The Efficacy of Music Therapy and the Role of Social Interaction in Elevating the Mood States a
Among the Institutionalized Elderly
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Key Words: Music Therapy, Social Interaction, Elderly, Mood, Depression, Friendliness, Mental Illness
Previous studies have demonstrated the benefits of using music therapy within the geriatric population in order to elevate mood states. The present study is an attempt to examine the efficacy of active and passive music therapy while controlling for the effects of social interaction in elevating the mood states of institutionalized elderly adults. The 7 participants in the study with a mean age of 71 had previous diagnoses of psychoses and were all randomly assigned to 3 conditions, active music therapy, passive music therapy, and social interaction through means of a Latin Square design. Each participant was tested on the depression and friendliness subscales of the Profile of Mood States questionnaire at baseline and after each condition. Marginally significant scores were found after passive music therapy on increased friendliness levels, whereas friendliness significantly decreased after social interaction conditions. The results of this study did not support the use of music therapy or the role of social interaction in elevating mood, and thus, were not in accordance with previous research. Future research should be conducted in non-mentally ill geriatrics in order to assess the efficacy of music therapy and the role of social interaction in elevating the mood states of the institutionalized elderly.
Recent advances have occurred in psychology that has led to the application of alternative psychotherapeutic methods within the geriatric population. The increased interest in psychological concerns of the geriatric person is due primarily to a greater life expectancy, leading to a larger population of elders than ever before in history. Among these modern interventions is music therapy, the practice of which dates back as far as to the eighteenth century. As John Armstrong stated in The Art of Preserving Health (1774), “There is a Charm: a Power that sways the breast; Bids every Passion revel or be still; Inspires the Rage, or all your Cares dissolves; Can soothe Distraction, and almost Despair. That Power is Music” (as cited in Lynch, 1987, p. 5). Many others have since realized the power of music as well. Hanser and Thompson (1994) have suggested that in the branch of geriatric psychology specifically, music therapy has shown significant results in elevating mood and reducing anxiety. The benefits of this form of therapy are abundant and assist in psychological, physical, and social aspects of the elder’s life (Randall, 1991). Music therapy is becoming more prominent within clinical psychology and is proposed to prove beneficial to the growing geriatric population.
It was in the eighteenth century that medicine first developed an interest in music therapy. Rorke (2001) summarizes the origins of many therapists’ interest in music therapy. The first documented case of using the powers of music to heal refers to a musician Farinelli, whose performance was said to drive out the evil spirits in King Philip V. Following this documentation was a burst of subsequent theories regarding the advantages of music in aiding the mentally disturbed. Richard Brocklesby, influential in his time with regard to medicine, is well known for contributing to the practice of music therapy. His novel, Reflections on Ancient and Modern Music with the Application to the Cure of Disease (1794) discusses the benefits and methods in which music can be therapeutic. According to Rorke (2001), Brocklesby stated that the cause for disease was due to an obstacle in the flow of bodily fluid, or animal spirits, through the body. He suggested that music would redirect the course of animal spirits throughout a person’s body. This would in turn lead to an increase in attention capacity, reduction of anxiety, tranquility, and a better mood state. In addition, Brocklesby theorized that music slows down the aging process due to more evenly distributed amounts of animal spirits in one’s body after being exposed to the music (Rorke, 2001). Although more advanced research has demonstrated a better understanding of the functions of brain structures, dismissing many of Brocklesby’s ideas, he continues to remain a pioneer in the field of music therapy.
Aldridge (1998) divides this therapy into two primary subgroups, active music therapy and passive music therapy. Active music therapy includes the patients directly engaging themselves in the music either by singing, dancing, or through some other interaction, such as producing music with instruments. Passive therapy takes place when the patient listens to the music that is being performed or administered by the music therapist. Today music is frequently used as a socially accepted therapeutic method in treating patients.
