Banging the drum: evolutionary and cultural origins of music and its implications for psychiatry
Dr Gurjot Brar & Prof. Henry O’Connell interview the co-authors: Dr Paul St John-Smith and Dr Gerry Rafferty.
The above article was recently published by the BJPsych Bulletin.
Dr Gurjot Brar & Prof. Henry O’Connell interview the co-authors: Dr Paul St John-Smith and Dr Gerry Rafferty. But first a brief summary of the article.
There is growing interest in music-based therapies for mental/behavioural disorders. In the paper, we begin by reviewing the evolutionary and cultural origins of music, proceeding then to discuss the principles of evolutionary psychiatry, itself a growing a field, and how it may apply to music. Finally we offer some implications for the role of music and music-based therapies in clinical practice.
Let’s begin by introducing yourselves to those who may not be familiar with your work
Paul:
Yes, my name is Paul St. John-Smith. I'm a consultant psychiatrist, nearly completely retired now. I'm also chair of the evolutionary psychiatry special interest group, at the Royal College of Psychiatrists, and I've been interested in evolution for well, probably since A-level really. I've been a psychiatrist full time since the 1980s and bringing evolution and psychiatry together was something that always interested me. It sort of came together after I read Randy Nesse’s book on ‘Why We Get Sick’, but I never thought it would encompass music as well, so being something of an amateur musician it’s interesting to be invited to have a talk about Evolution, psychiatry and music! Now just to go a little further back, I trained in medicine at Oxford and I did the Charring Cross training scheme and worked at Guys and Thomas’s and various places in London and then did my consultant years in Barnet and Hertfordshire, really to be near my parents both of whom in the latter years suffered from Alzheimer's disease, which I will come back to later with respect to music. And then I retired from full clinical practice in 2021 after doing several stints during lockdown. I decided I'd done…well quite a few years let’s put it that way!
Gerry:
I am Gerry Rafferty a year 3 HST in CAMHS working in Cork. I came to psychiatry late in life having being an Obstetrician for many years. I took a free standing job in the Drug treatment centre in Pearse Street Dublin and pardon the pun I was hooked so I started the training scheme, with a view to do CAMHS I was struck by the harm reduction model but I realised that most addictions start in late childhood or adolescence and that is where cure may be possible. I live on my wife’s family farm, where we breed race horses. I have children in College, secondary school and primary school, so that is useful resource when dealing with the CAMHS client base. My hobbies are Chess, Cricket and playing the bass guitar.
How did you get interested in music/what has been your journey in music?
Paul:
Yes, I can't remember ever living in a world without music! Although my parents weren't formally musical, my mother's father was a professional violinist who played for big London orchestras so I think something came through that route. My father was sadly tone deaf, but loved music and I remember at a very early age at primary school deciding I wanted to sing in the choir and I wanted to sing in the choir of a chap called George Stone, who was actually the mentor of Sir Andrew Davis, who conducted the BBC Symphony Orchestra and the Chicago Opera. Andrew Davis also lived 10 doors away from us, and I knew I was at school with his two brothers and he was a bit older than me. I joined the church choir at the age of about five or six, which was several years younger than most kids but I insisted the music teacher audition me and so I sung and he looked very astounded and said “Right. Well, if your parents consent, you're in.” So I joined a choir when I was, you know, hardly able to look over the choir stalls!
Then I went to Saint Albans and sung in the cathedral there and took up the flute and got to Grade 8 at about 16 and a distinction and then due to pressure of A-levels, didn't play so much. At university, where there were hundreds of flautists, the place was littered with woodwind players, and I had an uncle again, back to the genes here, I had an uncle who ran a brass band and he gave me a trombone - mainly to annoy my mother I think! But he gave me one of these contraptions at about the age of 17 and I took it to university and when I didn't get into the university orchestra (I was sort of #5 on the list of 4 for the orchestra they said) they looked at the trombone and said, “well, if you can play that you're in” and so the rest is history! I've played mainly the trombone, although I still played the flute for my own, you know, fun. I play the trombone semi-professionally in different bands and orchestras and get paid for it. I also write and arrange music and I have various contracts with Warwick Music. So music has been a serious part of my life and it's much more a part of it now that I'm mainly retired.
Gerry:
My obsession, and it is an obsession with music, began by watching Bohemian Rhapsody on ‘Top of the Pops’. I remember being fascinated by the story and more particularly the mix of styles. Prior to that I just thought there were only songs about boys and girls so I began to explore not so easily in the 70’s but I did. I became interested in instrumental music and enjoying the sound, then I discovered Tubular bells and I was now officially a music nerd! To this day I still listen to Mike Oldfield when going on summer walks around the farm, it is somehow so appropriate. When I started Secondary school I discovered Pink Floyd and Dark side of the moon, which led to my interest in psychiatry and imagery. Then punk happened just at the exact right time I was angry and the energy and rebellion excited me, I joined a band “the new Breed” I played bass and had a serious of silly hairstyles that got me sent home from school a lot. To be honest we were not that good. I am dyslexic and by 16 had begun to take a real liking to poetry, its cadence and rhyme makes it easy to remember and suits dyslexics.
