Efficacy of emotion-regulating improvisational music therapy to reduce depressive symptoms in young adult students: A multiple-case study design
Introduction
Depression is the most prevalent mental illness worldwide (Vos et al., 2015) and is often a seriously impairing condition (Kessler et al., 2009). It can be viewed as an emotion regulation disorder that impairs the capacity to label and identify affective states (Compare, Zarbo, Shonin, Van Gordon, & Marconi, 2014). Difficulties with emotion regulation are considered to be an important risk factor for the development of depression (Berking, Wirtz, Svaldi, & Hofmann, 2014). Indeed, people who experience depressive symptoms, also tend to experience difficulties in regulating their unpleasant emotional state (Herwig et al., 2018) and show a decrease in positive affect (Joormann & Stanton, 2016).
Young adults are at increased risk of developing depression with a peak rate of onset from 18 to 25 years (Breedvelt et al., 2018) and evidence suggests that the prevalence of depression amongst young adults is high (Barker, Beresford, Bland, & Fraser, 2019). Young adult students face many stressors that can adversely affect their academic performance (Andrews & Wilding, 2004), hence depression represents a significant health concern for universities with up to a third of students affected at any one time (Ibrahim, Kelly, Adams, & Glazebrook, 2013). As such, more attention should be given to the prevention of depression in university settings (Aalbers et al., 2019; Ibrahim et al., 2013).
Indicated prevention is delivered to those at risk for mental illness who may experience signs of mental health problems that have not yet developed into diagnosable clinical conditions (Conley, Shapiro, Kirsch, & Durlak, 2017). Common indicated preventive programmes for young adult students are often based on cognitive therapy (Breedvelt et al., 2018; Conley et al., 2017). However, some students may have problems expressing their thoughts and feelings verbally and so the examination of other preventive interventions, such music therapy are indicated (Aalbers et al., 2019).
Music therapy is the clinical and evidence-based use of music within a therapeutic relationship, conducted by a certified music therapist with the aim of accomplishing individualised goals (American Music Therapy Association, 2018). People use music in everyday life to regulate emotions (Juslin, 2019). Music can reduce stress (De Witte, Spruit, van Hooren, Moonen, & Stams, 2020) and evoke emotions (Koelsch, 2015) and music therapists are trained to use music in their therapeutic relationship to evoke change. Music therapy consists of two main methods, i.e. active and receptive. In active methods participants make music and in receptive methods participants listen to music (Aalbers et al., 2017; Aalbers et al., 2019; Bruscia, 1987; Bruscia, 2014; Edwards, 2016; Wheeler, 2015). A Cochrane review and meta-analysis showed that music therapy, including improvisational music therapy, is effective for depression, decreasing depressive symptoms and anxiety and improving functioning (Aalbers et al., 2017; Erkkila et al., 2008, 2011). Maratos, Crawford, and Procter (2011) suggested that improvisational music therapy may be effective because of the active music making within the therapeutic framework, offering opportunities for aesthetic, physical and relational experiences. Many music therapists consider emotion regulation as a potential benefit of music therapy (Marik & Stegemann, 2016). Recently, the first author developed Emotion-regulating Improvisational Music Therapy (EIMT; (Aalbers et al., 2019) as an indicated preventive programme using music in a therapeutic relationship (De Witte, Pinho et al., 2020), to improve emotion regulation in stressful situations in young students with depressive symptoms. EIMT belongs to the active method of music therapy.
In EIMT, emotion regulation is seen a key feature in depression (Gross, 2014; Herwig et al., 2018; Joormann & Stanton, 2016) and emotion dysregulation an important risk and maintaining factor (Berking et al., 2014). The music therapist uses the music therapy synchronisation technique to attune with the participant for the purpose of change (Aalbers et al. under revision; Aalbers et al., 2019; Bruscia, 2014; Bruscia, 1987). The synchronisation technique is a mirroring technique, playing what the student does simultaneously in various levels of precision using musical components like pulse or dynamic ((Aalbers et al., 2019; Aalbers et al. under revision; Bruscia, 1987). EIMT addresses five emotion regulation components (Scherer, 2009), i.e. expression, feeling, bodily responses, appraisal, and action-tendencies. By focusing on these emotion regulation components, EIMT aims to improve emotion regulation and reduce depressive symptoms.
Since EIMT has not been previously studied, a multiple-case study design, using qualitative and quantitative data collection (Fetters & Molina-Azorin, 2019; Fetters, Curry, & Creswell, 2013; Creswell & Plano Clark, 2010) was used to assess effects. The design is an efficient first step in evaluating and refining a novel intervention where multiple cases are measured on a regular basis (Gustafsson, 2017; Kazdin, 2011; Van Yperen et al., 2017). It aims to repeatedly demonstrate, per case, that behavioural change takes place when the intervention is applied. The more frequently that cases show behavioural change, the more plausible found effects can be attributed to the intervention (Kazdin, 2011; Van Yperen et al., 2017). Qualitative data was used to enhance understanding of the quantitative results and vice versa, thus validating one database with the other (Creswell, 2015). The Experience Sampling Method (ESM) was chosen as a structured diary technique making it possible to study experiences in everyday situations (Scollon, Kim-Prieto, & Diener, 2003) as shown e.g. in Hartmann et al. (2015), Randall, Rickard and Vella-Brodrick (2014), Telford, McCarthy-Jones, Corcoran and Rowse (2012). The main purpose of the study was to assess the effects of EIMT in decreasing depressive symptoms in young adult students. Objectives were: (1) Does EIMT reduce depressive symptoms?; (2) Does EIMT improve emotion regulation?; (3) Does EIMT increase positive affect (PA) and decrease negative affect (NA)?
Section snippets
Design
A multiple-case study design was used, including a pre-test, post-test and follow-up assessment using validated questionnaires to collect quantitative data and evaluate EIMT on depressive symptoms and emotion regulation (Fig. 1; Procedural diagram for collecting data). Qualitative data was collected by interviewing students concerning depressive symptoms and emotion regulation. The ESM was applied at the baseline-, intervention- and follow-up-phase using beep-questionnaires on a mobile-phone to
Participant flow and baseline characteristics
Between September 2018 and August 2019, recruitment and follow-up took place. Twenty-two participants (n = 21 female; n = 1 male) were assessed for eligibility. Seven were excluded. Three did not meet inclusion criteria (n = 3 had other treatment). Four declined to participate (n = 3 decided to start another treatment; n = 1 did not report reason). Fifteen female students signed informed consent, were enrolled and allocated to three different baseline lengths. Four were lost to follow-up,
Discussion
Results showed a decline in depressive symptoms after EIMT. This effect remained after four week follow-up. Overall, qualitative data supported these results, i.e. all students felt better, less sad, less tense and less or not anxious anymore. Several felt less or not irritated or panicked anymore. Many experienced more pleasure and interest, slept better, felt more energy, felt less psychomotor agitation or less retardation and felt less worthlessness or guilt. Several experienced a better
Funding
This work was supported by NHLStenden University of Applied Sciences, Leeuwarden, the Netherlands. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Declaration of Competing Interest
None.
Acknowledgements
The authors thank Martine Bootsma for checking thematic coding, music therapists for delivering the intervention and participating, Ruth E. Freeman (MRCPsych; Maudsley Training Programme, London, UK) for providing language help, Hans Ket (Vrije Universiteit Medical centre Amsterdam; VUMc) for conducting additional searches, student-counsellors for referring participants and participating, students for participating, the EIMT supervisor for supervising music therapists during the study and
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