The Social Architecture of Anxiety and Potential Role of Music Therapy
By Rebecca Zarate
According to the World Health Organization (WHO, n.d.), anxiety has become a serious international threat to global health, productivity, and sensibility. When a person suffers from anxiety, it impacts all aspects of their well-being as well as that of people close to them. This paper discusses the presence and impact of anxiety as a relational, multisensory, and embodied experience that occurs as a result of internal and external social environmental stressors. It supports the theory that the individual and collective impact of anxiety is an operational social construct produced from a deeply rooted history of competitive individualism, power in relationships and issues of difference in society. The way in which the field of music therapy currently conceptualizes anxiety suggests that more studies are needed to specifically target the larger relational and social contexts of anxiety. Thus, providing the potential for increasing the body of knowledge for the field and opportunities for music therapists to think and practice from such a critical perspective.
Keywords: anxiety; social justice; humanitarianism; interdisciplinary research; improvisation
Clinicians currently understand anxiety as a blanket term for a complicated bundle of clinically defined symptoms. Yet, in the United States (US), anxiety presents itself as an operationalized social construct, historically embedded in the social fabric in the form of a work ethic from the 1950s and sometimes referred to as the emblem of struggle (Tone, 2009). The social roots and the multisensory, intersubjective, relational, embodied presence of anxiety – in other words, the social architecture of anxiety – in the United States is not sufficiently recognized as an important component that informs clinical practice, theory development, or research in music therapy.
Music therapists work with a wide variety of clients who are experiencing stress and anxiety, yet the relational and subjective experience of these conditions have not received sufficient attention in music therapy literature. This paper starts from the premise that social pressures to be successful in Western society are linked to anxiety. Those social pressures have formed a social architecture of anxiety that is embedded within certain inherited power relationships and which manifests in an inter-subjective, embodied context. It is within this context that music therapy may be useful in the treatment of anxiety, contribute toward decreasing its prevalence, and help to increase the wellness and productivity of individuals and their roles within their communities.
Personal and Professional Context of the Author
Differences in culture (i.e. education, employment, and use of music) have always intrigued me. I am a White Cornish straight woman from the United Kingdom (UK) who has been privileged with an education from the UK and trained as a music therapist in the United States (US), and who currently lives in the US. As a practicing clinician and professor of music therapy, I am constantly cross-referencing my cultural boundaries and my trans-cultural identity because they will always be complicated, intriguing, and different from that of many colleagues and clients of the US. Yet, wherever I have lived or worked, certain community and collective phenomena and events have moved me to provide service in my field from within a trauma-informed approach. I have a passion and a privilege to use my craft to support vulnerable voices whose lives have been impacted by social hostility and to explore the relationship between social hostility and cultural/collective anxiety from a critical, reflective, and reflexive stance. I am curious to explore the cultural and collective unconscious motivations that are apparent in a social model of anxiety. Major events in my career that have shaped my current theoretical perspective have taken place in a variety of settings and countries, and have forged my motivation to continue a trauma-informed approach to my music therapy practice and pedagogy. Those experiences included practicing in quintessential English-countryside rural communities where mental health care services seemed to use the absence of empathy and professionalism as a psychological shadow tool to oppress a split part of the community psyche; and bearing witness to the terror of life bestowed upon children and youth in Romania in the wake of Nicolae Ceauşescu’s regime. In more recent years I have worked as a new Master of music therapy in the mental health hospital system in New York City through the 9/11 air attacks, and through Super-Storm Sandy, and the Boston Marathon bombings as a seasoned clinician and educator whilst also living in the affected communities. The deep social influence of these kinds of events and their relationship to anxiety is an area that I consider necessary for the field of music therapy to explore. I continue to be inspired to use my experiences and observations to look more closely at the cultural context of anxiety and the mechanism of collective anxiety from a humanitarian, psychoanalytic anthropology, and social justice perspective. My research is grounded in the US, but it also applies more broadly to the global context. Using a cultural lens, I hope to bridge the clinical-social gap in research on music therapy and anxiety.
The Cultural and Collective Context of Anxiety
According to the World Health Organization (WHO, n.d.), anxiety has become a serious international threat to global health, productivity, and sensibility. When a person suffers from anxiety, it impacts all aspects of their well-being as well as that of people close to them. Productivity, lifestyle, work, ability to maintain relationships with loved ones, and even the ability to do basic errands such as grocery shopping can be negatively impacted by anxiety. When the lens is widened and individual impacts on relationships become community or even trans-cultural issues the cultural and collective impact of anxiety can become a menacing social construct that requires inquiry and action. The presence and meaning of anxiety is different in all cultures; in certain countries there are very few reports of anxiety episodes, while in others, such as the US, anxiety is more prevalent. There is a rooted social history of anxiety in the United States that is directly linked to balancing success with a fear of failure. This history has created a widely accepted narrative of how the country has shaped itself culturally, including a clinical discourse that has, in turn, become an opportune landscape for pharmaceutical companies to explore how anti-anxiety medications can prevail a Western medical dominant narrative over potential alternatives.
Although fairly broad in terms of history and etiology, anxiety has been addressed in the literature primarily in terms of clinical treatment rather than the experience of anxiety from a social and cultural perspective. Certain authors, such as Rollo May (1996), Karen Horney (1992), Andrea Tone (2009), and Howard F. Stein (2004), have infused their psychological and medical research on anxiety with social theory, but by and large the clinical field of anxiety has remained separate from social and cultural studies.
