Introduction
Research focusing on the use of music as a serious treatment delivery tool for mental illness is currently underdeveloped, although the potential for positive effect is considerable (Maratos et al., Reference Maratos, Gold, Wang and Crawford2008; Mössler et al., Reference Mössler, Chen, Heldal and Gold2011). Among its many unique attributes, music can be viewed as an ideal medium for providing psychotherapeutic material due to its enjoyability, its flexibility as a metaphor for psycho-education, and its potential for creating a common language between therapeutic group members. Maratos et al. (Reference Maratos, Crawford and Procter2011) aptly describe the state of research involving music in a mental health context with the title of their paper, ‘Music therapy for depression: It seems to work, but how?’. It may be that associating a pleasurable activity like music with psychotherapy is a way to maximize treatment efficacy. Castillo-Pérez et al. (Reference Castillo-Pérez, Gómez-Pérez, Velasco, Pérez-Campos and Mayoral2010) conducted a randomized control study identifying that a receptive use of music therapy resulted in a greater reduction of symptoms of depression in clients with low and medium grade depression compared with clients in psychotherapy, although both groups showed positive results. Maratos et al. (Reference Maratos, Gold, Wang and Crawford2008) completed a systematic review of randomized trials targeting symptoms of depression with music therapy. In the review, the authors outlined the difference between ‘active’ and ‘receptive’ forms of music therapy. Active approaches utilize improvisational techniques in which both therapist and patient play musical instruments to work on songs or musical phrases that provide insight into relational or emotional problems identified by the patient, and receptive approaches to music therapy consist of patients listening to ‘different types of musical stimulus to directly induce physical and emotional changes’. Despite a wide variance of the interventions used, populations studied, and outcome measures tested, it was concluded that using music in therapy is accepted by individuals with depression and is associated with improvements in mood (Maratos et al., Reference Maratos, Gold, Wang and Crawford2008). There is a need to develop interventions that use music as a medium in which to deliver evidence-based psychotherapeutic treatments.
Cognitive behavioural therapy (CBT) has been established as an effective form of psychotherapy in the treatment of depression, anxiety and psychosis with a solid foundation of evidence (Butler et al., Reference Butler, Chapman, Forman and Beck2006). The national guidelines in the United Kingdom, USA, Australia, New Zealand and Canada recommend CBT for a variety of emotional and mental health problems, including depression and anxiety (APA, 2010; NICE, 2016; Parikh et al., Reference Parikh, Segal, Grigoriadis, Ravindran, Kennedy, Lam and Patten2009; RANZCP, 2004). There exist some obstacles to providing CBT. Even when CBT can be provided, clients might have to wait for a long time to access treatment, engagement might be poor and beneficial effects may only be seen after numerous sessions (Bennett-Levy et al., Reference Bennett-Levy, Richards, Farrand, Christensen, Griffiths and Kavanagh2010). Currently, there is a trend towards providing CBT in low-intensity form to address some of the above concerns (Naeem et al., Reference Naeem, Johal, McKenna, Calancie, Munshi and Hassan2017).
The effectiveness and popularity of low-intensity CBT, which includes CBT-based self-help and guided self-help, has been well documented. It is broadly defined as a ‘. . . CBT intervention that aims to communicate key CBT principles in accessible ways, to deliver content in a variety of flexible forms, to focus on the use of CBT self-help materials and techniques, emphasizing the value of between-session homework, and to assess, monitor and evaluate progress as an intrinsic part of the intervention’ (Bennett-Levy et al., Reference Bennett-Levy, Richards, Farrand, Christensen, Griffiths and Kavanagh2010). Low-intensity CBT is ideal for delivery through a variety of media, which may include: paper, electronic or even music.
Researchers have previously identified the potential for positive outcomes through the combination of CBT and music interventions. Hakvoort and Bogaerts (Reference Hakvoort and Bogaerts2013) propose the use of cognitive behavioural-based music therapy in forensic psychiatry, noting that the use of music as a delivery medium ‘. . .could become a motivator, inspirer, reinforcement, or even “seducer” to psychotherapy’. Similarly, Dingle et al. (Reference Dingle, Dingle, Gleadhill and Baker2008) used music therapy as an adjunct to group CBT (in separate sessions) and found increased attendance and engagement for CBT.
