Non-pharmacological interventions that have been beneficial for managing both pain and anxiety include those such as paced breathing techniques, muscle relaxation, or attention diversion (Symreng & Fishman, 2004). Indeed, relaxation has been shown to be an important element in relieving pain (Ezenwa et al., 2018) and anxiety (Nelson, Adamek, & Kleiber, 2017) and as musical experiences (e.g. music making such as singing or listening to pre-recorded music) elicit and evoke emotional responses in us, they are often used to regulate emotions (Lonsdale & North, 2011) but also for the purpose of pain relief (Tamplin & Clark, 2016).

Music interventions have been shown to be efficacious at relieving anxiety, depression (Lai, Li, & Lee, 2012), pain, and inducing a state of relaxation (Liu & Petrini, 2015). It is proposed music may act as a distractor from patients’ psychological and physiological sensations as well as reducing patients’ experiences of discomfort (Nilsson, 2008) by serving as an audioanalgesic, audioanxiolytic, or audiorelaxant, as well as music listening having an effect on hospital patients’ stress responses (Nilsson, 2009). A systematic review (Bradt, Dileo, & Shim, 2013) found that music listening might be beneficial for reducing anxiety in people with myocardial infarction, also indicating that music listening may reduce pain. Although music as a distractor is an important mechanism in anxiolytic responses (Nilsson, 2008), Bradt et al. (2013) argued that music also affords an aesthetic experience, able to offer comfort, and creative engagement in music may result in an increase in perceived control. In a surgical setting, Wu, Huang, Lee, Wang, and Shih (2017) reported significantly reduced anxiety for patients undergoing an awake craniotomy after listening to their preferred music. Although Gillen, Biley, and Allen (2008) found that anxiety reduction from music listening seems to be more strongly reflected in the psychological parameters (e.g. State-Trait Anxiety Inventory) rather than physiological markers of anxiety and stress (e.g. heart rate), the aforementioned overlap between the physiological and psychological aspects of pain and anxiety/depression points towards a cumulative intervention effect. This may be important in designing interventions for patients suffering from these psychological and physical symptoms. Results of studies presented here seem to generally suggest consistently positive and significant reduction in anxiety and pain due to music intervention, as well as increased relaxation and decreased depression.

Music interventions can also be delivered in a tactile manner such as with pulsed, sinusoidal, low frequencies between 20–120 Hz through a recliner chair or mattress combined with music listening and therapeutic interaction. When applied by a trained practitioner, these combined elements (see Figure 1) are referred to as Vibroacoustic (VA) treatment (Campbell, Hynynen, & Ala-Ruona, 2017). Low frequencies may also be delivered without music listening, based on the client’s needs and preferences, e.g. music may evoke memories or sensations which the client is not yet ready to address. The rationale for listening to music is therefore based on whether the music listening may enhance the experience for the client. For those who enjoy music, it may more readily enable relaxation and offer a source of comfort.

As is often the case for music listening, relaxation is one of the most commonly reported outcomes of VA treatment (Ala-Ruona, Punkanen, & Campbell, 2015; Campbell, Hynynen, & Ala-Ruona, 2017). The relaxation response, a relaxed but alert state elicited through repeated and focused meditative practices (Benson, 1975), is posited to be one possible explanation for the positive outcomes associated with this treatment modality (Punkanen & Ala-Ruona, 2012). Recent studies focusing only on the pulsed sinusoidal low frequency sound vibration, i.e. without music listening or therapeutic interaction, have shown that low frequencies are beneficial for pain relief and mood regulation (Braun Janzen, Paneduro, Picard, Gordon, & Bartel, 2019; Naghdi, Ahonen, Macario, & Bartel, 2015), anxiety reduction (Rüütel, Ratnik, Tamm, & Zilensk, 2004), spasticity in those with spinal cord and brain injuries (Rüütel, Vinkel, & Eelmäe, 2017), can be beneficial for decreasing both pain and stress, and increasing emotional enrichment, concentration, and physical and emotional relaxation (Ahonen, Deek, & Kroeker, 2012) as well as reducing anxiety and affording relaxation in those with Alzheimer’s disease (Clements-Cortés, Ahonen, Freedman, & Bartel, 2017). Campbell, Hynynen, and Ala-Ruona (2017) showed improvements in pain, mood, and relaxation for those receiving the combined treatment of low frequencies and music listening with therapeutic interaction. Skille and Wigram (1995) compared the effects of music plus vibroacoustic stimulation (40 and 55 Hz) to music alone for those with multiple physical disabilities, finding that vibroacoustics was beneficial in reducing muscle tone and increasing range of motion. Wigram (1996) compared new age music listening, vibroacoustics (40 Hz), and lying in silence with non-clinical participants and found reduced arousal in the vibroacoustic group compared to both the music and control group. Both vibroacoustics and music groups had reduced heart rate compared to the silence group. Rüütel (2002) also examined the effects of music, vibroacoustics, and silence on healthy people, finding that one or two sessions of vibroacoustics were beneficial for reducing fatigue or stress for healthy people in everyday life.