Whereas assessment criteria in the clinical field of anxiety have remained focused on pathology (The Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; DSM–5; American Psychiatric Association, 2013), other disciplines are also involved in the broader conversation on anxiety and culture, namely sociology and psychology. Since the 1970s, certain social psychologists, such as Rollo May and Karen Horney, have commented on and theorized about anxiety as a social phenomenon stemming from modernism sensibilities. Both Horney (1992) and May (1996) drew their ideas from contemporary sociologists who questioned humanity’s relationship with anxiety. Karen Horney (1992) identified the environment as a critical factor in personality development. Her writing also touched on the notion of social hostility that has permeated the interpersonal environment with the emergence of competitive individualism. Social hostility and basic anxiety provide an overarching mechanism to further understand anxiety as a larger, cultural phenomenom. Particular social themes that Horney addressed in addition to social hostility are anxiety as a cultural experience, economics of modern society and competitive individualism, and structures in cultural processes and their relationship to the structure of neurosis. May (1996) addressed the maintenance of self as a personality and the notion of threat and fear as main characteristics that challenge personal and collective adequacy and value.
One author whose work may be helpful in further bridging the gap between the clinical and social body of knowledge on anxiety is Iain Wilkinson (2001). Wilkinson is a seminal author in sociology and anxiety who presented the notion that society is more ‘risk conscious’ in contemporary culture and that this impacts the social dynamics of modern society. This construct is generally understood as a definition of cause of anxiety or an expression of anxiety. Wilkinson (2001) theorized that it is risk consciousness that perpetuates anxiety in society. His ideas move us toward an understanding of how and why anxiety appears on the collective level and complement those from the psychology world and add to the growing need for an understanding of social impacts in anxiety theory.
Stein (2004) presented a view similar to Wilkinson’s by addressing the unconscious motivations behind certain behaviors that seem to create a collective anxiety, as well as addressing behaviors that deliberately create hostility towards others. His refreshing critical perspective on unconscious desires to soothe collective anxieties has prevailed through building on the psychoanalytical construct of the shadow part of the personality structure and the mechanism of ‘othering’ through the creation of the “evil” other. Stein (2004) develops this idea through a psychoanalytic anthropology lens by asserting that the air attacks in New York and Washington in 2001 left a “free floating anxiety” (p. 8) that has permeated the consciousness of America. He further stated that this incident left US culture in a “vicious cycle of anxiety and defense” (p. 14). In brief, Stein (2004) theorized that the 9/11 attacks were a psychological de-masculinization of iconic American symbols and a double projective identification situation that was ultimately representative of rage towards parents. Stein further stated that the reaction to the attacks was one of humiliation and rage. The rage resulted in another cycle of projections towards a split part of the collective psyche. The anxiety literature on social and cultural context such as the work of Wilkinson and Stein points toward an overarching highly charged, inter-subjective, interactive theme and therefore positions anxiety as a relational concept.
Attempts to conceptualize the intersections of anxiety, culture, and diversity have been presented by a number of fields of inquiry. The Oxford Handbook of Anxiety and Related Disorders provides a current perspective of anxiety and culture through a multi-modal clinical and anthropological approach (Asmal & Stein, 2009). Other studies have investigated the impact of anxiety with college students (Abbassi, 1999), acculturation and ethno-cultural issues (Bissiri, 1999; Vandervoort, Divers, & Madrid, 1999), organizational health care (Hinshelwood & Skogstad 2000), diagnostic patterns of anxiety, globalization and cross-cultural issues (DeCoteau, Hope, & Anderson, 2003; Horowitz, 2006; Mak 2001; Rego, 2009; Salman, Diamond, Jusino, Sanchez-LaCay, & Liebowitz, 1997; Salzman, 2001; Takriti & Ahmad, 2000), religion, and treatment and urban violence (Bressan, Lucas, Andreoli, Araújo, Breen, Guindalini, & Mari (2009).
There is a small yet growing discussion of the social experience of dissonance for those who are treated for anxiety in the United States and who have certain religious or non-Western medical perspectives. For example, in some cultures certain letters and grammatical tools are perceived as symbols of negative higher powers. If acted upon, however, these perceptions are also representative of symptoms that meet the clinical criteria for obsessive-compulsive disorder (OCD) American Psychiatric Association, 2013; DiTomasso & Gosch, 2007). Similarly, a study by Yorulmaz, Gencoz & Woody (2009) suggested a connection between compulsive behavior and extreme religious behavior (also known as “religiosity”) and that such a behavior is shaped from a psychosocial perspective at a multicultural level. Studies such as these illuminate the need for caution in the treatment of anxiety in an increasingly culturally diverse country like the United States and in the age of globalization and convergence. It is a reminder of the potential to exacerbate the dichotomy between traditional Western medical models and others models that offer diverse means of treatment for anxiety. A literature that reflects this range of beliefs and practices could help to redefine how anxiety is viewed in relation to culture in diagnostic assessment and treatment-based forums.
The lack of a trans-cultural perspective may stem from the historical context of anxiety which is deeply grounded in state and trait theoretical explorations from the 1970s. One such theorist who began the conversation was Peter Lang. In 1971, Lang presented a model of anxiety that became known as the three-part response channels: (a) cognitive-anxious predictions, assumptions, beliefs and information processing biases; (b) behavioral-avoidance, compulsions, distractions, and overprotective behaviors; (c) physiological-physical sensations, palpitations, dizziness, and sweating. The emergence of this model brought forth various theoretical and research discussions that moved anxiety into empirical research and scholarly discussions from the 1970s through to the 1990s.
Two particular theoretical models have been prevalent in producing such movements. These theories are social learning theory and state-trait anxiety theory. Social learning theory (SLT) is based on the premise that individuals learn new behavior from observing their social environment. Albert Bandura (1977) is associated with formulating this theory. The state-trait anxiety theory was developed by Michael Eysenck (1997) and is based on the premise that there is a relationship between state-only anxiety, which could be a short-term internal experience to a threatening situation, and trait-only anxiety, which implicates part of an individual’s personality and genetic structure in response to threatening situations.
This paper supports the more contemporary construction of anxiety through Matt Ridley’s (2003) concept that builds from, and combines both of these particular theories of state via trait. Ridley’s work suggested that clinical practice could better integrate causes and effects of anxiety. It compliments both state-trait theory and SLT, while challenging current Western clinical culture and perspectives towards anxiety.
