Research on music therapy and mental healthcare

Mental healthcare is a large and complex area of practice. In mental health institutions we find service users with a great variety of diagnoses and symptoms, and I will not go into all facets of mental healthcare. Rather, I will pay attention towards some areas that are particularly relevant for compulsory mental healthcare. As we have seen in chapter 3, there are some diagnoses that predict the use of compulsory treatment and coercive means more than others, such as affective disorders and illnesses in the spectrum of psychoses (Færden, 2001; Knutzen et al., 2011; Myklebust et al., 2012).

In addition, coercion correlates with longer treatment periods and admissions (Furre et al., 2014; Knutzen et al., 2014, p. 714; Knutzen et al., 2011), which are often true for people diagnosed with affective- and schizophrenia-like illnesses. Thus, a fair share of the literature outlined in the following section targets music therapy for people with psychotic and affective illnesses.

49  The original report has not been published, according to an E-mail correspondence with the author himself. Extracts from the report, including the questions posed regarding music therapy, are available online as part of a Power Point-presentation from the author: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&-source=web&cd=1&ved=0ahUKEwi1kKCD7uXXAhXhK5oKHbe3BlEQFggzMAA&url=https%3A%2F%2Fwww.

napha.no%2Fattachment.ap%3Fid%3D1101&usg=AOvVaw0hHnLCVOZipvNESoqHLoMF (retrieved April 12^th 2019).

In the following I will portray some of the research literature about music therapy within mental healthcare, both quantitative and qualitative. This is not meant to be a full investigation of the literature on the field; rather I will outline some perspectives relevant for this study, based on the literature I have encountered.

4.2.1 Effect studies on music therapy and mental healthcare

Some studies have been performed on the effects of music therapy that have seemingly had a certain impact on the status of music therapy in Norwegian mental healthcare.

Some of the results from these works have been much cited in the meta-literature.

Music therapy for people with schizophrenia and schizophrenia-like disorders

A meta-study from the Cochrane Database points at positive outcomes from music therapy for people with schizophrenia and schizophrenia-like disorders (Geretsegger et al., 2017); 18 studies met the inclusion criteria, with a total of 1215 participants. The studies investigated vary in quality, providing overall moderate- to low-quality evidence, with a variation between seven and 240 sessions of music therapy. The authors still conclude that the numbers speak well for the different effects of music therapy:

There is evidence that music therapy, as an addition to standard care, can help people with schizophrenia improve their global state, mental state (general negative, depressive and anxiety symptoms), functioning (general and social), and quality of life over the short to medium term. Music therapy seems to address especially motivational, emotional and relational aspects, and helps patients improve regarding their social activities and roles. (Geretsegger et al., 2017, p. 25)

The results, however, show some inconsistencies across studies, and the effects of music therapy seem to depend on the number of sessions and on the quality of the therapy (Geretsegger et al., 2017). Even though the latest version of this review takes into account 115 studies, there is still a need for high quality research, especially regarding long-term effects of music therapy, and regarding the necessary amount of sessions needed for beneficial outcomes (Geretsegger et al., 2017).

Carr, Odell-Miller and Priebe (2013) investigated the literature on music therapy in regards to acute psychiatric care in general; they found several studies that pointed at positive effects in various ways, but conclude that these studies suffer to methodological

challenges and small samples. More high quality research is needed to learn more about the potential effects of music therapy in acute psychiatric settings.

Music therapy for service users with affective disorders

Also the research on music therapy and depression was investigated in a meta-study in 2008 (Maratos, Gold, Wang & Crawford, 2008). However, too few randomised controlled studies had then been performed in order to draw strong conclusions. In November 2017, a new meta-study was published, which included nine studies with a total of 421 participants (Aalbers et al., 2017). The latter study points at short-term beneficial effect regarding music therapy for people with depression. In addition, music therapy may reduce symptoms of anxiety, and enhance functioning in people with depressive symptoms.

Not much research has seemingly targeted long-term effects of music therapy (Maratos et al., 2008; Aalbers et al., 2017), but at least one randomised controlled study speaks well for music therapy on a three-month follow-up (Erkkilä et al., 2011). Although the numbers were not statistically significant on the six-months follow-up, these numbers do show a clear advantage for the people who had previously participated in individual music therapy.

