[Research Voices: Quantitative Study]
Women With Addictions Report Reduced Anxiety After Group Music Therapy: A Quasi-Experimental Study
By Susan C. Gardstrom & Wiebke S. Diestelkamp
Abstract
Roughly six million females in the USA abuse or are addicted to alcohol. Women are more likely than men to report depression and anxiety as triggers for substance use and relapse, which emphasizes the importance of therapies designed to help women mitigate anxiety.
Research supporting music therapy (MT) with women with addictions is scarce. In this quasi-experimental investigation, we hoped to learn: (1) What percentage of women with addictive disorders in a 45-minute group MT session will report pre-session anxiety?; and (2) of these, what percentage will report a palpable reduction in their post-session anxiety? We used a single group design: Participants self-reported anxiety before and after each session.
Study participants were 53 women in a gender-specific residential program. Voluntary group MT sessions were held twice weekly for 9 weeks. Four MT methods were used: Composition, Receptive (Listening), Improvisation, and Re-Creative (Performing). Of 53 first-session surveys, 39 (73.6%) indicated pre-session anxiety. Of these, 33 (84.6%) showed a reduction in post-session anxiety. A sign test confirmed an overall reduction in anxiety.
Outcomes may have been related to interventions, group cohesion, or other factors. The absence of a comparison group prevents suppositions of causality. Nonetheless, the results present a compelling case for the use of MT with women with anxiety. Because of the link between trauma and addictive disorders, we encourage exploration of the role and benefits of MT within trauma-informed models of addiction treatment.
Keywords: music therapy, addictions, anxiety, women
Introduction
This report attempts to answer preliminary questions related to anxiety among women with addictions who participated in group music therapy. Interest in the topic stems from the primary author’s experiences as an intermittent volunteer and undergraduate practicum supervisor on a women’s addictions unit within a larger behavioral health program. The women on this unit had repeatedly mentioned the benefits of music therapy, the single most frequently reported advantage being a reduction in anxiety; however, these women’s perceptions had never been systematically surveyed.
In 2006, the National Center on Addiction and Substance Abuse (Columbia University, USA) published Women Under the Influence, a compendium of more than a decade of research findings related to women and addictions[1] (CASA, 2006a). According to this resource, the problem of drug and alcohol abuse among females of all ages is rampant: More than 6 million girls and women in the USA abuse or are addicted to alcohol, and roughly 15 million use and abuse illicit and prescription drugs.
While rates for addictive disorders are thought to be higher among men than women, women are in fact more vulnerable to addiction (CASA, 2006a). They encounter unique challenges and stressors in their daily lives—domestic strife, job and financial instability, lack of health insurance, pregnancy, lack of suitable childcare, and social stigmas, to name a few (Zilberman, 2009; Hecksher & Hesse, 2009; Straussner & Attia, 2002). These stressors place women at risk for drug and alcohol problems, at the same time prevent them from seeking and receiving the professional help they need; CASA (2006b) reports that 92% of women fall into this category.
Females are also more likely than males to have poor self-esteem, depression, and anxiety. They are more apt to drink and use drugs to regulate these so-called “negative affects.” Women with addictions also are more likely than men to report relapse in response to depression and anxiety (CASA, 2006a; McKay, Rutherford, Cacciola, Kabasakalian-McKay & Alterman, 1996; SAMHSA, 2005a).
Furthermore, nearly two million girls and women in the USA are estimated to have co-occurring severe mental illnesses and addictive disorders (SAMHSA, 2005b), and females with addictions are more likely than their male counterparts to be co-diagnosed with anxiety disorders such as Generalized Anxiety Disorder and Posttraumatic Stress Disorder (PTSD), with some estimates as high as 30 percent (Brady & Hartwell, 2009; Grella, 2003; Kessler et al., 1997; Regier et al., 1990; Smith & Book, 2008). Kassel and Veilleux (2010) put forward that the connection between addiction and anxiety is seen not only in co-occurring mood and anxiety disorders, but in sub-clinical affective symptomology as well.
