Nordic Journal of Music Therapy, 2014

Vol. 23, No. 3, 202–223, http://dx.doi.org/10.1080/08098131.2013.829863

Music therapy and attachment relationships across the life span

Varvara Pasiali*

Queens University of Charlotte, 1900 Selwyn Ave., Charlotte 28274, NC, USA
(Received 15 July 2012; final version received 3 July 2013)

Attachment refers to the quality of relationships that humans form across

their life span. In music therapy, a growing body of clinical work focusing
on attachment is emerging. Because participation in music therapy can
promote positive and meaningful interactions over time, it creates a context
for developing healthy relationships. Drawing on insights afforded from the
fields of psychology and social neuroscience, the purpose of this paper is to
articulate an emerging conceptual model on how music therapy interventions
may target attachment across the life span. By reviewing and synthesizing
current literature, the author aims to expand theoretical underpinnings that
inform the work of therapists. Music-based interventions create a context-
fostering attachment by: (1) supporting parent co-regulation and mutual
responsiveness, (2) rebuilding capacity to form or restore relationships, (3)
reducing stress and mood disturbances, (4) supporting healthy partner inter-
actions by enhancing communication skills, and (5) providing social support
and building coping skills among families and individuals who are facing
challenging life circumstances. The author organizes and interprets the
information to outline different layers of prevention interventions and exem-
plify how music-based experiences may influence attachment relationships at
different life stages.
Keywords: attachment; relationships; mutuality; music therapy; prevention

Music therapy and attachment relationships across the life span

During the first year of life, attachment develops through ongoing parent–child
interactions. Within those ongoing interactions, an infant learns to organize
behavior and affect thereby developing expectations regarding the self and
others. Infant attachment involves a long evolutionary history of behavioral
and neurobiological patterns triggered to ensure the survival of the infant as
well as the mother’s reproductive success (Ainsworth, 1979; Ainsworth, Blehar,
Waters, & Wahls, 1978; Bowlby, 1958, 1980; Bugental, 2000). At an early age,
the child’s parents or other significant adults and caregivers constitute attachment

*Email: pasialiv@queens.edu
A draft version of this paper was presented at the International Society of Music
Education (ISME) Conference, Music in Special Education, Music Therapy and Music
Medicine Commission Seminar, Thessaloniki, Greece (July 2012).

© 2013 The Grieg Academy Music Therapy Research Centre

 Nordic Journal of Music Therapy 203
figures. In preschool years, attachment continues to develop as individuals
negotiate being independent and connected to others (Cicchetti, Cummings,
Greenberg, & Marvin, 1990). As a child ages, attachment behaviors are directed
toward peers. A developmental transition occurs in adolescence with the emer-
gence of romantic relationships (Campa, Hazan, & Wolfe, 2009). In older adults,
close friendships and social support peer networks become again a central focus
of attachment relationships (Baumeister & Leary, 1995).
Psychologists view attachment as a process used to achieve various goals in
different kinds of relationships across the life span (Bugental, 2005). The process
involves developing affectional bonds plus the element of security with another
partner (Ainsworth, 1989). Separation distress characterizes attachment relation-
ships, regardless of age. Adults may experience a sense of longing when
separated from their attachment figures. Infants seek physical contact and proxi-
mity whereas adults seek comforting communication by phone or e-mail (Campa
et al., 2009).
In music therapy, a growing body of clinical work focusing on attachment is
emerging. When relational bonds are at-risk or disruptions have occurred, music
therapists working with families have focused on strengthening relationships and
parent–child interactions (Edwards, 2011a, 2011b; Oldfield & Flower, 2008). I
develop an emerging conceptual model exploring the phenomenon of how music
therapists may promote attachment. I synthesize and integrate research literature
aiming to intensify the reader’s understanding of how music-based interventions
can foster meaningful and adaptive relationships across the life span.

