depend on cer-tain participant characteristics. Even though most participants
experience greater well-being when engaging in music inter-
ventions, our joint display of participant experiences andattitudes per treatment benefits suggests that listening to music
may cause distress as well, especially for patients who have a
negative outlook on life. Such patients may be at greater risk
for music ’s powerful capacity to access sad and traumatic
memories. Given their emotional vulnerability, the surfacing
of such memories may be highly distressing. At the same time,
these patients appear not to benefit from musicking either asthey perceived their music making skills as inadequate. The
notion of musical competence has been reported elsewhere as
a potential barrier to patients ’enjoyment of music therapy
sessions [ 26]. Therefore, it is important to carefully assess the
emotional state of patients before offering music for symptom
management. These patients may be better served by listeningto music in the presence of a music therapist who can help
with processing of emotions. Music therapists should be
mindful that in short-term care delivery, these patients maynot benefit from musicking as they may need a longer
timeframe to develop a trusting relationship with the
therapist as well as with mus ic. In contrast, patients
who strongly believe in the power of music and who
value the opportunity to process emotions with the
therapist appear to greatly benefit from both types ofmusic interventions.
The qualitative data furthermore indicate that some patients
prefer the familiarity of their own music. During this chal-
lenging time in their life, patients have a great need for
stability and emotional security [ 27]. Self-selected music pre-
sents predictable musical and emotional content, therefore
providing a safe holding environment. Repetitive listening to
songs may bring a sense of order to the chaos, and theaesthetic beauty of the music may feel like a warm blanket
for one who is shaken and afraid. Self-selected music has been
described in the literature as a powerful means to “constituteTable 4 Joint display of patient experiences per treatment benefits
Treatment benefits Change in music therapyaChange in music medicineaPatient experiences
↑MT, ↓MM 0.65 to 1.88 −0.11 to 0.38 Emphasize the importance of therapeutic relationship and
support by therapist
Enjoy the creative aspect of music making
Are hopeful for the future
↑MM, ↓MT −0.46 to 0.59 0.33 to 1.63 Apprehensive about active music making
Prefer familiarity of pre-recorded music
Hesitant about exploring feelings related to cancer
↑MT, ↑MM 0.61 to 1.07 0.73 to 1.37 Strong conviction about the power of music to support and give hope
Use music for mental escape
Use music for emotional exploration and value processing
of emotions with therapist
↓MT, ↓MM −0.67 to −1.03 −0.52 to −1.06 Hold little hope for the future
Music evokes sad and traumatic memories
Feel inadequate regarding music making and singing
Prefer aesthetics of original recordings
↑great improvement, ↓less improvement or worsening
aRange of overall z-scores (average of z-scores for mood, anxiety, relaxation, and pain)Support Care Cancer (2015) 23:1261 –1271 1269

ontological security ”through creating a sense of “aesthetic
belonging ”[21] (p. 131 –132).
Limitations and research recommendations
The results of this study are based on a small sample size, and
the majority of the patients were female and black. This limits
the extent to which these findings can be generalized to other
patients. In addition, although some patients readily benefitfrom MT sessions, others may need additional time for rela-
tionship building and therefore more sessions may be needed.
It is likely that the patients who enrolled in this study alreadyhad a special affinity for music. Finally, this study had re-
search funding available for the creation of individualized
playlists. This may not be feasible in all settings.
Both MT and MM appear equa lly effective for symptom
management. Although this is a small-sized study, it does
present the question of whether comparative RCTs for musicinterventions focused on symp tom management are a worthy
research investment. We suggest that future research efforts
should instead aim to enhance understanding of (a) how eachof these interventions can be optimized for symptom manage-
ment, (b) how music interventi ons can best serve patients along
the cancer treatment trajectory, and (c) what unique aspectsMM and MT interventions contribute to the care of patients.
Conclusions
The findings of this study advocate for the use of music in
cancer care. Listening to pre-recorded music may enhancesymptom management. In addition to symptom management,
music therapy, offered by a board-certified music therapist,
offers psychosocial support and may strengthen inner re-sources. This study provides guidelines aimed at stimulating
continued reflection and awareness in clinicians about the use
of music with adult cancer patients. Given our findings, inparticular the strong preference for music therapy services by
patients, it is recommended that music therapy is made avail-
able to cancer patients during active cancer treatment. Thefindings furthermore indicate the need for patient assessment
by a board-certified music therapist to determine which music
interventions will most effectively address the in-the-momentneeds of patients. Finally, the availability of a music therapist
is recommended even when listening to pre-recorded music is
offered since music can evoke strong emotional responses andpsychotherapeutic support may be needed.
Acknowledgments Research funding for this project was provided by
the Drexel College of Medicine Cancer Program. We would like to thankDr. John W. Creswell for his feedback on this manuscript and Dr. Michael
D. Fetters for his input regarding the joint displays of quantitative and
qualitative data.Conflict of interest The authors report no conflict of interest. The
authors have full control of all primary data and agree to allow the journal
to review their data if requested.
