According to a survey, constructed by the National Survey of Mental Health and Wellbeing in 2007, nearly half of adult population (aged 16-85) experienced a mental health disorder within 12-month or lifetime period, while the most common diagnoses among mental illnesses are depression and anxiety (Tiller, 2013). Other research estimated that 39% of consumers with Anxiety Disorder had symptoms of depression (Hunt, Issakidis, & Andrews, 2002). On the other hand, music therapy intervention was found to effectively improve depression and anxiety symptoms along with standard care in psychiatric hospitals (Erkkila, et al., 2011).
As my experience, it is common that consumers with principle diagnoses, for instance, Dementia or Anorexia nervosa, also showed symptoms of depression or anxiety. On the other hand, according to current researches, several music-intervention approaches in psychiatry involve verbal reflection which requires therapists’ counselling skills. To understand the basis and the application of music therapy in the mental health area and how to integrate it with other psychological therapies to reduce depression and/or anxiety symptoms, this literature review will mainly focus on group music therapy intervention with psychiatric patients. The following paragraphs will define the diagnosis and clinical needs of Depression and Anxiety disorder, describe the basis and the benefit of Group Music Therapy(GMT) and explain the approaches and relevant theories. Finally, synthesising results and giving suggestions for future research.
Initially, literature was derived from several databases including Cochrane library, Western Sydney University library and EBSCO Open Dissertations, while search terms were music therapy, depression and anxiety. To keep the information up to date, only scholarly literature published within twenty years were selected. However, treatment for reducing depression and anxiety symptoms were broadly used with various populations, including prisoners or cancer patients, therefore, the research was narrowed to music therapy with psychiatric patients. On the other hand, based on the current research, cognitive behaviour therapy was commonly combined with group music therapy in psychiatry, therefore, instead of describing the combination with several psychological treatments, this research will mainly explain the integration of cognitive behavioural therapy and music therapy.
Depression is a common reaction for people experiencing loss or trauma, however, when the state of depression persisted and the individual was incapable to anticipate pleasure, it was considered as a mental illness (Jackson, 2012). According to the American Psychiatric Association (APA, 2013), the criteria of Major Depressive Disorder included a significant change in daily functioning at least two weeks in either depressed mood or loss of interest or pleasure, along with four other symptoms, such as significant weight change, psychomotor agitation or retardation, loss of energy, feelings of worthlessness or suicidal ideation. The general symptoms written above may vary from individual to individual and the symptoms could overlap one another (Jackson, 2012). For instance, weight loss may result from a decrease in appetite, while the sense of worthlessness may be associated with unrealistic negative thoughts.
On the other hand, symptoms of Anxiety Disorder are commonly experienced by patients with depressive disorder (Fava, Rush, & Alpert, 2008). The types of anxiety disorder differ from the examinations of the anxiety-producing situation. For instance, avoidance of social situation might be defined as Social Anxiety Disorder. In contrast, generalized anxiety disorder is defined as excessive anxiety and worry, lasting over six months, regarding numerous events happening in multiple aspects of an individual’s life(APA, 2013). Anxiety Disorder may negatively impact on physical and emotional aspects, such as sleep disturbance or irritability. To avoid perceiving anxiety-producing activities, patients with Anxiety Disorder may tend to withdraw their feelings or contrarily experience a certain amount of distress which significantly affecting their functioning in a variety of areas (Jackson, 2012).
Clinical Needs and Common Goals
Instead of eliminating symptoms, researches mostly aim to reduce depression and anxiety and focus on reality orientation (Carr, Odell-Miller, & Priebe, 2013). In other words, facilitating consumers to utilize their strengths and resources to improve their current situation. From psychological aspects, the most common goals mentioned in researches are emotion regulation and socialization (Thoreau, 2016; McEntire, 2016; Tiller, 2013; Gold, 2011), however, some articles also emphasized the positive impact of physical relaxation for recovery (Zhou, et al., 2015; Tiller, 2013).
To further explain, physically, consumers with depression and/or anxiety mostly present with low energy resulting from their negative emotional state. While consumers with anxiety might have agitated behaviour, high-level energy usually useless in their daily functioning (Jackson, 2012). On the other hand, Consumers’ emotional reactions tended to be triggered easily and intensively partially resulting from their difficulties to recognize emotions and further modulate its (Mennin, Heimberg, Turk, & Fresco, 2002). To illustrate, since consumers possibly unable to identify and respond to negative emotions and thoughts, they often hardly develop a positive solution, such as coping skills, to improve their current emotion status, which might arise suicidal ideations along with the feelings of helplessness. Jackson (2012) stated that the inability to express their inner emotional experiences properly lead to the difficulty to interact with others.
