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 30
MUSIC THERAPY
Adam Patrick Bell

Introduction
Defining music therapy is a difficult task, a point well articulated by Aigen (2014): “The
diversity present in music therapy renders it impossible to make unequivocal statements about
the profession, a fact that can be vexing to people trying to understand it from the outside”
(p. xviii). Nevertheless, given that the title of this chapter is ‘Music Therapy,’ a definition—
even if incomplete or unsatisfactory to some readers—is warranted. Considering the inter-
national focus of this handbook, the World Federation of Music Therapy’s definition of
music therapy is most appropriate:

Music therapy is the professional use of music and its elements as an intervention in
medical, educational, and everyday environments with individuals, groups, families,
or communities who seek to optimize their quality of life and improve their physi-
cal, social, communicative, emotional, intellectual, and spiritual health and wellbe-
ing. Research, practice, education, and clinical training in music therapy are based
on professional standards according to cultural, social, and political contexts.
(2011)

Much can be gleaned from how music therapists integrate music technologies into their
Copyright © 2016. Taylor & Francis Group. All rights reserved.

clinical work and be applied directly to educational settings in schools and communities.
Aiming to provide music educators with a rudimentary orientation to the relatively brief
history of music-making technologies in the field of music therapy, this chapter examines
the past decade of related research.
Music technology in the service of music therapy is not a new phenomenon, but until
the mid-2000s it would most accurately be described as gestational. For example, Magee
(2006) surveyed 113 music therapists in the UK and only 30% of the sample reported using
electronic music technologies in clinical work. Further, 65% of the respondents agreed with
the statement “I don’t know how to use music technology in clinical work” (p. 143). In
contrast, Hahna, Hadley, Miller, and Bonaventura (2012) detailed that 85% of music thera-
pists surveyed from Australia, Canada, the United States, and the UK (N = 600) reported

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 Adam Patrick Bell

using music technology in music therapy. The inconsistency between these results raises
a number of critical issues, but perhaps the most pressing is terminology. What is meant
by ‘music technology’ in music therapy? Crowe and Rio (2005) reviewed approximately
40 years of literature pertaining to the use of technology in music therapy, spanning from
1960 to 2002. Their findings are organized into six categories: adapted musical instru-
ments, recording technology, electric/electronic musical instruments, computer applica-
tions, medical technology, and assistive technology for the disabled (p. 288). Burland and
Magee (2014) define the term ‘electronic music technology’ as “a wide range of devices,
equipment and software, spanning amplification devices, MIDI (musical instrument digital
interface) devices, computer software, assistive devices, brain computer interfaces, as well as
electronic musical instruments” (p. 179). Both definitions cast a wide net and identify many
subcategories; in comparison, this chapter analyzes the two overarching categories of devices
(hardware) and applications (software) used for music-making in music therapy. First, a brief
overview of the history of music technology’s role in music therapy is provided to situate
the studies surveyed throughout the chapter.

Beginnings
Music therapy pioneer Clive Robbins, co-creator of Nordoff-Robbins music therapy, was
a technological trailblazer in the field. Aigen (2012) surmised that Robbins used a portable
reel-to-reel tape recorder as early as 1960 to record clinical work. In the decades that fol-
lowed, Robbins’s technological enthusiasm led to the integration of video recording as an
integral component of documenting sessions with clients. Robbins set a precedent for music
therapists to embrace recording technology as an asset in clinical work, but it was reserved
for documenting and indexing sessions as opposed to music-making.
Ramsey (2014) remarked that when he commenced his practice in the early 1980s there
were few resources for music therapists to learn how to integrate music technology. Up
until the mid-2000s, those in the field who worked with music technology did so in relative
isolation (p. 12). Nagler and Lee (1987, 1989) made important contributions to the body of
knowledge with their research that posited the computer as instrument by introducing novel
interfaces including tracking an infrared light beam to convert a client’s head motions into
music. Adams and Lajoie (2014) report that head switches were in use for music-making
by clients at the Massachusetts Hospital School beginning in 1991. Robert Krout was also an
active figure in this explorative era of computing applications in music therapy (i.e. Krout,
1987; Krout and Mason, 1988), and authored a recurring column throughout the early to
mid-1990s on integrating technology (i.e. Krout, 1990, 1991, 1992a, 1992b, 1993a, 1993b,
Copyright © 2016. Taylor & Francis Group. All rights reserved.

