Proceedings paper

The Voice In Therapy: Monitoring Disease Process In Chronic Degenerative Illness.

Wendy L. Magee PhD SRAsT(M)
Music Therapy Department
Royal Hospital for Neuro-disability
West Hill
London SW15 3 SW
Department of Music
University of Sheffield
Sheffield S10 2TN

Jane W. Davidson PhD
Department of Music
University of Sheffield
Sheffield S10 2TN


From the moment we are born, our voice is the instrument with which we communicate through non-verbal vocalisations (H. Papousek, 1996). Intuitively, care-givers respond to these non-verbal vocalisations in an interactive way, imitating, extending and developing the pitch, melodic contour, rhythm, phrasing and volume of the infant's vocal gestures (M. Papousek, 1996; Stern, 1985). In this way, a child learns to interact and develops in their social and emotional functioning.

Therefore, the voice, with its shifting, fluid, musical make-up provides the basic vehicle for human communication and interpersonal relationships. However, an individual who acquires neuro-degenerative disease faces the possibility of total loss of voice and the most primitive and spontaneous means of communication. Although there are many augmentative communication aids and assistive technologies now available for people who can no longer speak, the psychosocial consequences of losing all ability to voice cannot be underestimated.

Music Therapy is the planned and intentional use of music to the meet an individual's social, emotional, physical, psychological and spiritual needs within an evolving therapeutic relationship. In the therapy session, the therapist and client explore the client's world together, basing all interaction on the client's musical utterances or musical preferences. This forms the basis for the therapeutic relationship.

Within the clinical literature with a neuro-degenerative population, particular focus has been given to the use of the music for emotional expression and personal interaction skills (Magee, 1995a&b; Brandt, 1996; O'Callaghan and Turnbull, 1987 & 1988; O'Callaghan and Brown, 1989) and life review processes through song choice and song-writing (O'Callaghan, 1984, 1990, 1995, 1996, 1999). Although music therapy programmes have also aimed to improve functional speech through rhythmic speech drills and singing (Erdonmez,1976; Crozier and Hamill, 1988), there has been little detail given to the role singing in therapy may play in the holistic social, emotional and physical needs of the patient who faces gradual voice loss as part of their degenerative disease process.


This paper presents a single case study taken from a larger study investigating music therapy in chronic neurological illness (Magee, 1998). This case study explores the experience of the physical act of singing in the therapeutic process for an individual living with chronic degenerative illness.


A group of adults with Multiple Sclerosis were recruited from multidisciplinary referrals and self-referrals at a residential and day care facility for complex neuro-disability. Participants received individual music therapy from a qualified, state registered music therapist as part of a wider clinical programme. The music therapist was the primary researcher and so worked as a participant researcher for the study.

The music therapy sessions took place weekly for a period of approximately six months for each participant. The session format included active participation in exploring instruments, joint clinical improvisation with the therapist and singing songs of the participant's choice which had particular meaning to them. Discussion of the musical material or personal material relating to it was included in the session if the participant indicated a desire to do so.

Primary data were collected in the form of focussed interviews held after sessions by the therapist/researcher. Secondary sources of data included the verbal, musical and behavioural responses from sessions, as well as open coding analytical notes made during transcription of the interviews. Three forms of data therefore emerged from the process.

A modified grounded theory paradigm was used to analyse data employing the steps of open and axial coding (Strauss & Corbin, 1990). Trustworthiness was gained through prolonged involvement, persistent observation, long-standing clinical experience with this population, and peer debriefing with the multidisciplinary team. Triangulation was implemented on several levels. Ongoing analysis of the clinical material was taken to an independent music therapy supervisor whose theoretical framework differed from the therapist/researcher's, offering alternative interpretations of events to those made by the researcher and thereby enhancing objectivity. This process was also implemented with selections of the interview analyses, using an independent auditor familiar with therapeutic theory. Case-study design was used to report the findings.


Open coding of the data found that individuals overtly or subtly monitored the changes in their physical, vocal or cognitive functioning resulting from their disease process. This phenomenon was entitled 'Illness monitoring'. This action included individuals describing a particular ability in different situational contexts, comparing one's ability with others', monitoring the type of change experienced, the extent of any change, and making temporal comparisons of 'now' to 'before'.

Individuals often consistently assessed different aspects of their own physical, cognitive and vocal functioning in relation to those around them, who lived on the same ward. Others with whom general living space was shared may have had the same diagnosis, but may have been in a more advanced stage of the disease. Monitoring change in this way served to increase awareness and self-knowledge thereby regaining some sense of control. Furthermore, by increasing self-knowledge, one was better prepared to employ strategies for dealing with the emotional consequences of a negative change in abilities.

A single case study will be used to illustrate the results of axial coding, examining the particular phenomenon of 'vocal monitoring'.

Case study: 'Jack'.

Jack was a Caucasian male in his late 50's who had a relapsing-remitting and chronic progressive form of Multiple Sclerosis. He had lived in a continuing care ward at the facility for approximately five years prior to this study, and had been diagnosed nine years prior to this study. Although he was wheelchair dependent, an electric wheelchair enabled him to be independent in his mobility around the confines of the hospital once he was in his chair. He had functional use of one hand and arm, and was able to communicate clearly and effectively using speech.

Jack presented as coping adequately in all of his social interactions, although in reality he was rather isolated from his family and had a medical background of depression and anxiety. He self-referred to music therapy, being very eager to find a place where he could sing the songs which were of particular importance to him. He saw music therapy as a place where he could experiment with his voice to sing 'his' special songs. These particular songs included 'Ol' Man River', 'Some Enchanted Evening' and 'What a Wonderful World'. It emerged in therapy that he used a variety of strategies to cope with the changes in his life caused by his illness, and he rarely lowered his particularly resistant coping front. His use of songs appeared to perpetuate this somewhat, as he talked about the meaning the lyrics held for him.

