The Effects of Group Musical Activity on Psychiatric Patients in India

By Katrina Rumball

Acknowledgements

I would like to thank the staff and clients of Antara hospital, West Bengal, for letting me conduct the research, with particular thanks to those staff and clients who participated. I would also like to thank A.I., the session leader, for speaking with me and letting me observe the sessions.

Thanks should also be given to Minds for Health, a UK based charity that supports the hospital, for providing me with a voluntary placement within the hospital.

Transcript coding system for references

The coding system used for quotes includes the participant code, the page number of the relevant transcript and the question number (if relevant). For example ‘PC9, p.3, q.b’ for participant client 9, page three of that client’s transcript, and question b, or coding beginning with ‘PS’ stands for participant staff, and ‘SL’ for session leader).

Introduction

This study explores the effects of singing workshops in persons with mental illness in long-stay wards within a psychiatric hospital. Differences between certain variables will be compared both during and following the sessions. Short-term implications of the singing workshop will be focused on, similar to most of the literature. The researcher hopes to bring an alternative cultural perspective to the typical research within the field, by the study being conducted within a Non-Government Organisation hospital in rural West Bengal, India. It is hoped that this will strengthen research within music therapy by drawing on a wider pool of participants with different cultural influences both socially and musically.

Although the sessions examined are not formally described as ‘music therapy’ most of the research considered within the literature review will focus on music therapy. The American Music Therapy Association’s (AMTA) (2004) current definition states that music therapy must be conducted by a trained music therapist, which the sessions examined within this study are not, thus they cannot be referred to as music therapy. However, examining various definitions of music therapy, the sessions conducted within this study are certainly encompassed by many definitions of the field, such as Bruscia’s (1989) definition:

“Music therapy is an interpersonal process wherein musical experiences are used to improve, maintain, or restore the well-being of the client . . . and to help clients find the resources needed to resolve problems and increase their potential for wellness.” (Bruscia, 1989, as cited in Camilleri, 2000, p.184)

Elaborating on this the AMTA describes how music therapy interventions can vary in design in order to either promote wellness, manage stress, alleviate pain, express feelings, enhance memory, improve communication, and promote physical rehabilitation (AMTA, n.d). However, in accordance with the AMTA definition, the sessions within this study will be referred to as ‘singing workshops’.

Many of the clients attending the sessions frequently commented on the contribution of the sessions to their lives. One client (A.I.) spoke very passionately about the sessions (in good English) and provided her definition: “[It] is a kind of emotional feeling. There are so many things we do in our daily lives to make our lives richer, but particularly when we sing Tagore[1]’s songs, or any of our favourite songs, it brings out the beauty in one’s inner being.” (PC1, p.5).

Theoretical Background

Music within a psychiatric setting

Music has various applications within a psychiatric setting, for example in background music, group singing sessions, music to accompany dance or music therapy. Within each of these areas, different studies argue numerous benefits of the application of music as a therapeutic treatment. One such study, by Degmečić et al. (2005), outlined various benefits that music therapy interventions can potentially provide. These benefits include some of those to be examined within this research, including the ability to make positive changes in mood and emotional states, to improve concentration and attention span, the exploration of personal feelings such as self-esteem or personal insight, and to interact socially with others. Other benefits that Degmečić et al. (2005) outlined were gaining a sense of control over life through successful experiences, enhancing awareness of the self and the environment, expressing oneself, developing coping and relaxation skills, and adopting positive forms of behaviour.

The effects music can have on depression is another well-researched area, with almost all published studies finding beneficial effects. Hsu and Lai (2004) assessed the effectiveness of soft music for treatment of major depressive disorder using Zung’s (1965) self-administered depression scale (Zung, 1965, as cited by Hsu and Lai, 2004). Participants were placed either in a group which listened to a tape of their preferred music out of a choice of six ‘soft-musics’, for 30 minutes or in the control group which had bed rest for 30 minutes (consequences of bed rest as the control, as opposed to another type of therapy or activity, is something to consider within this study). They found significantly better depressive scores in the music group cumulatively at each week interval, for pervasive affective disturbances, physiological disturbances, psychological disturbances and psychomotor disturbances. It can thus be concluded that this study found some excellent benefits of music therapy with depressed patients. Choi et al. (2008) found that after fifteen sessions of a music intervention, compared to a control group, participants receiving the music intervention significantly improved in depression and anxiety scores. Examples of other research that has found music to have beneficial effects on depression includes studies by Hanser and Thompson (1994) and Lai (1999). From a slightly different research angle, in Mitchell et al.’s (2007) study of pain perception and music, 15.8% of participants rated improvement in depression as a reason for how music helps with their pain.

There is also a depth of research exploring the effect of music with schizophrenic patients. Much of this research focuses on negative symptoms. This works conveniently as it is usually the negative symptoms that are more resistant to antipsychotic drugs than are positive symptoms (Keefe et al, 1999). Thus, progress in psychological and vocational therapies, such as music therapy, focused on negative symptoms is greatly beneficial. Ulrich et al. (2007) studied 21 schizophrenic patients receiving group music therapy, alongside a control group (n=16). Within the patient’s self-evaluations they found that musical activity diminishes negative symptoms, alongside improvements in psychosocial orientation, however, no significant improvement in quality of life was found. They concluded music therapy is particularly effective for patients in whom negative symptoms are more prominent. They argue these effects may assist patient’s abilities to integrate back into the community, although presumably only if they remain receiving music therapy (studies generally show affects to be short lived, e.g. Hayashi et al. 2002).

Similarly, Yang et al. (1998) studied schizophrenic patients by comparing a group-receiving individual and group music therapy for three months against a control group, focusing on music appreciation, performance and learning musicology, alongside a control group (both groups still received anti-psychotic medication). They found significant improvements in the experimental group for negative symptoms of sluggishness, blunted effect and poverty of thought (Yang et al., 1998, as cited by Ulrich et al., 2007). They also found a significant reduction in the severity of psychiatric disability three months following therapy. They also had significantly lower scores in emotional withdrawal, conceptual disorganisation, hallucination behaviour and unusual thought content.

Further support comes from Tang et al. (1994) who found chorus sessions to reduce negative symptoms and some interpersonal aspects of social disability. Also, Talwar et al. (2006) found that a group receiving 12 weeks of music therapy, focusing on improvised music, had significantly improved symptom scores in the PANSS Positive and Negative Syndrome Scale (Kay et al., 1987), compared to a control group. However, they did outline that baseline characteristics may have been the cause for the differences. As with the evidence supporting improvements in depressed patients, there is clear support for improvements in schizophrenic clients. It seems likely that this will be most apparent in negative symptoms.

De l’Etoile (2002) describes three factors that should be investigated when determining the effectiveness of therapy: psychiatric symptoms should be reduced, therapy should be perceived as helpful, and the likelihood of clients remaining in or returning to therapy should increase. Within a psychiatric group of participants their symptoms were found to be reduced between testings one and two; such symptoms found to improve were hostility, paranoid ideation, obsessive-compulsive, interpersonal sensitivity, anxiety and phobic anxiety. Changes were not significant (although did decrease) between testings two and three. She also found that eight out of ten curative factors increased (although not significantly), these were cohesion, altruism, guidance, vicarious learning or identification, self-understanding or insight, interpersonal learning, self-disclose, and catharsis. She concluded that music therapy with psychiatric patients was most affective in reducing anxiety related symptoms. It is important to consider when looking at the improvements made by the group of clients in this study that they are all long-stay patients and thus are likely to have been resistant to previous interventions. For this reason, many researchers, such as Degmečić et al. (2005), argue that research findings and clinical experiences attest to the viability of music therapy even in those who have been resistive to other treatment approaches. Consequently, it seems that the effects of music as a therapeutic tool should be explored, arguably particularly so within resource poor areas in which treatment for mental health may not have the financial freedom to encompass the various methods available for treatment for long-term patients.