Development of a low-intensity CBT-Music group
Development of a CBT-based music group can address the limitations of restricted access and poor engagement by using music as a delivery medium for CBT in a low-intensity group format. This therapy holds the potential to become an accessible, enjoyable and efficient therapy for the treatment of symptoms of severe mental illness. Music is conducive to the resource-saving group therapy format, it has the potential to introduce clients to CBT therapy concepts, and music may be able to sustain therapeutic engagement over and above the talking form of CBT. These hypotheses need to be tested with a standardized CBT-based music group protocol to identify the potential effects of low-intensity CBT being delivered through receptive musical activity (i.e. pre-written songs and musical activities). This is a novel treatment strategy.
The intervention was developed by C.T., R.T. and F.N. These authors met weekly for six months to develop the intervention. The intervention was based on low-intensity guided self-help CBT developed locally. Both C.T. and R.T. wrote songs and designed musical activities based on the subjects provided by F.N. During these meetings, further details of the group, such as frequency, number and format of the group were also agreed upon. The songs and activities focused on the following concepts: psycho-education, symptom management, changing negative thinking, behavioural activation, problem-solving, emotion regulation and learning breathing techniques. Each week of the intervention adhered to one of these topics, with a core CBT-based song performed as a group, and various musical activities, discussions and homework assignments reflecting the weekly theme. Each CBT-based song was adapted from a popular classic rock song with the original lyrics replaced with revised lyrics focused on principles of CBT derived from a CBT self-help manual developed locally.
We developed a low-intensity CBT-based music group to address symptoms of depression and anxiety. This paper describes feasibility testing of this innovative intervention.
Method
Trial design
This feasibility study was conducted using a randomized controlled clinical trial. This was a single-blind study.
Procedures
All participants were referred to the music group by mental health professionals at AMHS-KFLA and were initially seen by one of the facilitators for psychopathology, risks, and motivation to attend the group. The potential participants were given oral and written information about the study and written informed consent was sought. Consenting participants who met the inclusion criteria were randomly allocated to one arm of the trial. A blind rater interviewed participants at baseline and end of therapy. The raters were psychology graduates that had received training in the use of the scales used in this study. Assessors were blind to allocation and were based in a separate location.
Setting
Each low-intensity CBT-Music group was held at the H'Art Studio in Kingston, Ontario, Canada. The H'Art Studio is a non-profit arts centre for individuals with a disability. This setting was chosen as a location outside of existing community mental health services with the intent to foster an environment for creativity and the feeling of attending ‘band practice’ for participants.
Participants
Individuals invited to this study were attending community mental health services of AMHS-KFLA (Addiction & Mental Health Services – Kingston, Frontenac, Lennox & Addington) in Kingston, Ontario. The study was conducted from February 2014 to April 2015.
Participants were considered eligible for inclusion if the following criteria were met: (a) age 18–65 years; (b) living within travelling distance of the community mental health centre, as AMHS-KFLA covers a wide area; and (c) with a diagnosis of anxiety or depression according to the DSM-V. They were excluded if they had: (a) a co-morbid alcohol or substance dependence; (b) significant cognitive impairment; (c) active symptoms of psychosis; (d) high levels of disturbed behaviour or high risk of suicide or homicide.
A total of 52 participants were referred (Fig. 1). Of those meeting the inclusion criteria (n = 32), only four refused to attend. The remaining participants (n = 28) were equally randomized (14 in each group) to the intervention arm [low-intensity CBT-Music plus treatment as usual (TAU)] or the control (TAU) arm. Each participant in the low-intensity CBT-Music plus TAU group received intervention over 9 weeks.
Figure 1. Consort flow diagram of the study
Randomization
Participants who consented to participate were randomly allocated to one of the groups: low-intensity CBT-Music plus TAU (treatment group) or TAU alone (control group). Randomization was performed using www.randomization.com. Participants were assessed at baseline, and 10 weeks after baseline. At the follow-up appointment each assessment was re-administered. Research assistants, blinded to treatment allocation, carried out the assessments.
Outcome measures
Assessment of feasibility
Feasibility was assessed through recruitment, retention and informal feedback from participants and professionals. Participants at the end of the intervention were asked to describe their experience. They were also requested to name the sessions that they found the most helpful or unhelpful and suggestions to improve the intervention.
Assessment of clinical outcomes
Psychopathology was measured using the Hospital Anxiety and Depression Scale (HADS), and disability was measured using the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0). These scales were chosen for a high degree of inter-rater reliability, test validity, and open accessibility.