Pathways of promoting attachment

Supporting parent–child co-regulation and mutual responsiveness
Purposively planned music experiences can support mutual responsiveness in
parent–child dyads and create a context for developing adaptive reciprocal
interactions. Dyads who exhibit high mutual responsiveness have a close rela-
tionship that is characterized by coordinated routines/rituals during interactions,
bidirectional shared cooperation, positive affect, and empathetic perspective
(Aksan, Kochanska, & Ortmann, 2006). If parents through a history of ongoing
mutuality develop a secure relationship with their child, they create a social
capital that allows them, within the context of the relationship, to influence their
child’s moral development (Kochanska, 2002a), ability to regulate behavior
(Evans & Porter, 2009; Kim & Kochanska, 2012; Kochanska, Aksan, Knaack,
& Rhines, 2004), and self-regulated compliance (Kochanska, 2002b). Moreover,
parents who have high mutuality with their offspring tend to resort in less
forceful discipline to accomplish goals (Kochanska, Aksan, Prisco, & Adams,
2008).
Early in development, interactions are parent-driven. Gradually, parent-
driven interactions lead to the development of bidirectional reciprocity within
204 V. Pasiali
the relationship. A mother’s responsiveness to the child’s cues constitutes an
integral factor contributing to secure attachment. A secure relationship is char-
acterized by reciprocity in responsiveness to each other’s subtle cues. Ongoing
interactions between mother and offspring regulate and fine-tune the neurohor-
monal chemistry associated with attachment (Bugental, 2000).Traumatic early
experiences may lead to attachment difficulties by deregulating neurobiological
systems (Fries, Shirtcliff, & Pollak, 2008; Fries, Ziegler, Kurian, Jacoris, &
Pollak, 2005). Interestingly, Granot et al. (2007) have found provisional evidence
that a receptor gene of vassopressin, a hormone that affects social behavior and
bonding, is associated with musical memory. They hypothesized that music has a
social adaptive role affecting mother–infant interactions.
Reciprocal imitation of facial affect and vocalization patterns builds confi-
dence and trust between infant and caregiver, encouraging development of
knowledge and skills (Trevarthen, 2005). Mother–infant vocal interactions can
be spontaneous and may involve singing for and with infants. Those interactions
are a form of meaningful engagement that involves a shared focus and affective
involvement (Gratier & Trevarthen, 2008). As a result of such interactions,
mothers and their infants can engage in patterns of intentional nonverbal com-
munication. Such communicative exchanges are characterized by spontaneous
and improvised vocalizations (with varied pulse, pitch, timbre, and volume) that
could be described as musical (Malloch & Trevarthen, 2009). Based on the
“melodic and rhythmic co-creativity” that exists between mother–infant vocal
interactions, Malloch and Trevarthen (2009) developed the theory of commu-
nicative musicality. They described the ability of babies to engage in such
interactions as a form of “innate intersubjectivity” leading “before the end of
the first year to the learning of culturally conditioned meanings” (Malloch &
Trevarthen, p. 2).
Infant sensitivity to different musical sound features is similar across cultures
(Trehub, 2003). Through singing, mothers are able to modulate their infants’
arousal levels (Shenfield, Trehub, & Nakata, 2003). de l’Etoile (2006a) found
that “singing is just as effective as book reading or toy play in maintaining infant
attention, and far more effective than listening to recorded music” (de l’Etoile,
p. 465). Creighton (2011) described infant-directed singing and mother–child
vocalizations as a form of sustaining positive emotional ambiance in commu-
nicative interactions. Parents who use action/play songs to stimulate and lullabies
to soothe their infants in a developmentally sensitive manner support the devel-
opment of attachment bonds. Panksepp (2001) stated that an infant’s emotional
experiences should be congruent with cognitive experiences in order for the child
to develop healthy representational models of attachment. If mother–infant
intersubjectivity and emotional attunement develops through singing and vocal
interaction, then music-based experiences can become shared cognitive and
emotional tasks supporting attachment.
Several references in the literature substantiate that music can facilitate infant
self-regulation, therapist–child or parent–child co-regulation. By presenting
 Nordic Journal of Music Therapy 205
clinical case studies, Shoemark (2008) provided information on how spontaneous
singing and infant-directed songs facilitated the regulation of medically fragile
full-term infants. Furthermore, researchers and clinicians developed interventions
and training programs using music to benefit the mother–infant relationship.
Whipple (2000) found that training parents of premature infants in the
Neonatal Intensive Care Unit in music and multimodal stimulation decreased
infant stress behaviors and increased appropriateness of parent–child interactions.
Baker and Mackinlay (2005) facilitated a one-time training session showing first-
time mothers how to use lullabies to soothe, transition babies to sleep, or regulate
their emotional states. Singing lullabies helped the mothers be present in the
moment and avoid other distracting thoughts, enhanced perception of parental
efficacy, and made the bedtime task less stressful. Vlismas and Bowes (1999)
aimed to extend the mothers’ developmentally appropriate musical repertoire
with their infants. Mothers who participated in a 5-week program reported an
increase in using music for relaxation with their infants. A follow-up study using
a similar 5-week training program with first-time mothers indicated an increase
in dyadic reciprocal interactions and parental attachment to their infants
(Vlismas, Malloch, & Burnham, 2012-online).
As a conclusion, the examples above corroborate that carefully planned
music-based experiences create a context that may enable parents to rehearse
adaptive ways to interact with their child. Such interactions, over time, can
support the development of a secure and mutual relationship. The examples
discussed thus far involved parents who did not report difficulties in caring for
their infants. Clinical populations, such as parents diagnosed with a mental health
issue or parents caring for a child with a disability, may have difficulty attending
to their infants’ needs and interaction bids. Thus, they may face unique chal-
lenges in establishing positive parent–child relationships. Next, I examine how
music therapy with clinical populations may restore relationships and support
attachment.

