Table of Contents
CHAPTER 1. INTRODUCTION .. 4
In troduction to the Problem .. 4
Background of the Study . 4
Description of Music Therapy . 4
Music Therapy and Adult Mental Disorders . 5
History and Theories of Music Therapy . 6
Music Therapy and Mental Illnesses Research is Active . 7
Statement of the Problem .. 8
Purpo se of the Study . 8
Rationale . 9
Research Questions and Hypothesis . 9
Significance of the Study . 10
Definition of Terms . 11
Assumptions and Limitations . 12
Assumptions . 12
Limitations . Error! Bookmark not defined.
Nature of the Study (or Theoretical/Conceptual Fram ework) 13
Population and Site Selection, Overall Research Approach and Rationale . Error! Bookmark not defined.
Organization of the Remainder of the Study . Error! Bookmark not defined.
CHAPTER 2. LITRATURE REVIEW … Error! Bookmark not defined.
Introduction to the Literature Review .. Error! Bookmark not defined.
History and Theoretical Orientation for the Study of Music Therapy . Error! Bookmark not defined.
History of music therapy . Error! Bookmark not defined.
The application of music therapy . Error! Bookmark not def ined.
Theoretical orientation . Error! Bookmark not defined.
Review of Research Literature and Methodological Literature . Error! Bookmark not defined.
Review of research on the music therapy among adult with mental disorders . Error! Bookmark not defined.
Review of methodological literature relevant to this study . Error! Bookmark not defined.
Synthesis of Research Findings . Error! Bookmark not defined.
Critique of previous research . Error! Bookmark not defined.
Summary . Error! Bookmark not defined.
CHAPTER 3. METHODOLOGY .. 29
Purposes of the Study . 29
Research Design and Strategy . 30
Site Selection, Target Population and Participant Selection . 30
Sampling method . 31
Research Procedure . 32
Data collection . 33
Instrumentation . 33
Research Questions and Hypotheses . 34
Data Analyses . 35
Secondary Data Analyses . 35
Ethical Consideration . 36
Expected Findings . 36
REFERENCES . 38
CHAPTER 1: INTRODUCTION
Introduction to the Problem
Mental disorder is a psychological human problem and has a high prevalence rate in adults for various reasons. There are various interventions that are applied to mental disorders and music therapy is one of these interventions. The evaluation of the effectiveness of music therapy intervention on sleep disorders in people with depression calls for research and that is the essence for this study. This study is influenced by the availability of general information on music therapy as an expressive intervention therapy and its application sleep disorders among adults with depression. It is seeking to find more specific details and the exact success score in its application to adults with depression. This chapter is going to give an in-depth introduction to this problem, focusing on the rationale behind this study.
Background of the Study
The background of this problem will be given through appraisal of available data on music therapy and adult mental disorders. This will be done by giving a description of music therapy, history, theories, and practice of music therapy. The background will be organized in various subheadings to make it more sensible and easy to understand.
Description of Music Therapy
Music Therapy (MT) is one of the expressive therapies that are applied in within the perspective of psychotherapy, rehabilitation, counseling, or health care. The American Music Therapy Association (2004) describes music therapy as using prescribed music to influence positive changes in the physical, social, cognitive or psychological functioning of persons with educational or health problems. Music therapy employs music and music associated activities to adjust unproductive learning patterns, support emotional, mental, social, and physical development as well as to develop non-musical goals. Music therapy is a fully established and recognized by healthcare professionals as it can positively affect adults and children alike, as identified earlier by Bruscia (1998). This therapy can make the modification concerning isolation and interaction and has been proven through scientific research in situations concerning autism, pain, depression (and mental illnesses), anger, stress, time management, grief, loss, motivation, growth, procrastination, change, and improving communication (Crowe & Colwell, 2007).
Music Therapy and Adult Mental Disorders
Music therapists are trained specialists who have completed at least a Bachelor’s degree in Music Therapy and have been clinically supervised for 1,200 hours in a wide-range of settings like psychiatric facilities, hospitals, and schools. They are the people allowed by law to offer music therapy services to people/adults with mental health disorders (Crowe & Coldwell, 2007). The most common mental disorders in the United Kingdom (UK) comprises of depression, bipolar disorders, schizophrenia, anxiety disorders, post-traumatic stress disorder, and obsessive compulsive disorders (Scovel & Gardstrom, 2002). There are many forms of music therapy intervention. Some of the widely applied are improvisatory music (where music is improvised using instruments and/or found objects, body sounds, voices, etc.), re-creative (where vocal singing is done and/or playing pre-existing songs), composition (where the formation and documentation of a freshly composed song by the client with the assistance of the music therapist), and receptive (where clients do the listening to recordings of music) (Widiger & Shea, 1991; Scovel & Gardstrom, 2002).