Through the process of triangulation of the interview analyses, session evaluations and clinical supervision, it became evident that the act of 'singing' bore a deeper meaning for this participant which was not initially evident. In his daily life, he was surrounded by people on his ward who had lost all use of their voices, communicating through augmentative communication aids or through eye blinks for 'yes/no'. Some had no means of communication at all despite the wide range of assistive technologies available. Jack perpetually referred to his voice and throat within sessions. It emerged that, for Jack, music therapy was a physical activity in which he monitored his disease process through 'vocal monitoring'.

Each week when Jack chose to sing songs which held particular personal meaning. After singing, he would always engage in a critique of his voice, registering any changes in breath control, quality in vocal production, range of pitch and dynamic range achieved. In every session, he referred to his 'sore throat', 'croaky voice', 'cold', 'hay fever' or 'virus' in relation to how he was singing. He made comparisons in his voice production between sessions or situations, such as 'in this chair' or 'in bed'. He sought reassurances from the therapist to compare his voice from previous weeks. He not only monitored the quality of vocal sound produced, but also the depth of his breathing and the duration of notes he could hold. Jack did not overtly discuss his vocal monitoring, and in fact gave many reasons as to why his voice may have changed.

Although Jack derived the greatest meaning in sessions from singing his particular songs, it appeared tremendously difficult for him to overcome the physical experience of singing and allow himself to engage emotionally with the songs he sang. The occasions when he monitored his vocal production were marked by a lack of emotional engagement with or meaning attributed to the music. When he experienced the music-making as physical, he measured a higher degree of change in his voice by making temporal comparisons. Other important concepts which emerged in his experience were feelings of success, ability and skill attributed to the activity of singing. A negative experience of vocal monitoring was associated with lower levels of success and ability and lesser degrees of skill.

When Jack was able to engage emotionally with the music, singing became a less physical experience, with lesser evidence of vocal monitoring taking place. Greater emotional engagement occurred when he held stronger associations with songs. On these occasions, singing became a more emotionally meaningful experience during which he did not monitor the changes experienced in his vocal production. From the larger analysis of the group's data, it was found that individuals drew on coping strategies to a greater degree when the individual felt a lower sense of control, a higher sense of threat, and a greater sense of confrontation by their disease. Drawing on coping strategies in this way served to mask deeper responses to the disease process. It can therefore be assumed that the process of vocal monitoring stimulated emotional responses for Jack which he felt the need to control. When he was able to engage more emotionally with the music however, vocal monitoring was less likely to take place.


This case study highlights the importance which singing can hold for an individual with chronic degenerative disease. However, the meaning of singing found in this study does not support the ideas put forward in previous music therapy literature. Song themes were not a primary facilitative factor in Jack's use of song, as has been stated in previous music therapy literature reporting on the use of song-based techniques. Despite his illness process and the difficulty which Jack was experiencing in vocalising, he used the songs within his music therapy as a way to defy his illness process. Certainly he gained greater meaning in life through his act of singing songs within a therapeutic relationship. In reality, Jack died of pneumonia and respiratory failure two years after his participation in this study finished. Retrospectively, it is apparent that his experience of singing his songs represented life's breath running through him. The continual referral to his breathing, throat and voice, on reflection, indicate a high level of anxiety which he was attempting to conceal.

Considering theoretical frameworks offered by health sociology, through the act of singing Jack was testing the physical limits of his body and making comparisons in terms of temporal and situational parameters (Corbin and Strauss, 1987). In this way, he achieved greater senses of independence, skill and ability, which helped to shift his sense of identity using the therapist to validate his performance. The phenomenon 'Illness monitoring' which emerged in this study has elsewhere been entitled the 'dialectical self' (Charmaz, 1991). This phenomenon, like illness monitoring, involved taking the body as an object, appraising it, and comparing it with the self in different temporal and situational frameworks.

Active involvement in music therapy through singing facilitates a physical expression in which individuals explore their remaining physical capabilities. Through sustained exploration of their own individual physical change and loss, the physical experience becomes an intensely emotionally charged one relating directly to aspects of the illness identity. It is imperative for the music therapist working with this population to understand that through physical monitoring during the act of singing, individuals with chronic degenerative illness may become more acutely aware of their emotional responses to their illness process.


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Authors' note.

Wendy L. Magee BMus PhD ARCM SRAsT(M) is Head of Music Therapy at the Royal Hospital for Neuro-disability, London, holding a clinical post as a music therapist working with adults with acquired and complex neuro-disability, and developing research projects with this population. This research is part of doctoral research undertaken whilst registered at the Department of Music, University of Sheffield. Jane W. Davidson BA PGCE MA PhD Cert. Counselling is Senior Lecturer in Music at the Department of Music, University of Sheffield. She is editor of the international journal Psychology of Music and has researched on a wide range of topics from self and identity in singers through to expressive body movement and piano performance, having over 50 publications to her name in international peer-reviewed journals. Besides researching, she teaches a wide range of courses and is an active performer, artistic director and producer.

The authors would like to acknowledge the Living Again Trust, the John Ellerman Foundation, the Juliette Alvin Trust and the Music Therapy Charity who all contributed to funding this project. The author also would like to thank the research participants who took part in this study. The Royal Hospital for Neuro-disability received a proportion of its funding to support this paper from the NHS Executive. The views expressed in this publication are those of the authors and not necessarily those of the NHS Executive.

Address for correspondence: Dr. Wendy L. Magee, Music Therapy Department, Royal Hospital for Neuro-disability, West Hill, London SW15 3SW, UK


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