These studies have examined the effects of low frequencies alone, the combination of all three VA treatment elements, as well as comparing the effects of low frequencies with and without music. However, the role that music listening plays in the treatment session with therapeutic interaction has not been explored. As discussed, music listening has been shown to be efficacious at inducing a relaxed state and relieving pain, anxiety, and depression. Low frequency vibration has also been shown to do so, as has the combination of music listening, low frequencies, and therapeutic interaction. Given that both music and vibration can be beneficial for symptom relief, the aim of this study was to explore in more detail the role that the music listening element within a practitioner-supported VA treatment setting may have with a client suffering from chronic pain, anxiety, and depression. Furthermore, this study investigates whether the client’s perception and experience of her symptoms - and the influence VA treatment has thereon - are enhanced by music listening.

A mixed method, n-of-1 crossover design was used to explore the role of music in VA treatment, integrating quantitative and qualitative data to triangulate the results and findings to gain a greater understanding of these subjective physical and psychological phenomena. Although quantitative methods are helpful when addressing the relationship between specific variables, they are not suitable for answering process-oriented questions that can be addressed using qualitative approaches (Leech & Onwuegbuzie, 2007). Triangulation of mixed methods is used to describe an issue (e.g. pain) from several perspectives to gain a more complete impression of the phenomenon (O’Cathain, Murphy, & Nicholl, 2010). In case studies, the quantitative data can shed light on a patient’s change (e.g. potential improvement) during the therapeutic process, whilst the qualitative data may be used to understand the sudden fluctuations on the symptoms represented in the quantitative scales (Sandahl & Wilberg, 2006).

Jane was a 34-year-old mother of two living with her partner who was on disability sick leave. She first took leave in 2008 due to burnout and then due to surgery for a herniated disc in 2012 after a brief return to work. She had moderate depression, panic disorder and anxiety, difficulty relaxing and sleeping, stress, tension headaches, migraines, and shoulder pain, although there was no organic reason for these symptoms. The lack of discernible medical explanation for her collection of symptoms may be grouped under the term Medically Unexplained Symptoms (MUS). This includes musculoskeletal pain and ‘pseudoneurology’ – tiredness, sleeping issues, fatigue, and mood changes (Eriksen & Ursin, 2004). Although unexplained, these symptoms have, in addition to headaches, high blood pressure, and emotions such as anger, anxiety, and panic, been linked to negative stress (Yehuda & Seckl, 2011) such as from shock. She explained she would like to move forward with her life but was feeling stuck. Once or twice per month, Jane visited her local healthcare centre and spoke with the psychiatric nurse. She did not take any medication, except for analgesics when migraines were particularly severe. She had applied to participate in music therapy as part of clinical training at the Music Therapy Clinic for Research and Training at the University of Jyväskylä, Finland, and due to the severity and collection of symptoms, was approached by EAC regarding her willingness to participate in VA treatment instead of music therapy for managing pain and comorbid symptoms. The research was conducted at the music therapy clinic and therefore followed the general principles and rules of therapeutic work at healthcare units. She gave informed consent to have weekly sessions and to publish her experiences of the process.