The client needs are the main determinant of the kind of music therapy interventions to be used on him or her. Music therapy can be used to address the following: 1) to create a means of communication and interaction; 2) offers a passage for self-expression; 3) discovering self or other relationships; 4) advancing creativity and impulse, arouse sense, as well as improve perceptual and cognitive skills; 5) improving sensory-motor skills, substitute sequenced behaviors, increasing short-term and long-term memory; 6) to express and foster emotional integration; 7) improving behavioral organizational skills; 8) improving coping and self-reliance skills; 9) improving problem-solving skills; 10) improving and integrating communication experiences; 11) assimilating parts into whole; 12) supporting body awareness; and 13) advancing auditory skills (Vick, 2003).
Music therapy and its various forms of intervention create music stimuli that stimulate the central nervous system processes. Stimulation of such processes will evoke strong memories in the adults with mental disorders as the vibration will dissolve the blockages in nadis, meridians, arteries, veins, or nerves, causing a relieving effect that will intern help to relieve the mental illnesses (Unkefer & Thaut, 2005, p. 23).
History and Theories of Music Therapy
The recognition of music as a dominant instrument of operation towards wellness for an individual dates back to ancient times. However, music therapy as a professional field application is a recent occurrence. Music therapy began as a field in the 1940s, as several specialists in the field of psychiatry instigated treatment in a more holistic way (Nolan, 2003). Karl Menninger is an example of one of these prominent psychiatrists who intended to meet client needs using a broad variation of modalities. During this period, music was discovered to be containing essential fundamentals of therapeutic procedures and through scientific-based research, these qualities were confirmed empirically (Smith et al, 2002). After this crucial discovery, music therapy increased its acceptance into the medical field in Britain and globally. It developed considerably during World War II, as it was used to help veterans and its positive effects are seen in their recovery. Today, many music therapists work within a wide variety of locations and backgrounds, from hospital, to education, in private psychotherapy practices, as well as in applied mental illness intervention (Malchiodi, 2003).
Thaut and Unkefer (2005) discovered two most relevant theories of music therapy that are relevant to date. First is the theory of emotion arousal in music. This is very applicable in adult mental illness in the sense that when we listen to music, thoughts, and feelings are evoked that can be of great assistance in resetting the mental state of an adult with mental disorder. Second is the music stimuli and central nervous system processing (Weiner, 1999). Currently, neuro-scientific research have been used to discover neuro-substrates underlying music perception to improve various health conditions. The response is that music stimulates body nervous processes to give relieving and desired effects (American Psychiatric Association, 2003).
Music Therapy and Mental Illnesses Research is Active
In Europe and North-America, there are numerous universities that are actively involved in music therapy. Some of the most successful researches under this topic are Gold (2007), who discovered that music therapy improves symptoms in adults hospitalized with schizophrenia. Earlier in 2005, Gold had colluded with Heldal, Dahle, and Wigram (2005) to conduct a research on music therapy for schizophrenia or schizophrenia-like illnesses and the results were positive. Silverman (2003) did a meta-analysis of influence of music on the symptoms of psychosis. Ulrich, Houtmans, and Gold (2007), did a randomized study on the additional therapeutic effect of group music therapy for schizophrenic patients. Silverman (2006) interacted with adults with mental illnesses when he examined psychiatric patients’ perception of music therapy and other psych-educational programming. All these relevant studies and others will be discussed in detail in the subsequent chapter.
Statement of the Problem
Though the research in music therapy and mental disorders is active, the adult factor is missing in these researches. The adult population is very prone to mental illnesses; thus, more research should be done targeting this population. Vick (2003) mentions that research in music therapy should be more specific because it works differently in different groups; this is the essence of this study. The information so far in this paper mainly gives support to the success of music therapy in relative terms like positive, successful, and improved but more quantitative data is needed so that the percentage of effectiveness of music therapy intervention on mental illnesses can be calculated and known. There are a lot of research on other interventions on adult mental illnesses like psychoactive drugs, psychotherapy, and anti-depressants but there is minimum research on music therapy as one of the interventions.