Mental Health in India

Within the Sundarban region of West Bengal, close to the hospital within this study, the literacy level and the per capita income is far lower than the State average, with 42.5% of families subsisting on earnings below the poverty line (De, 1994, as cited in Chowdhury et al. 2001). Until recently, this rural region had no designated mental health services or community health programme (Chowdhury et al. 2001). The poverty, illiteracy and cultural ideas about mental illness, within the context of the available services within the area, influence the local population’s help-seeking behaviour. This means that, currently, many people still depend on local and traditional means of healing for all of their health problems, including mental health (Chowdhury et al. 2001).

Evidently, India’s mental health system is not as widely available or advanced compared to those normally focused on by studies within the fields of mental health and music therapy. The prevalence of stigma within India, and many other developing nations, makes it even more important to bring cultural variation to research. Not only should research from different cultures increase validity by providing a wider pool of results, but it is important that the progress within Western mental health and associated research can be applied to those with fewer facilities.

India’s Music Therapy Status

India has used the arts therapeutically for thousands of years, for example in Ayurveda and Yoga systems, and these traditional systems of healing also include various musical treatment approaches (Sundar, 2007). “[The] Indian system of music is an individualistic, subjective, and spiritual art, aiming not at symphonic elaborations but at personal harmony with one’s own being” (Sairam, 2006a, p.876). Compared to music therapy in Western countries, which is formerly more advanced and has its theoretical background predominantly based on psychotherapy, a largely Western concept, one of the key factors involved in Indian music is the expression of devotional feelings (Sundar, 2006b). Indian music’s raga system, with its subtle microtones, embellishments and a predominantly melodic nature “produces sweet and soft impressions in the minds of listeners” (Sundar, 2006a, p. 9). However, despite its strong ties to tradition, at present, music therapy is only in the early stages of development within India (Sundar, 2006b).

At the forefront of developing music therapy within India is the Nada Centre for Music Therapy, based in Chennai, a small and relatively new organization, with its first conference held in 2006. The centre works to increase use and awareness of Indian healing traditions, including music, and examines these traditions and their development through research. Additionally it has a specific focus on utilising music therapy to alleviate the stress of modern day life and promoting an integrative approach to health. (Sundar and Sairam, 2006). Other aims of the centre include evolving ‘appropriate’ music that is tailor-made to individuals, undertake comprehensive training programmes for music therapists and for targeting specific populations such as pregnant women and to produce recordings with therapeutic effects (Sundar, 2005). Encompassing these aims, the centre wishes to simultaneously meet international standards while honouring the uniqueness of the healing traditions of Indian music (Sundar, 2006c).

The ‘raga-based approach’ currently used within India involves application of musical pieces focusing on swara patterns (characteristic motifs of the certain raga, swaras being the seven notes of the scale), embellishments and appropriate rhythms and tempos. This approach can then be adapted to meet the clients need, such as to be stimulating, anxiolytic, sedative or to increase attention, and additionally the approach is able to consider factors such as musical preference and listening pattern (Sundar, 2007). Despite the many unique aspects of Indian music therapy and its rich influence from long-standing traditions, it may still learn from Western practice and theories since Western music therapy has been in development for over fifty years (Sundar, 2006c). Sundar’s (2007) article on traditional healing systems and modern music therapy in India, concluded that, being an emerging discipline, there is great scope for further study in music therapy within an Indian context.

India’s Music Therapy Research in Mental Health Facilitie

Due to the infancy of music therapy in India, there have been few research articles examining its effects within psychiatric setting. One study that did examine a group diagnosed with a psychiatric disorder was by Deshmukh et al. (2009) who studied fifty individuals diagnosed with Major Depressive Disorder, one group received music with selected raagas, while the other group was treated with hypnotic medications for a month. The measurements on depressive symptoms and sleep quality improved with the music group comparable to the group receiving hypnotic medications. These effects also persisted beyond the treatment period so the researchers thus concluded that music is comparable to hypnotic medication in improving quality of sleep in depressed patients and can thus work effectively for persons with depression. Sairam (2006b) focused on designing music training methods for children with special needs. Children were prescribed three systems for treatment, firstly, music with rapid fire orchestral rhythms to increase participation and alertness and manage anger, second, music without rhythms to induce relaxation and thirdly, repeated rhythms to regulate the emotions.

As previously mentioned, there have been few research articles examining the effects of music within psychiatric settings in India thus far. However, there has been some research exploring its psychological effects with participants suffering from physical conditions (as opposed to persons with psychiatric diagnoses). Sundar (2006 1) found that seven music-listening sessions of Indian devotional songs, in conjunction with a counselling treatment reduced the level of state anxiety with a cancer patient. Other findings included improved mood, improved sleep, a feeling of being relaxed with a ‘clear mind’ and a reduction in pain, and each of these findings were in specific reference to the music (as opposed to the counselling). Harikumar et al. (2006) examined seventy-eight patients undergoing elective colonoscopy. Patients were randomised into one group which they were allowed to listen to music of their choice during the procedure or a control group. The group were allowed to choose from six types of music, popular film songs based on classical ragas, classical music, devotional songs, folk songs, soft instrumental music, and bioacoustics (a mixture of soft instrumental music and nature sounds).Participants in the group listening to music received significantly less midazolam (a short-acting sedative) and their discomfort score was significantly lower, although pain ratings between the two groups remained similar. One study, that unfortunately lacks a clinical setting (studying a group of post-graduate male students), but use of Indian music allows it to remain relevant, is by Gupta and Gupta (2005). In this study participants listened to one raga, played on the flute (without lyrics) for 30 minutes a day for 20 days. Following the treatment the participants had a significant decrease in the scores on depression, state and trait anxiety, compared to the pre-test measurements.

Due to this limited research base within India, when examining specific factors of improvement with the use of music as a therapeutic tool it is thus important to draw from a global research field.

Mood

Many researchers base the benefits of music therapy in emotional explanations. For example, researchers have suggested that arts therapies can access emotions by directly bypassing intellectual processes (Cardone et al, 1982, as cited by Goldberg et al, 1988). This idea has been supported by other research; “Music’s effectiveness in therapy appears to stem from its ability to influence feeling and thinking patterns; both necessary pre-requisites for eventual behaviour change.” (De l’Etoile, 2002, p.69). This application of music is an obvious benefit for many clinical groups, particularly depressed patients. Defined as “a temporary state of mind or feeling” (The Oxford Dictionary of English, n.d.), many people commonly acknowledge the affect of music on mood; for example, Mitchell et al. (2007) found that mood change was rated a mean of 5.0 out of 10 for reasons to listen to music (although it should be noted that this investigates purely mood change, not type of change in mood). There have also been biological explanations studied for perceived mood change, helping to provide more scientific evidence for other research claims, for example, Mockel et al. (1994) found music increased circulating endorphin level.

Many studies outline the importance of investigating the relationship between music and mood. It is argued that an emotional response to music can be expected once the musical experience has found meaning, through cognitive appraisal (De l’Etoile, 2002), and thus musical experiences can create certain moods, intensify current ones or shift one mood to an alternative. When De l’Etoile (2002) examined the effectiveness of group music psychotherapy for eight adults at a community mental health centre, it was recommended that the principle issue to be addressed was the reduction of psychiatric symptoms. More specifically, this can be applied to patients with psychotic symptoms, or depressive symptoms, for which mood improvement is viewed as a diagnostic improvement. Supporting this is Covington’s (2001) argument that, within a psychiatric setting, music can be beneficial in its use in modulating mood.

Many studies (normally with a smaller sample size) have focused on more specific elements of mood, for example, Magee and Davidson (2002) studied the effect of music therapy on mood states in a single-subject study of a patient with complex neuro-disabilities. For composed-anxious, energetic-tired and agreeable-hostile mood states there was a significant improvement pre and post music therapy.

Change in mood with music is certainly affected by other variables; there are two most obvious contributing factors; the type of music played and the mood prior to listening. Pignatiello et al. (1986) found music shifting from neutral to elating or neutral to depressing contributed to the induction of the corresponding mood. Similarly, Stratton and Zalanowski (1991) examined mood in participants who, whilst listening to music, which was happy, sad or neutral, were instructed to tell either a happy, sad or neutral story. They found mood to change consistently in accordance with the ‘feeling’ of the music with neutral story instructions, however happy and sad story telling masked any affect of the music.