Rebuilding capacity to form or restore relationships

Participation in music therapy may transcend the effects of traumatic experiences
by rebuilding the capacity to form or restore relationships, thus creating a second
pathway toward fostering attachment. When working directly with individual
clients or families, a music therapist is, in essence, an external agent attempting
to perturbate expectations and interaction patterns affecting attachment. Because
music therapy is a shared experience, it creates a context within which clients
may switch previously learned maladaptive patterns of interaction and
relatedness.
Various life experiences or unexpected events may significantly disrupt
relationship bonds and attachments. Adults with experiences of abuse or post-
traumatic stress disorder (PTSD) are more likely to have unresolved attachment
difficulties. They may seek less intimacy and emotional involvement from
206 V. Pasiali
partners, thus avoiding connectedness (Bakermans-Kranenburg & Van
IJzendoorn, 2009). Mothers – who experienced negative relationship histories
with their parents – may have difficulty forming secure attachment with their
infants. However, those mothers who receive counseling and emotional support
and are able to discuss those negative histories in a coherent manner, are more
likely to develop secure attachments with their infants (Saunders, Jacobvitz,
Zaccagnino, Beverung, & Hazen, 2011).
A music therapist may gain access to the thought processes and emotions
experienced by a traumatized individual and gradually rebuild their capacity to
trust and connect to others. Co-creating music becomes a form of symbolic
connection with others. Making music promotes moments of togetherness
among participants. Techniques such as lyric analysis, clinical improvisation,
or song writing may allow a client to portray and project emotions. Pellitteri
(2009) stated that “as we engage in musical experiences with our clients, we
enter their psychological space and in doing so create a new interpersonal space.
It is in the context of the therapeutic relationship that emotions, once activated,
can find expression and be transformed” (Pellitteri, 2009, p. 4).
Clinical case studies indicated that music therapy helped a child with attach-
ment difficulties form a relationship with his foster mother (Burkhardt-Mramor,
1996), and assisted a child who had been sexually abused to develop self-
regulation (Robarts, 2006). Hussey, Reed, Layman, and Pasiali, (2008) discussed
a music therapy intervention protocol targeting attachment behaviors and the
development of social, interpersonal, and reciprocal relationships among children
who have experienced complex trauma. Felsenstein (2013) worked with pre-
schoolers who faced a traumatic experience to build resilience and capacity to
cope by supporting connections within the family and the community.
Moreover, researchers substantiated the benefits of involving families, who
have problematic relationship patterns, in music therapy. Specifically, researchers
attempted to change maladaptive interactional patterns and support development
of healthy relationships between parents and their children (Archer, 2004;
Nicholson, Berthelsen, Abad, Williams, & Bradley, 2008; Oldfield & Bunce,
2001; Oldfield, Bunce, & Adams, 2003; Pasiali, 2011, 2012; Shoemark, 1996;
Smeijsters & Storm, 1996; Trolldalen, 1997; Walworth, 2009; Williams,
Berthelsen, Nicholson, Walker, & Abad, 2012). Lastly, Jacobsen and Wigram
(2007) published an article discussing an assessment process for evaluating
parent–child interactions and the quality of the relationship through the use of
free improvisation, turn-taking, and leading activities.
When mothers experience symptoms of depression, the quality of their
infant-directed singing is affected. Their singing may lack emotional expression
and sensitivity toward the infant’s needs. Thus, mothers with depression may not
be able to use infant-directed singing for arousal regulation (de l’Etoile & Leider,
2011). However, the maternal symptoms of depression do not appear to affect a
child’s ability to respond to infant-directed singing (de l’Etoile, 2012). Research
showed that infants who have Down syndrome also respond to infant-directed
 Nordic Journal of Music Therapy 207
singing. However, when their mother sings to them, they display more inter-
mittent gaze (alternate looking at mom, then away) rather than sustained gaze.
The increase in intermittent gaze reflects a developmental deficit in shifting
attention. Longer instances of roaming or averted gaze reflect difficulties in
regulating the level of incoming stimulation (de l’Etoile, 2013). de l’Etoile
(2012, 2013) recommended coaching parents (who have depression or a child
with a disability), how to use infant-directed singing for maintaining optimal
arousal and improving emotional synchronicity in their relationship.
Within the context of the therapeutic relationship, a music therapist may
address attachment problems resulting from traumatic experiences. Working with
adults who had traumatic childhood experiences, Austin (2001) used a psycho-
dynamic music therapy approach employing improvised singing and verbal
processing. She pointed out how the therapist can simulate a mother–child
relationship within which issues of problematic attachment can be unearthed
and addressed. Bensimon, Amir, and Wolf (2008) conducted group therapy
sessions with six soldiers using drumming as a therapeutic intervention to
address post-traumatic stress symptoms. Drumming helped the participants
develop a sense of control, provided an outlet for expressing intense emotions,
and lead to developing a sense of connectedness and closeness among group
members. Another music-based intervention that has been shown to change
relationships and allow participants to connect to others is group or individual
guided imagery with music (GIM). The symbolic images triggered by the music
may allow individuals who struggle with PTSD, with the help of a therapist,
explore unresolved feelings and memories. Unresolved issues attenuate capacity
to connect to others (Blake & Bishop, 1994; Green, 2011).
To sum up, adverse and traumatic experiences influence an individual’s ability
and capacity for connecting with others. Music-based experiences seem to elicit
emotions, trigger memories, and allow individuals to address personal and inter-
personal stresses that may negatively affect their capacity to connect with others.
By participating in individual or group music therapy, clients may transcend the
effects of traumatic experiences and identify ways to restore problematic relation-
ships. Next, I focus on how music-based experiences can further promote psycho-
social health and attachment relationships by improving mood and reducing stress.