Purpose of the Study
The purpose of this study is to examine the effectiveness of music therapy interventions on sleep disorders among adults suffering from depression.
Another is to identify the obstacles that hinder the success of music therapy interventions on sleep disorders among adults suffering from depression. Finally, through qualitative inquiry via the questionnaire survey, the purpose of this study will be to collect and tabulate available data on music therapy interventions on sleep disorders among adults suffering from depression.
The rationale of this study is evident throughout this chapter. The main rationale of this study is the missing link between music therapy intervention on sleeping disorders in adults with depression and its success rating (effectiveness); this was expressed by Crowe and Colwell (2007) in their study that was aimed at identifying effective clinical practices in music therapy application for children, adolescents, and adults with mental disorders. Though they did a good study, they never identified the efficiency/effectiveness of this therapy among adults with depression. There have been several follow-up researches on children and adolescents with mental disorders who are under music therapy but little has been done on adults (Ulrich et al, 2007).
Research Questions and Hypothesis
ive main research questions were considered in this study:
1. What is the role of music therapy in the treatment of sleep disorders among adults suffering from depression?
2. How do adults suffering from sleep disorders and depression experience group and individual music therapy?
3. What are the indicating and contra-indicating factors for music therapy on sleep disorders with these adults suffering from depression?
4. How do participants believe music therapy impacts their overall treatment?
There are two key outcome expected in this study. The first is the overall effectiveness of the music therapy on sleep disorders among adult people with depression. The second is the level of effectiveness measured by success rate of music therapy on the same group.
The key hypothesis of this study is:
HO: Music therapy intervention on sleep disorders among adults suffering from depression is effective.
This will be tested against the alternative:
HA: Music therapy intervention on sleep disorders among adults suffering from sleep disorders is not effective.
Significance of the Study
There is limited available information on success rates of music therapy interventions on sleep disorders among adults with depression; thus, this study will significantly contribute to information boost in this sector. The constant research on how to improve existing and new interventions on mental disorders depends greatly on the available information; therefore, the awareness that will be created by this study will greatly contribute to identification of the weaknesses of music therapy, with the aim of improving its application and finding out other alternatives. Pursuing this topic will avail a deep understanding of clinical psychology scenario and improve the level of comfort when handling sleep disorder cases among adults with depression.
Definition of Terms
Adult: A person who is 18 years and above.
ADHD: Attention Deficit Hyperactivity Disorder.
Biofeedback: A process of treatment that applies monitors to feed back to patients physiological information of which they are normally uninformed.
Bipolar disorder: A mood disorder also referred to as manic-depressive illness or manic-depression that typically comprises series of depression and ecstasy or obsession.
Brain: The part of the central nervous system that is situated within the cranium/skull. The brain is the primary receiver, distributor, and organizer of information for the body. It has the right and the left hemispheres.
Chronic: This is very important term in this study and clinical psychology; it means “on-going for a long time”.
Depression: A mental illness that affects the body, mood, and thoughts; it disturbs the way a person eats and sleeps, the personal perception, and thinking. A depressive disorder is not similar as a passing blue mood.
Electroconvulsive Therapy (ECT): It is the process of passing electric current through the brain to create controlled convulsions (seizures) to treat patients with depression, mainly people who cannot take or respond to antidepressants while they are experiencing severe depression or are at high risk for suicide.
Group Therapy: This is a psychiatric care method in which numerous patients encounter with the supervision of one or more therapists at the same time. It is very effective for psychiatric illnesses that are support-intensive, like anxiety disorders. It can also be used to refer to psychoanalysis in which patients examine each other with the help of one or more psychotherapists.
Music Therapy: This is the application of prescribed music to influence positive changes in the physical, social, cognitive, or psychological functioning of persons with education or health problems.
Mental Disorder or Mental Illness: This is a psychological or behavioral array, normally related to personal distress or disability that transpires in a person. It is usually not part of culture or norms. They are characterized by behavioral, affective, and perceptual components as well as cognitive disorders. They are well-elaborated in the introduction.
Psychiatry: The medical specialty that deals with the diagnosis, prevention, and treatment of mental illnesses.
Psychology: The study of the mind and mental processes, particularly in relation to behavior.