In the early- to mid-1990s, Antony and Barlow (1996) and Clark and Watson (1991) provided new working definitions of anxiety. They established two unique core elements: the emotion associated with anxiety is fear, and anxiety is a future-oriented cognitive and emotional process that includes a highly charged negative affect, difficulty concentrating, a tendency to worry, and a heightened sense of lack of control over a situation. Both research papers found that the fear factor included an alarm reaction and an intense motivation to escape from perceived danger. In addition, accompanying physiological symptoms of heart-racing, sweating, and shaking were found to be more predominant in those suffering from anxiety. These landmark studies added to the growing body of literature about anxiety and launched theoretical exploration and treatment of anxiety into a new realm.
There is an important body of literature that directly connects anxiety to relationships. Originally formulated by John Bowlby in 1969, and later updated in 1982, attachment theory has influenced clinical and theoretical approaches in the field of developmental and social psychology. Bowlby postulated two key components of attachment theory: anxious and disorganized attachment in children and fearful-avoidant attachment in adults. More recent research based on working with individuals who experience fear and avoidance or anxiety in relationships is from a couple perspective (Previti & Amato, 2004) and a transgenerational perspective (Hesse & Main, 2000; Lieberman, Padron,Van Horn, and Harris, 2005) and highlights two important psychodynamic and biological mechanisms: (a) adult fearful-avoidant attachment as a developmental disorder borne out of primary caregiver experiences occurring in childhood; and (b) acknowledgement that both environmental and genetic factors are involved in shaping generational familial patterns of anxious and benevolent behavior. Beck (2010) expanded this foundational social research in anxiety by addressing the unique processes that compound issues of anxiety in the interpersonal environment. He approached this through the lens of relational theories of friendship formation, cyclical interaction patterns between parents and children, biological influences, social experiences, and the impact of anxiety disorders. Beck’s work has also increased awareness of the contribution of early bullying to adult social anxiety. Beck (2010) also was influenced by the main principles of three seminal interpersonal theories of anxiety: the aforementioned attachment theory (Bowlby, 1982), along with the interpersonal circumplex theory by Donald Kiesler (Kiesler, 1996), and the relational theories of friendship formation from the works of Harry Reis and Philip Shaver (Reis & Shaver, 1988). All of these theories focus on (a) developmental approaches and early social processes; (b) self-schemas built around others’ reactions to individual; and (c) stored information about significant others.
Some of the newer and less-researched approaches to anxiety are in the cognitive and biopsychological fields. In the cognitive group, one theory appears frequently in juried searches: attentional control theory. This theory has been tested in a growing number of studies by Coombes, Higgins, Gamble, Cauraugh, and Janelle (2009), and Eysenck, Derakshan, Santos, and Calvo (2007). Whilst they represent a small body of knowledge, these studies generate thought provoking ideas and reveal that state and trait anxiety reduces attention. This is similar to social learning theory which predicts the reaction to a task is slower when anxiety is present (Powers, Vervliet, & Smits, 2010; Rescoria & Wagner, 1972). The idea that a person’s ability to carry out simple tasks is debilitated by high levels of anxiety suggests potentially significant problems in society at large.
Intergenerational transmission of anxiety is also being discussed in the current literature. Some of the pioneers of that line of inquiry are Erik Hesse and Mary Main (2000), Evelyn Fox Keller (2010), and Matt Ridley (2003). These authors have pushed forward the exploration of links between learned patterns of anxiety and intergenerational transmission through extra-genetic influences on DNA. It seems fitting to integrate the idea of nature via nurture as previously presented in the work of Ridley (2003) and also in the work of Keller (2010). Keller’s findings in epigenetics research suggest that anxiety may be passed down through generations. This kind of work suggested that anxiety may not necessarily be hard-wired into genes, and therefore that the anxiety state could be influenced through non-pharmaceutical approaches.
As noted above, the WHO (2009) stated that anxiety has become a global economic concern. The connection of anxiety to relational and lived experience may contribute to intergenerational anxiety where a pattern of fear response to triggering events among individuals and certain groups or populations is passed down. The growing awareness of violence and global discord and links to community anxiety is reflected in the related theories of Bozo, Tunka, and Slimsek (2009). These studies have further opened the conversation and assisted efforts to bridge the gap in understanding between clinical and social impacts of anxiety. They bring us into close and intimate proximity with many perspectives on anxiety albeit with one underlying rationale: to expose and explore the impact of the relational and psycho-cultural and socio-cultural function of anxiety.
The Need for a Critical Social Theory of Music Therapy and Anxiety
The way in which the field of music therapy currently conceptualizes anxiety suggests that more studies are needed to specifically target the larger relational and social contexts of anxiety. Music therapists currently treat and discuss anxiety in vast array of clinical contexts (Kim, 2008; Lata & Dwivedi, 2001; Smith, 2008), including terminal illness (Clark et al., 2006; Ferrer, 2007; Grocke, 2008); state anxiety (Gadberry, 2011); neurobehavioural disorders (Hitchen, Magee, & Soeterik, 2010); transplants and music listening (Akombo, 2007); pregnancy and delivery (Chang, Chen, & Huang, 2008); root canal operations (Lai et al., 2008); pre-operative anxiety (Miluk-Kolasa, Klodecka-Rozka, & Stupnicki, 2002); Alzheimer’s (Guétin et al., 2009); intimate partner violence (Hernández-Ruiz, 2005; Teague, Hahna, & McKinney, 2006); students and stress (Wu, 2002); and inpatient psychiatry (Choi, Lee, & Lim,2008).