Many different types of music are capable of elevating mood in the elderly, and thus can be used in therapy sessions. For instance, Olson (1984) conducted a study on the effects of piano music on the motor responses, cognitive functioning, and general affect of the elderly, using 11 participants for five therapy sessions. After observing changes brought on by music, the results of the study suggested piano music increased exercise related movement and overall mood of geriatrics. It was also suggested from this study that both familiar and unfamiliar music increased mood and physical activity. In a related study, Jonas (1991) found institutionalized elderly to prefer country music to jazz, art music, and music popular at the time of the study after surveying 63 nursing home residents. Randall (1991) also notes jazz and gospel music as effective in mood elevation. Thus, various types of music appear to be beneficial to elderly.
Two influential studies in regards to music therapy were conducted by Hanser and Thompson (1994) and Suzuki (1998). The previous study indicated music therapy as a promising alternative to traditional methods in elevating mood states. Ten underwent music therapy in a home setting with a licensed music therapist. Another 10 subjects self-administered music therapy alone after receiving a list of music to play for themselves and only spoke with a therapist for a period of twenty minutes over the course of one week, for eight consecutive weeks. The remaining 10 participants were the control group who received no form of therapy. All of the participants were evaluated on various psychometric tests such as the Geriatric Depression Scale (GDS), the Brief Symptom Inventory, the Self-Esteem Inventory, and the Profile of Mood States questionnaire (POMS) before, during, and after the course of the study. The two groups assigned to music therapy had significantly lower levels of depression and anxiety compared to the control group that scored higher depression and anxiety levels after the study than they had previously reported. Furthermore, those who had received music therapy showed continued better mental health with lower levels of depression and anxiety in the nine-month follow up. The Hanser and Thompson study attempts to address the issue of social interaction effects by instructing subjects to “self-administer” music, or, listen to music alone. Results show that both forms of music therapy, one conducted in a social environment where therapist and participant interacted, in addition to the other condition where subjects were alone and conducting their own music therapy are beneficial to the participant. However, more studies are needed to validate and control for a third variable of interacting with others, which may influence the elevation of mood levels. Nevertheless, the results of this study offer insight into the promotion of music therapy as an alternative to traditional psychotherapeutic methods in the care of geriatrics.
A second influential study conducted by Suzuki (1998) examined the trends of depression seen in the institutionalized geriatric population. This study is of particular importance because depression is commonly seen in elderly patients residing in nursing and rehabilitation centers. The common occurrence of depression is in part due to how understaffed these facilities are. The Burns et al. study conducted in 1988 (as cited in Suzuki, 1998) found that though geriatrics are receiving proper physical care for the most part, it is possible that these patients are not receiving the appropriate social support and interaction with others necessary for a higher quality of life. A common source of depression in the elderly may stem from poor social environments. This can occur due to loneliness, loss of important roles, loss of proper physical functions, as well as the loss of significant persons in one’s life (Suzuki, 1998). Because this is such a widespread problem, therapists have begun to experiment with music therapy as a potential alternative to medicine or even as an aid to lowered prescriptions of anti-depressant medication. In the experiment conducted by Suzuki, nine nursing home residents with depressive symptoms were screened for mental illness before and after undergoing music therapy sessions as measured by the GDS. This experiment also measured positive and negative memory recalls in the patients prior to, and following, the music therapy through means of the Positive and Negative Affect Scale in conjunction with a memory retrieval test. During these therapy sessions, subjects participated in a sing-along, music making, relaxation or movement to music, as well as listening to music. The results showed a significant decrease in negative mood, as well as a significant decrease in the number of recalls of unpleasant events after all of the music therapy sessions were completed. This study further validates the benefits of using music therapy to aid the institutionalized elderly.
Therefore, the present study was conducted to further understanding of the efficacy of music therapy in elevating mood states among the elderly. Furthermore, Clair (1994) suggested music therapy increased amiable feelings among the elderly, because music acted as a shared common bond for participants who had previously been isolated and withdrawn. In accordance with previous studies, the present study will also test for mood and sociability changes after undergoing music therapy and the control condition of social interaction, through means of the depression and friendliness subscales of the POMS. Also using Aldridge’s (1998) distinction between active and passive music therapy, the present study will also discriminate the effects of the two distinct form of music therapy.