The HADS (Zigmond and Snaith, Reference Zigmond and Snaith1983) rating scale consists of fourteen items, equally divided into anxiety (HADS-A), and depression (HADS-D) items. The scale has been used internationally in many studies. Studies most commonly employ a cut-point of ≥8 for each of the constituent subscales, as suggested by its authors, to indicate probable cases.
The WHODAS 2.0 (Üstün et al., Reference Üstün, Chatterji, Kostanjsek, Rehm, Kennedy and Epping-Jordan2010) was developed by the World Health Organization to measure disability due to physical and psychological problems and has been used extensively in research settings.
The intervention
The low-intensity CBT-Music group is a 9-week guided self-help group used to provide CBT for individuals with symptoms of depression and anxiety. The intervention adheres to a traditional CBT group structure, including theme weeks (e.g. thinking, behavioural activation), use of behavioural experiments, thought records and providing homework at the conclusion of each session. There was additionally a focus on skill-building. The intervention consists of songs and musical activities based on CBT components from guided self-help material that had been tested locally for its effectiveness. This intervention aims to infuse music into nearly every aspect of CBT group therapy as a means for deeper understanding and engagement with the material.
A primary goal of the group was to promote the feeling of attending ‘band practice’, so the group was held in an arts-performance space in the community outside of mental health services. Even group guidelines adhered to the musical metaphor (e.g. ‘arrive on time for band practice’, ‘one solo at a time’ and ‘practice at home’). Participants were asked to participate in singing, playing instruments and even contribute to songwriting for the group. All the musical instruments were accessible to non-musicians, with no prior musical experience for participants necessary. A prior musical background was not necessary for group facilitators, although enthusiasm for playing music and some basic knowledge of guitar chords was helpful. Figure 2 gives an example of a song lyric used in the group.
Figure 2. ‘Your Beatin’ Heart’. A song on the connection between thoughts, emotions and physical reactions (to the tune of Hank Williams’ ‘Your Cheatin’ Heart’).
Some salient CBT adaptations that we incorporated into the music group were:
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• A fixed session group (nine sessions)
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• Each session followed the typical format of a CBT group, with review of homework (15 minutes) at the start of each session, CBT music adaptations (60 minutes) and feedback, and homework assignments (15 minutes) at the end.
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• Each week a CBT-based theme song was presented and a psycho-education hand-out was provided to the participants that described the same concept in details.
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• Re-writing popular song lyrics – lyrics for the core CBT songs, which describe the basic concepts of CBT for depression and anxiety, were adapted from popular songs. For example, ‘Your Beatin’ Heart’ (formerly ‘Your Cheatin’ Heart’ by Hank Williams) describes how thoughts and emotions share a close link to our physical state. ‘Eight Days a Week (of Problem Solving)’ (formerly ‘Eight Days a Week’ by The Beatles) describes the steps to effective problem-solving.
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• Analysing lyrics from popular songs for themes of CBT for depression and anxiety – for example, ‘Sittin’ on the Dock of the Bay’ by Otis Redding and ‘I Can See Clearly Now’ by Johnny Nash were both used as examples of songs with lyrical content that alludes to symptoms of depression and negative thinking patterns.
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• Thought records – for example, participants were asked to complete a ‘musical’ thought record for a homework assignment in which they rated their mood and anxiety levels and had the opportunity to prescribe themselves a song that may have a positive effect on their mood and/or anxiety. Figure 3 is an example of the musical thought record used in the intervention.
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• Behavioural experiments – for example, participants were asked to play a novel instrument, one they had never played before, in front of their peer group as part of exposure to an anxiety-provoking situation. They are supported by the facilitators and other group members playing guitar and shaker instruments. In this case, the novel instrument is a Moog Theremini that can be adjusted to only play notes that are in the key of C, so effectively, no wrong note can be played. They discuss their expectations and experience with the group.
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• CBT psycho-education music metaphors.
The five-piece band model – a link was drawn between the standard ‘four-piece rock band’ (i.e. guitar, drums, bass, vocals) playing a live show and the five-part model of CBT. For example, a scenario was presented where a guitarist of a fictional band is overwhelmed with negative thoughts regarding his/her romantic relationship during a concert and how this might affect the entire band's performance. This was used as a metaphor to describe how negative thoughts might have a negative effect on emotions, behaviours and physical reactions.