Mood improvement can also be examined alongside other factors, such as pain. When Mitchell et al. (2007) studied 85 participants in how music helped their pain, 11.8% said they listened to music to improve/change mood and 19.3% of participants rated mood to be a reason in how music contributes to reduce pain. The effect of music on mood and pain has also been investigated in a sample of eight adult hospice patients diagnosed with cancer. Those who received music therapy via tape-recordings for forty-five minutes per day for five days had a positive increase in mood for fatigue, anxiety and energy (Longfield, 1995, as cited by Hilliard, 2005).

From the literature it appears the potential relationship between music and mood should be utilised within a psychiatric setting. Nielzen and Cesarec (1982) found that expressiveness within music was perceived in the same way in psychiatric patients and people without mental illness. Additionally, Reinhardt and Ficker (1983) found therapeutic music for schizophrenic and depressed patients to facilitate improved mood and motivation and increased awareness of emotional states (Reinhardt and Ficker, 1983, as cited by Covington, 2001).

Attention and Ability to Focus

Another factor that within a psychiatric population would be beneficial if improved is a person’s attention level or ability to focus. Attention can be defined as the “notice taken of someone or something, the regarding of someone or something as interesting or important” (The Oxford Dictionary of English, n.d.) and focus as “the centre of interest or activity” (The Oxford Dictionary of English, n.d.), so in terms of ‘ability to focus’ how well a person can centre their interest and activity.

There are many examples in the literature of how music can increase attention span, many arguing this is due to the stimulation the music provides, covering various diagnostic categories. As discussed above, Degmečić et al. (2005) named improvement of concentration and attention span as one of the more general potential benefits of music therapy. Zwerling (1979) argues that arts therapies bring a “reality-based focus” with a more real and immediate presence compared with something or someone a patient can talk about. Whilst exploring pre-academic skills with music therapy programmes, Gunsberg (1988) found that skills including attention span, on-task behaviour and skills of initiation improved through the application of music therapy (Gunsberg, 1988, as cited by Gold et al, 2004).

Most of the previous research found on attention level and music therapy has been on varied groups of participants, with research specifically on psychiatric patients being more difficult to source. One example of an alternative participant group is Kydd’s (2001) study on working with the elderly, particularly those suffering from forms of dementia, which highlighted increased attention span as a possible music therapy goal, which researchers such as Clair (1996) and Kovach and Henschel (1996) have also previously found. A study of physically disabled children found that music can be used as a background stimulus to increase attention span and decrease levels of anxiety (Thaut, 1992, as cited in Davis et al, 1999). In a study of children suffering from developmental or behavioural disorders, Gold et al. (2004) suggested within their study, that it may have been the way in which music therapy, especially active music making, helped increase focus and sustain attention that they found such a large Effect Size.

Energy

Similar to mood, energy levels can work as a good indication of general well-being, with energy commonly defined as the “strength and vitality required for sustained physical or mental activity” (The Oxford Dictionary of English, n.d.). It seems common opinion that music can be either relaxing or arousing, which the research from Bernardi et al. (2006) supported when they studied twenty-four normal subjects listening to music. They found that music can induce an arousal effect, which is predominantly related to the tempo; slow or meditative music can induce a relaxing effect.

Energy is clearly an important attribute to a person’s perception of wellness, and, like low mood, a lack of energy is a symptom for many mental illnesses, including schizophrenic and depressed patients. Previous research has found music therapy an affective method of improving energy within these client groups. For example, the previously discussed research by Yang et al. (1998) found schizophrenic patients to be significantly improved in their symptom of ‘sluggishness’, following group music therapy sessions (Yang et al, 1998, as cited by Ulrich et al, 2007). Mazza and Price (1985) described music as particularly useful, considering the low energy of depressed patients, at stimulating group interaction and improving interpersonal aspects of depression (Mazza and Price, 1985, as cited in Alissi and Casper, 1985). Clearly, the research discussed in relation to energy, and mood also relates well to the literature previously discussed in relation to depression.

Self-Confidence and Self-Esteem

Self-confidence and self-esteem are also factors previously found to be improved with the application of music as a therapeutic tool and are good indicators of a person’s well-being. Clearly, by definition, self-confidence defined as “a feeling of trust in one’s abilities, qualities and judgement” (The Oxford Dictionary of English, n.d.).and self-esteem as “confidence in one’s own worth or abilities” (The Oxford Dictionary of English, n.d.), we can see that these are positive attributes of a healthy mind. Within the literature there is a wide variety of examples of music helping to increase self-confidence and self-esteem with various types of individuals. Certain diagnostic groups, such as depressed patients, are clearly more in need of activities to build self-confidence. Sausser and Waller (2006) concluded from their study that music enhances self-expression and self-esteem, in particular they found that self-esteem and self-worth may increase as a student achieves musical success. More specifically, they argued that musical spontaneity and instrument improvisation can be utilised in building self-confidence and offer opportunities for positive social interactions.

Few papers focus specifically on issues of self-confidence and self-esteem within the music therapy setting. Instead it often becomes an afterword, another finding that has co-occurred alongside other positive aspects of the therapy. For example, in Hill’s (1997) paper, she reported how Beresford-Pierse and Howat described, at the United Kingdom Rett Syndrome Association Conference in 1988, that by working on improving movements and visual and physical contact, other improvements, such as increased self-confidence and self-esteem, are likely to co-occur. Moreno (1995) described music therapy as similar to traditional healing methods in its ability to support positive belief systems, enhance feelings of group support and individual self-esteem. Here, Moreno seems to have encompassed self-esteem into a wider beneficial effect of music therapy.

Traditional music therapy has found positive results in many cases for self-esteem. Research by Henderson (1983), using the Coopersmith Self-Esteem Inventory (Coopersmith, 1981), found self-esteem had increased following a music therapy intervention with thirteen hospitalised patients diagnosed with ‘adjustment reaction to adolescence’. Another example is by Smeijsters and Hurk (1999) who conducted an in-depth case study of a woman suffering badly from grief and had issues finding a personal identity. They found music therapy enabled the client to express part of her personality, which had been suppressed, and during the music therapy process, her self-esteem increased. Within a population of autistic children, Brunk (1999) argued that music therapy and adapted music lessons may both influence self-esteem.

There are also examples of other applications of music to build self-confidence and self-esteem, for example, Guided Imagery in Music, therapy centred on the listening to music process, has also gained positive results. Maack and Nolan’s (1999) questionnaire results on GIM found this method may be helpful for clients who wish to increase their self-esteem. Another alternative is the song-writing process, which Freed (1987) found can help clients by enhancing self-esteem, self-expression, and interpersonal communication. Finally, Gardstrom (1987) found that musical performance can also help to build self-esteem, and expression. From this literature, it is clear that a range of musical activities can all produce a positive effect on self-esteem and self-confidence. It seems that this effect should be particularly apparent within a therapeutic environment, especially if it is emphasised as an aim of the therapy.

Interaction

Self-esteem and self-confidence may also increase due to the opportunity of interaction involved in therapy (Sausser and Waller, 2006). The sociability typically involved within group music therapy sessions can provide a form of social skills training, with sessions involving active participation and emotional expression potentially able to improve self-esteem (Yang et al., 1998, as cited by Ulrich et al., 2007). As mentioned previously, Mazza and Price (1985) described the use of music at stimulating group interaction in relation to energy (Mazza and Price, 1985, as cited in Alissi and Casper, 1985). Within their study, Yang et al. (1998) found loneliness and social withdrawal improved by 34.1%, which they argued occurred due to the process of music therapy (Yang et al., 1998, as cited by Ulrich et al., 2007).

Interaction, “reciprocal action or influence” (The Oxford Dictionary of English, n.d.), is a vital social behaviour, and much research, for example Standley (1996), argues musical activities could be beneficial to social behaviours. Expanding on this idea, Robb (2000) examined the contextual support model of music therapy based on Skinner and Wellborn's (1994) motivational theory of coping with hospitalised children (Skinner and Wellborn, 1994, as cited by Robb, 2000). This theory argues that therapeutic musical environments possess elements of structure, autonomy support, and involvement that lead children to become more actively engaged with their environment. She found that music therapy elicited significantly more social engaging behaviours than other hospital activities. Similarly, Freeman (1994) argues that music therapy helps to stimulate and motivate, and this provides opportunities to facilitate social interaction. In Bunt’s (1994) examination of child health, with children of various different disabilities, she found that teachers, and herself as an observer, noticed a change in social interaction, 99% of which they felt was a positive change. With some client groups, purely an increase in social interaction represents improvement. For example, Sambandham and Schirm’s (1995) research with Alzheimer’s disease sufferers found that when music was played, they showed a decrease in verbalization and unrelated interactions, indicating that they were focused. However, when the music finished they showed an increase in interactions with each other. Similarly, Pollack and Namazi (1992) showed that individualized music therapy resulted in increased social interaction both during and after music sessions for eight Alzheimer’s disease residents.