Vibroacoustic (VA) treatment consists of three elements: pulsed sinusoidal low frequency sound vibration (20-120Hz), (client preferred) music listening, and therapeutic interaction between client and practitioner (Campbell, Hynynen, & Ala-Ruona, 2017; Ala-Ruona & Punkanen, 2017). The music listening and low frequency sound vibration are received simultaneously. The sound vibration is transmitted through devices such as chairs, cushions, or mattresses whilst the music listening is typically delivered through headphones. In general, the procedure is conducted in several stages: preparation for the session (setting up the equipment), introducing the client to the treatment modality, beginning the combined sound vibration and music listening, monitoring the client’s reception, ending the stimulus, and post-stimulus work (e.g. processing) (Grocke & Wigram, 2007). The therapeutic relationship between the client and practitioner may take the form of verbal interaction between the client and practitioner, usually before and after the low frequency sound vibration and music listening. However, in some cases, the client may wish to interact with the practitioner during the stimulation. A client may fall asleep during the stimulus and the practitioner’s role thereafter is to reassure and guide the client back to the present moment. Before and after the stimulus, the practitioner plays an important role in experiential processing. This may take the form of offering comfort and helping the client to process and reflect on experiences and sensations.

The VA treatment procedure in this study was as follows: 10 VA treatment sessions were planned with the client (hereafter referred to as ‘Jane’) to take place once per week in a single case crossover design of Vibroacoustic sessions with (VA-Music) and without (VA-Silence) music listening. Jane wore headphones in all sessions, but no music was played during VA-Silence sessions. Before the first session, the practitioner asked Jane to send a list of her preferred music listening choices. Jane suggested some artists to which she sometimes listened and the practitioner made a playlist based on these suggestions. The VA sessions took place in a music therapy clinic equipped with a Next Wave Physioacoustic recliner chair (Next Wave, n.d.). The client lay in a supine position on this chair with a blanket during all sessions and the lights were dimmed during the low frequency stimulation. The same 20-minute low frequency programme (ranging from 29—61 Hz) was used in all sessions; this frequency range has been beneficial for managing physical and psychological disorders and inducing relaxation (Campbell, Hynynen, & Ala-Ruona, 2017).

The client received eight sessions in total; two sessions were cancelled due to illness. Four sessions (S1, S3, S5, S6) comprised usual protocol for VA treatment: low frequency sound vibration, music listening, and therapeutic interaction (VA-Music). Four sessions (S2, S4, S7, S8) comprised all of these elements minus music listening (VA-Silence). It was planned that every second session would be VA-Silence, however this change in scheduling was made for therapeutic reasons (discussed in sections Control through choice and Music as a translational mechanism).

Sessions 1 and 2 focused on preparing Jane for the procedure and becoming accustomed to the sensation of low frequencies and discussing her difficulty with relaxation in general. Sessions 3-5 focused on how Jane could become more aware of her physical sensations as a way to anchor her in the present moment. She was also paying attention to the effects of the treatment and beginning to integrate these changes into her daily life. Sessions 6 and 7 were about making choices for her regarding self-care (e.g. taking medication, receiving massage) and noticing other changes outside the sessions. The final session further explored making choices and how the effects of the sessions may be translated into daily life, and expressing a willingness to continue to try and help her.

The data for this study consisted of both qualitative and quantitative measures. The qualitative data were transcribed discussions between Jane and Practitioner, whilst the quantitative data comprised Visual Analogue Scales (VASs). A VAS is a unidimensional self-complete scale composed of a horizontal 100mm line with two verbal descriptors on either end (Hawker et al., 2011). The scales used in the present study assessed pain (VAS-P), mood (VAS-M), anxiety (VAS-A), and relaxation (VAS-R) and were completed by Jane before and after each 20-minute treatment programme in each session. The anchors for these scales were: 0 (worst pain imaginable) to 100 (no pain); 0 (depressed) to 100 (happy); 0 (very anxious) to 100 (no anxiety); and 0 (tense) to 100 (relaxed) respectively. At all VAS measurement points, Jane was asked to mark each scale to represent her current state at that moment, thereby enabling an assessment of both within- and between-session change. Visual Analogue Scales are widely implemented in diverse populations due to low respondent burden and ease of administration (Hawker, Mian, Kendzerska, & French 2011).