References
1. Bufalini A (2009) Role of interactive music in oncological pediatric
patients undergoing painful procedures. Minerva Pediatr 61(4):379 –
389
2. Smith M, Casey L, Johnson D, Gwede C, Riggin O (2001) Music as a
therapeutic intervention for anxiety in patients receiving radiationtherapy. Oncol Nurs Forum 28(5):855 –862
3. Clark M, Isaacks-Downton G, Wells N, Redlin-Frazier S, Eck C,
Hepworth J, Chakravarthy B (2006) Use of preferred music to reduce
emotional distress and symptom activity during radiation therapy. JMusic Ther 43(3):247 –265
4. Harper E (2001) Reducing treatment-related anxiety in cancer pa-
tients: comparison of psychological interventions Southern
Methodist University, Texas, USA
5. Cassileth B, Vickers A, Magill L (2003) Music therapy for mood
disturbance during hospitalization for autologous stem cell transplan-
tation: a randomized controlled trial. Cancer 98(12):2723 –2729
6. Beck S (1991) The therapeutic use of music for cancer-related pain.
Oncol Nurs Forum 18(8):1327 –1337
7. Bradt J, Dileo C, Grocke D, Magill L (2011) Music interventions for
improving psychological and physical outcomes in cancer patients.
Cochrane Database of Syst Rev (8). doi: 10.1002/14651858.
CD006911.pub2
8. Dileo C (1999) A classification model for music and medicine. In:
Dileo C (ed) Applications of Music in Medicine. National
Association of Music Therapy, pp 1 –6
9. Gold C, Erkkilä J, Bonde L, Trondalen G, Maratos A, Crawford M
(2011) Music therapy or music medicine? Psychother Psychosom 80:
304
10. Gillen E, Biley F, Allen D (2008) Effects of music listening on adult
patients ’pre-procedural state anxiety in hospital. Int J Evid-Based
Health 6(1):24 –49
11. Beaulieu-Boire G, Bourque S, Chagnon F, Chouinard L, Gallo-Payet
N, Lesur O (2013) Music and biol ogical stress dampening in
mechanically-ventilated patients at the intensive care unit ward: aprospective interventional randomized crossover trial. J Crit Care
28(4):442 –450
12. Blood AJ, Zatorre R (2001) Intensely pleasurable responses to music
correlate with activity in brain regions implicated with reward and
emotion. Proc Natl Acad Sci 98:11818 –11823
13. Bradt J, Burns DS, Creswell JW (2013) Mixed methods research in
music therapy. J Music Ther 52(2):123 –148
14. Creswell JW (2015) A concise introduction to mixed methods re-
search. Sage, Thousand Oaks
15. Creswell JW, Plano Clark V (2011) Designing and conducting mixed
methods research. Sage, Los Angeles
16. Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz
NP, Kerns RD, Stucki G, Allen RR, Bellamy N, Carr DB, Chandler J,
Cowan P, Dionne R, Galer BS, Hertz S, Jadad AR, Kramer LD,Manning DC, Martin S, McCormick CG, McDermott MP, McGrath P,Quessy S, Rappaport BA, Robbins W, Robinson JP, Rothman M, Royal
MA, Simon L, Stauffer JW, Stein W, Tollett J, Wernicke J, Witter J,
IMMPACT (2005) Core outcome meas ures for chronic pain clinical
trials: IMMPACT recommendations. Pain 113(1 –2):9–19
17. Harris P, Taylor R, Thielke R, Payne J, Gonzalez N, Conde J (2009)
Research electronic data capture (REDCap) —a metadata-driven
methodology and workflow process for providing translational re-search informatics support. J Biomed Inform 42(2):377 –3811270 Support Care Cancer (2015) 23:1261 –1271

18. MAXQDA (1989 –2014) Version 11. VERBI Software – Consult –
Sozialforschung GmbH, Berlin, Germany
19. Braun V , Clarke V (2006) Using thematic analysis in psychology.
Qual Res Psych 3(2):77 –101
20. O ’Callaghan C, McDermott F, Michael N, Daveson B, Hudson P,
Zalcberg J (2014) “A quiet still voice that just touches ”: music ’s
relevance for adults living with life-threatening cancer diagnoses.Support Care Cancer 22:1037 –1047
21. Batt-Rawden B, DeNora T, Ruud E (2005) Music listening and
empowerment in health promotion: a study of the role and signifi-
cance of music in everyday life of the long-term ill. Nordic J MusicTher 14(2):120 –136. doi: 10.1080/08098130509478134
22. DeNora T (2000) Music in everyday life. Cambridge University
Press, Cambridge23. Mathieson C, Stam H (1995) Renegotiating identity: cancer narra-
tives. Sociol Health Illn 17(3):283 –306
24. Rolvsjord R (2010) Resource-oriented music therapy. Barcelona
Publishers, Gilsum
25. Heiderscheit A, Chlan L, Donley K (2011) Instituting a music
listening intervention for critically ill patients receiving me-
chanical ventilation: exemplars from two patient cases. MusicMed 3(4):239 –246
26. Daykin N, McClean S, Bunt L (2007) Creativity, identity and
healing: participants ’accounts of music therapy in cancer
care. Health: Interdiscip J Soc Study Health Illn Med 11(3):349–370
27. Williams S (2003) Medicine and the body. Sage Publications,
LondonSupport Care Cancer (2015) 23:1261 –1271 1271