The effects of fifteen one-hour per-week singing workshops on female patients suffering from chronic psychoses in were investigated by Hayashi et al (2002). They found a significant advantage of the sessions on some negative symptoms; patients became less socially withdrawn and became more empathetic toward other people. However, four months following the course the scores returned to baseline levels, which suggests this may be only be presumptive or that improvement is only superficial with the sessions barely influencing the core pathology of patients’ symptoms (Hayashi et al., 2002).

There are also many examples of group music therapies in comparison with other alternative treatments. Goldberg et al. (1988) compared group music therapy to verbally based interactional group psychotherapy. They studied twelve short-term in-patients, for which t-tests found the two groups to be equal demographically and diagnostically, in improvisation based therapy sessions, focusing on interaction with each other. For patient satisfaction there was no significant difference between the groups, with 59% of patients rating it as very, or extremely, helpful. No differences were found between curative factors as a whole so they were not investigated separately. Therapists rated music therapy to involve more interaction between patients and that it needs less intervention by therapists to facilitate the interaction. Music therapy groups were voted as more insightful, emphasising emotional expression, catharsis and creativity, whereas verbal therapy groups were more thorough in emphasising problem solving and reality testing of psychotic ideation.

The ability of music therapy as a medium for interaction, be it because it occurs within a group, or just as an alternative form of interaction, has particular potential for people who are not accessible through verbal language. This includes individuals who are unable to communicate verbally, or use verbal expression as efficiently, in particular to rationalise their own emotions (Gold et al, 2004). “Music therapy can help to foster non-verbal expression, which aids interaction as it allows the free expression of feelings.” (Hill, 1997, p.125). It appears clear from the literature that the interaction music sessions involve can provide a rich amount of benefits. The effect of group interaction and additional communication the sessions can provide seems more interesting within a hospital setting in which clients are kept in separate blocks and also because gender differences are far more apparent within India than in Western cultures.

Method

The administered singing workshops

The singing workshops examined are of a long-established on-going programme so any effects influenced by the sessions are already taking place. The sessions took place every Saturday morning and were situated in a small room joined to the male sub-acute ward within a Non-Government Organisation psychiatric hospital in West Bengal, India. An average of 47 clients would typically participate in each weekly session.

Session Format

The clients would come to the room from their wards (accompanied by a nurse) and take a seat on the floor of the room facing the session leader who would be seated at the front of the room. Alongside the session leader was a dance teacher (also a volunteer) who also sat at the front of the room during the sessions and initiated clapping and traditional dancing using just her hands. Additionally, a local tabla player would sit amongst the clients.

The sessions began with a short quiet prayer and then lasted around one hour, typically including five-ten songs. The session leader would sometimes teach the clients a new song (hence on some weeks only five songs were sung) during which attention would be paid to details of rhythm and pitch, alongside the meaning of the lyrics. On other weeks the sessions included up to ten different songs. The session leader often encouraged discussion of the ‘feeling’ of the song. The sessions would finish with a prayer before the clients would return to their wards.

Music Within the Sessions

North Indian music is based on taal and thaats; taal being the rhythmic patterns mainly provided by the tabla, a pair of drums played with the hands, and thaats being the melodic notes making up the scale, with each note individually referred to as a swara (Bakshi, 2005). The sessions here use tabla and a harmonium (also known as a baja or peti); a reed organ with a hand-pumped bellow. As previously mentioned, a local man from a neighbouring village would come to play the tabla each week, and the harmonium would be played by the session leader. Alongside the singing, many clients would clap to the beat of the song.

Most of the songs in the sessions were written by Rabindranath Tagore, a Bengali poet, playwright, artist and composer, and strong symbol of local pride (Thompson, 2003). The session leader (A.S.) chose Tagore’s music for the sessions because it relates to nature and to the character of the self, blending them within his lyrics and music. His songs were also chosen because Tagore has written many songs about the mind, including the minds of people and of other things such as trees and the sky. His music also relates to imagination, allowing clients’ thoughts to travel elsewhere, away from their illness, which A.S. considered very important.

The Session Leader

The sessions were conducted by a volunteer who has run the sessions for over three years and otherwise works as a professional musician. Although he has no formal training in mental health or as a therapist, he has a strong interest in music and other arts as therapy and is extremely enthusiastic about the singing workshops.

Participants

For the purpose of clarity participants will be defined into two separate groups: Clients: N = 18 (m = 7, f = 11). Age range: 21-53.

Clients came from four different wards of the hospital: male and female sub-acute wards, and male and female group homes. The sub-acute wards treat clients whom have moderate, but not severe symptoms, and the group homes are for long-stay clients more mentally stable than those on the sub-acute wards but who would still be unable to cope independently outside the hospital. Clients were chosen to participate in the study by their respective ward supervisors from the average weekly total of session attendees (n = 47; male = 24, female = 23). Regular session attendees, and those who had been attending the sessions for a minimum of six months, were prioritised. Attendance was also checked at the beginning of the questionnaires, 17 of the participants answered that they attended every week, and one client answered he attended most (‘two out of three’) sessions. Clients were not selected for participation if the ward supervisors thought they may be confused or lack sense answers.

Diagnostics: Only the clients’ primary disorders are outlined below (a list of any secondary diagnoses are available on request). The sample included: paranoid schizophrenia (n = 8), bipolar II disorder (n = 4), depression (n = 4), brief psychotic disorder (n = 1), disorganised schizophrenia (n = 1).

Staff: N = 5. Four of the staff included ward supervisors from each of the four wards whose clients attend the sessions. These staff are all usually present during the singing workshops and are present with the clients for the rest of the day following the sessions. Each of these staff members has worked on their relevant ward for a minimum of six months, so knew clients well and should be able to observe any changes effectively. The fifth member of staff is the session leader (A.S.).

Procedure

Initial study – Explorations

The procedure began with the researcher conducting a semi-structured interview with A.S. (see appendix A for schedule) to investigate his opinions of how the sessions benefit clients. He discussed clients’ short-term gains separately from their long-term benefits and these answers helped to develop variables to be examined in the client and staff interviews and questionnaires. The results from this interview helped frame the study in a useful and necessary way.

A.S. outlined two main short-term benefits, which can be classified into categories of energy and interaction. He believes energy is encouraged through the rhythms of the songs, providing regularity to their speech and songs. He described this metaphorically; “when a person is physically healthy their heart beats with a regular pulse, a rhythm, but when a person is mentally ill they often lose the ability to move their body with rhythm. I believe the sessions help them do this.” (SL, q.6, p.2) The next benefit he outlined was how the sessions involve sharing. He contrasted this with his belief that normally clients can feel quite isolated, however, within the sessions, clients share music and space without conflict. He tries to have as many one-to-one conversations within the sessions as possible, not only using this to encourage interaction, but also to grasp their attention.

A.S. outlined three major long-term benefits: self-confidence, mood, and attention level. He described how the sessions provide a long-term self-confidence boost from the clients’ knowledge of their ability to perform. Relating to their increased self-confidence he believes clients achieve a sense of optimism through the sessions and that this elevates their mood (during the sessions as well as long-term). He emphasised how he believes it is the combination of rhythm, tune and lyrics, which create a positive and enjoyable feeling, resulting in an improved mood. He next discussed how, when he began running the sessions over three years ago, the attention level was very low; clients being capable of only a short duration of listening and singing. He believes that for the long-term attendees this has improved remarkably; details are remembered and they can even separate sections in songs between genders, and they have been able to put on hour-long performances. He argues that the sessions achieve this by helping them to forget other distractions.