To assess the validity of the analysis, a member check interview – otherwise referred to as a validation interview – was conducted with Jane to discuss the emergent themes and their genesis based on the transcripts, and to “confirm, substantiate, verify or correct researchers’ findings” (Buchbinder, 2011), i.e. to discuss whether the themes presented accurately represented the discussions and her experiences during the treatment process. In the interview, EA-R presented both quantitative results and the qualitative findings to assess if these were accurate representations of her experience during the process or not, whether she wished to add something to the outcomes which she felt was important, or whether there were aspects she wished to correct in the results and findings to better portray the sessions. (EAC’s role in this process is discussed in the subsequent section.) Conducting the member check interview – termed as descriptive triangulation – in which the researcher(s) show the findings or interpretations to the participants in order to assess accuracy, was a means of increasing trustworthiness of the qualitative findings (Leech & Onwuegbuzie, 2007).

When viewing the overall process, Jane recorded clinically relevant pain decrease and relaxation increase were when only the pre- treatment score from Session 1 and the post-treatment score from Session 1 are presented (i.e. both VA-Music and VA-Silence sessions). At the end of the process, her pain corresponded to no pain and relaxation corresponded to mild tension when following the interpretation guidelines (Jensen et al., 2003). Mood and anxiety deteriorated during this time to a minimal clinically relevant degree (see Table 1). Both mood and anxiety were moderate at the end of the treatment process.

When comparing the mean VAS outcomes between the music and silence sessions, VAS-M, VAS-A, and VAS-R showed improvement; VAS-P change was negatively clinically relevant change in the silence sessions, but showed improvement in the music sessions, indicating that music was at least somewhat beneficial for pain. VAS-M improvement was clinically relevant in the music sessions, but VAS-A and VAS-R were substantially clinically relevant in both conditions according to the MCID (see Table 1). These results indicate that the VA-Music sessions were more beneficial for anxiety and relaxation than for pain or mood.

VA-Silence pre-treatment scores were generally better compared to VA-Music, as the mean pre-treatment score for VA-Silence was in the minimal category and for VA-Music was in the mild category. From an individual session perspective (see Figure 2), substantial improvement was recorded in Sessions 3 (VA-Music), with MCID in Session 5 (VA-Music). MCID negative change was reported in Sessions 1 and 6 (VA-Music) and Sessions 2, 4, and 7 (VA-Silence). There was relatively high variation between the conditions; however, when the pre-treatment score was the worst (Session 3), the improvement was also the most substantial.

Mean mood scores for pre-treatment VA-Music sessions was in the moderate category and VA-Silence in the mild category. Again, Session 3 (VA-Music) showed substantial improvement (see Figure 3), whilst Sessions 1 and 6 were also clinically relevant. For VA-Silence sessions, moderate improvement was reported in Session 4, clinically relevant improvement in Session 7 but negative clinically important change in Sessions 2 and 8. Therefore, although the final score at the end of the process was worse than the beginning of the process, the mean change over time was nevertheless towards improvement, although only clinically relevant for the VA-Music sessions.

Pre-treatment scores in both conditions on average were moderate and post-treatment scores were mild for both conditions, suggesting that both were beneficial for anxiety relief. There was greater relief recorded for the music sessions, however. Minimal clinically important change was reported in Sessions 1 and 7, with moderate improvement in Sessions 4 and 8, and substantial improvement in Sessions 3 and 6. As seen in Figure 4, on days when anxiety was the worst, Jane reported the greatest improvement (Session 3, 143%; Session 6, 184%).

The greatest improvements overall were recorded for relaxation (see Figure 5). Pre-treatment scores for both conditions were moderate, changing to mild post-intervention. MCID was recorded in Session 5, moderate improvement in Session 6, and substantial improvement in Sessions 1, 3, 4, 7, and 8. Again, Jane experienced the greatest increase in relaxation in those sessions with relatively higher tension pre-treatment.