1994a, 1994b, 1995) that was continued by Johnson (1995, 1996, 1997a, 1997b).
By the late 1990s an increasing amount of technology-focused research began to surface
with promising possibilities. Paul and Ramsey (1998) evaluated the ability of patients with
paralysis on one side of the body to improve shoulder and elbow movements using adjust-
able drum pads connected to a synthesizer via MIDI. When clients performed the desired
movement to strike the pad with a drumstick, the sound of their choosing was triggered
and played through a public address system, providing instantaneous visual, tactile, and aural
feedback.
Hunt and Kirk (1997) also harnessed the potential of triggering MIDI data, developing
both MIDIgrid and MIDIcreator. Consisting of a customizable grid interface in which
each cell houses a different sound, MIDIgrid converts clients’ mouse gestures to trigger

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 Music Therapy

pre-programmed notes, chords, and sequences (Hunt, Kirk, and Neighbour, 2004). Using an
array of switches and sensors, MIDIcreator could be customized to accommodate a client’s
limited range of movement. As an example, Hunt and Kirk (1997) explained that a room
could be transformed into an instrument: “pads on the floors, pressure-sensitive items to
pick up and squeeze, ultrasonic beams which detect movement around the room, and but-
tons and sliders on the walls” (p. 159).
Ellis (1997) and Hillman (1998) reported using the Soundbeam, a triggering device
that uses ultrasound sensing to convert body movements to sounds. Assisting a child with
cerebral palsy who required the use of a wheelchair, Ellis (1997) positioned the Soundbeam
to track the client’s head movements, which enabled developments in the client’s physical
control and ability to ‘play’ the Soundbeam with expression. Hillman (1998) praised the
Soundbeam as “a wonderful motivational tool to teach extension, fine motor control, body
awareness or any physical movement” (p. 52).
These pioneering efforts in chaperoning music technology into the compass of music
therapy exhibited an optimistic outlook, but as recent as 2011, Magee et al. remarked,
“There remain few guidelines for practice, empirical investigations, or detailed descriptions
of this emerging area of practice (p. 147). As technology-related studies in music therapy
proliferated in the 2000s, the application of technology remained largely unchanged. MIDI-
triggered switches and sensors in an assortment of contexts continued to make up the core
of investigations undertaken in the 2000s, with some notable exceptions that branched into
consumer-based technologies such as the Wii and iPad. The proceeding section examines
the types of devices and their uses in music therapy over the past 10 years.

Devices

Sensors and Switches

Switches are the most commonly used devices for “individuals who have severe physical
and/or cognitive deficits” (Bache, Derwent, and Magee, 2014, p. 64). The authors cite two
models for categorizing switches: user activation method (i.e. mechanical, proximity, electri-
cal, pneumatic, sound, or voice) or whether or not the interaction involves contact (contact
vs. non-contact), and if present, the quality of contact, which is defined by the type of ‘tar-
get.’ For example, a non-target switch requires sustained contact with multiple movements
such as squeezing, whereas a target switch requires a momentary incident of contact, such
as pressing a button.
Several music therapists have described clinical scenarios in which switches have been
Copyright © 2016. Taylor & Francis Group. All rights reserved.

implemented. Lindeck (2014) described the central role of switches and sensors in her
music therapy practice at a children’s hospice. Citing the case of a 10-year-old boy with
multiple and complex needs, including the use of a wheelchair, Lindeck described how the
client was able to trigger the sounds of a hi-hat and bass drum with his fingers using two
MIDIsensors. In a second case, a 16-year-old girl with spastic quadriplegia demonstrated the
ability to play the Soundbeam with her arms.
Based on their clinical experiences supporting children and youth with visual impair-
ments or blindness, Martino and Bertolami (2014) outline a scaffolded approach to increas-
ing the complexity of switching in music-making. Clients typically commence using a
single message switch, which is limiting in that it can only perform one operation. Initially,
clients explore the properties of the switch, but soon move onto a second phase of impulse