Obvious associations between past and ongoing trauma (e.g., physical and sexual abuse) and the development of addictive disorders among females should not be overlooked (Hien, 2009). Among adolescents, twice as many girls as boys report physical or sexual abuse in the year prior to entering addictions treatment. And, among adults seeking treatment for substance abuse, a diagnosis of PTSD linked to past physical and sexual trauma is more common in women than in men (National Institute on Drug Abuse, 2012). One study indicates that 23 percent of pregnant women and new mothers entering treatment had been physically abused and 14 percent had been raped (Martin, Beaumont, & Kupper, 2003).
In light of this evidence, it stands to reason that most, if not all, women will enter addictions treatment with some level of anxiety—whether sub-clinical, as a feature of a co-occurring disorder, or both. To begin with, women undergoing detoxification often experience nervous system arousal and agitation as a result of physical withdrawal from certain substances (i.e., alcohol, opiates, benzodiazepines, etc.). Additionally, the treatment process itself can be anxiety provoking, as women may re-visit and explore traumatogenic material without the aid of their usual defenses against the difficult emotions that arise in doing so. And, while residential treatment for some women initially means welcomed abstinence, safety, and opportunities to reclaim their “lost” lives, in the long run, it means loss of independence and privacy, uncomfortable changes in daily routine, the heartache of separation from children and other loved ones, the potential for interpersonal conflicts with other residents, and a host of other factors that can trigger and aggravate symptoms of anxiety.
The deleterious effects of anxiety[2]—too numerous to mention in totality here—may compromise treatment efficacy. In addition to its link with relapse, we know that anxiety is correlated with myriad somatic complications and a cluster of vascular, hormonal, immunological, neuronal, and degenerative diseases (Härter, Conway, & Merikangas, 2003; Scaer, 2001). Anxiety leads to increased distractibility, with concomitant effects on focus, attention, and short-term memory (Bhagia & Pal, 1986; Eysenck, 1992; Henckens, Hermans, Pu, Joëls & Fernández, 2009; Huppert & Smith, 2005). Furthermore, women’s optimism, essential for treatment success, appears to be negatively impacted by anxiety (Dewberry & Richardson, 2001).
These few aforementioned “risks” of anxiety—not the least of which is the fact that women are more likely than men to report relapse due to negative affective states such as anxiety—bring to the foreground the importance of therapeutic modalities and interventions designed to help women, in particular, mitigate their anxiety, both during treatment and in subsequent recovery.
Music Therapy and Anxiety in Addictions Treatment
Because of the complex nature of addictions, eclectic and multidisciplinary approaches to treatment are endorsed (Dijkstra & Hakvoort, 2010; Hedigan, 2010). Music therapy, as one nonpharmacological treatment modality, has been used in addictions treatment toward numerous aims. Yet, quantitative research on the use of music as an anxiolytic within addictions treatment is scarce. In 2008, Mays, Clark, and Gordon conducted a systematic review of published books and peer-reviewed journal articles in English and found only 19 studies relating to music therapy applications in addictions treatment. The researcher classified 14 of these as descriptive articles, and 5 were considered “outcome research.” Only one of the five outcome studies targeted anxiety as a dependent measure (Jones, 2005). Jones (2005) provided single session group music therapy for men (n = 23) and women (n = 3) in a nonmedical detoxification program. Using an adapted visual analogue mood scale, she measured the comparative capacities of lyric analysis and songwriting to elicit emotional change in 11 emotion variables, anxiety among them. Although mean scores revealed that self-identified intensity of Anxiety/Nervousness/Anticipation moved in rank from 9 at pretest to 7 at posttest, this change was not statistically significant.