Almost all of the above examples address clinical interventions in either group work or individual inpatient issues during or after treatment for other diagnoses and disorders where anxiety became a prevalent secondary factor. Although Smith (2008) reflected a movement towards contributing to defining anxiety from the perspective of stress in the workplace, the field of music therapy is far from presenting a comprehensive view of the treatment of anxiety based on empirical evidence. There is some recent discussion about the relationship among neuroscience, music, psychoanalytic anthropology, and anxiety that may support the theoretical development of music therapy that combines these fields as well as including the more known fields of music psychology and psychology. There is however, a growing presence of the notion of social medicine in resource and recovery focused approaches in music therapy and mental health that is currently active in Europe with the work of Randi Rolvsjord (2010) in particular. Rolvsjord’s perspective compliments the pragmatist-constructivist position of this article on how collective anxiety is developed in the relational environment and how the relational-musical environment can work towards transforming those constructed meanings.
Pertinent and related literature in the musical, clinical, medical, and philosophical scholarly discussions of Karen Estrella and Michele Forinash (2007), Gemma Fiumara (2001), Mitchell Kossak (2015), Melissa Smith (2008), and Peter Vuust and Morten Kringelbach (2010) support the notion of a vibrant multisensory environment that can be harnessed through creative inquiry. Fostering such an environment allows therapists to better appreciate the kind of relationship that is built between client and therapist in music therapy. The unique interpersonal environment of music therapy provides a space to inquire about and acquire a clearer approach towards working with the relational, multisensory aspects of anxiety. Creating a sense of internal and external safety for a person experiencing anxiety is an important factor in treating that anxiety. The most reasonable way to create such safety is through an interdisciplinary approach because simply attempting to soothe anxiety as a one-dimensional operating symptom that is not in relationship to someone or something is a misrepresentation of the complex causes and impacts of anxiety. Exploring the relational connections between anxiety arousal sequences and music therapy arousal/ intervention sequences from such a multisensory perspective may shed light on the inter-subjectivity of anxiety within the music therapy context.
The famous quote from the play “The Mourning Bride” by William Congreve claims: “Music hath charms to soothe a savage breast, to soften rocks, or bend a knotted oak” (Congreve, 1697/2008). This often-misinterpreted quote (“breast” being replaced by “beast”) exemplifies the power of music to break down barriers and change the structure of things thought to be immutable. The replacement of breast with beast over time suggests that music soothes rather than re-structures, as the original quote intended. The same stance can be applied in this paper. Anxiety has many shapes, forms, and structures, and soothing certain clinical symptoms is only one part of a complicated whole. There are other voices of anxiety that require a platform for expression.
In my work with clinical improvisation and anxiety, I have witnessed the impact of the learned power dynamics in my clients’ relationships with others. This has been an important practice-based observation that has contributed to my theoretical development. The links uncovered from the sound symbols and themes that have emerged through this work have helped to uncover roots of early caregiver relationship ruptures, complicated grief, ethnic and cultural difference, and a general sense of loss and disempowerment in certain clients’ relationships. I have learned through my research that these ruptures can manifest in circumstantial situations that cause unique responses to fear of something or someone, an inability to relax, and nervousness.
In a study carried out from 2010-2012, I explored this concept using psychodynamically informed improvisation methods and vocal psychotherapy methods. Three main “sounds” emerged, which were associated with the most frequently reported symptoms of anxiety: inability to relax, nervousness, and a fear of the worst happening. These symptoms found voice in each individual clients’ improvisations through specific thematic discourse, which led clients to find root, relational, and embodied causes for their anxiety experiences, not just alleviate the symptom in the present moment. The individuals in the study who showed the most significant decrease in anxiety over time were those who suffered with generalized and social anxiety; these clients reported improved sense of wellness and productivity and increased behaviors of empowerment.
I have come to use the term behaviors of empowerment because clients reported experiencing transformations in the way they walked in the world; how they self-advocated in situations that were once perceived as disempowering, such as with people of authority (for example, bosses, teachers, parents or siblings) and how they resolved complicated grief losses that had debilitating impacts on social functioning. Clients reported that real-life enactments of relational shame and perceived danger (either physical or emotional) had eased away, and were replaced with productive engagement and participation in each individual’s social circles. In other words, the participants had re-gained a sense of transformed identity, and what I now consider the concept of productive power.
Implications for a Theory and Model of Anxiety in Music Therapy
Based on the above literature review, anxiety is best described as a relational, embodied phenomenon that is a lived, multisensory experience on individual level and in social circles. Engaging in the music therapy process is also a relational, embodied, and multisensory experience. I argue that the way in which music therapists organize ourselves through the creative process of active music engagement with the purpose of facilitating transformation makes music therapy a valuable approach for working with the larger phenomenon that we call anxiety. My intention is to take this approach beyond the walls of the clinic and into community practice. To do so will require working with groups from various backgrounds and contexts to find the “group” or ‘community” anxiety sound or sounds, and dialoguing with that group/community to seek relationships to fears and move toward group productive power. As described below, there are certain qualities to the musical experience in this context that would provide a vital role in the application of this approach. The music experience is multi-sensory as it entails relationship, supports the process of creating and providing safety, and provides an encounter with perfectionism, performance, and flow.
Anxiety as a multi-sensory, embodied experience. Given the array of options for anxiety treatment presented in the literature, there is surprisingly little discussion of the importance of visceral and multisensory memory and its relationship to anxiety. The trauma literature, however, does acknowledge the multisensory environment (Lieberman, Padron, Van Horn, & Harris, 2005; Pender, Brandt, Mahfouz, & Tylim, 2007), as does neuroscience with the emerging understanding of the neurological structures of music expectation and sensation of predictability (discussed below) (Vuust & Kringelbach, 2010). As argued above, the literature on anxiety reflects an interest in the effect of behavioral changes on symptoms but has not addressed other ways of working with the relational etiology of stress, whether from genetic or environmental sources, that leads to anxious behaviors. However, the overall climate of scholarly discussion suggests that a movement towards learning more about the brain’s functioning in times of stress and anxiety has begun. Such a body of knowledge may allow for the discovery of how anxiety is experienced on cognitive, behavioral, emotional, social, biological, and spiritual levels, rather than from a single perspective. There are certain authors who have contributed to foundational work in this discussion. Estrella and Forinash provided insights into the multisensory environment from a narrative inquiry perspective, and Fiumara (2001) exposed the idea of the mind’s affective life from a philosophical and theoretical perspective. Vurst and Kringelbach (2010) brought forth new knowledge in neuroscience regarding the mechanism of music expectation and how that mechanism is activated when the music is internally processed through the imagination or externally through a recorded or live musical sample. Kossak (2015) discusses a need for a deeper understanding of attunement as a healing agent that is foundationally bio-physical and organized through relationships between humans, sound rhythm, and certain frequencies.