Then the revolution happened a girlfriend of mine at the time played me Astral Weeks by Van Morrison and my view of everything grew and expanded, from there it was a steady progression to Dylan, Tom Waits, Nick Cave, Neil Young, Leonard Cohen and onwards to an almost infinite universe of lyric and tone describing, explaining and empathising with the human condition. It struck me if I got get so much solace or understanding from a song when there are a near infinite universe of songs, then perhaps I could use it in my other passion, Child psychiatry.
How have you applied music to your practice?
Paul:
Well, not in adult general psychiatry. I failed to mention earlier that I was an adult general psychiatrist, but in learning disabilities as a special interest while I was a senior registrar. On one occasion I was working in an old asylum, I think we'd called it these days, for people with learning disabilities and they would have a whole week of music for all the, let's call them inmates because that's what it seemed to be.
Those that had sat in front of the television rocking would come alive and try and sing and dance. And we let people sing, you know, we got a little band together of all the instruments that other doctors and nurses could play. I wrote various arrangements for a sort of jazz band, consisting of an oboe, a trombone and a guitar and drums. You know, it's sort of a bit strange, but nevertheless I think there was a guy with a saxophone who was a charge nurse, and there was a singer, but we let the patients sing, you know, because they could nearly get it right. But the way people came alive with enthusiasm, either listening to live music or trying to participate and they were given percussion instruments and so on and so forth, which caused an enormous row and a clatter - I can see why they didn't run it every week! But there was tremendous fun to be had and I was very lucky I had a very a sympathetic consultant that let me do the music for the whole week instead of being on call and have to run around patching people up and prescribing!
That's the only time I've done it formally I have to say, although I've seen music therapy where the art therapists or OT's have applied it and used it, listening to music to evoke thoughts and feelings. But that's more as an aid for psychotherapy or counselling. I haven’t seen it used positively as an actual therapy in treatment, but I also I've seen it used to great effect at our local dentist. He has a wonderful choice of music and he has a wonderful, gentle touch, he’s South African and an absolute charmer, and the combination of his music and his gentle touch, people need very little.. anesthetic or sedation?
Gerry:
The challenge in CAMHS is that you need to relate to patients in an age congruent way. You have to relate and not patronize. The taxonomy of attachment disorder is not conducive to an open discussion, “Do you fear abandonment?” is a stupid question, who doesn’t? Also you have to be mindful that you can be dealing with a vulnerable and potentially suggestable cohort. What we found in writing “Banging the drum “is that there are recurrent universal responses to certain tones. Jung would have called them archetypes, that is why we examined music from an evolutionary psychiatry perspective. Therefore I use music in two particular ways. Firstly in symptom discovery, I would ask the patient to make a playlist for me of meaningful songs that the patient selects, then we talk about them. This I find is a good way to build rapport and the patients enjoy it, they find the enquiry itself validating. The second use is therapeutic and by exploring music we can uncover a tool for emotional regulation but the collaborative nature of the process leads to enhanced therapeutic alliance.
What are the best outcomes you envision from music based therapies in psychiatry?
Paul:
So I think these things are powerful and it's all tied in parallel with the placebo effect, something I've written about. I think music, for want of a better way of putting it, tunes in to those pathways, that form of informal psychotherapy is immensely powerful and it tunes into actual body chemistry. There are things which change, which you can either do pharmacologically or you can do by evoking these experiences. So I think it does have power and it's not just a distraction, which in itself is a perfectly valid use. I also do think it does change pain sensitivity and our sensitivity to anxiety and such like. But I think it would need properly controlled studies. And I think it's also fraught with the slight hazard of it's got to be the right music for the right person, so I think you can't just have a blank cheque and say, well, let's put soothing music on in this genre, but I think if you if you can tailor it the right way and make sure you're culturally sensitive it can work.
There seems to be two major threads in modern contemporary music, there are the ones with melody and sort of lyrics. We call them songs. Then there’s rhythmic stuff which doesn't need a tune, and I think also between the pure melody with harmony and the pure rhythm with drumming, there's everything in between in Western styles of music and in fact, as you know with shows like Hamilton etc, and rap where the words in a way are probably more important than the music. But there are other things where you've got like opera where you don't need to understand it. The music is used to express the moods, far more than the words although there are words there, but it's probably an Italian or German and anyway, and when you read the words of opera, they’re not always particularly illuminating!
Gerry:
If music was a drug it would conform to every ideal criteria. Its effective, has no side effects cheap and non-addictive, but it is not a drug it doesn’t need a prescription so everyone can deploy it. There is clear evidence it affects neurobiology. I would like to see more rigour into research on music in psychiatry. I would like to see it on par with art therapy and music therapists to be common place and widely available.
What has been the most impactful/memorable?