Developing Materials

From the five outlined benefits discussed within the interview, the researcher chose mood, attention and energy level for quantitative assessment. These three factors were chosen because it was felt they were easier factors to quantify.

Self-confidence would need a larger scale for accurate assessment, for example the Coopersmith Self-Esteem Inventory (Coopersmith, 1981). Interaction was not selected for questionnaire quantitative assessment because it will definitely increase within the sessions, and thus should definitely increase in quantitative ratings. Interaction is instead easily assessed by observation, particularly in terms of participation, and qualitative responses are likely to elaborate on this. Both these factors were still able for discussion within the interviews.

Measures

This study involves three measures: observation, semi-structured interviews and questionnaires, administered to both clients and staff. The researcher conducted participant observation of seven of the singing sessions, which were also recorded by Dictaphone. The observation was chosen to complement the other measures, and so when clients refer to specific attributes or occurrences of a session the researcher will be able to understand what a session consists of. Observation was unstructured, although it was guided by two main criteria: active participation during each song (criteria being either singing or clapping) and all non-song dialogue was recorded. Details of the structure of each session (number of songs, time spent on singing and/or discussing each song) were also recorded. Observation is expected to validate comments made on the questionnaires and in interviews, by examining the consistency between them and the sessions.

Both of the questionnaires and interview schedules, once initially drafted, were discussed with the session leader and a ward assistant to examine whether they were suitable: aspects examined included clarity of language and concepts, layout and scale. Due to a lack of available participants, this process functioned well to replace a pilot.

For the client questionnaire a Likert scale was chosen for ease of reading by the participants due to the language barrier, which was especially necessary for those participants who required an interpreter (additionally no items were reversed to make the questionnaire as reader-friendly as possible). The questionnaires focus on the three main areas of focus drawn from the session leader interview. They explore how the sessions affect their mood, attention/focus and energy levels, both during and after the sessions. The questionnaires were designed to establish whether the three concepts had changes during the sessions, but more importantly whether these effects (if any) lasted later into the day. It should be noted that it would have been interesting to explore whether there were any further lasting (or permanent) effects to these concepts, however because the sessions were on-going (not put in place for the purpose of the study) this would be hard to distinguish, additionally, effects may be hard to distinguish as specific benefits of the singing workshops as opposed to any other therapies clients may have been receiving during the week.

The questionnaire had a Likert scale of 1-5, with a baseline of 3 representing how the client usually feels, 1 representing that the client feels much worse than normal, and 5 representing that the client feels much better than normal, so clients and staff could decide a factor was either improved, worse (on a scale) or the same than how a client feels normally (please see appendix D for full questionnaire). The researcher recognises that the methodology could be improved with a comparison/control group who took part in an alternative group activity. However, there were unfortunately no other groups running within the hospital that the musical sessions could be compared with. Use of the Likert rating of ‘3’ representing a day without the therapy aims to take the absence of a control group into consideration. Below each Likert rating participants were asked to elaborate on why they think their mood, energy level or focus/concentration is different (for example, "If your mood is different, why do you think it is?") to further examine specific factors that may be most therapeutic. The staff participant questionnaire (see appendix F for full questionnaire) was almost identical in format whilst, similar to the staff participant questionnaire, allowing for them to provide their opinions based on their observation of clients’ behaviour.

Client participants completed a semi-structured interview which assessed their opinions of the sessions and the benefits or problems they entail (see appendix C for schedule). Staff participants (the four ward supervisors) also completed a semi-structures interview (see appendix E for schedule) Both interviews were devised as semi-structured so that the participants had the freedom to fully explain the effects of the sessions alongside allowing to explore any additional noted benefits (or problems) from those outlined in the interview with the session leader. Additionally, the interviews were designed with close thought to potential issues of a language barrier and working with a translator; short and simple sentences were chosen, and additional text was kept to a minimum.

Within the client participant questionnaire, the first question "Why do you go to the sessions?" was designed to clarify whether they went to the sessions because they enjoyed them, found them therapeutic or whether they went due to a less desirable reason such as to avoid boredom. Question two "What do you enjoy most about a session?" was used to decipher the specific elements of the session that the clients enjoy (and hence may hold a large amount of any therapeutic qualities). Question three "What do you think the benefits of going to sessions are for you?" was used to explore whether the participants had any insight into any therapeutic benefits of the sessions. Questions four "How do you feel during the singing in a session?", five "How do you feel for the rest of the day following the singing workshop?" and six "Is this feeling different from a normal day, and if so, in what way?" were designed to allow for comments that would elaborate on the questions within the questionnaire. The final question "What would you change about the sessions?" was designed to explore any possible future improvements to the sessions. The interview also allowed for any "extra information" the participant wished to add.

The staff participant interview schedule was designed so that they could provide their opinions of benefits (or problems) based on their observation of clients’ behaviour. The first question "Is the behaviour of individual clients different on days they attend the singing workshops than from normal days? How so?" was used to establish observable effects of the sessions for the remainder of the day of a session. The second question "What do you think clients enjoy the most during the sessions?" was used to establish which parts may bring the most to clients and explore whether there were differences between what the staff thought the clients enjoy and what the clients say they enjoy. The third and final question "Which aspects of the sessions do you think have the most benefits for the clients? Which things in the sessions help clients the most?" included two questions which essentially both explored the same issue (this was to maximise use of this question in case there were any issues with language) and was designed to explore which aspects of the sessions they expect to hold any therapeutic effect. Again, the interview also allowed for any "extra information" the participant wished to add.

Data Collection Process

During the last three weeks of the observation period, the interview and questionnaire data was gathered. All participants were given an informed consent sheet (see appendix B) explaining the study before commencement of this process. The appropriate questionnaires and interviews were both given to the client participants and staff participants during the same sitting, which on average lasted sixteen minutes per participant. Six of the client interviews and questionnaires were conducted through an interpreter.

Once interviews were completed, they were transcribed from the Dictaphone recordings. Points made by more than one person were highlighted, and a tally system of these repeated similar comments was used to examine the most popular responses. Unless the response was particularly specific to the question asked within the interview, due to the nature of a semi-structured interview, the tally system encompassed comments from throughout the interview. In depth descriptions were also highlighted to allow for further discussion.

Results

As outlined within the methodology, observation was used to provide the background knowledge necessary to explore the effects of the sessions. Thus, within the results section, attention will first be paid to data gathered from observation on the participation of the sessions (however data on active participation within the sessions will be discussed in particular within the section on interaction). Data from the questionnaires will then be analysed before discussion of the factors individually. Results are concluded with a focus on specific musical factors to emphasise how the various factors are affected by musical qualities.

Participation

Unlike most similar systems in other hospitals, the clients here are not given coupons for attending the sessions; they all come because they want to. An average weekly total of n = 47 (m = 24, f = 23) clients attend the sessions, out of a possible 77 clients from each of the four wards able to attend (61%). However, in reality, not all 77 clients are always able to attend the sessions. They are not formally excluded, but the more severely affected clients on the sub-acute wards may be disruptive, or the sedative effects of medications that some clients receive may make them too drowsy to enjoy participating in the sessions. This voluntary attendance emphasises that clients must feel positive effects from the sessions or they would not attend. Interestingly, the only client who answered on the questionnaire that he attended ‘most’ sessions (as opposed to every session), had less positive ratings on the questionnaire than other participants, with an overall average of m = 3.33.

Alongside overall participation of the sessions themselves, it is important to examine participation within the sessions. Observation was used to explore how actively different clients take part, and in which parts of the sessions do they do this the most.

Questionnaire Results

Cronbach’s alpha was calculated for the questionnaire items, using the scores of clients and staff, to examine item reliability. The alpha reliability of the six-item scale was 0.77 indicating the scale had good reliability.

The results from the clients’ self-rating questionnaires were placed into a table to show the means and standard deviations.

Table 1: Client self-ratings of items placed into rank order with means and standard deviations.