Reducing stress and mood disturbances

A music therapist can observe and evaluate client idiosyncratic responses during
active or receptive music-based experiences. By listening and responding to
clients, a music therapist can create a therapeutic space that allows the energy
of negative emotions to manifest and change. The therapeutic goal is to help
clients achieve an expanded awareness of life barriers and stressors that elicit
anxiety and depression. Rather than projecting those feelings, thoughts, and
emotions to others, clients can cultivate focused awareness on how to regulate
their reactions.
208 V. Pasiali
Interventions that prevent or ameliorate stress, anxiety, and mood distur-
bances are appropriate when addressing attachment difficulties. Stress, anxiety,
and mood disturbances in adults increase the likelihood of insecure parent–child
attachments across the life span (see Bettmann, 2006; Milan, Snow, & Belay,
2009). Parent–child relationships are a dynamic process. When adults experience
stress, anxiety, or mood disturbance, they may not be able to respond to their
infants and children in ways that are supportive and non-intrusive. For example,
research showed that adults with low levels of secure attachment exhibited
heightened arousal (increased heart rate and electrodermal activity) to attach-
ment-related challenges such as infant crying. Such psychophysiological
responses translated as an attempt to inhibit a fight–flight stress response that
may lead to decreased parental responsiveness to infant distress signals
(Roisman, 2007). Even though mothers with symptoms of depression may
have difficulty interpreting and responding to infant affective cues, previous
musical training may be a protective factor. Mothers with depression who had
four or more years of musical training were more adept at responding to infant
distress cues than those with less than four years or without training (Young,
Parsons, Stein, & Kringelbach, 2012).
Anxiety and mood disturbances may affect attachment relationships across
the life span. Adults who experience attachment anxiety may seek continual
approval from others because they fear being rejected or abandoned. Attachment
anxiety, when combined with a need for perfection (avoidance of making mis-
takes and fear of failing tasks), is directly linked with depression mood (Wei,
Mallinckrodt, Russell, & Abraham, 2004). Hence, a third pathway for promoting
secure attachment relationships is using music therapy interventions to alleviate
stress, reduce distress, and improve mood.
Humans have bodily and emotional responses to music. Each experience of
listening or actively making music is unique and complex. External factors (e.g.,
the social context or performance venue), internal factors (e.g., thoughts, feel-
ings, mood, or fatigue), and musical factors (e.g., formal training and familiarity
with genre), create idiosyncratic reactions when engaged in active or receptive
music-based experiences (Hodges, 2009; Juslin, 2009). Music-based experiences
may induce physiological responses, such as affecting pulse rate, skin conduc-
tivity, blood pressure, respiration, body temperature, muscle tension, and bio-
chemical hormones. Such responses are directly linked to how musical elements,
such as harmony, melody, rhythm, musical structure/form, or tempo may increase
or decrease arousal levels (Hodges, 2009). Multiple mechanisms may underlie
induction of emotional responses to music. Those mechanisms may include: (1)
how we reflexively react to certain acoustic properties of music, (2) perceiving
emotions in music and subsequently internalizing the feeling, (3) remembering or
associating specific memories or events when listening to or performing a
specific piece of music, (4) validation or violation of musical expectations, and
(5) induction of visual and/or sensory sensations while experiencing music
(Juslin, 2009). A music therapist has the training to observe, evaluate, assess,
 Nordic Journal of Music Therapy 209
encourage, and facilitate those idiosyncratic responses to music in order to bring
forth therapeutic change.
Research conducted with adults showed that music interventions can reduce
stress hormones, affect mood, and increase immune function (Bartlett, Kaufman,
& Smeltekop, 1993; Kreutz, Bongard, Rohrmann, Hodapp, & Grebe, 2004;
McKinney, Antoni, Kumar, Tims, & McCabe, 1997). Participation in six
Bonny Method of Guided Imagery and Music (BMGIM), a form of music
psychotherapy, reduced cortisol levels in healthy adults. Elevated cortisol levels
are related to increased stress and anxiety, which may lead to mood disturbances
and overall health deterioration (McKinney et al., 1997). Moreover, participation
in 25 one-hour music therapy group sessions, decreased immunoglobulin A
concentrations in eight older adults with dementia (Suzuki, Kanamori,
Nagasawa, Tokiko, & Takayuki, 2007). Lastly, Maratos, Gold, Wang, and
Crawford (2008) conducted a systematic review of randomized controlled trials
examining the effect of music therapy interventions for treating depression. Five
studies met the inclusion criteria. In four out of five studies, participants reported
greater alleviation of symptoms in music therapy. Given that adherence to
treatment is vital for mental health well-being, the fact, that all five studies
included in the meta-analysis had low dropout rate from music therapy treatment,
is important.
Music therapists use both receptive and active music therapy techniques as
means of affecting client mood and alleviating anxiety. The therapeutic space
created by a music therapist can reduce avoidance, resistance, and aversion to
strong feelings and emotions that affect mood and cause stress. Clients may learn
to relate differently to experiences they cannot change. During sessions, the
therapist can listen and respond to clients guiding them to develop ways to
cope with stress, anxiety, and mood disturbances that compromise their ability
to connect to others. Next, I explore how participation in music therapy allows
for symbolic expression of thoughts and feelings that may enhance communica-
tion with others.