Jane’s experiences of VA treatment and the role that music played in this process were explored in the interaction between her and the practitioner during the eight VA sessions. Three superordinate themes emerged from the analysis: Trapped by her anxiety, Control, and A changing self-reflection; the interrelationships of these themes are shown in Figure 6. Each superordinate theme had subthemes, which are presented narratively with exemplative quotations. The first two superordinate themes were interconnected – Jane sought control as she was trapped by her own anxiety – and the second and third superordinate theme were interconnected – Jane began to see changes by using music listening as a means to take control in a different way. The interrelationships of these themes are represented in the figure such that Jane’s anxiety and need for control were pervasive and connected to each other. Being Trapped by her anxiety overlapped with her need to control all situations, yet her anxiety and need for control were starting points in the process and are therefore stacked rather than linear as both themes were equally prevalent. The superordinate theme A changing self-reflection is justified to the right as it signifies the process of moving forward, rather than the stagnation of being trapped by one’s emotions. It overlaps with Control because Jane was nonetheless struggling to make this change, but was able to try with the help of the VA treatment sessions.

Jane was unable to relax at home – she sometimes found solace wandering the shops and could relax there because she was alone and it was quiet; she described her attempts to relax at home as “chaos.” She equated this chaotic feeling with the inability to relax during her first VA-Silence session: “But it is the same if I’m at home and I try to relax and I have that same kind of feeling as now without the music.” She felt trapped in feelings from which she could not escape, her health situation, and being so sensitive to each sensation she felt caused her great distress: “It’s too distressing…I feel as though I am in a box and I can’t get out of it.”

She admitted that she found it difficult to be out of control of a situation: ‘I’m that kind of person that needs to always know what is happening next’. This stemmed from the sudden need for surgery after a herniated disc and as a result being afraid of each sensation she felt, anxious that it may lead to something more serious: ‘I worry about what’s coming. It’s pretty hard’. She also felt unable to control her own thoughts and incapable of calming herself down. During the process, she was awaiting a phone call from her doctor with results from a scan. She explained that she felt extremely anxious the night before the expected phone call and was unable to relax. Nevertheless, she felt that she was lucky that she had not been worrying the whole week, suggesting that she felt her anxiety was out of her control: ‘Luckily I didn’t worry before’.

Both quantitative and qualitative outcomes of this study showed that Jane was in a state of suffering. Throughout Jane’s process, it was possible to see her move through an isolated and anxious state of suffering towards the hopeful understanding of the possibilities that music offered her in symptom management and in showing her that it is possible to relieve her anxiety. She displayed how one may struggle to cope but also how VA treatment can be used to help retrain one’s focus from negative sensations towards developing a sense of self-efficacy, making choices based on her own needs.

The findings revealed that anxiety had control over Jane’s ability to engage in daily activities, which was sometimes overwhelming; her need for control in general was magnified when she felt out of control of her own thoughts. She began to take small steps towards discovering and enacting her own needs and this was highlighted at the pivotal stage of choosing to first have music in Session 6 and then not in Session 8. Control was overlapping both her struggles with anxiety and her changing self-reflection, and the means of taking control for her was to utilise the music listening to regulate her anxiety within music sessions when needed, but also to choose when not to listen to music. Music affected her during the process by enabling her to make this choice and increase her sense of control. Bradt, Dileo, and Shim (2013) also found that engaging in music can increase the perception of control. During the first VA-Silence session (Session 2), pain, mood, anxiety, and relaxation got worse; this negative reaction was supported by her verbal processing of the experience (‘My mind was much more agitated without music. … The thoughts lasted the whole time, it was terrible, it wasn’t good, no, no, just terrible’). In the next session (VA-Music), Jane reported substantial improvements in pain, anxiety, and relaxation, and moderate improvement in mood with the VASs, and also verbally reported as such (‘My mind was much more peaceful than without music, even though I wasn’t necessarily listening to the lyrics, but still somehow…it was relaxing!’). Jane’s perception of being calmer during VA-Music sessions is also represented in the mean outcomes per condition (i.e. VA-Music vs VA-Silence), as mean improvement for anxiety was substantial in VA-Music sessions, yet substantial improvement was clear for relaxation in both VA-Music and VA-Silence sessions. The VA treatment thematic interrelationships with control as a catalyst for this positive development are shown in Figure 4 and presently individually discussed.

