Active Music Therapy’s Application in India versus Psychotherapy

Music has been used therapeutically for centuries, but only recently in treatment of mental health issues. Music therapy is defined by Bruscia as a “systematic process of intervention wherein the therapist helps the client to promote health, using music experiences and relationships that develop through them.” Music Therapy varies cross culturally. In India it is mainly used in connection to religion through chanting and faith healing. It hasn’t yet been considered at a broader scope such as in Neurologic Music Therapy or Psychoanalytic Music Therapy which are used in other countries. In this review, we consider the efficacy of music therapy in the Indian Context in relation to treatment of psychiatric disorders, especially as psychotherapy is still not widely accepted by the Indian Subcontinent. It is also not effective in all cases.

Music is an art form that has healed and brought people together since the beginning of time. It can be defined according to Dictionary Reference as "an art of sound in time that expresses ideas and emotions in significant forms through the elements of rhythm, melody, harmony and color". Music consists of rhythm (the time and beat), pitch (the tone), dynamics (emotion) which are arranged in various harmonies (the chords) and melodies (the notes). It is capable of inducing; eliciting or changing emotions based on the above qualities of that piece of music and can cause electro physical changes. The question is to what extent music can be used therapeutically and scientifically to treat mental illness.

Psychotherapy in India
Studies show that Psychotherapy is not easily applicable in India.
Verma raised objections to the applicability of the Western type of psychotherapy in India. He pointed out seven distinct features of the Indian population, which may not help psychotherapy work in the Indian context in comparison to the western population. They are as follows: 1. Dependence/interdependence. 2. Lack of psychological sophistication. 3. Social distance between the doctor and the patient. 4. Religious belief in rebirth and fatalism. 5. Guilt attributed to misdeeds in past life. 6. Confidentiality. 7. Personal responsibility in decision making.
Furthermore, the role of religion and faith in Indian psychotherapy is much more prominent. Due to differences in religious beliefs between both people and therapists, the subjectivity of psychotherapy is increased. India doesn't have enough resources or support as of yet to enhance this kind of therapy and the effectiveness of it. The technique itself isn't completely scientific due to its ambiguity and subjectivity. Results and interpretations can vary from therapist to therapist. Thus, it is necessary to use more concrete techniques which people can connect with.

Indian Classical Music and the Therapy used
In India, music therapy is based on the usage of ragas and rasa. Ragas are arrangements of notes in a way such as to elicit a rasa -"emotions and psychological responses to that particular set of melodies" inducing various physiological and emotional changes based on the way it flows and changes. In a study carried out by Shantala Hegde, it was noted that ragas with more major notes were seen to have a positive valence on the emotional state of person while ragas with more minor notes had a more negative valence.
Patients are made to listen to music and then discussions are made on how the music makes them feel.
This kind of music therapy is effective in Indian culture due to the deep connection to religion and faith.

The connection of the cognitive and autonomic functioning to music
What is the relation with the emotional responses music elicits to cognitive functioning? On conducting fMRI scans, it is noted that the emotional responses generated by music activate the limbic and Para limbic systems which are connected to feelings of reward/motivation. In essence, merely listening to music gives one a sense of gratification and enhancing emotional processing. The emotion maybe created due to the creation of associations between the music and certain emotion felt at the time when it is heard. It helps to a person to visualize imageries to relax the mind. People also attempt to regulate their emotions based on what they feel is an appropriate response to the musical valence, potentially useful in mood disorders.
Due to a property of the brain called as neural plasticity, the brain is dynamic and keeps changing or adapting based on the environment. As seen in Maguire's taxi study, the brain changes in order to better enhance the cognitive functioning based on the situation. The brain organizes itself differently in order to better accommodate the individual, restoring and altering brain functions. Musicians have better memory and co-ordination, planning, strategizing, and attention; using almost all parts of their brain while playing, enhancing motor skills. It helps to co-ordinate usage of both hemispheres and acts as a bridge between them. Furthermore, the brain can be modified permanently with musical training-areas such as the corpus callosum are larger. Hormones such as dopamine and endorphins are released on listening to certain kinds of music. Beta endorphins and cortical levels-connected to stress-have been noted to reduce significantly with music. Listening to music can help in regeneration of neural pathways and repair of cerebral nerves.

Psychoanalytic Theory and Music
This theory brings to light the role of expressing unconscious id impulses in a less harmful way. The listener or musician himself is able to convert these emotions into a form which doesn't cause emotional pain and acts cathartically, bringing the feelings out. Musicians use the ego defense mechanism of sublimation. Music is said to reach the unconscious and humans have a lesser tendency to block it out.