Paul:
Well, I mentioned my parents had Alzheimer's, both responded to music even when they were quite advanced in dementia. I remember my mother coming round for Christmas, she was utterly dependent in a nursing home and she could sing the Christmas carols! She'd remember the tune and most of the words, but we could barely get her to speak otherwise.
And so I do think it says something. I mean, I'm not a neuroscientist, but it suggests to me there are different pathways that are perhaps preserved. I mean, you can't generalise from one case, but if you read some of Oliver Sacks and also Steven Mithen, book on ‘The Singing Neanderthals’, it does appear that there are different pathways. In discussion with Riadh about this perhaps there is something more fundamental to the pathways of music than there is to speech and cognition. Likely more deeply set and thus lost later. Similar to Ribot’s law that ‘the last in is the first out’ in dementia.
Steven Mithen’s contention is that it's pre-language and so perhaps that's something that people researching Alzheimer's disease ought to look at. I certainly know when I went into the homes to see my parents, there would be music. They would bring little groups of choirs and seeing them even people who weren't particularly religious would remember hymns from their school days. And you see all the old ladies and of course, as we know, it's mainly old ladies in many of these homes, you see them singing these songs, many of whom were not practising Christians in any meaningful sense, since, they were children at school. I think there is something very fundamental there and of course no accident that certainly in the West there's a lot of music in church services.
In fact, there's a lot of music in Hollywood and film and television, and I think that's not a coincidence. If you've ever watched a film without the music or a television drama without the music in the background, it can be quite dry and actually be ever so slightly I'm not sure it's dull, but it seems to be it. It seems to be colourless. I mean, you can't really think of Hitchcock and the shower scene in Psycho without the violins! I mean, it would just be somebody slashing at the shower curtain and stabbing somebody. That's not a very positive experience for people but I think the music evokes these deep things in people and I'm sure it's being researched but probably not highly funded that people are looking at how this can be used in a much more prospective formal way. Yeah, but do I think it would treat dementia as such? No, I think it's about the journey of dementia being made more pleasant. Do I think he would treat schizophrenia? Probably not. Affective disorders. Probably transiently.
Gerry:
I treated a 16 year old who had been subjected to significant abuse. They had a number of significant episodes of self-harm and suicidal ideation. They concealed their face and were largely selectively mute in attending the clinic, they had left school and felt unable to leave the house without their mother. I inherited her, I felt it unlikely I would get her to talk so I didn’t try, I suggested the music approach combined with art therapy as they were an accomplished artist. I offered every second consultation remotely and then saw weekly. This allowed them to give me a narrative of how they were feeling. After 3 weeks they were talking face to face, after 3 months they joined a DBT group with excellent results. They returned to college did the leaving certificate and have completed successfully the first year in the national college of Art and Design.
Are there any pitfalls to be avoided and/or any advice for other psychiatrists keen to employ music in their practice?
Paul:
Well, I think probably you can't put music into the standard consultation. It's a distraction. Also I did find there was a bit of a distraction the week that I was playing in the learning disability establishment. There’s a distraction between acting as a musician and acting as a doctor. Nurses would come up to me and aske me to prescribe things whilst I was playing a trombone! And you're thinking I can't quite do that, so I think it's difficult to mix. You need to set boundaries on that. Also I had a similar experience when I've been playing professionally in operas or shows and things for local audiences. I've had people want to have a consultation in the interval and so it does get a little bit complicated, because I'm there as a musician not to deal with some person with particular needs because they see me in the pit orchestra. So boundaries need to be made quite clear, but do I think there could be a framework similar to art therapy or occupational therapy? Yes, of course.
I think it needs to be properly funded, properly thought through and and looked at where it can be applied most cost effectively. It's different to just being a sort of disc jockey and playing music to the patients to keep them quiet on the ward, you know.
Gerry:
I would caution the risk of trying to suggest music you like and might be helpful, one of the unique selling points of this approach is that it is invidualised. It is important that you are listening and validate the young person’s feelings. A lot of songs that young people suggest reference drugs and sex and the language can be fairly colourful especially if they have a penchant for rap music. They may choose to try and shock you or convey somethings such as sexual abuse that they can’t name. Although these sessions can feel unstructured the psychiatrist should have a structure in mind and be mindful of boundaries.
Is there anything else you wanted to mention or you had thought about that occurred to you?
Paul:
I would just recommend that people have a look at our paper, which is a mixture of phylogenetic and current, as well as somewhat speculative but thoughtful ideas about music. I think there is a way forward and I do think that evolution does have a role in music. I think music is very important, I went to Pompeii and saw what they called flutes, which are clearly reed instruments as you never play a flute with these things, so obviously, instruments were there in ancient Rome. And if we can believe the paleoanthropologists, music goes back 30-40,000 years and they found probable musical artifacts - bone flutes in what seemed to be Neanderthal excavations and I think this poses some very important questions about music and its importance to the human race and hopefully evolution, psychiatry and music will be something which will be explored in much greater detail in the future.
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