It should be noted that at least two relevant studies do not appear in the review by Mays, Clark, and Gordon (2008). The first is a controlled trial by Hammer (1996), who used “guided imagery through music and relaxation techniques” (p. 61) with 16 volunteer staff and residents from a chemical dependency/alcoholism unit in Minnesota. Analysis of data from the State Trait Anxiety Inventory (Spielberger, Gorsuch, Lushene, Vagg & Jacobs, 1983) supported a statistically significant decrease from pretest to posttest in state anxiety among the individuals who were exposed to the intervention. In addition, significant posttest differences were found in anxiety between the experimental and control groups. Trait anxiety was found to decrease slightly but not significantly in the experimental group.
The second outcome study, by Cevasco, Kennedy, and Generally (2005), was published during the same year as Jones’s but may not have been in print at the time of the review by Mays, Clark, and Gordon (2008). As in the present study, this study targeted the effects of group music therapy on emotional states of women in a residential addictions treatment program. Dependent variables were depression, stress, anxiety, and anger.[3] Of 20 original participants, 10 women completed the research protocol. Analysis of scores on two standardized inventories showed no significant pretest-posttest differences on the dependent variables for each of three, activity-based interventions (movement-to-music, rhythm activities, and competitive games). Likert scale scores in resident journals “indicated progress for several individuals on decreased levels of depression, stress, anxiety, and anger” (p. 74), although the analysis leading to this claim is not explicated.
Since the 2008 review was published, additional outcome studies on the topic of music therapy and addictions have appeared. For instance, in a program evaluation study, Erkkilä and Eerola (2010) found that people with gambling addictions reported decreased anxiety in response to a “multimethod treatment programme” consisting of physioacoustic treatment, group and individual music therapy, therapeutic discussion, and cultural activities. It is assumed that both men and women were involved as participants, although the authors do not specify sex. And, more recently, Albornoz (2011) published her findings from a controlled trial that adolescents and adults with substance use disorders who were randomly assigned to participate in 12 improvisational music therapy sessions (in addition to standard treatment programming) registered significantly less depression on a standardized inventory than clients who did not receive music therapy. The findings of this study—one of a handful of randomized controlled trials on the impact of music therapy on depression—provide further evidence of the potential of one particular music therapy method to alter negative affect among individuals with addictions. Although anxiety was not a targeted dependent variable, the high prevalence of comorbid depression and anxiety (Huppert, 2009), particularly among women (Greco & Zajecka, 2000) supports the relevance of Albornoz’s research to the present discussion.
This brief literature review suggests the need for further research to guide clinical practice with women with addictive disorders who experience anxiety. Jones’s (2005) study—while pertinent to the present inquiry in that participants had active addictions—involved both men and women. She writes, “Twenty-three of the 26 subjects were male, therefore the results likely reflect responses typical of male clients only and may not give a clear indication of how females in this population may respond to music therapy techniques” (p. 105). And, while Cevasco, Kennedy, and Generally (2005) worked with women exclusively, only ten women completed their study.
Our investigation was an attempt to gather data from a more robust, all-women participant base as a catalyst for further, controlled research and as a foundation for effective clinical practice with this clientele. More precisely, we hoped to answer the following questions: (1) What percentage of women with addictive disorders in a 45-minute group music therapy session will report pre-session anxiety?; and (2) Of these, what percentage will report a palpable reduction in their post-session anxiety levels? Based largely on unsolicited feedback from prior residents, our predictions were that a majority of women surveyed would register pre-session anxiety and that, of these, most would report a discernable reduction in anxiety post-session.
Method
To answer the research questions, we used a single group, pretest posttest design: Participants were asked to self-report their levels of anxiety before and after each group music therapy session.
Participants
The study participants were 53 women in residence in a 20-bed unit of an addictions treatment facility in Dayton, OH. The women were predominantly Caucasian (50%), African-American (25%), and Hispanic (25%). Ages ranged from 18 to 60 years. All women were addicted to alcohol and other drugs, and many had multiple substance addictions. Other stated behavioral addictions included sex and gambling. In each case, the substance addiction was the primary diagnosis and the reason for treatment. Approximately 25% of the residents were court-ordered to the facility and 75% were voluntary admits. According to staff estimates, at least 50% had been in treatment previously; however, none of the women reported having received music therapy prior to the study.