In the member check interview, Jane confirmed that she felt less pain and anxiety, was in a better mood, and was more relaxed after the VA-Music sessions, and that VA treatment was a “good model” for managing her pain and anxiety. She also felt that, although there was a lot of variation and disruption in her quality of sleep, the relaxation and “maybe a little more of a tired feeling” after VA-music meant she did not ruminate as much before bed, attributing this to her better sleep.

She confirmed that although her pain was not severe during the process, it was persistent and interconnected with her anxiety and mood and that her MD had confirmed there was no detectable cause for her symptoms. Her experience of music or no music was contradictory, “sometimes it was good, sometimes not.” This, she explained, was dependent on her level of coping at the time. Jane noticed she was hypersensitive to sensory stimuli. If feeling low or stressed, she could tolerate only soft/quiet music. When she did listen to music, however, she found that it was difficult for her to focus on herself; during the VA-music sessions became immersed in the experience and felt like “being on top of waves, and the waves just carried me” but found this was a way she could also avoid working on her issues. She also told she was able to gain different perspectives on her issues through the discussions with the practitioner, experiencing a clarity of mind – “basically somehow lighter.”

She confirmed that her experience of the treatment was both a physical and mental one: “when the chair was vibrating, I could feel it in my body, but when I was quiet and concentrated on just that, again it affected my mind.” She told that during the process she learned to concentrate on herself and learned that the anxiety would not overwhelm her; if she could become quiet, she was then able to enjoy “a sort of…peaceful moment.” Initially, the non-music sessions were difficult for Jane because she had to “tolerate myself.” She was constantly aware of things happening in her surroundings, which was burdensome. She also commented if she noticed a new pain, she immediately categorised it as the worst possible pain – “I’m very sensitive to that.”

Jane acknowledged the themes from the qualitative analysis were representative of her experience and agreed that control is a major part of her personality. She also explained that her pain and anxiety were very tightly intertwined and that they usually co-existed. She confirmed that she felt trapped by her anxiety, that she struggled to remain in control of all aspects of her life, and that she began to change the way she thought about and approached situations because of the VA treatments: “I noticed that I have pain even if I did nothing and I learned to just live with it a bit better and then it was easier.” She felt that it was “always a kind of holiday feeling or something quite exciting [going to the sessions] … I could cope somehow better… my head was a bit emptier,” but initially the sessions were frightening for her because she did not feel in control of the situation. When not in control, “I’m terribly anxious” and she found schedule changes very difficult: “If something surprising happens, I feel that the whole meeting is gone to pieces.”

Jane agreed with the finding of her changing self-reflection during this process. She began to teach herself how to approach things differently: “maybe that kind of more relaxed view, way of being.” Through attending the sessions, she felt that “my head got a bit of a break;” this clarity of mind was a contrast to the “lump” on her chest that she described as her anxiety. Finally, she told she was encouraged by the fact that the findings from the analysis were relevant to her and that it was “really nice for me that they are really my things and I felt I also got something from these results [discussed in the member check interview]”.

The findings showed that Jane was struggling to cope with her unpredictable symptoms as well as uncertainty within her family structure, which contributed to an overall sense of suffering. Suffering is characterised as a state of distress instigated by threat and loss of wholeness, an individualised and subjective experience that includes assigning negative meaning to an event or perceived threat (Cassell, 1998; in Deal, 2011). After the surgery in 2012 she reported as unexpected, Jane was constantly afraid of various pains or sensations she felt, fearing they would result in more medical procedures. She was under continuing psychological threat to her subjective wellbeing. Medically unexplained symptoms (Eriksen & Ursin, 2004) are highly representative of Jane’s suffering. The lack of identifiable cause also may have added to hyperawareness of her symptoms. Although the lack of discernible disease source for her physical pain was confirmed by a scan during the process, she was suffering from the psychological stress and anxiety associated with her fear of new pain and what implications it may have. Attentional (hypervigilance) biases in interpretation are strongly related to anxiety (van Diest et al., 2005). The theory of cognitive sensitisation for medically unexplained complaints (Brosschot, 2002) outlines that those who have an extreme concern about somatic disease will develop a cognitive bias for information related thereto. This bias appears in an activated cognitive network, meaning that signals related to, for example, pain are more closely observed and noticed by us. As a result, one would over-report, misattribute, or over-interpret these somatic sensations based on their own fears or illness beliefs. Jane was highly sensitised to all sensations – both somatic and psychological – and had developed a continued level of anxious suffering because of this cognitive sensitisation to her medically unexplained symptoms. As she explained in the member check interview, she was trying to re-train this response.