Musicalize your breathing – to demonstrate effective deep-breathing techniques, each participant was given a harmonica to help ‘musicalize’ the breathing process. Facilitators played a harmonica in certain ways to demonstrate the difference between shallow breaths and breathing from the diaphragm, with group members echoing the playing style. The aim was for group members to make a connection between the sound of the harmonica and techniques of deep-breathing. Group members were given the harmonicas to take home for practice.
Figure 3. An example of a ‘musical’ thought record
Facilitators
The group facilitators were authors C.T. and R.T., trained mental health crisis workers, each with more than five years of experience working in the Canadian mental health system. Both facilitators have experience playing in musical groups and have received specialized training in providing CBT in both group and individual formats. Author F.N. provided fidelity checks to song writing and musical adaptations of CBT material, and training in the use of low-intensity CBT with regular supervision.
The TAU
Local primary care services (AMHS-KFLA) provided treatment as usual. All participants received an initial assessment along with TAU. We obtained the details of any treatment received by each participant. Group facilitators delivering the intervention were not involved with the participants in an additional role outside of the music group. TAU normally involves case management with crisis support and prescription of medication via community mental health services.
Statistical methods
Analyses were carried out using SPSS v 22. SPSS frequency and descriptive commands were used to measure descriptive statistics. The SPSS explore command was used to measure normality of the data, using histograms and the Kolmogorov–Smirnov test. Comparisons between the two groups were made on an ITT (intention-to-treat) basis. Continuous variables (for example, the questionnaire scores at baseline) were compared using t-tests while categorical variables (for example, gender) were compared using χ-squared or Fisher's test. End of therapy scores on various outcome measures between the treatment and the control groups were compared using an analysis of covariance (ANCOVA) to adjust for baseline scores.
Results
Recruitment, retention and engagement
Recruitment to the intervention was successful. Of the 52 referrals initially received, 41 participants were reachable and were screened for suitability. Of these, 32 participants were considered suitable for the group. Four individuals were unable to participate (one was moving out of Kingston, another was unable to join because of work schedule, and two refused to attend). This amounts to a recruitment rate of 93.75%.
The CBT-Music group gained immense popularity with the group being run in other areas of local mental health services with very positive feedback. Other areas of the mental health system, notably Child and Adolescent Mental Health Services and the Early Intervention in Psychosis services, invited the group facilitators to run the CBT-Music groups in Kingston and the vicinity. The demand for the group is ongoing.
Retention to the intervention group was excellent, with only one drop out (92.85%). A drop-out criteria of six or fewer sessions was established. Engagement with the group was high, with one participant attending seven sessions, two attending eight sessions and 10 participants attending all nine sessions (76.92% of all the participants who completed therapy).
Treatment acceptability
The study received very positive feedback from almost all of the participants and their carers. Informal feedback from the participants and the professionals was positive; they described the intervention as acceptable and helpful. The authors (C.T. and R.T.) were invited to conduct similar groups in other community and hospital settings, which highlights the acceptability of the treatment.
Almost all of those who completed the study reported the intervention to be easy to understand and engaging. Of those who completed the intervention, participants (13/13) described the session on breathing to be the most helpful. Participants also found sessions on behavioural activation (11/13), thoughts (9/13), problem solving (8/13) and explanation of CBT (9/13) helpful.
Some examples of the positive feedback included: ‘music brought us together as a group’, ‘there was less of a medical focus with this group’, ‘I had heard about CBT, but didn't expect it to be so fun’, ‘music brings soul to the process of dealing with mental illness’, and ‘it gave me more options to cope’. One notable negative comment was: ‘I wish there were more sessions’. In terms of making suggestions for improving the intervention, two common themes emerged: suggestions for playing songs related to the participant's favourite genre of music and having recordings of the songs from the group available online for listening in between sessions.
Clinical outcome measures
Baseline demographics and clinical characteristics of the participating individuals are shown in Table 1. There were no statistical differences in any baseline values between the two groups. Table 2 illustrates the differences between the two groups at the end of the intervention and in comparison with baseline.
Table 1. Difference in demographic variables and psychopathology at baseline
Figures are: number (mean) SD for age and psychopathology, while the rest are: number (% age). *p: values using t-test for age and psychopathology, and χ-squared test for rest.
Table 2. Differences between the treatment (CBT-Music & TAU) and control (TAU) groups
Analyses were carried out using analysis of covariance. Reduction in scores means improvement. *p values using ANCOVA.
