The Dangers of Overestimating Music Therapy

It's comforting to believe that songs can help dementia patients recall their lost selves. But music can also harm as much as it helps, creating false memories, confusion, and distress.

Henry’s back in the news.

On November 18, 2011, a video was uploaded to YouTube. We follow a woman down a corridor of what looks like a long-term care facility. We learn that she is a recreation therapist as she tells us about the power of music to reach a female patient who seemed all but unreachable. But we never see that patient. Instead we see a name: HENRY.

Henry is a patient at the facility: a black man, quite advanced in years, hunched over in his wheelchair, baseball cap on, unresponsive. His daughter comes to visit him, but he doesn’t recognize her. Ten years earlier he began to experience seizures. Before that, his daughter says, he was “fun-loving, singing. Every occasion he would come out with a song.” But that’s not the man we see at first.

Another cut. Henry sports a different shirt. He has a lapel microphone on. The recreation therapist speaks to another person about the type of music the therapist would like for Henry: religious music, “because he enjoys music and is always quoting the Bible, so I’d rather have that for him.”

Then comes the talking head, none other than Oliver Sacks, M.D., preeminent author on music and neuroscience, who narrates what happens next. The therapist appears: “Henry, I’ve found your music.”

Headphones attached to an iPod are placed on his ears—an iPod, Sacks says, “containing, we know, his favorite music.” As the music plays, Henry’s eyes, previously listless, grow large. His body begins to move. He quietly sings along.

And when the headphones are removed, he talks and talks and talks. The music appears to have awakened him from a deep sleep. Henry is made new.

Nearly three years and 1.4 million views later, we discover that Henry’s story is part of a larger project. “Music can conjure up memories from the past, transport us to another place and make us feel incredible joy or profound sadness. A new documentary called Alive Inside takes a look at how music is changing the lives of some older Americans.” This was the pitch for the June 30, 2014, show Katie Couric aired to promote “a joyous cinematic exploration of music’s capacity to reawaken our souls and uncover the deepest parts of our humanity.”

Alive Inside won the Audience Award at the 2014 Sundance Film Festival, and based on its trailer, it’s easy to imagine how viewers watch the transformations on screen and leave feeling elated that an iPod can miraculously help Alzheimer’s and dementia patients recover their lost selves. And it will soon be coming to a city near you.

I teach a course on music, neuroscience, and ethics, and Henry featured prominently in one of our class discussions last year. Most of my students see nothing but the upside when they witness Henry’s change from catatonia to euphoria. And testimonials about the impact of personalized playlists provide further support to the notion that well-chosen music can profoundly affect a patient’s life in exclusively positive ways.

So at the risk of being a skunk at the garden party, let me raise some concerns about these therapeutic interventions, lest we all become irrationally exuberant about the power of music in the lives of those we love.

Go back to the original video. At 3'45", Henry talks about what music means to him and identifies Cab Calloway—a performer not known for religious music—as one of his favorite artists. At 4'30", he sings his favorite Cab Calloway song: I’ll Be Home for Christmas.

But I’ve not been able to turn up a recording of Calloway singing this song. In looking at two different books about the songwriter and bandleader, I found no mention of the 1943 song that Bing Crosby made famous. Out of more than 300 different versions compiled by a website devoted to cover songs, Cab Calloway is not mentioned. Calloway did perform on A Jazzy Christmas at the Cotton Club, but unless his Harlem Hospitality incorporates the tune, the song isn’t represented on that album by Calloway.

Perhaps Henry saw Calloway perform the song live at a significant moment in Henry’s life. Or perhaps Henry, pressed by the interviewer to come up with an answer about his favorite Cab Calloway song, manufactured and mimicked a non-existent performance. It is a fact that Henry named a favorite song. But the truth—both of what his favorite song really is and of the existence of the song he named—appears to lie elsewhere.

We can expect someone Henry’s age to confuse facts and express false memories. So we should understand that these iPod interventions might not be returning these patients to their teens and early adulthood. On the face of it, such therapy brings joy to these patients. But as Henry’s staged testimonial suggests, it can also bring confusion as the patient attempts to make sense of the disjuncture between a song heard right now and a recollection of where and when that patient might have heard the song before.

In fact, hearing and scent are two of our most atavistic senses—they take us back to times and places where we first experienced particular sensations. For someone suffering from dementia, we have no easy way of knowing whether she is genuinely recalling a song and how the recall challenges her present situation, which is decidedly not that earlier time and place. We hope that the patient is experiencing joy, but that joy can be laced with anxiety or even terror from being awakened by familiar sounds into an unfamiliar world.

As for the physical changes that take place when Henry starts to listen, we shouldn’t be surprised that music has the power to make humans sing and move. It has that effect on infants and toddlers in ways that appear to be completely involuntary. And if these gestures are involuntary, we have to remind ourselves continually that some of these individuals are not free agents who can choose to listen or not. If we can imagine ourselves being under a spell and being forced to move against our will, we might want to think twice about making others move who cannot give their consent, even if the movements are—or appear to be—pleasurable.

Dementia patients’ inability to consent and their confused responses lead to yet one more reason to tread carefully in this area: the potential for injury. Emotional injury, not physical injury. As the Couric pitch says, music can “make us feel incredible joy or profound sadness.” I can easily imagine that, should I outlive my husband, songs that bring me joy today might one day bring me pain, because those songs will make me think of him. The same likely holds true for patients who cannot coherently tell caregivers about their musical triggers.

At its core, Alive Inside tells us that we should not underestimate the power of music. I couldn’t agree more, which is why I urge caution when we deploy music in therapeutic ways. Henry is an example of both my point and the documentarians’. He is indeed made new by music. But we can’t know how connected the new Henry is to the old Henry.

Music can make us feel things we haven’t felt in a long time—or maybe never felt before—and make us say things that have no relation to reality. That’s how forceful music is. And Henry is the proof, for good and for ill.