Factor	M (sd)
Attention during	4.56 (0.62)
Mood during	4.50 (0.71)
Mood after	4.28 (0.70)
Energy during	4.17 (0.62)
Attention after	3.94 (0.73)
Energy after	3.78 (0.81)

This table shows that the mean scores were improved for all three factors both during and following the sessions. It also shows that that mean scores were generally higher during the sessions (except for ‘mood after’). The standard deviations of each item are relatively consistent, indicating that the questionnaire results were also reasonably consistent for each item. These means have been placed in a clustered bar graph to show the results.

Figure 1: Clients’ self-rated mean scores of mood, attention and energy levels during and following the music sessions.

 

This graph clearly indicates that mean scores were improved on all items as compared to normal days (a score of three).

A t-test was used to examine the significance of improvement on each of these six measurements. The t-test used the baseline figure of 3 representing the neutral condition, ‘same as other mornings’ or ‘same as other days’ (see appendix D), as there was no alternative group activity for which ratings could be compared with (see methodology). The table below shows the t-values:

Table 2: Each questionnaire variable compared with the baseline score by t-tests.

	t	df	Significance
Mood during	9.00	17	P
Attention during	10.72	17	P
Energy during	8.01	17	P
Mood following	8.10	17	P
Attention following	5.53	17	P
Energy following	4.08	17	P

The t-test found each variable was significantly improved as compared to how the client normally feels (df = 17, p

T-tests were also conducted on the client scores to examine if scores for variables were higher during sessions. Mood was not significantly higher during the sessions than following (t = 0.22, df = 17, p = n.s). However, attention level was found to be significantly higher during the sessions (t = 3.05, df = 17, p t = 3.29, df = 17, p

The results from the ward supervisors’ observational-ratings on their questionnaires have also been placed into a table to show the means and standard deviations.

Table 3: Ward supervisor observational ratings of items placed into rank order, with means and standard deviations:

Factor	M (sd)
Attention during	4.50 (0.58)
Mood during	4.50 (0.58)
Energy during	4.50 (0.50)
Mood after	4.25 (0.50)
Energy after	4.00 (0.00)
Attention after	3.50 (1.00)

The table shows that improvement for each of the three variables was again consistently found to be stronger during the sessions than following them. Unfortunately, staff observations, due to a smaller sample size, did not differentiate between which factors improved the most during the sessions. The standard deviations also vary much more than the clients’ questionnaires, which is likely to be due to the small available sample size of ward supervisors.

Although there are slight differences between clients and staff on the different variables, neither group was found to rate the variables any higher overall. Clients’ average score was m = 4.21, equal to the staff’s average score (when calculated to two decimal places). In terms of differences between the groups on individual items, it may be because some variables are more noticeable by outside observers that has produced these differences in scores.

Mood received very positive scores for both during and following the sessions, with both groups rating it with a minimum mean score of 4.25. In client self-ratings, energy following the sessions received the lowest mean score. A simple explanation may be that the clients are left feeling drained. However, this was higher in the staff observation scores. The staff observations reveal the lowest result was for attention following the sessions and the clients rated their attention levels as second lowest, which contrasts the fact that attention during the sessions had the highest self-ratings. The quantitative results of mood, energy and attention will now be discussed within individual sections with reference to qualitative results from interviews and observation.

Qualitative Responses (Interviews, Questionnaires and Observation)

The qualitative responses for the factors of mood, attention and energy within the questionnaires often had relatively interchangeable answers, and the responses within the interview tended to elaborate on these (both questionnaires and interview transcripts are available on request). These results have thus been placed into clusters of the beneficial factors. There was little difference in responses between clients and staff, except that the staff responses tended to answer the question more clearly, so the results of the two groups will be discussed together, with individual examples outlined when necessary. The results section is concluded with a section on ‘musical factors’ this outlines the specific music factors mentioned by participants, highlighting the links between the factors explored and music aspects of the sessions. Neither clients nor staff named any negatives relating to the sessions, and nearly all participants were able to talk specifically about certain attributes of the sessions that they find helpful.

Mood

Clients’ ratings of mood were significantly improved during a session compared to normal days, and remained significantly higher than normal days for the remainder of the day of a session. Staff also commented on how this improved mood was easily observed. This finding is supported by previous research such as by Covington (2001) who concluded that music can be useful within a psychiatric setting at modulating mood.

During

A strong and obvious explanation for improved mood is simply that clients enjoy the sessions. In twelve out of the eighteen clients’ interviews, participants commented on how they like/love to sing. Staff also commented on how they enjoyed taking clients over to the sessions, thus creating an all round positive atmosphere. Observation within the sessions supported this, as it found clients to appear happy. Many clients would often be smiling whilst they sang, which seemed more apparent with louder and faster songs, or those they knew very well. Within this study it is thus important to acknowledge that attendance of the group music sessions is voluntary and it is an activity that those clients look forward to, as a person’s mood prior to listening to the music is likely to be important in determining the resulting mood (Wheeler, 1985).

Following

When questions were focused on why they thought their mood remained better following the sessions, five clients and two staff members commented on how they enjoy thinking or talking about the songs later in the day. Mood improvement is a particularly important therapeutic factor for clients with depression. The four clients interviewed that were diagnosed with depression all answered that their mood was either better or much better than normal, both during and after the sessions, a clear benefit for depression sufferers. This finding is supported by other research such as Hanser and Thompson (1994) and Choi et al.’s (2008) study, whose participants significantly improved in depression and anxiety scores following a music therapy intervention.

Three clients described how the songs helped their mood by helping them express their inner feelings. One client in particular (J.B.), who rated her mood during the sessions as "much better", elaborated on this “I’m very happy. I express my voice through singing. It means I can say things I cannot normally say. Things no one hears. All my pain and everything is expressed in singing.” (PC9, p.3, q.b). Previous research such as that by Moreno (1995) has showed benefits of music therapy in allowing the expression of conflicts musically rather than verbally for emotional release. Active music therapy groups in which students participate in a hands-on manner can encourage self-expression and may help channel frustrations in a positive and creative way even more so than standard music therapy practices (Sausser and Waller, 2006).

Attention and Ability to Focus

Clients’ ratings of attention were also significantly improved during a session, and remained significantly higher than normal days for the remainder of the day.

During

Three of the ward supervisors’ opinions of why attention was improved during the sessions were that the active participation helps the clients, for example, by focusing on singing the lyrics and working together as a group. These comments relate to Gold et al.’s (2004) findings that active music making helps to increase focus and sustain attention, which provides good support for these results. Similarly, Zwerling (1979) argued that arts therapies bring a reality-based focus to participants.

Following

Client ratings of attention levels following the sessions remained higher than normal days. This supports previous findings that attention span was improved following music therapy interventions (Gunsberg, 1988, as cited by Gold et al., 2004). One client (J.B.) described why she believed her attention level remained improved following the sessions: “Even after coming back, when I am working I think about the songs I learnt and I feel focused. Whatever I am asked to do I do it well that day.” (PC9, p.4, q.g). This feeling of focus can represent an appreciated sense of well-being for the clients. However, only two staff members reported attention level as improved following the sessions (the other two rated it as the same as normal days).

From the data, it appears that the singing sessions help improve attention of the clients, potentially because, as the staff mentioned, clients are stimulated by the music.

Energy

On the questionnaire, energy levels were found to significantly improve during the sessions, and remained significantly higher than normal for the remainder of that day.

During

Within sessions, particular songs created a higher energy level within the room, which seemed predominantly related to the tempo of the songs. This supports Bernardi et al.’s (1996) findings (previously discussed) that music can induce an arousal effect which is predominantly related to the tempo; slow or meditative music can induce a relaxing effect). Within the interview seven clients’ described that the sessions ‘give them energy’. Similarly, four clients commented that the sessions make them excited.

Following

Comments about energy levels following the sessions were the most varied of responses. Although no clients answered on the questionnaire that their energy levels were any worse than normal, two clients report being tired afterwards within the interview. However, four clients still reported their energy level was much better than normal, and there were five comments within the interviews that they still have extra energy after the sessions.

The most obvious benefit of clients experiencing an increase in energy levels is that it shows that the sessions are stimulating. As mentioned previously, A.S. had described how he viewed the lack of stimulation for the clients as a problem. For the schizophrenic clients all (n=9) reported that their energy was improved (better or much better) during the sessions, and seven of these clients still scored it as improved following the sessions. More specifically this may be an improvement for ‘sluggishness’, one of the negative symptoms of schizophrenia. These findings support previous research by Yang et al. (1998) who found that schizophrenic patients were significantly improved on some negative symptoms, including sluggishness, following group music therapy sessions (Yang et al., 1998, as cited by Ulrich et al., 2007).