Discussion
To the best of our knowledge, there is no previously reported trial of a low-intensity CBT-based music group for depression and anxiety. The results demonstrate that CBT can be adapted to a musical context and that music can be used as a medium to deliver guided self-help for depression and anxiety. This low-intensity CBT-Music intervention proved to be feasible, acceptable and became very popular locally. There was also a reduction in disability. However, the results did not reach statistical significance in reduction of psychopathology. This might be due to the fact that the clients were attending secondary care and therefore had a higher level of severity of symptoms than would be expected to be addressed by a low-intensity intervention.
Low-intensity CBT-Music may be a positive step forward in improving access and availability for individuals with mental health problems to individual therapy in a stepped care model. Difficulties in overcoming barriers to accessibility and availability of CBT are numerous (Williams and Martinez, Reference Williams and Martinez2008). One way forward might be to promote low-intensity CBT. The most commonly used self-help material is delivered through paper or digital media. However, these might not be to everyone's taste, and therefore other media need to be assessed. Popular media like music and drama can be used to improve accessibility and availability.
Music is often described as a universal language, and it is rare to find a person who does not have a positive relationship with music in some manner. Despite a wide variety of recorded music and musical ability, there appears to be a basic level of innate musicianship and shared awareness of popular music in the general population that allows it to be an ideal medium through which to understand mental health and treatments.
The burden of common mental disorders (e.g. anxiety and depression) to society is immense and includes economic, social and human costs. These common mental disorders can be addressed through low-intensity CBT approaches and self-help. With this in mind, there is a need to employ population-based approaches to promote well-being. The major advantage of CBT-Music is its potential for reaching a wider range of the general population. This can not only deal with those with mild emotional and mental health difficulties but also target those at high risk of developing mental health problems.
There is evidence to suggest that music therapy can be effective in helping those with mental disorders (Maratos et al., Reference Maratos, Gold, Wang and Crawford2008). However, music therapy is currently not included in evidence-based guidelines. It is not just because of lack of robust evidence, but also due to a lack of theoretical underpinning of this therapy (Maratos et al., Reference Maratos, Crawford and Procter2011). We have suggested that it is important to attempt to discover the underlying therapeutic processes that heal emotions, as well as using music as a medium to deliver evidence-based and theory-driven interventions to help those with mental health issues (Naeem, Reference Naeem2016).
However, so far no attempts have been made to use music as a medium to deliver CBT. We believed that delivering CBT through music is achievable if the songwriters can write lyrics that convey the core concepts of self-help material in structured sessions. We therefore successfully wrote songs that are based on self-help material using CBT. These songs are then sung along with other activities in a music group setting. We believe this approach has not just helped in developing an intervention that is grounded in the theory that underpins evidence-based psychological interventions, but in its current manualized form is also repeatable and testable across situations.
This study opens a new avenue in delivering evidence-based therapy in a low-intensity format. If the larger randomized controlled trials find this intervention to be effective, and if the rates of engagement remain high in future studies, we can offer CBT to a greater number of participants with common mental disorders.
Limitations and recommendations
Several study limitations are noteworthy. This was a small-scale study that focused on the feasibility of the intervention. Due to limited resources, we were not able to assess the detailed acceptability of the intervention using qualitative interviews. However, unstructured feedback was received throughout the study. No prior power calculations were conducted. Given this, future research may seek to test this intervention in larger, well-designed studies with long-term follow-up. Some clients might not find music engaging, and this needs to be explored in future trials. These future trials can also test whether this intervention can be delivered by different facilitators, and by comparing it with CBT in a group format. There is also a need to explore therapeutic processes and to engage clients to further improve the intervention through qualitative work.
Conclusions
This trial shows that it is feasible to offer a low-intensity CBT-based music group to participants who regularly attend community mental health services. Further studies are needed to generalize these findings.
Acknowledgements
We acknowledge the support of staff at AMHS-KFLA, Kingston, Ontario, Canada. We are also grateful to all the clients who participated in this study.
Funding: None
Conflicts of interest: C.T., R.T., J.P., C.M. and F.N. have no conflicts of interest with respect to this publication.
Ethical approval: The study was approved by the Queen's University Ethics Review Board (no. PSIY-434-14) and was conducted in compliance with the Declaration of Helsinki. In addition, the authors abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the American Psychological Association (APA).
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