As a facility volunteer, the primary author did not have access to clinical records and thus was not privy to the women’s substance(s) of choice or secondary psychiatric diagnoses unless they elected to disclose this information. Alcohol, crack cocaine, marijuana, heroin, and methamphetamine were most frequently mentioned. Women who revealed their secondary diagnoses usually stated that they had some form of mood or anxiety disorder. Depression was frequently referenced; some of the younger residents specifically disclosed experiencing post-partum depression. Most women talked about feeling overwhelming psychological anxiety, using descriptors such as worried, apprehensive, nervous, and afraid. Most also either professed or demonstrated anxiety-related somatic symptoms, such as headaches, muscle tension, psychomotor agitation, restlessness, distractibility, and insomnia. Distress was reported as both situational and pervasive in nature, stemming from substance withdrawal (for some women, lasting the duration of their treatment), worrisome situations or events (e.g., upcoming court appearances or spousal visits, interpersonal conflicts with staff or other residents in the facility, etc.), and specific anxiety disorders, with PTSD mentioned most often. It is not known what percentage of the women had been co-diagnosed with an anxiety disorder.
The Women’s Residential (WR) unit was one of three units in the program and was part of a larger continuum of behavioral health services, including drug screening, testing, outpatient therapy, education, and aftercare. WR was a gender-specific program that provided daycare services for the women’s infants and toddlers. In this regard, it was unique among other treatment programs in the geographical region. Length of stay in the program was typically 30 days but varied considerably, ranging from 1 week to 60 days, depending on insurance coverage, aftercare arrangements, and legal mandates.
Participation in music therapy was entirely voluntary, but the session time slot was consistent and unopposed by required treatment sessions, so all WR residents were typically in attendance, barring illness, medical appointments, court appearances, and the like. Group configuration changed on a regular basis, in accordance with the flow of program admissions and releases. Group size ranged from 6 to 16 in any given session. More than half of the total women involved in the study attended multiple sessions. Facility professional and paraprofessional staff attended sessions on occasion.
Measurement Tool
A written survey, comprised of two identical 7-point visual scales, was created by the primary author and used to gather information about the residents’ perceived anxiety levels pre- and post-session (see Appendix A). The pre-session scale appeared on one side of a half sheet of paper and the identical post-session scale on the other. The single question posed above both scales was, “How anxious (nervous, worried) are you feeling right now?” (The synonyms were selected from the women’s vernacular and with feedback from a subject matter expert in substance use disorders). Descriptors provided underneath the scale included not anxious (“1” – far left), somewhat anxious (“4” – midpoint), and very anxious (“7” – far right). Residents were asked to circle the number on the scale that best represented their current emotional state. After the women answered the pre-session question, they placed the sheet under their chair or in a folder where it stayed until they were invited to answer the post-session question on the other side of the sheet.
Each time the surveys were distributed, the participants entered the same self-selected code in a blank provided in the upper right-hand corner of the sheet. The suggested code was comprised of the first two letters of their last names followed by the last two numbers of their birth years. This system allowed the women to maintain anonymity, as we did not know their last names or birthdates; at the same time, it allowed us to track cases over time as we reviewed the data. Completion of the survey was entirely voluntary and private and typically took less than one minute each to answer the pre-session and post-session questions. Although it was clear that some of the women had been diagnosed with anxiety disorders, the measurement tool used in the present study was designed to capture changes in situational anxiety only, as data were collected for a single session during which trait anxiety would not be expected to change.
Procedures
Prior to the commencement of data collection, the study was approved by the facility clinical director and the University of Dayton IRB. The residents were informed of the general purpose of the study and of their rights with an IRB-approved verbal script (see Appendix B). Completion of the survey was an indication of the women’s consent to participate.