Self-confidence and Self-esteem

Within the interview there were various comments relating to self-confidence and self-esteem.

During

Within the interviews, four clients commented on how they feel more confident during the sessions. Similarly, two clients commented that they feel successful or feel like they can succeed whilst they are in the sessions.

Following

Each of the four above mentioned clients said that their increased self-confidence remains with them for the rest of the day, and that this makes them feel much better than other days. Two staff members also commented that clients’ self-confidence lasts. This relates well to Sausser and Waller’s (2006) description that as students achieve musical self-esteem, self-worth tends to rise. Many other findings, discussed previously, support this study’s findings, such as Henderson (1983), Brunk (1999) and one of Smeijsters and Hurk’s (1999) case studies.

Literature searching has been unable to find research on self-esteem or self-confidence in music therapy with this specific client group (the three specified above cover hospitalised adolescents, autism and individuals dealing with grief respectively). Within previous research, results on self-confidence often seem an afterthought, from an unpredicted finding, left open for discussion at the end of the studies. This research helps to identify self-confidence as a benefit in a more specific psychiatric setting.

Interaction

Interaction was only outlined by clients, not by the ward supervisors (although was highlighted within the initial study explorations within the interview with the session leader). This section will first outline the typical participation within sessions, using some more specific examples to emphasise what occurs during the sessions and how involved the clients are within them. For the purpose of clarity, sections have been split into ‘singing’ and ‘movement’.

During

Singing: Sessions usually began with a well-known song with the aim of getting as many clients involved as possible from the start. There were three songs that were sung in every session, for which most clients would sing along. In two of these songs the men and women would sing separate parts. In one song ‘Rimmy chim’ the two genders sang separate lines, and then everyone sang together for the chorus. Similarly, another song was only sung by the men, and then the women would join in for the chorus. Both of these songs would get most clients (around 40) singing, presumably because they found the separate parts more interesting and thus more enjoyable to sing. A few male clients (around five) would usually not sing, but came to the sessions because they enjoyed listening, although two of these men did occasionally clap when encouraged by A.S.

One client (H.M.) also played the harmonium and he would also often, once or twice per session, sing solos over a drone during the introductions of the songs. During the third session observed, another male client (M.S.) also sang a solo, during which about half the other clients clapped along, and when he finished all clients applauded. Within interview client H. M. emphasised how he felt confident following the sessions, which he related to how A.S. makes him feel that he is an important member of the group because he gets to perform.

Movement: One client stood up whilst singing and clapped for roughly a third of the songs in a session. Often at the end of the songs he would shout out ‘I like it, I like it’. Occasionally two other clients would also stand during songs. During the fifth song in the third session one client began to clap rhythmically, and then started to teach those around him to do it.

The dance teacher (sat at the front of the room during each session) initiated clapping on certain songs using eye contact with the clients to get their attention. There were normally around 10 clients clapping in each song, but this would usually double for the more familiar songs. She would also use her hands to dance along to certain songs, when she did this there was a group of four women who would always copy her. One of these clients, (N. S.) described this within her interview, that she felt that the movement helped her feel more in touch with the music, and that she listened more closely to the rhythms of the songs when she danced with her hands.

As A.S. emphasised in his interview he believes that normally clients can feel quite isolated, but the sessions provide time together, and many of the clients described how they enjoy making music together as part of a group. They enjoy choosing the songs, talking about the songs with A.S., and the singing process itself, all done collectively, as a group. This attributes a sense of importance to the sessions because they are all bought together, illustrated well by one client’s (R.M.) comment: “I work very hard to sing well so I can join in with the other people, so the music we make together sounds good”. (PC6, p.1, q.4). These sessions clearly provide appropriate interaction that so many of the clients enjoy, complementing previous research that has highlighted the ability of music therapy to enhance feelings of group support (Moreno, 1995). As discussed previously, this supports Yang et al.’s (1998) conclusion that the various benefits of music therapy that they outlined, and the process of the sessions, improved social aspects within their participants (Yang et al., 1998, as cited by Ulrich et al., 2007).

Although clients came from large wards they rarely participated in activities together and the genders are completely segregated except when they have visitors, which is not a regular occurrence for most clients. The appreciation of the interaction between genders (seated together in the one room, although men and women are on separate sides) was particularly evident in the younger clients. For example, one young woman and a young male would sing looking at each other whilst smiling, this woman (R.B.) commented in her interview: “I like seeing all the different people.” (PC8, p.1, q.3) Many other clients described how they like being in a big group, spending time with clients from other wards. These findings relate strongly to Robb’s (2000) finding that music therapy elicited significantly more socially engaging behaviours than other hospital activities. The therapeutic environment that the musical sessions provide due to their involvement within the music, alongside other factors, means that clients can potentially become more actively engaged with their environment (Skinner and Wellborn, 1994, as cited by Robb, 2000).

Following

Once sessions are over the morning’s activities provide something to talk about with each other, which many clients find important, as they often feel under-stimulated whilst living in the wards. When talking about thoughts for future improvements of the sessions, A.S. suggested that smaller musical groups within individual wards could run mid-week or that the sessions could be video-recorded and watched again during the week. This would bring clients together and allow them to reflect on the sessions with each other again, enjoy listening and singing to the songs and think about how to make the music sound better as a group.

Musical factors

Certain musical factors were outlined specifically as more beneficial to individuals. As described as the ‘most beneficial’ factor by A.S., many clients frequently commented on how they enjoy the rhythm of the songs. Alongside the clients being encouraged to clap along to the songs, the tabla works decoratively and also embellishes rhythms in the melody, making the music sound full of interest. Most clients when asked to specify what they enjoyed most about the rhythm of the songs stated that it generates energy within them. Some clients also commented on how the rhythm makes them want to dance, and that clapping along with the beat makes them want to sing louder.

The meanings of the songs were often used as an explanation for enjoyment. Clients enjoyed the subject matter of songs are about and that most of the songs are written by Tagore (a symbol of local pride) with most clients feeling strongly that they can relate to his songs. For example, client A.I. described how she finds many of his nature based songs peaceful “the songs remind me of the sounds of nature and life outside the hospital” (PC1, p.1, q.2). A.S. described how Tagore’s songs relate to nature by expressing the character of the self and the environment – within and around, for example one song frequently sang is about clouds and dreams. Another client D.G. described “the songs help me use my imagination; they let my mind travel anywhere” (PC13, p.1, q.4). Other song topics included one about inner strength and one about the monsoon rain, both very positive and binding subjects. When the clients were learning a new song they would discuss the meaning of the song, for example in session two, A.S. spent ten minutes explaining what the new song they were learning meant, with many clients asking questions. This finding highlights how the songs or pieces played within a music therapy session should be carefully considered to reap the most benefit. Client A.I. described Tagore’s songs, “with Tagore’s songs we get carried away by nostalgia, we reach that feeling of when we were well.” (PC1, p.6). Meanings should be considered beyond issues of mood, which is most often prioritised, and consider cultural relevance, and with psychiatric patients, songs focused on the mind may be of particular interest to them, considering the environment in which they live.

The inclusion of numerous musical factors in the clients’ and staffs’ descriptions enables the research to conclude that music, as a specific method of therapy, has particular benefits due to its format.

Discussion

One factor became apparent through interviews that had not been predicted – the influence of the process of learning within the sessions. The sessions, for some clients in particular, are a very active-process (see interaction section above), and many clients commented on how they find the sessions provide them with a goal to learn something: that it makes them prepare for something. For example, clients work together in their wards during the week to make the songs sound their best, and some clients work to learn the lyrics by heart. Ward supervisors commented that reading the lyrics is also an important part of this active process. Research has outlined various benefits of reading, besides enjoyment of the process, and social implications. These include stretching the imagination and the mental work you have to do to process and store that information (Johnson, 2005). Another cognitive process likely to have similar benefits is the process of memorising lyrics, also involving cognitive effort.