Safety, relationship, and transformation. There is a wide range of ideas within the areas of safety, relationship, and transformation for music therapists to consider. As discussed above, music therapists have a respect for and deep knowledge of the lived experience and the unique capacity for deep transformations to occur within the music therapy relationship. According to Beck (2010), Keller (2010), and Ridley (2003), anxiety is an interpersonal phenomenon that is activated through a learned conscious or intergenerational fear response pattern to perceived danger. The unique interpersonal environment is an area from which theoretical inquiry into a clearer approach towards working with the relational aspects of anxiety can begin. Creating a sense of internal and external safety for a person experiencing anxiety is a foundational first step.
For example, Benedicte Scheiby (2005) illustrated the uniqueness of the music therapeutic relationship, describing it as a more “mutual relationship than the typical relationship in verbal psychotherapy. Because the music therapist also plays music in the work [and] in order for transformation to take place, the music therapist and the client must go on a musical journey together” (p .10). Baker and Wigram (2005) stated: “The process of creating, notating, and/or recording lyrics and music by the client or clients and therapist within a therapeutic relationship [is used] to address psychosocial, emotional, cognitive, and communication needs of the client” (p. 67). Working from a multicultural perspective, Shapiro (2005) shared that by “appreciating, learning about participating in another person’s musical culture, and encouraging them to share it with others can be influential in forming therapeutic relationships, especially with people who cannot speak the dominant language” (p. 29). Oldfield (2006) also placed emphasis on the intrinsic interactive qualities of the therapeutic alliance in music therapy.
According to Mitchell Kossak (2009; 2015), attunement is the fundamental ingredient required for healing to occur in the therapeutic alliance. When this attunement is shared through sound, it is amplified, and the unique experience of playing music together matches the constant flux of stem cells in the brain to work in syncopation in real time. Kossak postulates that this is where the physical transforms into the emotional state, and the therapeutic relationship allows for a change in perception of such states. Kossak’s theory suggests a potential perspective of applying attunement as an active mechanism from a critical social improvisation perspective; one that supports the idea of cultural difference and anxiety as being held in real time in improvisation. This consideration offers an opportunity to de-mystify and dismantle the learned, or conditioned lived experience of difference and consider a broader conversation around trans-cultural healing of collective anxiety between communities.
Perfectionism, Performance, and Flow
There cannot be a full discussion of anxiety and music without spotlighting core concepts of performance anxiety and their impact on individual and group sense of productivity and purpose. Performance anxiety is similar to a more general “fear of the worst,” which is a frequently cited problem for many individuals (Zarate, 2012).
The major studies in music therapy research on performance anxiety lean towards behavioral psychology in design and approach and address cognitive responses (Elliot, Polman, & McGregor, 2011; Kim, 2008; Orman, 2004; Silverman; 2010;), music listening and neurophysiological responses (Krout, 2007), live music-making in the workplace (Smith, 2008), the effect of live music-making on performance anxiety with musicians (Kim, 2008), and performance wellness that works with the “polarizing perfectionist” (Montello, 2002, 2005, 2010, p. 112). The performance wellness model aims to transform the polarizing elements in the musical themes through a variety of improvisational techniques, such as musical self-statements and group music improvisation. It has been the predominant relational and improvisational-based music therapy model used to treat performance anxiety with musicians specifically. In the field of music psychology, however, Kirchner, Bloom, and Skutnick-Henley (2008) have investigated the experiences of performance in terms of sense of relaxation or sense of flow. This is an area that music therapy theory and practice could draw upon to address the social contexts of anxiety for musicians and non-musicians. The researchers’ work with musicians highlighted certain areas of experience such as (a) relaxed/feel-good/enjoyment, (b) emotional expression, (c) loss of awareness of time/pain/sound, (d) reaching goals/getting the right feel effortlessly, (e) being absorbed/immersed/focused, (f) transcention/dissociation, and (g) not having to think. Such areas are similar to qualities of empowerment and presence with self and other that may benefit a broader group of people (i.e. non-musicians).
Exploring the Broader Impact: Music and Productive Power
Music is a global resource that can be harnessed to strive for social sustainability and social agency in villages, towns, or cities. A recent compendium released by the United Nations, Music as a Global Resource (Heinemann & Hesser, 2011), reported a number of different studies and projects that have used music in education, as art, and as therapy. Those studies and projects collectively revealed positive outcomes in quality of life in various communities throughout the world. Specifically, a sense of social agency gained through music in the community is seen in the work of musicologists and music therapists who have established this paradigm and begun critical conversations on and action-oriented direction of individual and collective movements (DeNora, 2004; Hadley, 2013; Hahna, 2013; Kenny, 2006; Navaro Wagner, 2015; Pavilcevic & Ansdell, 2004; Ruud, 2010; Stige, 2002).The discussion I put forward in this paper highlights anxiety as an embodied, relational, intersubjective social construct with rapidly growing transgenerational and transcultural components. Music therapists hold a unique expertise in and knowledge of how to transform and transcend such an omnipresent construct. An anxiety and music therapy theory has potential to better identify and define anxiety within our convergent current culture.
