Actually, Music Therapy Does Work: Our Response to the TIME-A Study

Alan Turry, D.A., MT-BC, L-CAT

The Journal of the American Medical Association published the TIME-A Study: a randomized controlled trial, a major study on music therapy1 which asserted that improvisational music therapy does not work—the music therapy intervention did not reduce symptom severity in children on the autism spectrum.

When I read the study, I was struck by the apparent lack of therapy process measures, such as the quality of the therapeutic relationship, in the research design. Engagement is a key ingredient for the success of any therapy. Research across different types of therapeutic relationships consistently shows that the more engaged a client is, the more benefits he or she is likely to achieve. We know from clinical experience that increased musical engagement results in increased attention, awareness, responsiveness, organization, and flexibility in music therapy participants.2

But it turns out there was an entire component of the Time-A study that did in fact, look at the role of client engagement, but it was not included in the published article. Mossler, Gold, et al (2017) published findings in the Journal of Autism and Developmental Disorders reporting that when the quality of the relationship between therapists and children with autism, as measured by the Assessment of the Quality of Relationship (AQR)4 was high (strong engagement) children’s social and communication skills increased, as measured by the Autism Diagnostic Observation Schedule (ADOS).5 Specifically, the Language and Communication sub-domain of the Social Affect Scale showed significant improvements in the high engagement condition at 5 months, though these faded somewhat at 12 months. SRS scores (parent ratings that assess symptoms of ASD social awareness, social information processing, capacity for reciprocal social communication, social anxiety/avoidance and autistic preoccupation and traits) also increased in conditions of high engagement.  In sum, music therapy worked when clients and therapists co-created strong engagement--really just what one would expect.

There is a larger issue beyond research design that needs to be addressed—the issue of cure vs. functional gains, gains in strengths, and gains in quality of life.

Let’s start with a basic premise: To look at symptom reduction—to use cure metrics as one would use with depression or anxiety—is inappropriate when looking at how any kind of therapy can help autistics. Autism, as understood by contemporary clinicians and autism advocates, is a neurological difference that can manifest in a myriad of ways. What was once understood as symptoms or disturbed behaviors are now recognized as coping strategies and innovative mechanisms to enhance potential development and engagement. Simply put, the goal of cure--eliminating/reducing symptoms--is considered by autism advocates to be an out of date misguided approach to helping autistic people live more satisfying lives.6

Functional gains and improvement in quality of life are more appropriate outcomes in this new model. In fact, the authors of the JAMA study state this themselves as a major limitation of this study.

How does spontaneously creating music in therapy lead to these gains? The reciprocal communication developed between the music therapist and the autistic child is essential for the child in building motivation to emotionally attach to and understand another person. By being attuned to and joined musically, the child experiences relatedness in a way that is difficult to do otherwise. These musical interactions are a key factor in developing a therapeutic relationship. Music therapists improvise together with the child and guide the child to express themselves musically with increased attention, focus, flexibility and responsiveness. The child has a shared emotionally meaningful experience that motivates the child to continue to communicate and build social skills. These experiences gradually help the child to develop greater awareness, emotional regulation, and overall social reciprocity.

Music therapy does not cure autism. It never claimed to.  The promise of music therapy is that it builds on strengths. If researchers take a strength-based perspective rather than view treatment solely from a medical model perspective, findings will be more meaningful.

 

References

1. Bieleninik L, Geretsegger M, Mossler K, et al. Effects of improvisational music therapy vs enhanced standard care on symptom severity among children with autism spectrum disorder: the TIME-A randomized clinical trial. Journal of the American Medical Association. 2017; 318(6), 525-535.

2. Turry A. Response to effects of improvisational music therapy vs. enhanced standard care on symptom severity among children with autism spectrum disorder: the TIME-A randomized clinical trial. Nordic Journal of Music Therapy. 2017; 87-89.

3. Mössler K, Gold C, Aßmus J, Schumacher K, Calvet C, Reimer S, Iversen G, Schmid W. The Therapeutic Relationship as Predictor of Change in Music Therapy with Young Children with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders. 2017. doi: 10.1007/s10803-017-3306-y

4. Schumacher K, Calvet C, Reimer S. The EBQ—Assessment of the Quality of the Relationship and its Developmental Psychological Basis (2nd ed). Gottengen: Vandenhoek & Ruprecht; 2013. 

5. Lord C, Rutter M, DiLavore P, & Risi S. Autism Diagnostic observation schedule (ADOS). Los Angeles: Western Psychological Services; 2013.

6. Silberman S. NeuroTribes: The legacy of autism and the future of neurodiversity. New York, NY: Penguin Random House LLC; 2015.