In all, eighteen 45-minute group music therapy sessions were held over the course of 9 weeks on Tuesday and Thursday mornings. The group met on the WR unit in a long, narrow room with a window on one wall and a blackboard on the opposite wall. Sessions were designed and facilitated with the following overarching aims in mind: (1) increase the women’s knowledge about and comfort with group therapy processes; (2) showcase the women’s musical knowledge and skills; (3) help the women develop emotional self-awareness and expressive abilities; (4) promote group cohesion; 5) teach about ways to use music in recovery; and (5) help the women reclaim a sense of personal agency/mastery.
Two undergraduate, female music therapy students and the primary author, a certified music therapist (henceforth termed the therapists) planned and co-facilitated each session, which was comprised of an introduction, pretest, “check in”, core experience, closure, and posttest. To begin, the therapists introduced themselves by name and provided basic information about music therapy. When new group members were present, “veteran” members sometimes shared a bit about their prior experiences in the group. The therapists distributed the survey, read the script, and allowed time for survey completion.
An emotional “check-in” was next (i.e., how are you feeling right now?), wherein residents were given the option of sharing verbally (i.e., “Right now, I feel ______.”), sharing musically (i.e., playing their current emotion on a tubano or frame drum), or passing (i.e., not sharing anything about their current emotional state). The purpose of the check-in was threefold: to provide the therapists with valuable information for subsequent clinical decisions (i.e., assessment of current state), to establish the normalcy of emotional sharing in the group, and to prepare the women for the core experience.
The core music experiences were drawn from Bruscia’s four music therapy methods (1998): composition, receptive (listening), improvisation, and re-creation (performing). The therapists adopted a decision tree model (Eyre, 2008) in selecting the experiences rather than presenting all four types of core interventions in a random sequence or following a scripted, manualized protocol. While the latter strategy may align neatly with the “gold standard” of the Randomized Controlled Trial (Bradt, 2012), they may ignore or compromise emergent clinical realities and priorities, which could be seen as advancing a researcher’s (rather than a therapist’s) agenda or, worse, supporting a “one size fits all” approach to treatment. The decision tree model, on the other hand, supported the primacy of the women’s immediate clinical needs, both those expressed by the women themselves and those discerned by the therapists during the check-in. A more fluid way of presenting music experiences also allowed the therapists to act authentically and with loyalty to treatment facility values and their own client-centered leanings. Typically, core experiences were completed within the session time frame. Occasionally, if warranted, a core experience was repeated or continued in the following session. A complete listing of core experiences appears in Appendix C.
Closure of the session was verbal or musical with a verbal component, depending on the nature and outcome of the core experience. At this point, the women were invited to complete the post-session question and all surveys were collected by one of the therapists and placed in a designated envelope before the participants went to lunch.
Data Analysis
To obtain an independent sample, data from each woman’s first music therapy session only were analyzed, regardless of how many sessions she attended during the data collection period. At the conclusion of data collection, the envelope with all of the raw data was given to a research assistant who prepared Microsoft® Excel data sheets for statistical analysis via SPSS. This assistant was blinded to the purpose of the study.
A sign test was conducted by the secondary author, a professional statistician who had no connection to the treatment facility and no contact with the women. Because the objective was to investigate whether women would report a decrease in anxiety, pre-session scores of 1 (and, thus, with no potential for a decrease) were eliminated prior to this analysis.
Results
A total of 53 women participated in at least one group music therapy session, yielding 53 data pairs. Of these, 29 women (54.7%) attended multiple sessions. Fourteen of the 53 women (26.4%) indicated no anxiety on the pre-session survey and where therefore excluded, as noted above. (Incidentally, none of these 14 women reported an increase in anxiety after the session.)