With the introduction of music therapy, geriatrics have the option of an effective alternative to traditional psychotherapeutic methods to improve quality of life and elevate mood states. Previous studies have shown the success of the alternative therapeutic method of music therapy (Ashida, 2000; Hanser & Thompson, 1994; Olson, 1984; Randall, 1991; Suzuki, 1998). However, a possible confound in these previous studies is that subjects may not be benefiting from the music, but instead from the interaction with the experimenter, which relieves the elder from isolation and loneliness. Because the music therapist increases the attention given to the subject through discussion, he or she will not continue to experience isolation. Thus, it is difficult to parcel out whether it is the music or the social interaction between therapist and patient that is improving mood states. Another study must be done in order to control for this third variable where a control group receives personal interaction without music therapy in order to determine the efficacy of music as a psychotherapeutic intervention. Given the amount of documented material on the efficacy of music therapy, only receiving social interaction may not have significance in elevating mood states, whereas music is predicted to yield significant scores in decreasing depression and increasing friendliness.
Additional studies should be conducted to determine what type of music therapy is most effective. The present study is an attempt to differentiate between active and passive music therapy effects. Thus, active music therapy is operationally defined as making music with instruments, whereas passive music therapy is listening to the music being played by the research instructor (Aldridge, 1998). Because active music therapy directly involves the actions and involvement of the subject, it is predicted that subjects will report higher levels of mood elevation in the active music therapy condition as compared to the passive therapy condition where subjects will be exposed to piano music. Testing will be on the POMS subscales of depression and friendliness. Though all conditions are assumed to produce increases in mood, active music therapy is hypothesized to yield the most significant results, followed by passive music therapy, which also is predicted to significantly alter levels of depression and friendliness in the participants. Finally, though subjects in social interaction conditions may report more positive affects, the changes in mood state are not predicted to be significant. Thus, the expected results of the present study state that while experiencing active music therapy, mood states will increase at higher levels as compared to the passive music therapy, which will in turn increase more than in the social interaction sessions.
Ten consenting participants from the enhanced living unit at a nursing home in New England were used for this study. The mean age of participants in the present study was 71. Three participants refused continued participation as the testing sessions progressed, and as a result, the study examined the scores of seven participants. Six participants were females and one participant was a male. Diagnoses of the participants included bipolar disorder, chronic schizophrenia, anxiety disorder, major depression, kleptomania, onset of dementia, and other unspecified psychotic disorders. All participants were known to have complete hearing acuity.
This study was approved by the Institutional Review Board at Saint Anselm College and was conducted in accordance with guidelines set forth by the American Psychological Association.
The depression and friendliness subscales of the Profile of Mood States Questionnaire (POMS) were issued prior to undergoing music therapy sessions at baseline, as well as after completion of the therapy sessions in order to test and compare mood state levels across conditions. The POMS is a 65-item likert type numerical scale with different subscales issued by McNair, Lorr, and Doppleman (1971), however, for the purposes of the present study, 22 questions from the depression and friendliness subscales were used.
The participants used musical instruments in the active music therapy sessions in order to make their own music, including drums, tambourines, rain-makers, symbols, and castanets. In the passive music therapy session, participants were exposed to the music of pianist Jim Brickman through means of his CD Picture This (1997).