Enhancing partner communication skills

The way partners understand and explain their various social actions to each
other is central to close relationships. Moreover, ability to respond to a partner’s
nonverbal communication cues and behaviors affects intimacy. Nonverbal inter-
action behaviors arise from meanings partners have ascribed to the communica-
tion cues between them. Problems in couples’ communication skills can be
addressed by building a concrete relationship between music, sound, and them-
selves. Whether engaging in improvisation, songwriting, or song discussion,
couples may benefit by using music as a form of interplay between each other
and their environment. Thus, active engagement with music may become the
process through which couples may work through certain issues in order to
achieve mutual goals for nurturing the relationship.
210 V. Pasiali
Adult attachment working models involve the relationships parents form with
their own children, the relationship with their own parents, and the relationships
they form with significant others (Dickstein, Seifer, & Albus, 2009). For exam-
ple, Saffrey and Ehrenberg (2007) found that young adults with problematic
internal attachment representations exhibit fewer positive adjustment behaviors
following relationship breakups. Problematic communication between couples
may lead to attachment difficulties in offspring (see Bifulco, Moran, Jacobs, &
Bunn, 2009; Dickstein et al., 2009). Thus, finding ways to enhance communica-
tion skills of adult partners during music therapy may indirectly affect the quality
of relationships within the whole family ecosystem, thus becoming a fourth
pathway of fostering attachment.
Music therapy can enhance adult communication. Kenny (2006) views music
as an agent that allows individuals to express and share feelings. Music may
function as the symbol of drawing insights about concrete life situations. Those
symbols may allow individuals to understand everything in relation to others.
Thus, music may allow them to move from thinking as an “I” in forming
connections with others. Stige (2002) describes active music making as a situated
cultural experience that taps into our innate capacity for nonverbal communica-
tion. Music co-creation thus becomes a transactional process of learning new
responses in social contexts. Similarly, Rolvsjord (2010) refers to music co-
creation as “doing together.” She states: “In music therapy, the mutual engage-
ment with music is more than having another channel or media for communica-
tion.Making music together in music therapy is inevitably also putting a
dimension of ‘doing together’ into the therapeutic relationship” (p. 217).
The literature contains references on how music therapy interventions can be
adapted for couples’ therapy. Botello and Krout (2008) designed the music
therapy assessment of automatic thoughts (MTAAT), an intervention based on
cognitive-behavioral therapy aiming to increase communicative skills between
couples. The assessment involves completing music improvisation exercises
designed to identify thought patterns and beliefs that might hinder the couple’s
ability to communicate effectively. For the improvisation, the researchers choose
drums and cymbals because couples could easily use them to produce a good
quality of sound, creating a back and forth production of rhythmic patterns
resembling a conversation. Psychologists Duba and Roseman (2012) adapted
music therapy techniques to help couples communicate feelings, thoughts, and
experiences to each other. Similar to Botello and Krout (2008), they used
drumming and instrumental improvisation to resemble a back and forth “dialog”,
followed by verbal discussion. They also used lyric composition and song
discussion to represent a couple’s relationship.
Music therapists have worked with couples when one partner is medically
hospitalized (Hinman, 2010), has cancer (Körting, Marmé, Verres, & Stammer,
2005), has alcohol addiction (Gallant, Gallant, Gorey, Holosko, & Siegel, 1997),
or has dementia (Baker, Grocke, & Pachana, 2012). Participation in one-day
communication workshops involving active improvisation enhanced
 Nordic Journal of Music Therapy 211
communication skills, connectedness, and closeness between partners (Körting
et al., 2005). Using singing, songwriting, music improvisation, and verbal
processing helped couples in a hospital experience intimacy, and may have
increased their ability to support each other (Hinman, 2010). Training spouses
to use music as an intervention without the supervision of a music therapist
helped revive elements of the couple’s spousal interpersonal relationship that
were affected by dementia. The home-based music therapy involved techniques
such as singing familiar songs, movement to music, and listening to relaxing
music (Baker et al., 2012). Music therapy with couples involved in outpatient
treatment for alcohol addiction decreased psychosocial problems. Song discus-
sion as an intervention helped women participants feel less lonely (Gallant et al.,
1997).
In couple’s therapy, music becomes a container of intense emotions illumi-
nating issues that can hinder connectedness. Music-based experiences that allow
couples to “make and receive music together” (Hinman, 2010) can provide a
flexible, yet structured framework for communicating needs, clarifying thoughts,
and sharing emotions. Improving communication skills can nurture affectional
bonds and increase the element of security between partners. Next, I focus on
how music therapy can engage and bring family members together during
adverse life events, preventing deterioration of attachment relationships.