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 Adam Patrick Bell

control in which the therapists guide appropriate use in the musical context. Ideally, clients
progress to more complex switching, such as playing multiple single message switches or
devices capable of outputting multiple messages. Martino and Bertolami also piloted the
incorporation of the Soundbeam into therapy for some clients providing two different
examples. First, for clients with ‘motor challenges,’ a sensor is placed on a body part that
the client is able to consistently move, morphing the movement to be musically expressive.
Second, the Soundbeam can be used as an ‘acoustic marker,’ which allows these clients, many
of whom have “decreased body awareness and gravitational insecurity,” to “openly explore
physical space” (Martino and Bertolami, 2014, p. 169).
Adams and Lajoie (2014) describe the switch ensemble program at the Massachusetts
Hospital School, which serves students ages 7 to 22 with complex medical conditions.
Beginning skills with simple switches include attending to the conductor, following direc-
tions, activating the switch on command, turn-taking, and working within the group.
Advanced ensembles require the use of multiple switches to play more complex composi-
tions including Bach and Herbie Hancock. In addition to the musical skills that are ascer-
tained by the clients, a range of individual skills (i.e. discipline, self-confidence, self-respect,
critical thinking, decision-making) and group skills (i.e. collaboration, a sense of commu-
nity, supporting peers, teamwork) are honed in the switch ensembles.
Zigo (2014) provides an insightful explication of vocal output communication aids
(VOCAs) based on her work with students with various cognitive impairments. Used for
either communication or participation in music-making, VOCAs play a pivotal role in
music therapy activities. Zigo stresses the importance of positioning switches and sensors
as well as selecting optimally on behalf of the client based on the most appropriate activa-
tion mechanism (i.e. toggle, plate, twitch, squeeze, and pull). In the music therapy context,
VOCAs are surrogate voices and musical instruments, providing clients with a means to
speak, sing, or play notes. The capacity of VOCAs to record and sample sounds aids cli-
ents in creating music, fostering individual and group identities, and manifesting affective
responses.

Camera-Based Sensors
For clients who are unable to physically activate switches, some studies have piloted alter-
native methods of sensing. Ahonen-Eerikäinen, Lamont, and Knox (2008), Chau, Eaton,
Lamont, Schwellnus, and Tam (2006), and Tam et al. (2007) reported developing and test-
ing web camera sensor systems to make music. With the camera centred on the client, an
augmented environment is created in which clients see themselves on-screen with colored
Copyright © 2016. Taylor & Francis Group. All rights reserved.

shapes superimposed. These shapes act as virtual triggers, when a client moves a part of their
body to the area of the colored shape a sound is played. The authors of each of these reports
emphasize the value of participation for incubating a sense of purpose and self-expression
for children who have severe physical disabilities, fostered by these virtual musical instru-
ments (VMIs) or movement-to-music (MTM) technologies help to foster.
Music Maker, designed by Gorman, Lahav, Saltzman, and Betke (2007), operates on a
similar principle, but was designed for more specific purposes pertaining to physical rehabil-
itation such as improving “motor function and hand-eye, foot-eye, or bi-manual coordina-
tion” (p. 40). Guided by the improvisational underpinnings of creative music therapy, Lem
and Paine (2011) present a different philosophy using a web camera as a sensor. Whereas
the aforementioned approaches are dependent upon sample triggering, Lem and Paine’s

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“sonification system” produces sound in response to “velocity, acceleration, and direction

of gesture” (p. 182). Similar to VMI and MTM, Oliveros, Miller, Heyen, Siddall, and Haz-
ard (2011) developed Adaptive Use Musical Instruments (AUMI) to convert gestures into
musical improvisation. AUMI is adaptable to clients’ abilities and can be configured to track
slight movements such as the raising of an eyebrow.
Lastly, the most futuristic interface is the Brain–Computer Music Interfacing system
(BCMI) (Miranda, Magee, Wilson, Eaton, and Palaniappan, 2011). Brain signals, as measured
by changes in electroencephalogram (EEG) amplitude using electrodes affixed to the head,
can be converted to musical output. Whereas the aforementioned camera-based sensors
relied on physical movement to make music, the BCMI operates on the principle of gaze
intensity, which invokes change in EEG amplitude. Miranda et al. depict the BCMI as a
musical instrument, one that requires skill and learning to play and further, an instrument
that is accessible to people with limited physical function.