The application of music therapy of all kinds
Music therapy can either be active or receptive. In India, mostly the receptive approach is used in which the patient listens to specifically composed music in order to reduce anxiety. The receptive forms can be used for progressive relaxation or autonomous training. It uses the "raga based approach" and music is tailored to the listener's preference.
In a study by Deshmukh, 50 individuals with Major Depressive Disorder were studied. When made to listen to music with certain ragas, the depression scores improved, even after treatment was stopped while pharmacological treatment didn't have the same effect.
In schizophrenic patients, there is significant effect on negative symptoms (which are more difficult to treat with drugs for the disorder), depression, anxiety, and overall functioning. In a study by Banerjee, a sample size of schizophrenic patients displayed an overall improvement in reading time in part W and C of the Stroop test for Schizophrenia, implicating the role of music in improving cognitive functioning.
It can further be used in paediatric patients with developmental disorders-music therapy is noted to significantly improve communication skills.
Dementia patients are seen to have improved psychomotor and cognitive skills as therapy forces them to consciously make an effort. The patient learns to regulate him/herself through keeping time with beat and focuses better. The music improves memory and functioning. Most studies used the active method.
This Psychoanalytic active form is more connected to the creation of music with the aid of a therapist and relies on psychoanalytic theories in terms of replicating feelings and releasing them. There is transference and counter transference between the patient and therapist who gives the patient the environment and care to release any impulses which are difficult to speak about. Feelings can more easily and socially acceptable be released. It can help in building of better relationships amongst individuals and create a motivation for the future. The approach is more practical as the patient is experiencing rather than speaking and as many patients have difficulties in communication, this is ideal. It can be used to help the patient gain an understanding of how they act in a social context. The patient can project emotions and uses free associations. This is perhaps more applicable than mainstream psychotherapy as the patient experiences these emotions and enacts them through music. There is a stronger effect due to the satisfaction from the creation of an end product. For clients with severe anxiety, the music can provide a calming environment to aid emotional release during difficult therapeutic sessions. Music therapists are highly trained to be able to identify and recognize various personality traits and emotional issues based on how the client creates the music and the type. There is a higher sense of closeness in the therapeutic relationship and the therapist guides the client. The client feels lesser guilt and is less inhibited in comparison to normal talk therapy.
Research by Errkila on depression patients showed that those with 15 sessions of active music intervention significantly improved as compared to those with standard care and treatment. The patient discussed an experience and then created an improvisation. All of these improvisations were recorded. Symptoms of depression were measured with the MADRS scale and General Functioning with the GAF.

Neurologic Music Therapy
Due to brain plasticity, actively engaging in the creation of music can improve executive functioning. It is "the therapeutic application of music to cognitive, sensory and motor dysfunctions". Non-music domains/ regions of the brain are linked to music and its effect on cognitive, psychological, and physiological aspects.
Cognitive Remediation helps patients in performing difficult tasks and improves problem solving skills. Combined with NMT, the improved cognitive functions from music therapy are transferred to non-music domains in order to help a person in everyday functioning.
In a study of patients with Traumatic Brain Injury, sessions were provided to patients targeting attention, memory, executive functions and emotional adjustment. There was also a control group which wasn't exposed to music therapy. The results of the study showed significant positive changes in executive functioning, mental flexibility with a large effect size (d=1.21) and a significant decrease in depressed mood (d=.52) If therapies as such can help bring TBI patients back to normal level functioning, then surely it can help patients without brain injuries. With NMT, a person gains control of his/her body and in the process, creates a better emotional state -sublimation-by releasing pent up feelings. Mental illness often causes slowing of cognitive functioning, even if there is nothing physically wrong with a person. Hence, NMT can be used not just for those with brain damage.

MT techniques include:
• Rhythmic auditory stimulation (RAS): Facilitates rehabilitation of movements that are intrinsically biologically rhythmical. • Patterned sensory enhancement (PSE): Uses rhythmic, melodic, harmonic and dynamic aspects of music to provide temporal, spatial and force cues for movement. • Therapeutic instrumental music playing (TIMP): Uses playing musical instruments to exercise and stimulate functional movement patterns. • Speech stimulation: Uses musical and song patterns to stimulate non-propositional speech. • Melodic intonation therapy (MIT): Utilizes client's unimpaired ability to sing to facilitate spontaneous and voluntary speech. • Rhythmic speech cueing (RSC): Uses rhythmic cueing to control the initiation and rate of speech through cueing and pacing. • Vocal intonation therapy (VIT): Stimulates the prosody, inflection and pacing of normal speech by intoned phrases. • Therapeutic singing (TS): Allows to practice articulation or initiation of speech as well as increase breath control and posture. • Oral motor and respiratory exercises (OMREX): Uses different musical elements to practice muscular control of a speech apparatus to facilitate the production of specific sounds.

CONCLUSION
Active Music Therapy can be applied in the Indian context due to music's universal appeal. The approach is more scientific and focuses more on bringing a person back to normal, everyday functioning. The therapy is more practical as the person is actively engaged and there is a sense of self efficacy and a need to apply oneself. The patient is not wholly dependent on the therapist as a lot more effort comes from his/her side. It can be used both combining both Psychoanalaytic music therapy as well as Neurologic Music Therapy to create a holistic therapy which tackles all aspects of a person's well-being. NMT can be applied to schizophrenic patients for example due to disorganized behaviours and motor dysfunction or catatonia. Many psychiatric disorders cause some level of physical strain and difficulty. Music Therapy can help in reintegration back into society as therapy will not only enhance mood but improve basic cognitive skill sets. It gives a person a sense of belief that yes, he or she can complete tasks and is not incapable of functioning. It is also an activity that helps to improve relationships and brings people together due to the appeal of music. Through psychoanalytic music therapy, patients understand where their relationships are going wrong and use transference and music to re-enact them and for catharsis. The NMT can help improve brain functions that have deteriorated through the progression of the illness.