Consent forms were issued to and signed by the legal guardians of the participants. Before the study began, participants were given written instructions, which were also read to the subjects. The study was conducted as a within-subjects Latin Square design in order to reliably determine the effects of the three different conditions participants were assigned to, as well as to control for individual differences. Throughout the five-day span of the study, all seven participants experienced each of the three following conditions: active music therapy, passive music therapy, and a social interaction condition. The study was thus conducted as a within-subjects Latin Square design. Participants were randomly assigned to groups, one undergoing active music therapy first, while another started with passive music therapy, and the last group began the study in the social interaction condition. Active music therapy began at 9:30am, followed by passive music therapy at 10:15am, and concluded with social interaction at 11:00am for three non-consecutive days (time allotted for test taking on POMS are included in the 45 minute sessions). All received the POMS subscales of depression and friendliness before each session began in order to self-report mood levels at baseline. After each session, lasting approximately 30 minutes, the POMS was re-administered to determine the effect, if any, the condition had on the mood levels of the participants. Upon completion of the experiment, debriefing forms were given to inform the participants of the purpose of the study.
Six Paired-Samples t tests, (a = .05), were conducted on the scores of subscales depression and friendliness of the POMS to determine significance. Overall, mean scores within the group did not differ significantly. However, a comparison of mean scores on friendliness at baseline and after the social interaction condition showed a significant decrease [t(6)= 2.71, p=.04]. Additionally, after a comparison of baseline and after passive music therapy conditions, there was a marginal increase on the friendliness subscale [t(6)= 2.19, p=.071]. Mean scores found before and after baseline are shown on Table 1, along with standard deviations on scores.
Active Passive Social
Baseline 19.86 14.43 17.71
(15.14) (14.43) (11.73)
After 24.14 17.29 14.57
(21.87) (17.29) (9.96)
(2.21) (3.73) (3.27)
(4.55) (2.42) (1.09)
After conducting Paired-Samples t tests on data collected from the depression and friendliness subscales of the POMS, the results did not support the previously stated hypothesis. Group mean scores on the POMS subscales of depression and friendliness indicated that neither active music therapy, nor social interaction were effective in increasing positive mood states in the elderly. Additionally, significance was not found in passive music therapy’s effects on treatment of depression. However, passive music therapy and social interaction were found to alter levels of friendliness among participants.
The results of the present study indicate that passive music therapy increased self-reported levels of friendliness in participants. These results were marginally significant. This suggests listening to music may be used as a way to elevate amiable feelings in the elderly, and thus, possibly decrease isolation. This finding is in accordance with Bruck (1996) who discussed Southeastern Music Therapy services, a music therapy program that has found through years of practice that music increases socialization among the elderly. Additionally, Clair (1994) suggested music therapy increased sociable feelings among the elderly, because music acted as a shared common bond for participants who had previously been isolated and withdrawn. However, scores of friendliness after undergoing the social interaction condition showed a significant decrease. Thus, participants reported lower levels of friendliness after social interaction. This suggests that communication with a new person may actually be detrimental to socializing among the elderly.
Though the hypothesis was not supported by the data, it does not follow that music therapy is an ineffective means through which to elevate mood levels in the institutionalized elderly. Previous research on music therapy has demonstrated otherwise (Ashida, 2000; Hanser & Thompson, 1994; Olson, 1984; Randall, 1991; Suzuki, 1998). Instead, there may have been confounding variables that led to overall insignificant data.
One factor that most likely contributed to the failure to show differences between music therapy and social interaction conditions was that the experiment was conducted in the enhanced living unit at the nursing home. Residents were placed in the enhanced living unit because of a diagnosis of mental illness, including chronic schizophrenia, bipolar disorder, anxiety disorders, major depression, substance abuse, and various other unspecified psychotic disorders. Because the subject pool was not known at the time the study was conducted, research on the effects of music therapy did not center on mental illness, with the exception of depression. Thus, it is likely that these mental illnesses may have led to insignificant results, being that the research instructor was not trained in working with the mentally ill or knowledgeable in that field. Additionally, symptoms of these disorders, such as paranoia, anxiety, and aggressive behavior may have resulted in skewed data and inconsistent individual S’s.