Providing social support and building coping skills

Challenges or hardships across the life span can affect the robustness of attach-
ment relationships and bonds. Music-based experiences can provide both exter-
nal supports and increase personal competencies that contribute to maintaining
relationships in the face of adversity. Music therapy can become a risk-activated
strategy focusing on enhancing the attachment system of individuals who need to
cope with adverse events.
Attachment patterns do not remain stable over time and may be affected by
changes in family stress or circumstances. Marital discourse may affect the
availability and dependability of the mother, serious illness of a sibling may
add to family stress, or loss of income may change living conditions (Thompson,
2000). Hence, the fifth pathway for fostering attachment involves the use of
music therapy interventions for enhancing family ties and relationships during
challenging life circumstances.
The type of support during stressful situations must be differentiated accord-
ing to situational, personality, and attachment style factors. Whereas emotional
support may help individuals who are securely attached, avoidant attached
persons may benefit more from problem-solving discussions. Ventilation of
feelings may not be beneficial to anxious-ambivalent persons (Mikulincer &
Florian, 1997). When dealing with challenging experiences, adults with secure
attachment patterns exhibit more constructive approaches to maintaining their
relationships. On the other hand, adults with avoidance attachment systems may
212 V. Pasiali
downplay stressful events and deny their emotions, often reacting in a hostile
manner toward partners. Adults with attachment anxiety may use excessive
worry and retaliatory anger to capture a partner’s attention. Overtime, such
behavioral patterns can alienate family members causing isolation and abandon-
ment (Shaver & Mikulincer, 2007). A music therapist must therefore purpose-
fully assess attachment styles and relationship dynamics when working with
families and individuals who are experiencing challenging life situations.
Evidence in the literature involves multiple examples on how music therapy
interventions support families in the midst of challenging situations such as: (1)
coping with life-threatening or terminal illness (Clements-Cortés, 2011; Krout,
2003; Lindenfelser, Grocke, & McFerran, 2008; Magill, 2011; O’Callaghan,
Hudson, McDermott, & Zalcberg, 2011), (2) coping with the role of caregiver
of a loved-one with dementia (Brotons & Marti, 2003; Choi, 2010; Clair, 2002;
Clair & Ebberts, 1997; Hanser, Butterfield-Whitcomb, Kawata, & Collins, 2011),
and (3) dealing with grief and loss (Hilliard, 2001, 2007; McFerran-Skewes,
2000). In these examples, participation in music therapy seemed to moderate the
impact of overwhelming life stressors and benefited physical and psychological
functioning.
Complex and dynamic interactions between attachment styles, coping
mechanisms, resilience, and the presence or absence of support systems deter-
mine psychosocial outcomes and subsequent relationships when facing adversity.
Timely and appropriate music-based interventions may help individuals acquire
and maintain the type of relationships and bonds that are conducive to managing
a variety of emotional demands across the life span.

Music therapy as an attachment intervention in prevention

By evoking both physiological and psychological responses in individuals, music
therapy may support the presence of attachment behaviors functioning as a pre-
vention intervention. Prevention occurs at different levels: universal, selective, and
indicated. Universal prevention encompasses the total population in general.
Selective prevention uses interventions that target specific populations identified
as at-risk of developing maladaptive responses. Indicated prevention focuses on
specific groups in which problems or symptoms have already been identified
(National Research Council and Institute of Medicine [NRC/IOM, 2009]). Next,
I use the outlined prevention layers as a conceptual model to discuss how music-
based experiences may influence attachment relationships at different life stages.
The goal is to articulate an emergent template for music therapy as an intervention
for preventing attachment difficulties across the life span.