There were 39 women (73.6%) who indicated some level of anxiety on the pre-session survey (i.e., a score greater than 1 for their first session). Of these women, 33 (84.6%) reported a decrease in anxiety (i.e., the post-session survey indicated a lower anxiety level than the pre-session survey). Two women (5.1%) reported an increase in anxiety. Four women (10.3%) indicated the same level of anxiety before and after the session (no change). Table 1 shows the various degrees of change for all three categories.
A sign test was carried out using scores from the 39 women who reported pre-session anxiety to determine whether the anxiety level had decreased overall for these women. The resulting p-value was < 0.001[4], confirming that the anxiety level had significantly decreased from the beginning to the end of the sessions.
| Change | # of cases (of 39) | % |
|---|---|---|
| -4 | 1 | 2.6 |
| -3 | 9 | 23.1 |
| -2 | 13 | 33.3 |
| -1 | 10 | 25.6 |
| 0 | 4 | 10.3 |
| 1 | 2 | 5.1 |
Discussion
The purpose of this study was to gather information about the self-perceived anxiety levels of women with addictions who participated in group music therapy as a foundation for further research on the topic and effective clinical practice with this clientele. Our predictions that a majority of women surveyed would report some level of pre-session anxiety and that most of these women would indicate a post-session decrease were supported. Scores indicate that nearly three quarters of the respondents entered their first session with anxiety. The vast majority of these individuals registered a decrease post-session, with the magnitude of change ranging from 1 to 4 points on the 7-point survey scale.
There are many plausible explanations for this desirable outcome. One optimistic interpretation is that the perceived change resulted from a factor integral to the therapy itself, such as the musical and verbal interventions that were employed in the sessions. Had it been possible within the facility to employ a comparison group and control for confounding variables, one might more confidently conjecture a causal relationship. Unsolicited verbalizations by the participants at the close of sessions and written statements on their surveys, however, do offer some support for the supposition that the music therapy experiences themselves promoted a positive change in affect. In particular, instrumental re-creation (e.g., rhythmic imitation and drumming) and instrumental and vocal improvisation were believed to have allowed for a release of physical tension leading to decreased psychomotor agitation. This feedback is consistent with published research about drumming in addictions treatment (Mikenas, 1999; Winkelman, 2003). Vocal re-creation (e.g., singing of familiar songs) appeared to have encouraged an important emotional release, or catharsis, that paved the way for a greater sense of inner calm. This aligns with research findings on singing to address dementia-related agitation (Lesta & Petocz, 2006), as well as reactions from men and women with addictions who were participants in a similar study (Gardstrom, Bartkowski, Willenbrink, & Diestelkamp , in press).
Another conceivable explanation for the reported decrease in anxiety relates to the power of suggestion. As noted above, experienced members of the group sometimes spoke at the start of the session about the benefits of music therapy. More often than not, these veterans relayed that music therapy had improved their mood, helped them to relax, boosted their self-esteem, and contributed to a general sense of wellbeing. It could be that the first-timers’ expectations about these benefits somehow influenced the scores. Unfortunately, we did not track in which particular sessions the returning members shared their positive perceptions.
Furthermore, while the music experiences were integral to the sessions, positive changes in group dynamics during a session, such as an increased sense of trust and cohesion through the sharing and validation of personal challenges and triumphs (Yalom & Leszcz, 2005) might help to explain the decrease in scores. This explanation may apply particularly if initial anxiety scores reflected reactions to interpersonal incidents or situations in the group, which the women did, in fact, mention from time to time. Even so, the case could be made that the music interventions, which were designed to promote group cohesion, served as a catalyst for the resultant decrease.