A study conducted by Pavlicevic, Trevarthen, and Duncan (1994) found individual music therapy sessions for chronic schizophrenics to be effective in improving communication skills and quality of life on the Music Interaction Rating for Schizophrenia. This study was conducted over a span of 10 weeks, with 21 subjects receiving individual music therapy sessions and 20 controls who received no music therapy. This study demonstrates a more effective way of using music therapy for the mentally ill.
The small sample size used and subject attrition may have altered the results found in the present study. All participants included in the study were given permission to participate by a legal guardian. Many other guardians of the residents at the nursing home did not grant permission to allow the person in their custody to take part in the study. Therefore, the experiment began with a sample of 10 subjects. As the study progressed throughout the week, three participants refused further participation in the study. Thus, the results are based on the sample size of seven participants, limiting the statistical power of the study.
Another concern was that participants may or may not have been musically inclined. A person who does not like to make or listen to music may not experience a significant elevation in mood after undergoing music therapy. Two participants in the study stated that they enjoyed music and had both regularly played the piano in their younger years. Another subject also demonstrated an appeal to music by singing along to different songs throughout all three conditions in the study. The other participants did not reveal any inclination or disinclination towards music.
Furthermore, several subjects reported a dislike towards the specific music chosen for the passive music therapy condition (Jim Brickman, Picture This), while other participants reported a strong liking of the music. Individual differences in preference of one type of music over another therefore may have influenced depression and friendliness scores after the passive music therapy condition. Additionally, Jim Brickman is a pianist, and as a result, his music is very relaxing and somber. Also, none of the participants in this study recognized Brickman’s music. Despite previous findings that both familiar and non-familiar music used in therapy enhanced mood (Olson, 1984), it would perhaps be beneficial to use familiar music, in another study, such as country music (Jonas, 1991) jazz, or gospel music (Randall, 1991).
The repeated testing of the subjects on the POMS at baseline and post-treatment, which was necessary to measure mood elevation in each specific condition, may have also influenced self-reported scores. Subjects verbally reported frustration at the repeated testing on the POMS subscales of depression and friendliness. The agitation may be accounted for in the scores, and thus, may not be a true account of the efficacy of music therapy or the impact of social interaction on participants’ mood states. Furthermore, it should also be noted that five out of the seven subjects required the assistance of the research instructor while answering the 22 questions on the POMS. This may have had an effect on the way subjects responded to personal questions dealing with typically private emotions.
The length of the study was three non-consecutive days over the course of the week, with actual conditions, separate from test taking time, equaling half an hour. Limited time was allowed for time of conditions for a number of reasons. These include schedules in effect at the nursing home, such as meal times and previously scheduled activities. A lack of participants’ ability to concentrate over long periods of time also limited available time for each condition. Previous research with significant results for elevation of mood after music therapy have been conducted over longer periods, such as an eight-week study conducted by Hanser and Thompson (1994) examining the efficacy of music therapy on the depressed elderly. Though a study done by Randall (1991) illustrated the immediate positive effects of music therapy, nevertheless, increasing the length of this study may still have resulted in significant data.
The present study attempted to look at the differences between active music therapy and passive music therapy, in addition to whether or not social interaction does indeed play a role in elevation of mood levels. In the present study, the limited sample pool resulted in using subjects with mental illness. As a result, the data collected from this study may not demonstrate external validity. Thus, while it cannot be concluded that neither active, nor passive music therapy is entirely beneficial to geriatrics, it also cannot be inferred that music therapy is not advantageous to the elderly. In addition, the present study had wished to examine the role of social interaction in typical music therapy treatments. However, the fact that many subjects were schizophrenic and had anxiety disorders and, as a result, may have experienced anxiety while interacting with new people. This produced difficulties in examining whether or not social interaction in music therapy sessions results in the elevated mood levels of the typical patient. Therefore, another study involving non-mentally ill elderly should be conducted over a longer period of time, in order to determine which form of music therapy, active or passive, is most beneficial to the patient, as well as whether or not social interaction with the therapist confounds the typically positive effects of this alternative psychotherapeutic method employed in treating the elderly.
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