Music therapy for people with low motivation for treatment

Regardless of diagnoses, or other mental health challenges, Gold et al. (2013) performed a study targeting people with low motivation for treatment. The authors found that music therapy together with standard healthcare is more effective than usual care alone, regarding negative symptoms, functioning, clinical global impressions, social avoidance, and vitality. In addition, music therapy participation may be linked to moderate effects on motivation for treatment.

Through a postmodernist perspective, as well as through a humanistic view on health, I find it meaningful to look at general challenges for people within mental healthcare, rather than classifying or researching people based on specific diagnoses attributed by expert opinions. In addition, low motivation for treatment is a difficult variable that often makes it hard to engage in activities, to partake in the recovery process, and to maintain fruitful relationships with health professionals (Gold et al., 2013). As Gold et al. (2013) point out, diagnosis is not usually the most used criterion for referring service users to a music therapist; low motivation for treatment is perhaps a more frequently used reason for offering music therapy. Accordingly, low motivation for treatment might be

an especially important area of investigation, and a critical issue that music therapists should pay attention to.

4.2.2 The user perspectives on music therapy in mental healthcare According to Solli and Rolvsjord (2014) not many studies target the user perspectives on music therapy within mental healthcare. Some studies are performed though, and I will in the following describe some of the knowledge that I find relevant for this study.

Music helps in various ways

Through his investigation of user experiences for service users receiving music therapy in an adult psychiatry unit, Ansdell (2010) reminds us that the benefits of music therapy can target in a broader manner than measurable symptomatic changes: The joy of par-ticipating in music therapy can occupy the participant and keep the mind off the illness, and sometimes the participants feel that music therapy helps, even though it is hard to explain how (Ansdell & Meehan, 2010). In addition, music therapy can be something that affects the whole experience of living with mental illnesses, such as general moods, concentration, experienced isolation, and low confidence:

Yeah, I never feel worse coming out of here. I might feel the same, but usually I feel better… At best I feel my mood has changed completely, and I’d feel a bit more relaxed and less isolated… [L]. (Ansdell & Meehan, 2010, p. 34)

Participation in music therapy is also said to work as a stress releaser, and for some people music therapy may help to concentrate and to clarify goals and wishes (MacDonald, 2015).

Music therapy can be motivating

Music therapy participation, and even the thought of music therapy, can motivate service users; when having a bad day the expectations and hope of positive or joyful outcomes can revive sparks of engagement:

You know, they say music soothes the savage soul, but also, it can also ignite it too, you know, because every day is not a good day, but every day isn’t a bad day either. But on that bad day, you look forward to things like music therapy.

I might just need those instruments to shake, shake it out, shake the anger out, you know. [Frank] (MacDonald, 2015, p. 6)

Also Ansdell and Meehan (2010) found that music therapy have the potential to engage participants who are regarded as ‘isolated, treatment-resistant, and difficult to access therapeutically through verbal insight-oriented approaches’ (2010, p. 31).

In a study by Silverman (2006) the participants reported that music therapy was regarded as more helpful than other treatments and psycho-educative approaches. Also more than half of the participants (N=73) named music therapy as their favourite class/therapy:

[…] music therapy appeared to be the dominant class/therapy. It was consis-tently ranked higher than any other offered class/therapy despite what the-rapeutic aspect of patient treatment was being evaluated. Music therapy was rated as the most relaxing, fun, and motivating program offered. Participants also rated it higher than other programming for increasing communication, self-esteem, anger management, mood, and self-expression. Additionally, 57%

of participants rated music therapy as their favorite group and 54% notet they felt most comfortable in music therapy. (Silverman, 2006, p. 120)

Solli and Rolvsjord (2014) also mention that certain people are more motivated for attending music therapy than other treatments. For some, music therapy is the only thing to look forward to during the week within the hospital walls, and people wish they had more than only one music therapy session a week.

Service users’ relationships with music

Music therapy resonates well with music therapy participants’ previous relationships with music, and their previous experiences of the relationship between music and health (Ansdell & Meehan, 2010). Music holds and intrinsic value of experienced meaningful-ness, and music therapy participants highlight this perspective in research on music therapy within mental healthcare (MacDonald, 2015). Service users’ relationships with music might be a relevant part of their motivation to participate in music therapy; they like music and are familiar with the roles that music can have in their life, and for their experienced health.