Two women, each in a separate session, registered a 1-point increase in anxiety. It could be that they simply were more prone to anxiety than their peers and thus more resistant to influence in a positive direction. Another explanation is that they were experiencing withdrawal symptoms or had been diagnosed with a Substance-Induced Anxiety Disorder (DSM-IV-TR, 2000), in which symptoms of anxiety develop during or within a month after severe intoxication or withdrawal. It could also be that these particular women experienced interpersonal anxiety (i.e., social anxiety), in which simply being in a group setting for 45 minutes—let alone interacting with others and doing so on an emotional level—may have been overwhelming. They may have been experiencing difficulty with their anti-anxiety medications, a situation frequently referenced by study participants. Or, if they were smokers who did not have a cigarette break immediately prior to meeting, which did occur occasionally, their anxiety may have mounted during the course of the session.
Of course, the possibility that anxiety increased for these two women as a result of a particular intervention must not be dismissed. Music can elicit profound and idiosyncratic emotional responses, neither giving us warning nor seeking our permission to do so. For a woman with addictions, particularly in the beginning stages of the recovery process, this emotional vulnerability may pose a threat that "kicks off" or exacerbates situational anxiety.
While addiction for both men and women is thought to result from a complex interplay of biological, emotional, behavioral, cognitive, and social factors, there exists strong support for traditional and modified negative reinforcement models, which purport that people learn to use certain substances to avoid or escape from so-called “negative affects” such as depression and anxiety. Negative affects may arise from both endogenous sources (e.g., withdrawal from a substance) and exogenous sources (e.g., anticipated or experienced environmental stressors) (Baker, Brandon, & Chassin, 2004; Epstein, Willner-Reid, & Preston, 2010; Khantzian, 1985, 1997; McCarthy, Curtin, Piper, M & Baker, 2010). Social anxiety, in particular, sustains some individuals’ involvement with substances in spite of their injurious effects (Stewart & Conrod, 2008). In the absence of a repertoire of healthy coping strategies, such compensatory use of substances to regulate affect—whether consciously or unconsciously applied—has implications not only for the development of an addiction but also for lapse and relapse after a period of abstinence (Ficken, 2010; Khantzian, 1997). Kassel and Veilleux (2010) assert that
…substance abuse is almost always accompanied by emotional pain; that is—and counter to the notion entertained earlier that addiction may simply reflect uncontrolled hedonistic desire— individuals who abuse drugs are most often depressed, or anxious, or manifesting any number of symptoms of emotional distress (p. 7).
It ought to be stated here that the goal of therapy (including music therapy) may not always be the reduction of anxiety—or for that matter, the amelioration of any distressing affect. Situational anxiety is considered to be a typical and even facilitative human reaction to a real or perceived threat; this is part of the so-called “fight or flight” response, and it is neither possible nor desirable to eliminate it altogether, particularly for women who are at risk for physical harm in post-treatment placements. Moreover, there are those who believe that a “feel good” approach to treatment has limited effectiveness and who claim that a certain amount of distress is a necessary catalyst for the admission of an addiction and an ongoing commitment to treatment. In fact, some research verifies that women with addictions are likely to seek professional help only when negative consequences of use—of which depression and anxiety assume prominence—become severe (RachBeisel, Scott, & Dixon, 1999; Weisner & Schmidt, 1992), in what has been described in the vernacular as “hitting bottom.” Furthermore, in long-term, intensive addictions treatment, the evocation, exploration, and resolution of difficult emotions tied to traumatic experiences typically are viewed as essential processes for lasting recovery.
In the present study, the amelioration of anxiety was, in fact, a desired outcome as part of a more comprehensive aim to help the women explore and develop strategies to cope with their addictions. Treatment was short-term, and the facility philosophy was considered supportive (Wheeler, 1983) rather than confrontational or analytical. Facility administrators and staff viewed decreased anxiety and concomitantly increased wellbeing as contributing to the women’s overall treatment receptivity and productivity.