Consumer Electronics as Controllers

Video game controllers such as the Wii have been explored as a means to engage in music-
making to increase self-confidence and motivation for clients with Alzheimer’s disease (Bou-
lay, Benveniste, Boespflug, Jouvelot, and Rigaud, 2011), and for clients in pediatric medicine
to address physical goals such as movement and coordination (Whitehead-Pleaux, Clark,
and Spall, 2011). Electronic MIDI-based drum kits have been used with stroke patients to
examine upper extremity movement in rehabilitation (Schneider, Schönle, Altenmüller, and
Münte, 2007; Yoo, 2009). Using piezoelectric sensors embedded in paddle drums that con-
nect via MIDI to a sound module, Ramsey (2011) designed music rehabilitation instruments
that simultaneously measure clients’ physical functions such as range of motion.

Applications

GarageBand
In clinical contexts where clients do not require assistive devices, music therapists have her-
alded various software applications for fostering novel yet meaningful experiences in the
therapeutic process. Digital audio workstations (DAWs), especially GarageBand, have been
incorporated into an array of clinical settings and lauded for cultivating client creativity.
In the late 1990s, when DAWs first cropped up in the consumer market, music therapists
began to establish project studios in clinical settings (e.g. Krüger, 2000). Based on the survey
Copyright © 2016. Taylor & Francis Group. All rights reserved.

responses of 253 music therapists and 110 music therapy students and interns, Cevasco and
Hong (2011) reported that GarageBand was the most used software.
Sadnovik (2014) structured recording activities for adult psychiatric clients in Brook-
lyn, New York, to produce original hip-hop works. With GarageBand, clients were able
to self-produce, learning how to loop, cut, and paste samples and make beats. By over-
dubbing, clients sang in unison or harmonized with their pre-recorded vocals. Sadnovik
reflected that “patients often realize that they are capable of self-nurturing and gain a sense
of empowerment as they realize that they have structured their own therapeutic environ-
ment” (p. 251). Sadnovik observed that clients who experienced difficulty rapping live
could edit raps together in post-production, recording phrase by phrase, promoting self-
esteem and self-awareness.

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At a day centre in the Bronx, New York, Weissberger (2014) supported a group of
elderly people with chronic health conditions (e.g. stroke, dementia) as they crafted original
compositions with GarageBand. Clients were guided through a process of selecting loops
and sounds to lay the foundations of their compositions before adding vocals in sectional
groups. Weissberger noted that providing clients the opportunity to sing solo verses over
extended loops was a particularly effective approach in helping to rectify various issues such
as performance anxiety, rhythmic awareness, and memorizing lyrics. The group activity also
entailed mixing, including the addition of effects to vocals such as reverberation.
Using a similar approach, Martino and Bertolami (2014) conducted a group-composing
task with GarageBand for adolescent boys with visual impairments. The researchers observed
that despite multiple incidents of conflict, the clients learned to advocate for themselves
and to compromise individual interests for group goals. In London, Street (2014) pressed
GarageBand into service for adults with acquired brain injuries (ABIs). Street suggests that
GarageBand allows clients to identify with their contemporary sound worlds, and through
the compositional process they develop cognitive and communication skills. Street advo-
cates for clients to commence composing by auditioning and pasting loops to form the
musical backbone of the piece. Referencing the case of a man with a history of drug and
alcohol abuse, Street witnessed the manifestation of the client’s creative capacities and com-
municativeness as he created original musical ideas.
Whitehead-Pleaux, Clark, and Spall (2011) reported GarageBand-based music-making
tasks as being effective in reducing anxiety about surgery, facilitating self-expression, and aid-
ing with transitions for clients at a children’s hospital. Magee et al. (2011) reported that
composing with GarageBand in individual and group settings provided creative and self-
expressive opportunities for a visually impaired adolescent with “mild cognitive impairments
and emotional regulation difficulties” (p. 150). Smith (2012) structured a sequence of song-
writing stages for at-risk girls using GarageBand in which the clients developed social skills
and expressive abilities through writing and recording lyrics and music as a group. Similarly,
MacDonald and Viega (2012) used GarageBand in a hip-hop songwriting program to support
at-risk elementary-aged school children in Philadelphia to express their fears and concerns
related to the social struggles within their community such as violence, drugs, and poverty.