Universal level
At the universal prevention level, pragmatic realities such as economic, political,
and societal priorities may limit access to music therapy. Whereas, it may be
 Nordic Journal of Music Therapy 213
beneficial for parents of newborn infants to receive a one-time individual con-
sultation by a music therapist on how to use lullabies or spontaneous songs for
regulating affect and establishing calming rituals, such should be a major public
health program that is unlikely to receive funding. Realistically, families who
enroll in early childhood music classes, taught by qualified teachers who can
model additional ways of engaging in back and forth musical interactions, have
middle to higher income. As the child enters public schools, peers become the
central focus of attachment relationships. Despite multiple references in the
research literature attesting to the positive relationships between active participa-
tion in music and various psychological and sociological variables (see Hallam,
2010), budget cuts and economic realities often lead to the reduction or elimina-
tion of music programs from public schools.
A successful example of a grant-funded program providing early childhood
music therapy to at-risk groups or socioeconomic disadvantaged groups is the
“Sing and Grow” program in Australia (Nicholson et al., 2008). Nicholson et al.
(2008) implemented an evaluation protocol to document changes in parenting
skills and interactions. The participants were 358 parents and children from
families categorized into three groups: (1) social disadvantage, (2) young parents,
or (3) parents of a child with a disability. The researchers measured changes in
self-reported parenting behaviors, parent–child interactions, parenting self-
efficacy, and parent mental health over time. In addition, they measured changes
in parent-reported children’s social, communication, and behavioral skills. They
found significant improvements over time for parental irritability, parent mental
health, child communication skills, and child social play skills for all families
belonging in either one of these three groups (social disadvantage, young
parents, or parents of a child with a disability). Parent-reported parenting warmth
and child behavior problems did not show significant changes over time.
Parenting self-efficacy improved over time for parents belonging to the social
disadvantage and young parents groups, but showed a slight (nonsignificant)
decline for parents in the disability group. Across all groups, clinician observa-
tions showed significant improvement of parent–child behaviors. The results of
Nicholson et al. (2008) study indicated that experiences in music therapy short-
term group intervention affect different aspects of child and parent functioning.
Parents who have a child with a disability, however, may need additional
supports to improve their sense of self-efficacy.
Through participation in amateur groups, community/church choirs, and
orchestras, adults have the opportunity to mingle with others who may share
the same interests and passion for music making. Participation in ensembles
boosts well-being by decreasing stress. For example, participation in an amateur
choir increased immunoglobulin A (S-IgA) and decreased cortisol (Kreutz et al.,
2004). Similarly, rehearsals with a university chorale group increased S-IgA
levels and decreased cortisol (Beck, Cesario, Yousefi, & Enamoto, 2000).
Older adults who participated in music lessons experienced fewer symptoms of
depression, anxiety, and perception of loneliness (Koga, 2005). For older adults,
214 V. Pasiali
as the focus of attachment relationships re-centers on close friendships, amateur
music groups provide both a creative and social avenue for connecting with
others. The literature documented the benefits of involvement in music ensem-
bles such as intergenerational programs involving college students and commu-
nity choirs (see Belgrave, Darrow, Walworth, & Wlodarczyk, 2011; Bowers,
1998) or the “New Horizons” band program for older adults, which was funded
by the National Association of Band Instrument Manufacturers and the National
Association of Music Merchants (Coffman & Adamek, 2001; Ernst, 2001; Ernst
& Emmons, 1992). To help buffer adults against challenging life events that may
threaten social adaptation, music therapists may also conduct interventions or
short-term wellness groups accessible to non-help seeking adult populations
(Ghetti, Hama, & Woolrich, 2008).
Lastly, established in 2009, the music as a natural resource (MANR) initia-
tive is a not-for-profit organization that explores the potential of music to bring
forth social change. Their publication, edited by Hesser and Heinemann (2010),
contains information about 55 programs that musicians and music therapists have
established in urban and rural settings in 33 countries around the world. Those
programs used music as a natural resource for building connectedness within
communities by decreasing vulnerability of at-risk youth, promoting mental and
physical heath, supporting trauma survivors, teaching new skills, and peace-
building. Attesting to the enabling power of music, those programs have success-
fully transcended economic, political, and societal priorities to provide access to
music.