Limitations
Limitations of the study stem from the nature of the available testing site and clientele, as well as the primary author’s role as a part-time volunteer. The pre-test post-test design afforded some rigor, but the lack of a comparison group prevents suppositions of causality and generalizability. Neither blinding of clients nor researchers was possible, and testing and social threats may have influenced the findings. While we would have preferred to use a more detailed, standardized tool, measurement was impacted by facility rules pertaining to client privacy (demanding as “minimally invasive” a questioning process as possible), a facility schedule necessitating the collection of meaningful data in as little time as possible, and substance-related cognitive deficits that would have made it difficult for the women to complete a lengthy or sophisticated survey. Additionally, in our interpretation, we must account for situational variables over which we had no control (e.g., medication effects, the impact of nicotine withdrawal, fatigue, etc.).
Conclusion
Regardless of one’s perspective on the etiology and treatment of addictions, research verifies that chronic and prolonged anxiety contributes to myriad health and mental health problems and sets the stage for craving and relapse (Koob et al., 2004; Scaer, 2001). Accordingly, we would be well served by further inquiry to garner meaningful information about the anxiolytic properties of the four music therapy methods and their variations (Bruscia, 1998). Carefully designed studies within both quantitative and qualitative paradigms are needed to answer salient questions and improve clinical practice with women who have addictions.
As noted above, a belief in the primacy of immediate and emergent client needs—rather than a desire to isolate or randomize treatment conditions—drove the therapists’ decisions about which interventions to employ in the present study. More than one type of intervention was used in each session, making it impossible to “tease out” differential outcomes, and the lack of a control group precludes confident assertions of causality. Randomized controlled trials will help us to build a base of empirical evidence of cause-effect relationships between specific interventions and anxiety levels of people with addictions. Comparisons between the methods, as well as between music and other modalities, individual and group therapy, single and multiple sessions, sub-clinical and clinically diagnosed anxiety, and men and women would be of particular value.
Qualitative research can help us to identify and answer other important questions concerning our clients’ experiences of music therapy as related to their anxiety. Individual and group interviews may help us to understand more thoroughly women’s idiosyncratic and collective/contextual responses to music therapy. Ultimately, this will enable us to design and facilitate meaningful interventions aimed at empowering women to tap into existing personal resources for recovery and discover new ones. And, with the ever-increasing awareness of the profound and enduring somatic and psychological correlates of traumatization among women, we strongly encourage further investigation of the role and benefits of music therapy within trauma-informed models of addiction treatment.
In spite of identified limitations, the results of this inquiry present a compelling case for the use of music therapy with women who experience situational or chronic anxiety as a feature or outcome of their addictive disorders.
Notes
[1]The terms substance abuse, chemical dependence (or dependency), and addiction have been used interchangeably in the professional literature, but they are not synonymous. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) of the American Psychiatric Association (2000) makes some important distinctions. According to criteria in the Substance Use and Addictive Disorders category, a person may use or abuse a substance without demonstrating dependence on that substance. With dependence comes tolerance (i.e., the need to use increasing amounts of a substance in order to achieve the desired impact) and withdrawal (i.e., specific physiological symptoms associated with cessation of use). Furthermore, the words chemical and substance tell us that the individual is using alcohol and other drugs, whereas the terms addiction or addictive disorder connote not only substance dependence, but other compulsive behaviors, such as gambling. In this report, for the sake of consistency and to reflect the fact that many of the study participants were not only dependent on substances but also revealed other compulsions, we have used the term addiction unless specific literature with different terminology is being cited.
[2]Anxiety has been defined and categorized in myriad ways. Apart from definitions in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), perhaps the most commonly accepted nomenclature comes from Spielberger and colleagues, who distinguished between two types of anxiety in the development of a broadly used anxiety inventory (Spielberger et al., 1983). State anxiety, also called situational, transient, or temporary anxiety, is apprehension or worry that varies in intensity and comes and goes in response to specific circumstances or events in a person’s life. Trait anxiety, on the other hand, is chronic and intense distress. In both types, psychological angst and discernable physiological changes frequently go hand in hand.
[3]The relationship between stress and anxiety—long debated and even confounded by reckless use of these terms in the professional literature—was not made evident in the report.
[4]The p-value was 0.0000002.
Appendices
References
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