Group Music Therapy in Psychiatry
Based on the selected articles, most of the researchers focused on short-term interventions, therefore, the immediate effect of a single session and short-term goals are prominent for consumers (Carr, Odell-Miller, & Priebe, 2013). The average length of interventions varied from 13 weeks (Crocke, et al., 2014) to 20 weeks (Erkkila, et al., 2011), while the interventions usually were conducted once (Gutiérrez & Camarena, 2015; Aalbers, et al., 2019) or twice (Silverman & Marcionetti, 2004; Gold, 2011) per week.
Music therapy is an evident-based and non-invasive intervention that can be understood from neurobiological and psychological perspectives. From neurobiological aspects, Koelsch(2009) stated music therapy can stimulate various parts of the human brain, for instance, the activation of limbic structures is related to emotional modulation. A randomized control trial also demonstrated that music intervention can increase frontal theta power, which has a positive impact on improving anxiety symptoms (Fachner, Gold, & Erkkilä, 2013). On the other hand, several articles indicated that music therapy can improve consumers’ emotional states (Legge, 2015; Carr, et al., 2012; Gutiérrez & Camarena, 2015). For instance, Juslin and Sloboda (2010) stated that music interventions not only facilitated people to explore and process emotions in different ways but also build positive relationships, which was essential for mental health improvement, among therapists, music and consumers. Besides, the lake of pleasure and meaning in life was recognised as a symptom of depression and anxiety (Maratos, Crawford, & Procter, 2011). McEntire(2016) indicated that receptive approaches, such as listening, can facilitate consumers to recognize positive experience in their life while socially meaningful experiences can be created via active music interventions, such as song-writing activity.
As for group music therapy, improvement of social isolation and communication skills were frequently mentioned in researches since group-based sessions provide more social opportunities. Furthermore, when consumers realised their peers experienced similar problems regardless of different psychiatric diagnoses, they mostly become more concentrated in the session to understand and learn from each other (Silverman, Therapeutic mechanisms in psychiatric music, 2015).
Integration with Cognitive Behaviour Therapy
Music therapy interventions for mental illnesses are commonly combined with other treatment, such as medications and psychiatric counselling (Jackson, 2012), while the integration with Cognitive Behaviour Therapy (CBT) is frequently referred in several articles. The concept of CBT believes that developments of psychological disorders result from maladaptive thoughts, feelings and behaviour, hence, the symptoms can be reduced by developing consumers’ coping skills and altering interpretations of information (Tiller, 2013). In other words, CBT focuses on facilitating consumers to recognise, challenge and change their negative thoughts and further utilised their resources, such as coping skills or personal strength, to improve their mental disorders. Besides, the altering of interpretations was considered to be an effective way to improve emotion regulation, which was one of the dominant goals for consumers with depression or anxiety disorders (Aalbers, et al., 2019). This approach was commonly adapted with GMT due to the optimization of personal resources and immediate effectiveness (Gutiérrez & Camarena, 2015). The combination of MT and CBT usually applied in activities relying on verbal reflection, for instance, songwriting activity. In Stige’s study (Solli, Rolvsjord, & Borg, 2013), verbal reflection after listening to the music can stimulate consumers’ awareness of emotions, while therapeutic counselling skills can facilitate patients to express their feelings. Besides, those reflection evoked by musical experience can be correlated to emotion regulation and depression symptoms in daily life (Aalbers, et al., 2019).
However, verbal psychotherapy might be insufficient since some individuals may find it distressing or intrusive (Slootsky, et al., 2016). Therefore, researchers also emphasized the non-verbal component of music therapy, for instance, playing musical instruments as an alternative way to express feelings. On the other hand, the musical elements, pulse, phrases or dynamics, were related to emotions and could be used to communicate with consumers. For example, therapists might reinforce an implied direction to attune consumers’ melodic fragment or playing a counter melody as responses to consumers’ improvised thoughts (Maratos, Crawford, & Procter, 2011).
Hence, the integrative treatment of CBT and MT in mental health may focus on assisting consumers to utilize their resources to overcome current mental illness via verbal or non-verbal approaches.
Music therapy can be conducted in various form depending on consumers’ individual need. To establish a comprehensive framework, this paragraph will examine the outcomes of four major approaches, receptive, re-creative, improvisational and compositional, being used in psychiatry.