iPad Apps
Categorizing the iPad as an application (app) is a misnomer, but in music therapy the iPad is
best conceptualized as a multi-instrument that is app-dependent. For example, Knight and
LaGasse (2012) suggest “a client can play a ‘stringed instrument’ with the touch of a finger
Copyright © 2016. Taylor & Francis Group. All rights reserved.

or a ‘wind instrument’ by blowing on the device microphone” (p. 194). Knight (2013) has
compiled a list of iPad apps useful for a variety of music therapy contexts, organized into
the categories of instruments, recording and notating, playback, and sound manipulation.
To date, the reports of music therapists integrating tablets into their clinical work tend to be
anecdotal and explorative commentaries using instrumental apps.
Kern and Humpal (2013) and Krout (2014) advocate for the iPad in music therapy for
young people with autism spectrum disorder (ASD). Krout frames the iPad as an inroad
to assisting in the development of deficits associated with ASD including social interac-
tion, communication, engagement, cognition, and behavior. He recommends several instru-
mental apps (e.g. Kalimba, Percussions+, Air Harp, Virtuoso Piano, and Pocket Drums)
because of the vast timbral palette they offer and the visual appeal due to the integration of

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 Music Therapy

skeuomorphism in the interface designs. An additional advantage of the tablet is its multi-
functionality. In one instance it serves as a musical instrument, but with a purposeful tap
it can transmute into a communication tool to aid those with ASD. Apps such as Autism
Express assist with recognizing facial expressions and emotions, and Tap to Talk assists com-
munication by converting symbols to speech. Similar to Krout (2014), Clements-Cortès
(2014a) compiled a guide to selecting iPad apps for therapeutic settings.
In the case of a 23-year-old female cancer patient, Kubicek (2014) found that the app
BeBot was effective in enabling musical improvisation, and that the karaoke app Glee was
well suited to the client’s affinity for singing, allowing her to record her own renditions of
popular songs. Whitehead-Pleaux, Clark, and Spall (2011) observed that an 8-year-old girl
with decreased hand, arm, and core strength was able to participate in music-making activi-
ties for longer durations using apps such as TouchXylo in comparison to traditional musical
instruments. Clements-Cortès (2014b) suggests that the TNR-i-US—the app based on the
Tenori-on, an electronic instrument that consists of a 16× 16 grid of LEDs—could poten-
tially aid in increasing social interaction, improving self-esteem and increasing non-verbal
communication. Clements-Cortès’s survey of 43 Canadian music therapists and music ther-
apy interns using the Tenori-on reported that it was used to address a variety of clinical goals
including: “turn taking, sensory stimulation, songwriting, motor skills, social interaction,
improvisation, self-esteem, mood modification, expression, creativity and attention” (p. 68).

Future Directions
If the past 10 years of literature reviewed in this chapter are any indicator, new branches of
music technology in music therapy will bud and come to fruition at increasingly rapid rates
in the future. Tried and true approaches such as incorporating MIDI-triggered switches and
sensors, electronic instruments, DAWs, and instrumental apps into the therapeutic context
will continue to flourish, but they will also evolve and adapt to new challenges and possibili-
ties. Hints of how these new possibilities might take shape have surfaced, such as e-music
therapy (Baker and Krout, 2014) and technologically afforded “alternative identities” (Bur-
land and Magee, 2014), but it is the collaborative kitchen of coders and clinicians that are
concocting the resolute recipes for the future of this interdisciplinary field.
In 2014, Berklee College of Music in Boston hosted the first-ever music therapy hack.
Music therapists and music technologists collaborated to produce forward-thinking tech-
nologies for the service of music therapy. Makey Makey prototyping devices, Kinect sensors,
webcam-based sensors, light sensors, and accelerometers were put to service to construct
tangible models of 24-hour-old ideas. While this hackathon was not the first attempt to
Copyright © 2016. Taylor & Francis Group. All rights reserved.

prototype new instruments for music therapy (i.e. Crowe and Ratner, 2012; Norman and
Norman, 2011), it signaled a new direction. Young adults who have grown up in a coding-
conversant computer culture are programming and designing new applications and interfaces
themselves. As this generation ages and enters into occupations such as music therapy, they
will usher in a new paradigm in which designing and refining technologies for music therapy
will become an increasingly valued and even expected skill of the future music therapist.

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