Selective and indicated level

In addition to the intervention examples proposed in the previous section,
families may need further support at this level of prevention. For psychoeduca-
tional or psychotherapeutic uses of music, training in music therapy is needed.
Training beyond the undergraduate level, experience, and supervision are all
required, due to the multifaceted needs of individuals or families who have
attachment difficulties.
Music therapists may collaborate with music educators and/or community
musicians, as well as other professionals to identify individuals who need more
help and may benefit from music therapy. In meta-analyses of prevention efforts
targeting parental sensitivity and child secure attachment (Bakermans-
Kranenburg, Van Ijzendoorn, & Juffer, 2003) and disorganized attachment
(Bakermans-Kranenburg, Van Ijzendoorn, & Juffer, 2005), interventions imple-
mented after the children were 6-month-old were more effective. Interventions
that maintained a broader focus (e.g., considering parental support or representa-
tions) seemed less effective than sensitivity-focused interventions (aimed to
reduce intrusive, unresponsive, or frightening parental behavior). Interventions
with fewer than 5 sessions or between 5 and 16 sessions were more effective than
longer interventions. When measuring the increase in parental sensitivity and
 Nordic Journal of Music Therapy 215
development of secure attachment relationships, potential moderators, such as
characteristics of the sample (e.g., SES, adolescent pregnancy, psychopathology)
and accumulation of multiple risks, did not alter effect sizes. Interventions with
clinical samples (either adults or children), however, were more effective than
general non-clinically referred samples, indicating that prevention efforts target-
ing parental sensitivity and secure relationships should be implemented at a
selective or indicated level. Noteworthy is that the type of risk experienced by
families was a potential moderator. Interventions with children considered at-risk
for developing attachment problems (e.g., children who were adopted or exhibit
high irritability as infants) seemed more effective than interventions with parents
considered at-risk (e.g., maternal depression) (Bakermans-Kranenburg et al.,
2005). To sum up, the meta-analyses indicated that interventions that target
attachment need to have a narrow scope, short duration, and begin when children
are at least 6 months. Interventionists working with parents at-risk may need to
provide additional support to the family in order to prevent attachment problems.
de l’Etoile (2006b) proposed that infant-directed songs (such as lullabies or
action songs) may provide opportunities to increase maternal sensitivity and
infant affect regulation. She discussed a model for coaching mothers who have
depression on how to use infant-directed singing for eliciting positive interac-
tions with their infants. Her recommendations meet the guidelines for using
music therapy as an intensive short-term intervention. Similarly, Bargiel (2004)
developed specific guidelines for training parents on how to interact musically
with their infants to regulate their affect. Clinicians however, should keep in
mind that mothers who have depression may need additional referrals and
support in addition to the music therapy intervention for increasing sensitive
interactions.
I propose dyadic parent–child sessions, or family-based group music therapy
as a preferred delivery mode in early childhood. Thereafter, as the focus shifts to
peers, group therapy may be a preferred approach. In adulthood, depending on
the individual needs, group or individual therapy may be indicated. With infants
or parents at-risk, selective and indicated prevention may begin at the hospital
prior to discharge. Conducting a follow-up meeting with parents considered at-
risk (given that parental risk is a potential moderator) after discharge may be
helpful in reinforcing training and the use of music-based interventions at home.
Short-term music therapy interventions, targeting the development of parental
sensitivity, should begin after children are 6 months. For children (0–3 years),
those interventions may have direct benefits in increasing secure attachments and
indirect benefits such as improving the home environment, child, or parent
functioning. For toddlers, preschoolers, and young children, the therapist should
continue to involve the child’s attachment figures in therapy.
Since attachment affects multiple systems, and focused short-term interven-
tions may be more effective, therapists must carefully assesses and triage the
needs of their clients considering a broader context of possible constraints on the
attachment system at the child level (e.g., genetic risk, temperament, diagnosed,
216 V. Pasiali
or suspected disability), parent level (e.g., maternal depression, marital discord),
and family level (e.g., poverty, isolation, race, and culture). Recognizing that
families who experience cumulative environmental risks and/or higher initial
distress need a more individualized and intensive treatment approach (Lundahl,
Nimer, & Parsons, 2006; Nowak & Heinrichs, 2008) music therapists should
collaborate with other professionals through community agencies to provide for
the needs of the family in a holistic manner. Because peer dynamics may become
a vehicle fostering change, older children may benefit from group music therapy
that targets attachment behaviors. Individual therapy, couples therapy, or group
therapy may be a delivery treatment mode for adult clients. Overall, adaptive
functioning, not just distinct behavioral problems in isolation, should be
addressed in therapy, focusing on how the individual performs in salient and
age-appropriate tasks relevant to the attachment system.

Conclusion
Believing in one’s ability to elicit responses from others as well as a sense of
mastery over social relationships gradually develops though our attachment
relationships. Secure relationships formed in early childhood create a form of
capital ensuring subsequent success in relationships, bonds, and close friend-
ships. Later positive outcomes, however, are not guaranteed, as many variables
affect adaptive functioning. Active and receptive forms of music therapy, as
described in the research literature contained in this paper, may address the
motivational bases of attachment such as feeling connected to peers/family
members, clarify expectations about relationships, and develop parental sensitiv-
ity and responsiveness between parent–child dyads. In the midst of dealing with
stressful situations, music-based interventions may trigger neuroendocrinal
responses affecting an individual’s stress and mood, restore relationships, and
support coping skills. As shared relationships are central to attachment
(Ainsworth, 1989), researchers should capitalize on how music promotes healthy
relationships by facilitating positive and meaningful interactions over time.
Identifying ways by which we can be preemptive about developing healthy
attachment behaviors is important in establishing music therapy as a preventive
intervention. Rigorous qualitative or quantitative research will elucidate what
happens during music therapy that promotes change and growth in our clients in
domains relevant to attachment.

Notes on contributor
Varvara Pasiali, PhD., MT-BC received a BA Honors in Music, from the University of
East Anglia, Norwich, UK. Subsequently, she worked as a public school music teacher
and a freelance flute performer in Cyprus. In 2002, she completed her equivalency/
Master’s degree in Music Therapy at the University of Kansas. Upon graduation, she
worked as a music therapist in private practice (Ohio, US) with children and families at-
risk and at the Cleveland Music School Settlement (Cleveland, Ohio), where she
 Nordic Journal of Music Therapy 217
conducted individual sessions. Also, she was subcontracted to work at BeechBrook, a
residential treatment facility for children with socioemotional and mood disorders. She
completed her PhD in Music Education with a cognate in Music Therapy at Michigan
State in 2010. Currently, she is an assistant professor of music therapy at Queens
University of Charlotte, North Carolina. Her research interests include early intervention,
prevention, resilience, and parent–child attachment/reciprocity. Dr Pasiali is a regular
presenter at conferences and has published in various journals. She also serves on the
editorial board of the Journal of Music Therapy, and Approaches: Music Therapy &
Special Music Education.

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