Receptive Music listening
This form of intervention involves listening to pre-recording or live-performing music by the therapist and verbal reflection with participants after listening activity. A study with adults on a hospital neuroscience unit found that consumers were more likely to select receptive music listening rather than active music therapy, either singing or improvisation, due to not feeling comfortable playing the instrument (Rebecca & Michael, 2020). However, fewer researches adapted receptive music listening as domestic intervention. From neurological aspects, Legge (2015) suggested that music listening can induce emotions and allow consumers to explore different feelings. According to his research, autobiographically relevant music can activate left-hemispheric sites of the human brain which were related to long-term memories, while different musical stimuli may evoke various emotion responses, for instance, dissonant sounds may result in activation of the amygdala, a part of brain region used to process fear. Another study at a psychiatric hospital demonstrated that consumers with schizophrenia showed a significant improvement of depression symptoms after receiving musical interventions, involving listening to familiar music and group reflection, compared to the controls (Lu, et al., 2013). However, the study also indicated that the improvement of the intervention group was declaimed after three months.
This form of intervention involves vocal or instrumental ensembles using pre-composed music and often along with verbal reflection regarding lyrics or melody. Although withdrawal and isolation from others are frequently experienced by clients with depression or anxiety, self-disclosure or self-exploration at the early treatment stage might be too exposed for consumers (Jackson, 2012). Whereas engaging in music ensembles allow consumers to connect with others in a non-threatening environment. On the other hand, playing musical instruments involve physical movement which correlates highly with the alleviation of depression (Maratos, Crawford, & Procter, 2011).
The choice of the song was usually advised by participants. A study conducted by Silverman suggested that the meaning behind song choice may have potential to achieve multiple goals (Silverman & Marcionetti, Immediate effects of a single music therapy intervention with persons who are severely mentally ill, 2004). For instance, consumers may select a song related to a positive experience which might be their resources to cope with difficult feelings. Through the discussion after playing the song, the result possibly facilitates consumers to build their insight and further understanding of their mental illness.
Improvisation could be implemented with vocal or either tuned or untuned instrument. Jackson (2012) stated that consumers with symptoms of depression or anxiety often claimed they stuck in a certain mood state. To address the needs, therapeutical improvisation is used to mobilize affect by creating music to stimulate a variety of emotional expression. Another study demonstrated the use of verbal reflection during and after improvisations can facilitate clients to build insight of emotional patterns (Aalbers, et al., 2019). On the other hand, some literature stated the benefits provided by the non-verbal component of improvisation (Aalbers, et al., 2019; Erkkila, et al., 2011; Jackson, 2012). For instance, the musical elements, pause, phrases or counter melody, can form a conversation between therapist and clients and possibly build a positive relationship among participants. Furthermore, it allowed consumers, who tend to avoid verbal communication, to express their feelings in an unthreatening way.
The creation of original music and lyrics can support consumers to explore their experience and emotions, while the final composition can be recorded or performed repeatedly by participants (Windle, Hickling, Jayacodi, & Carr, 2020). Furthermore, discussion with peers can inspire other coping skills to overcome difficulties in their lives. In other words, the process of songwriting involves self-expression, social skills, building resources and problem-solving, besides, the topics of the song are highly adaptable to consumers’ need.
A result of short-term group intervention in psychiatry demonstrated a significant improvement regarding symptoms of depression and anxiety after songwriting intervention (Windle, Hickling, Jayacodi, & Carr, 2020). According to the same research, consumers described their enjoyment to express themselves in a safe environment and the process of songwriting rebuilt their connections with others. However, consumers also revealed feeling lost which might result from the high intensity of the short-term intervention, when the group was terminated.
On the other hand, there were fewer researches focused on compositional intervention in a group setting. Songwriting activity often required a longer period for participants to discuss and integrate ideas whereas group members in psychiatry can be highly floating due to different length of stay or other medical situations.
Results and Suggestions
To conclude, instead of eliminating symptoms, music therapy for consumers with depression or anxiety mainly targeted at emotional aspect, such as emotion regulation or coping with difficult feelings. Additionally, music intervention implemented in group setting can facilitate to rebuild positive relationship with others. The benefit of group music intervention may vary depending on the level of group cohesion. However, due to the high mobility of group members in psychiatry, research on maintaining group cohesion for each session in this environment is needed.
On the other hand, since the result of this literature review demonstrated that music intervention in psychiatry often contains a great amount of verbal reflection, the intergration with cognitive behaviour therapy can facilitate consumers to alter maladaptive thoughts and further finding different ways to cope with different feelings. Besides, the non-verbal components of music therapy allow consumers to express themselves in different ways if they refused to express verbally.
Finally, in terms of the form of interventions, although Rebecca and Michael (2020) reported consumers preferred to choose receptive music listening rather than active music making, most literature focused on the outcome of active music approaches including songwriting, vocal and instrumental ensembles. However, one of the study also indicated that the improvement of symptoms decreased after the termination of receptive music intervention (Lu, et al., 2013). Overall, the result shows that the collaboration of different forms of intervention to address individuals’ needs and maintain the efficiency is necessary.