To conclude, the way we think about anxiety in the creative process of music-making is key to understanding the broader negative impacts of anxiety in communities. Engaging and participating in the conversation about anxiety from a multisensory, psychoanalytic anthropology and humanitarian perspective supports the idea of a social architecture of anxiety and music therapy theory. New areas of our work may emerge by harnessing the qualities of the multisensory environment and relational characteristics in our music-making with others. More poignantly, this theory could address key symptoms of anxiety by analyzing their impact on individual and group empowerment and sense of productive power. It is difficult to form a theoretical structure around a topic that is, as Pearson (2008) pointed out, simultaneously “unbearably vivid yet insanely abstract” (p. 11). I presented an idea that challenges our own music therapy culture on how we define and locate anxiety. I am eager to engage with those who would like to continue the discussion and are moved to approach the work through this lens.
Abbassi, A. (1999). Culture and anxiety: A cross-cultural study. Dissertation Abstracts International, 59, (11-A), 4065.
Akombo, D. (2007). Effects of listening to music as an intervention for pain and anxiety in bone marrow transplant patients. Dissertation Abstracts International, 68, (1-A), 19.
American Psychiatric Association (2013). Diagnostic and Statistical manual of Mental Disorders, 5th Edition (DSM-5). Washington, DC: American Psychiatric Association. doi: 10.1176/appi.books.9780890425596
Antony, M. M., &. Barlow, D. H. (1996). Emotion theory as a framework for explaining panic attacks and panic disorder. New York, NY: Guilford Press.
Asmal, L., & Stein, D. J. (2009). Anxiety and culture. In M. Antony (Ed.), The Oxford handbook of anxiety and related disorders (pp. 657–666). New York, NY: Oxford University Press.
Baker, F., & Wigram, T. (2005). Songwriting: Methods, techniques, and clinical applications for music therapy clinicians, educators, and students. Philadelphia, PA: Jessica Kingsley Publishers.
Bandura, A. (1977). Social learning theory. New York, NY: General Learning Press.
Beck, G. J. (2010). Interpersonal processes in the anxiety disorders: Implications for understanding psychopathology and treatment. Washington, D.C: American Psychological Association. doi: 10.1037/12084-000
Bissiri, K. A. (1999). Self-construals, culture change, and the expression of distress in Chinese and Chinese Americans (aculturation). Dissertations International: Section B: The Sceinces and Engineering, 59(10-B), 3594.
Bressan, R. A. Q., Lucas, C., Andreoli, S. B., Araújo, C., Breen, G., Guindalini, C., … Mari, J. J. (2009). The posttraumatic stress disorder project in Brazil: Neuropsychological, structural and molecular neuroimaging studies in victims of urban violence. BMC Psychiatry, 9, 30. doi: 10.1186/1471-244X-9-30
Bowlby, J. (1982). Attachment. Attachment and loss (2nd ed., Vol. 1). New York, NY: Basic Books.
Bozo, O., Tunca, A., & Slimsek, Y. (2009). The effect of death anxiety and age on health-promoting behaviors: A terror-management theory perspective. Journal of psychology: Interisciplinary and Applied, 143(4), 377–389. doi: 10.3200/JRLP.143.4.377-389
Chang, M-Y., Chen, C-H., & Huang, K-F. (2008). Effects of music therapy on psychological health of women during pregnancy. Journal of Clinical Nursing, 17 (19), 2580–2587. doi: 10.1111/j.1365-2702.2007.02064.x
Choi, A. N., Lee, M. S., & Lim, H. J. (2008). Effects of group music intervention on depression, anxiety, and relationships in psychiatric patients: A pilot study. The Journal of Complimentary Medicine, 14(5), 567-570. doi: 10.1089/acm.2008.0006
Clark, L. A., & Watson, D. (1991). Tripartite model of anxiety and depression: Psychometric evidence and taxonomic implications. Journal of Abnormal Psychiatry, 100, 316 - 336.
Clark, M., Isaaks-Downton, G., Wells, N., Redlin-Frazier, S., Eck, C., Hepwrok, J. T., &Chakravarthy, B. (2006). Use of preferred music to reduce emotional distress and symptom activity during radiation therapy. Journal of Music Therapy, 43, 247–265. doi: 10.1093/jmt/43.3.247
Congreve, W. (2008). The mourning bride: A tragedy. Retrieved from http://www.amazon.com/dp/B0056IC8I8/ref=rdr_kindle_ext_tmb
Coombes, S., Higgins, T., Gamble, K. M., Cauraugh, J. H., & Janelle, C. M. (2009). Attentional control theory: Anxiety, emotional and motor planning. Journal of Anxiety Disorders, 23, 1072–1079. doi: 10.1016/j.janxdis.2009.07.009
DeCoteau, T. J., Hope, D. A., & Anderson, J. (2003). Anxiety, stress, and health in northern plains Native Americans. Behavior Therapy, 34,365–380. doi: 10.1016/S0005-7894(03)80006-0
DeNora, T. (2004). Empirical musicology: Aims, methods, prospects. London: Oxford University Press.
DiTomasso, R. A., & Gosch, E. A. (2007). Anxiety disorders: A practioner's guide to comparative treatments. New York, NY: Springer.
Elliott, D., Polman, R., & McGregor, R. (2011). Relaxing music for anxiety control. Journal of Music Therapy, 48, 264–288. doi: 10.1093/jmt/48.3.264
Eysenck, M.W. (1997). Anxiety and cognition: A unified theory. East Sussex, UK: Psychology Press.
Eysenck, M. W., Derakshan, N., Santos, R., & Calvo, M. G. (2007). Anxiety and cognitive performance: Attentional control theory. Emotion, 7, 336–353. doi: 10.1037/1528-35220.127.116.116
Estrella, K., & Forinash, M. (2007). Narrative inquiry and arts-based inquiry: Multi-narrative perspectives. Journal of Humanistic Psychology, 47, 376–383. doi: 10.1177/0022167807301898
Ferrer, A. (2007). The effect of live music on decreasing anxiety in patients undergoing chemotherapy treatment. Journal of Music Therapy, 44, 242–255. doi: 10.1093/jmt/44.3.242
Fiumara C. G. (2001). The mind’s affective life. Philadelphia, PA: Taylor and Francis.