This research was different from most previous research into the value of music as therapy in two ways; firstly, the sessions are delivered by a musician who is not a trained music therapist, and secondly the delivery of the intervention in a practice-as-normal situation rather than under a trial conditions. However, this study did not set out to investigate music therapy, but a singing workshop in a therapy situation. The intervention in this study was conducted by a volunteer who otherwise worked as a professional musician. He was highly skilled and worked very effectively with the group due to his long-term experience of working with them. Due to his knowledge of the group, he continued to vary his approach in accordance with what he found most effective. Most research has looked at sessions of music therapy conducted especially for the purpose of the study, normally following a set quantity of sessions including introductory and concluding sessions. It could be argued that the practice-as-normal methodology used in this study is more relevant to application within real treatment; when such interventions are already in place we can assess how well they work and then seek to improve them, instead of simply finishing the study and discussing possible improvements that are not necessarily implemented

During the study, no specific weaknesses were outlined, however in particular it seems that the impact of interaction that the sessions provide could be improved by following a few simple suggestions (financial consideration is also important here). As previously mentioned, smaller group sizes would allow more individual expression. Additionally, a smaller group size would allow the clients to sit in a circle, which would likely increase interaction, which may thus increase the positive influences on socialising and enjoyment. One further recommendation to improve sessions would be to have performances once monthly, perhaps simply to other clients at the hospital and to staff-members, as this may further improve their self-confidence and provide them with additional motivation by working towards a goal (but care must be taken to prevent clients becoming too anxious about such performances).

Much of the theory around Western music therapy is focused on adapting it to meet the patient’s needs. It emphasises how each patient should be assessed as an individual and then a plan made from there adapting as necessary in the process (Wigram, 2003). One method commonly used within Western music therapy is the use of improvisation. The inclusion of improvisation within the sessions explored in the current study may further benefit clients in terms of self-expression (this method would need to be facilitated by smaller group sizes as previously mentioned). This improvisation technique can allow the individual to explore what they enjoy most on a personal level, often achieving a sense of identity through the music (Wigram, 2003). Within the sessions explored the use of improvisation may be facilitated by the use of a few additional percussive instruments that could be shared within the group. These instruments should be easy to play and to learn a few simple rhythmic patterns on, this also may make the

clients feel even more involved in the sessions and they would likely enjoy the extra sense of involvement. Having discussed the merits of a smaller group size, it must be acknowledged that bringing clients together into a large group for the sessions holds the positive aspect of an additional stimulant to the clients.

In terms of what Western practice could learn from this application of music within India there are three key elements to consider. The inclusion and consideration of songs involving aspects of nature seemed to encourage a peaceful feeling within the sessions. If appropriate, the inclusion of religion or spiritual meaning to the sessions many benefit many individuals. Finally, the choice of one key composer within these sessions, Tagore, who represents such great local pride also had held positive implications and this also represents the key tie the music had to local traditions, for example within many European countries music therapy could incorporate traditional local folk music.

Throughout history, music has been used for a variety of therapeutic purposes all over the world (Futamata, 2005). McCaffery (1992) named music’s universal cultural appeal as one of the benefits of listening to music as a form of therapy. The singing sessions explored within this study require very little funding or facilities. This study should work to encourage such activities globally, which could be utilised within a therapeutic environment. Studies examining therapy in different cultural settings can also be of value to those from other cultural backgrounds seeking help in Western settings. It makes for a strong argument that “music therapists should have a basic working knowledge of a wide variety of representative world music genres.” (Moreno, 1988, p.17). Even for therapists purely working within the United Kingdom (UK), a more varied approach and knowledge of cultural considerations will certainly have advantages, particularly considering the UK’s growing diversity. Moreno (1988) argues that different world music genres can “enhance communication for clients of specialised ethnic backgrounds, and motivate otherwise unresponsive mainstream music therapy clients into musical experiences through the exotic appeal of unfamiliar music styles.” (Moreno, 1988, p.17).

There have been few studies examining how patients feel during music therapy; most only measuring the benefits at the end of the session(s). It seems important to examine the relationship between beneficial variables both during and following the sessions, exploring how short- and long-term effects relate to each other. This study was able to examine both elements.

The results of many of the studies discussed may have been influenced by the Hawthorne effect, due to the awareness of their subjects of being studied. Because this study was not an intervention put in place purely for the study, and because the observation was not perceived as research, this effect should be less significant.

Confounding variables

Because of the practice-as-normal setting, the group membership may have introduced some bias factors. Not everyone who was eligible opted to attend the sessions; the self-selected group, who were familiar with the session content, may have increased positive expectation. The sessions may be more effective with the self-selected individuals; hence, those that do attend typically have regular attendance. Also due to the naturalistic setting, the group membership varied slightly between sessions, which may further have influenced the outcomes for individuals.

Reker (1991) outlines that music therapy makes a welcome change from the normal routine for many psychiatric in-patients (Reker, 1991, as cited by Ulrich et al, 2007). It could be argued that the positive benefits of the sessions actually stem from the opportunity to be in a group or from participating in activity together, rather than from the musical content itself. Due to the constraints of setting and time, and the absence of any similar group activity, it was not possible to study a comparison group to test the group effect in this study. However, because so many clients, and the ward supervisors, related the benefits of the session to musical factors, this study concludes that the musical content was a specific therapeutic factor.

The presence of an observer (the researcher) within the sessions may have had a distorting effect, either positive or negative, on the sessions. However, the researcher sat at the back of the room to be as inconspicuous as possible; also, the clients are used to Western volunteers within the hospital, so the presence of the researcher within the sessions was not unusual for them.

Conclusions

It would be interesting, in further studies, to explore how the factors found in this study relate to Yalom’s (1995) eleven curative factors of group therapy. It can be speculated that some of these factors relate to findings in this study. These include the instillation of hope – most clients appeared to have faith that the sessions were effective, development of socializing techniques – as described within the interaction section, interpersonal learning - receiving feedback from the session leader and learning from it, group cohesiveness - clients enjoying being part of a group and working together, catharsis – the singing provides a needed opportunity for many of the clients to express emotions.

Many of the potential benefits of music therapy outlined by Degmečić et al. (2005) were found within this study. These potential benefits include the exploration of personal feelings such as self-esteem or personal insight, the ability to make positive changes in mood and emotional states, to express oneself, to interact socially with others, and to improve concentration and attention span. To have studied these factors in the same depth as in Degmečić et al.’s (2005) study, a larger measure, such as her Symptom Checklist-90 Revised, would have been required. This would have been difficult due to linguistic differences and with a larger participant group than she had used. Similarly, to assess the effects of the musical activity on self-confidence in more depth a measure such as the Coopersmith Self-Esteem Inventory (Coppersmith, 1981), which Henderson (1983) used, would have been necessary.

It is concluded that the singing workshop sessions had six main benefits; mood, energy level, attention level, self-confidence/self-esteem, interaction and learning and that these effects were present during and after the sessions. These benefits are emphasised by the therapy taking a musical format. Reflecting on the three factors outlined previously by De l’Etoile (2002) that would illustrate the effectiveness of therapy: psychiatric symptoms should be reduced, therapy should be perceived as helpful, and the likelihood of clients remaining in or returning to therapy should increase. The effects investigated such as mood and concentration show a general improvement (but investigated for the day of the sessions only) in certain symptoms for depression and schizophrenia. The therapy was perceived as helpful by patients and staff members illustrated by comments of improvement (again, for the day of the session only). All but one of the eighteen client participants studied went to the sessions every week and as previously mentioned, it is clear the clients attend the sessions because the find some benefit from them (unlike most similar systems in other hospitals, the clients here are not given coupons for attending the sessions).

It is important that this study can be generalised. Countries do differ in their musical traditions, and India can be viewed as a country in which it is more normal to play music within a social setting. Thus, the research needs to be explored in a variety of cultural settings. These findings can be used to encourage the use of music as a therapeutic intervention within this particular hospital, and can, hopefully, encourage its provision in other hospitals with similar cultural populations in India and elsewhere.

Notes

[1]Rabindranath Tagore a Bengali poet, playwright, artist and composer, and strong symbol of local pride (Thompson, 2003).

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