Music therapy may provide a sense of freedom

Solli and Rolvsjord (2014) mention explicitly that eight out of nine research participants were treated compulsorily in their study on user experiences of music therapy for people with psychoses, making their study directly relevant for my own research. They found four key themes emerging from interviews with the research participants: Freedom, Contact, Well-being, and Symptom relief. The research participants speak of experienced

enjoyment, satisfaction, mastery, hope and motivation through music therapy. They also state that music therapy enables an extended contact with oneself, with emotions, and with other people. An important aspect as regards this study, I believe, is the key theme of freedom: music therapy enables a time and place away from illness, from the everyday life within mental health treatment, and from the stigmas that follow people with mental health challenges:

I think I got to express some thoughts and stuff without necessarily having someone trying to fix it. Just see how it is…(…) Often when someone talks…

or if I say something… almost always someone will suggest what I should do with it, or give me extra pills, or whatever… Whereas when we made up [a]

song, then it wasn’t… there wasn’t any answer… it was just a sort of expression.

(P2) (Solli & Rolvsjord, 2014, p. 9)

Other participants in music therapy seem to appreciate the openness within music therapy improvisations, and the ability to create music without moral restrictions or aesthetic boundaries:

I think it’s the freedom to play… whatever. What I’ve enjoyed the most is being able to improvise… there’s no structure… you can just play freely and build up from there… which has been good fun... and the freedom of doing that’s been great… not to feel restricted. [D] (Ansdell & Meehan, 2010, p. 33)

The latter study also found that service users seem to experience equality between the participant and the therapist within the musical companionship (Ansdell & Meehan, 2010). One could question if this makes it easier to pay less attention to social and musical norms within the music activities. MacDonald (2015) found that expression through music therapy activities for people within adult psychiatric care help to clarify such feelings and their relationships to the experienced life.

Especially for service users within compulsory mental healthcare, it is essential to offer activities that afford free and creative expression. For people treated through coercive measures, and perhaps even for people treated voluntarily within the locked ward, there are already many restrictions for what people are allowed to do, where they are allowed to be, and what they are allowed to say. It makes sense that people appreciate such free engagements with music.

Even though not entirely related to the field of mental healthcare, I find it relevant to mention an article by Tuastad and O’Grady (2013), in which the authors discuss music therapy as a freedom practice for people in correctional services. They argue

that engagement with music can facilitate for freedom in two ways: 1) ‘escaping reality’, which points at the ‘free space in an authoritative, suppressing and institutionalized environment‘ (Tuastad & O’Grady, 2013, p. 210), and 2) ‘entering reality’, which refers to the process towards a normal life, and the sense of becoming humanized, and re-connected with an emotional life.

Music therapy and the participants’ resources

In a qualitative study about user experiences, Randi Rolvsjord (2015) demonstrates that she does not only write about recovery- and resource- orientations, she also performs these mind-sets throughout her research; instead of interviewing the clients as passive receivers of therapy, she investigates what the participants do themselves to make music therapy work. Rolvsjord identified four main themes regarding the engagement and agency of the participants: taking initiatives, exerting control in sessions, commitment to the relationship, and engagement across contexts. Several of the participants took the initiative to engage in music therapy in the first place, and a recurring topic was the effort given to actually attending the appointments when having a bad day. In general the participants tended to give of themselves, contributing in the musical activities, and to committing to the therapeutic relationships and the music therapy processes.

Based on a structured literature review on music therapy within acute psychiatric settings, Carr et al. (2013) support a resource-oriented approach to music therapy, as they conclude that: ‘[…] an emphasis on building a therapeutic relationship and building patient resources may be of particular importance‘ (Carr et al., 2013, p. 17).

The attention towards the participants’ resources seems to be important for under-standing music therapy processes in mental healthcare. The focus on the participant engagement reminds us that music therapy is not something that can be applied to anyone, and be expected to merely work on its own. According to the citation below by DeNora and Ansdell (2014), in might argue that music therapy works because of the engagement and the different activities music affords, as a social and cultural form of art, and as a way to facilitate togetherness:

In all cases it is not the music per se that accomplishes this enhancement but rather what is done with, done to, and done alongside musical engagement.

It is music plus people plus practices plus other resources that can make a change for the better. In a sense then, music can do nothing and everything.

Its potential to promote flourishing, even in extremis, is simply waiting to be tapped. (discussion)