Four themes related to suffering are noted by Reed (2003, in Deal, 2011): isolation, hopelessness, vulnerability, and loss. Essential to alleviating suffering is a sense of hope, with a focus on a realistic future. Our perceived reality becomes clouded when one loses hope, as it results in a lack of desire to survive the experience (Rolley, Chang, & Johnson, 2014). Jane’s experiences can be categorised under these themes of suffering such that she was alone in her suffering and initially felt hopeless and helpless, struggling for control, leading her to a feeling of vulnerability. She greatly disliked being out of control in all situations and since her sudden health issues, she had lost the life she had once led and was lost in her own sphere of anxiety, trapped in her own thoughts.

Yet, Hart (2018) discussed two types of suffering: one in which one feels worried, hopeless, miserable, angry, and worthless with the “stressful anxiety of loss and responsibility” (p. 142), and the other in which one glimpses hope, learning to see things optimistically and gratefully. The act and experience of suffering is not only a solitary state but also one in which one learns to see the way forward; it is both dissonance and consonance. Music listening - and the choice to listen or not – was a marker of both of these types of suffering for Jane. First, having sessions without music listening were impossible in this worried, hopeless, and miserable state, but later, in choosing to not listen to music in Session 8 - thereby listening to her own needs - she was able to see things optimistically, leaving the sessions with a “free feeling” and getting over her fear of silence (“I think I beat my fear”). Music is widely used to increase one’s sense of wellbeing and act as a distractor from thoughts and feelings, improve mood and reduce anxiety, and decrease pain (Kemper & Danhauer, 2005; Nilsson, 2008), which was certainly the case for Jane. Hanser (2014) describes the role of music in framing the experience of pain as “an ever-changing phenomenon that rises and falls as the music changes in synchrony. As these dimensions shift, the perceptual path of pain ebbs and flows, and it is possible for pain to dissipate in the mind of the listener” (para. 15). This was also the case for Jane and her anxiety; as the music played, the perceptual path of her anxiety ebbed and flowed so that it dissipated and she was able to relax, reducing her bodily tension and pain.

Due to Jane’s isolated suffering, she lamented having no one with whom to talk and thus resorted to suppressing her emotions, spurring more anxiety. One’s attempts to understand and endure one’s suffering are eased by the sharing of this experience with others, so a listener is an important aspect of any therapeutic process (Deal, 2011). Listening to and conveying that the client has been heard and understood are important elements in building up a supportive environment (Pinto et al., 2012). In the case of VA treatment, the practitioner takes on a supportive role for the client’s self-exploration in a client-centred approach by providing the client the opportunity to make choices supporting their own healthcare. Patient empowerment and self-efficacy are essential for eliciting change and clients taking control of their own lives and wellbeing; further, there has been increased emphasis on the identification of patients’ healthcare wishes and an increase in patient autonomy (Laugharne & Priebe, 2006). One way in which practitioners can support patient empowerment is to assume a guiding or coaching role (Chamberlin, 1997). In Jane’s case, this involved affording her the possibility to make the choice to listen to music through listening to her own needs. Jane listened to and expressed her own needs, which the practitioner heard and acknowledged. Choice has been shown to have positive consequences in educational, workplace, and health contexts (Patall, Cooper, & Robinson, 2008), leading to a sense of personal control (Taylor, 1989, cited in ibid.). When a choice has important implications (i.e. eliciting relaxation for anxiety reduction), it may be more difficult to make (e.g. choosing whether to listen to music or not), particularly when the options are equally attractive; individuals experience increased motivation, perseverance, performance, and production when they assert their autonomy through choice-making (Patall, Cooper, & Robinson, 2008). Choice has also been suggested to influence patients’ commitment and motivation for attending therapy (Rokke, Tomhave, & Jocic, 1999). In the case of providing choice of music to which patients could listen for managing pain, their preference was important as there was ultimately no difference in the pain outcomes between patients choosing Taiwanese or American music (Huang, Good, & Zauszniewski, 2010). The authors wrote that preference is integral when one employs music listening on a long-term basis for pain management. Jane’s choice was a pivotal moment in her treatment process, as it opened the door towards exploring the meaning and use that she could herself attribute to the music listening.