Gadberry, A. (2011). Steady beat and state anxiety. Journal of Music Therapy, 48, 346-356. doi: 10.1093/jmt/48.3.346
Grocke, D. (2008). The effect of music therapy on anxiety in patients who are terminally ill. Journal of Palliative Medicine, 11, 582–590. doi: 10.1089/jpm.2007.0193
Guétin, S., Portet, F., Picot, M. C. Messaoudi, M., Djabelkir, L., Olsen, A. L., . . . Touchon, J. (2009). Effect of music therapy on anxiety and depression in patients with Alzheimer's type dementia: Randomized, controlled study. Dementia and Geriatirc Cognitive Disorders, 28(1), 36–46. doi: 10.1159/000229024
Hadley. S. (2013). Dominant narratives: Complicity and the need for vigilance in the creative arts therapies. The Arts in Psychotherapy, 40, 373–381. doi: 10.1016/j.aip.2013.05.007
Hahna, N. (2013). Towards an emancipatory practice: Incorporating feminist pedagogy in the creative arts therapies. The Arts in Psychotherapy, 40, 436–440. doi: 10.1016/j.aip.2013.05.002
Heinemann, H. N., & Hesser, B. (Eds.). (2011). Music as a global resource: Solutions for social and economic issues. Retrieved from http://www.international-iccc.org/MAGR_FINAL_2011.pdf
Hernández-Ruiz, E. (2005). Effect of music therapy on the anxiety levels and sleep patterns of abused women in shelters. Journal of Music Therapy, 42, 140–158. doi: 10.1093/jmt/42.2.140
Hesse, E., & Main, M. (2000). Disorganized infant, child and adult attachment: Collapse in behavioral and attentional strategies. Journal of the American Psychoanalytic Association, 48, 1097–1127. doi: 10.1177/00030651000480041101
Hinshelwood, R. D., & Skogstad, W. (2000). Observing organizations: Anxiety, defense and culture in health care. New York, NY: Routledge.
Hitchen, H., Magee, W. L., & Soeterik, S. (2010). Music therapy in the treatment of patients with neuro-behavioural disorders stemming from acquired brain injury. Nordic Journal of Music Therapy, 19, 63. doi: 10.1080/08098130903086404
Horney, K. (1992). Our inner conflicts: a constructive theory of neurosis. New York, NY: Norton.
Horowitz, J. (2006). Culture-bound syndromes of anxiety disorders and mutlicultural competence. Dissertation Abstracts International: Section B: The Sciences and Engineering, 66(7-B), 3949.
Keller, E. F. (2010). The mirage of a space between nature and nurture. USA: Duke University Press. doi: 10.1215/9780822392811
Kenny, C. (2006). Music & life in the field of play. Gilsum, NH: Barcelona Publishers.
Kim, Y. (2008). The effect of improvisation-assisted desensitizaiton, and music-assisted progressive muscle relaxation and imagery on reducing pianists' music performanc anxiety. Journal of Music Therapy, 45, 165–191. doi: 10.1093/jmt/45.2.165
Kiesler, D. J. (1996). From communications to interpersonal theory: A personal odyssey. Journal of Personality Assessment, 66, 267–282. doi: 10.1207/s15327752jpa6602_6
Kirchner, J. M., Bloom, A. J., & Skutnick-Henley, P. (2008). The relationship between performance anxiety and flow. Medical Problems of Performing Artists, 23(2), 59–65.
Kossak, M. (2009). Therapeutic attunement: A transpersonal view of expressive arts therapy. The Arts in Psychotherapy, 36, 13-18. doi: 10.1016/j.aip.2008.09.003
Kossak, M. (2015). Attunement in expressive therapies. Springfield: IL. Charles C. Thomas.
Krout, R. E. (2007). Music listening to facilitate relaxation and promote wellness: Integrated aspects of our neurophysiological responses to music. The Arts in Psychotherapy, 34,134–141. doi: 10.1016/j.aip.2006.11.001
Lai, H., Hwang, M. J., Chen, C. J, Chang, K. F., Peng, T. C., & Chang, F. M. (2008). Randomized controlled trial of music on state anxiety and physiological indices in patients undergoing root canal treatment. Journal of Clinical Nursing, 7 (19), 2654–2660. doi: 10.1111/j.1365-2702.2008.02350.x
Lang, P. (1971). The application of pyschophysiological methods to the study of psychotherapy and behavior modification. New York, NY: Wiley Publishers.
Lata, S., & Dwivedi, K. (2001). The effect of music on anxiety. Psycho-Lingua, 31(2), 143–146.
Lieberman, A. F., Padron, E.,Van Horn, P., & Harris, W. W. (2005). Angels in the nursery: The intergenerational transmission of benevolent parental influences. Infant Mental Health Journal, 26(6), 504–520. doi: 10.1002/imhj.20071
Mak, W. W. S. (2001). A culture specific model of vulnerability to psychological distress: The role of self-construals and cognitive personality styles on anxiety and depression. Dissertation abstracts international: Section B: The sciences and engineering, 62(3-B), 1586.
May, R. (1996). The meaning of anxiety. New York, NY: The Ronald Press Company.
Miluk-Kolasa, B., Klodecka-Rozka, J., & Stupnicki, R. (2002). Polish Psychological Bulletin, 33(2), 55–60.
Montello, L. (2002). Essential musical intelligence. Wheaton, IL: Quest Books.
Montello, L. (2005). The performance wellness manual. Honesdale, PA: Innovations Press.
Montello, L. (2010). The performance wellness seminar: An integrative music therapy approach to preventing performance-related disorders in college-age musicians. Music and Medicine, 2(2), 109–116. doi: 10.1177/1943862110364231
Navaro-Wagner, A. (2015). The art of re-framing. Voices: A World Forum for Music Therapy, 15(1). DOI: doi: 10.15845/voices.v1i1.769
Oldfield, A. (2006). Interactive music therapy: A positive approach. Philadelphia, PA: Jessica Kingsley Publishers.