The results and findings from this study suggest VA treatment in general may be beneficial for improving pain, mood, anxiety, and relaxation for a client with medically unexplained symptoms. As such, when comparing the influence of music within the treatment protocol, an important finding of this research is that the client’s preference for listening to music should supersede the theoretical understanding of the physiological and psychological effects music has on us (discussed in the section Music interventions for relieving pain and mood). The practitioner’s role within the treatment sessions to support a client’s therapeutic process and safely deliver VA treatment also means the practitioner should help the client to make an informed decision on whether music listening could be used; this would be based on the needs and goals of the overall process as well as a single treatment session. Therefore, this study supports the use of goal-directed music listening rather than delivering music listening solely based on research evidence.

The study design employed here, the single case experimental design, was chosen to evaluate how one client receiving VA treatment sessions would respond to both the presence and absence of the music listening element. Therefore, carryover to other patients – even those with a similar configuration of symptoms – is problematic (Charness, Gneezy, & Kuhn, 2012). In general, the disadvantages of exposing one participant to multiple treatments relate to the confounding elements inherent in an individual’s experience, especially in a more naturalistic setting (ibid.). As such, the results presented here are to be interpreted with caution, as the treatment process over time – regardless of the specific condition of each session per se – influenced the overall effects of the music listening element. AB designs as such can be useful in exploring the feasibility of an intervention, but do not provide definitive indications of the effectiveness of a treatment (Manolov, Gast, Perdices, & Evans, 2014). On the other hand, the varied treatment responses also highlight the difficulty in managing medically unexplained symptoms and the many external factors influencing a therapeutic process.

Another potential limitation of this study is the fact that EAC filled two roles, one as the VA treatment practitioner and the other as a researcher. She collected all data in the role of practitioner and also conducted all data analysis and interpretation; despite the qualitative and quantitative data being analysed separately in their entirety before the integrated analysis, this process could not be completely separate as a result of this role overlap. This nevertheless may also be seen as advantageous, as EAC had a complete picture of the process from a practitioner’s perspective from the sessions to the member check interview as a result of the dual roles (as discussed in section Roles of the researchers / practitioner).

Finally, Visual Analogue Scales may have been too simplistic a measurement tool to assess Jane’s nuanced experiences. The verbal processing / qualitative data were therefore extremely important in supporting the quantitative results. The broader topics of discussion between the client and practitioner during the sessions allowed for a more complex examination of Jane’s contextual therapeutic experiences, but the integration of diverse data sources – the quantitative as specific and qualitative as more general explorations – was more complicated as a result. Although it may have potentially been beneficial to conduct more formalised interviews of her experiences pertaining directly to the variables under examination, this would have compromised the integrity of the therapeutic context. The research process and outcomes of this study therefore support the use of mixed methods as a means of exploring how a client may respond to a therapeutic intervention when having diverse symptoms of no discernible medical source, despite the potential pitfalls of single case research in general.

The client’s specific connection to their preferred music may be important in sensation perception. Having a clearer idea of how an individual responds to certain music would be an important step in further understanding the interaction of the VA treatment elements. This supports the necessity of the therapeutic and supportive role of the practitioner in planning and executing the therapy process, with the client sharing the responsibility in how their treatment progresses. Understanding more closely the individual benefits and cumulative effects of each arm of the VA treatment triad works towards more effective and safe utilisation of VA. More research is also needed to explore how the VA treatment elements work together for various target groups such as patients with complex and interacting symptoms.