Orman, E. K. (2004). Effect of virtual reality graded exposure on anxiety levels of performing musicians: A case study. Journal of Music Therapy, 41, 70–79. doi: 10.1093/jmt/41.1.70
Pearson, P. (2008). A brief history of anxiety: Yours and mine. New York, NY: Bloomsbury USA.
Pender, V. B., Brandt, J. C., Mahfouz, A., & Tylim, I. (2007). Approaches to prevention of intergenerational transmission of hate, war, and violence. The International Journal of Psychoanalysis, 88, 507–514. doi: 10.1516/BX7R-1468-0207-7Q75
Powers, M. B., Vervliet, B., & Smits, J. A. J. (2010). Helping exposure succeed: Learning theory perspectives on treatment resistance and relapse. In M. Otto & S. G. Hofmann (Eds.), Avoiding treatment failures in the anxiety disorders (pp. 31–49). New York, NY: Springer Science + Business Media.
Previti, D., & Amato, P. R. (2004) Is infidelity a cause or consequence of poor marital quality? Journal of Social and Personal Relationships, 15(3), 93–94. doi: 10.1177/0265407504041384
Rego, S. A. (2009). Culture and anxiety disorders. In S. A. G. Eshun & A. R. Regan (Eds.), Culture and mental health: Sociocultural influences, theory, and practice (pp. 197–220). Chichester, UK: Wiley-Blackwell. doi: 10.1002/9781444305807.ch10
Reis, H. X., & Shaver, P. (1988). Intimacy as an interpersonal process. In S. W. Duck (Ed.), Handbook of personal relationships (pp. 367–389). Chichester, UK: Wiley.
Rescoria, R. A. & Wagner, A. R. (1972). A theory of Pavlovian conditioning: Variations in the effectiveness of reinforcement and nonreinforcement. In A. H. Black & W. F. Prokasy (Eds.), Classical conditioning II: Current theory and research (pp. 64–99). New York, NY: Appleton-Century-Crofts.
Ridley, M. (2003). Nature via nurture: Genes, experience, and what makes us human. New York, NY: HarperCollins.
Rolvsjord, R. (2010). Resource-oriented music therapy in mental health care. University Park, IL: Barcelona Publishers.
Ruud, E. (2010). Music therapy: A perspective from the humanities. Gilsum, NH: Barcelona Publishers.
Salman, E., Diamond, K., Jusino, C., Sanchez-LaCay, A., & Liebowitz, M. R. (1997). Hispanic Americans: Cultural issues in the treatment of anxiety. New York, NY: Guilford Press
Salzman, M. (2001). Globalization, culture, and anxiety: Perspectives and predictions from terror management theory. Journal of Social Distress & the Homeless, 10, 337–352. doi: 10.1023/A:1011676025600
Scheiby, B. (2005). An intersubjective approach to music therapy: Identification and processing of musical countertransference in a music psychotherapeutic context. Music Therapy Perspectives, 23, 8–17. doi: 10.1093/mtp/23.1.8
Shapiro, N. (2005). Sounds in the world: multicultural influences in music therapy in clinical practice and training. Music Therapy Perspectives, 23, 29–35. doi: 10.1093/mtp/23.1.29
Silverman, M. J. (2010). The effect of pitch, rhythm, and familiarity on working memory and anxiety as measured by digit recall performance. Journal of Music Therapy, 47, 70–83. doi: 10.1093/jmt/47.1.70
Smith, M. (2008). The effects of a single music relaxation session on state anxiety levels of adults in a workplace. Journal of Music Therapy, 19, 45–66.
Stein, H. F. (2004). Beneath the crust of culture: Psychoanalytic anthropology and the cultural unconscious in American life. New York: NY: Rodopi B.V.
Stige, B. (2002). Culture centered music therapy. Gilsum, NH: Barcelona Publishers.
Takriti & Ahmad. (2000). Anxiety disorders and treatment in Arab-Muslim culture. In Ihsan Al-Issa (Ed.), Al-Junun: Mental illness in the Islamic world (pp. 235–252). Madison, CT: International Universities Press.
Teague, A. K., Hahna, N. D., & McKinney, C. H. (2006). Group music therapy with women who have experienced intimate partner violence. Music Therapy Perspectives, 24, 80–86. doi: 10.1093/mtp/24.2.80
Tone, A. (2009). The age of anxiety. New York, NY: Basic Books.
Vuust, P., & Kringelbach, M. L. (2010). The pleasure of music. In M. Kringelbach & K. C. Berridge (Eds.), Pleasures of the brain (pp. 255–265). New York, NY: Oxford University Press.
Vandervoort, D. D., Divers, P. P., & Madrid, S. (1999). Ethno-culture and irrational beliefs. Current Psychology, 18, 287–293. doi: 10.1007/s12144-999-1003-5
Wilkinson, I. (2001). Anxiety in a risk society. London, UK: Routledge. doi: 10.4324/9780203465462
World Health Organization (n.d.). Global health observatory data repository. Retrieved from http://apps.who.int/ghodata/?vid=20800&theme=country
Wu, S. M. (2002). Effects of music therapy on anxiety, depression and self-esteem of undergraduates. Psychologia: An International Journal of Psychology in the Orient, 45(2), 104–114. doi: 10.2117/psysoc.2002.104
Yorulmaz, O., Gencoz, T., & Woody, S. (2009). OCD cognitions and symptoms in different religious contexts. Journal of Anxiety Disorders, 23(3), 401-406. doi: 10.1016/j.janxdis.2008.11.001
Zarate, R. (2016). Clinical Improvisation and its effect on anxiety: A multiple single subject design. The Arts in Psychotherapy, 48, 46-53. doi: 10.1016/j.aip.2015.11.005
Zarate, R. (2012). The Sounds of Anxiety: A Quantitative Study in Music Therapy and Anxiety. Proquest dissertations and theses, UMI: 3509411.