Psychotherapy: The process of treating a behavioral disorder, mental illness, or any other condition by psychological means.
Schizophrenia: This is one of the mental disorders whose dominant symptoms are the loss of personality/flat affect, confusion, catatonia, psychosis, unusual behavior, agitation, and withdrawal. The illness mostly starts in early adulthood.
Therapy: this is the treatment of various diseases using an intervention.
Assumptions and Limitations
Some aspects of correlation and naturalistic paradigm are applicable, given several similar assumptions in this study: (a) individual adult participant will build his or her own reality, contributing to the compound realities within the group to be studied; (b) this is a group that need high guidance and the researcher will be present with the participants during filling of the questionnaires; thus, the researcher’s actions will influence participant reactions; (c) the already done sampling was context bound; (d) it is possible to differentiate course from effect and outcome as the research progresses; finally, (e) the morals and ethics of the participants and the researcher are vital to the meaning of the outcome of the study (Leedy & Ormrod, 2005).
This study was restricted to short term treatment of sleep disorders using music therapy. It is limited to adults whose ages range from 18 to 65 years, who have been identified and were diagnosed with depression, and already admitted to in-patient treatment. On the other hand (though of least limitation), participants in the study are people whose ages range from 18 to 65 years. This study focused on the use of music therapy intervention in a mainly group setting. The study focused more on identifying success/effectiveness of the music therapy and less on the quality and contents of the therapy within each session. The lack of cooperation with the participants after the interviews may affect data analysis (Howitt & Cramer, 2000).
Nature of the Study (or Theoretical/Conceptual Framework)
Population and Site Selection, Overall Research Approach and Rationale
The overall research approach and rationale of this study is based on a successful research by Gold (2007) on the role and how music therapy improves sleep disorder symptoms in adults hospitalized with depression. This research dealt with the adult population with depression and music therapy; its methodology was very relevant given the similarities in the purpose with this study. The natural rehabilitation center setting is very necessary given the availability of adult people with depression and sleep disorders.
This study is based in a Psychosocial Rehabilitation Center (PSR) in the United States of America (USA); where there are adults who have already been primarily diagnosed with sleep disorders and depression. Eliminations or segregations, that is, secondary diagnoses of dementia or organic psychosis, were also looked upon. The music therapy intervention is applied in this center; has a range of musical instruments; every patient has a weekly individual session, which takes a period up to 45 minutes. They will be observed for up to 12 weeks. The center has already given permission to be involved. After passing all the necessary steps, this study also will be approved by the Capella University Institutional Review Board (IRB); this is very necessary to ensure protection of the rights of both respondents and researchers. The primary outcome is measured by the symptoms’ total score using the Positive and Negative Syndrome Scale (PANSS). The secondary outcome is measured by the satisfaction with care, where the adults will be required to fill up the Client Satisfaction Questionnaire (CSQ); under this, the Global Assessment of Functioning Scale (GAF) is applied. A mandatory patient follow-up of 85% is observed. The study was intended to include the participants’ input through researcher’s observation, interviews, and filling up of questionnaire (Rubin & Rubin, 2005).
Organization of the Remainder of the Study
The next chapter will take an in-depth analysis of the available literature on this topic in the form of a literature review. The literature review will be arranged under various relevant subtopics. Then, chapter three will now define and elaborate the methodology of this study. It will give all the necessary details and describe all the processes that are undertaken to come up with the data to be used to solve the problem. Chapter four will avail the collected data and will show analysis to give meaning and sense to them. Finally, chapter five of this documentation will give results, conclusion, and recommendation.
CHAPTER 2: LITRATURE REVIEW
Introduction to the Literature Review
The literatures reviewed for this study will mainly focus on the general information regarding music therapy as an intervention on sleep disorders among adults with depression, the theoretical frameworks of music therapy and on the use of music therapy in psychiatric settings. This review provides an overall picture of the state of music therapy application as an intervention among adults suffering from depression and research information on how music therapy has been implemented in depression treatment. The literatures highlighted in this study have been filtered according to relevance and date of publication. Some aspects of methodology that were also considered in the literatures of the studies reviewed were: if the methodology violated the policies of scientific research or ethical violations. The outcomes of the studies highlighted in this literature review had also to be processed using reliable social science research tools to validate their consistency. The tool for checking validity that was commonly applied in these studies by previous researchers was the T-Test.
History and Theoretical Orientation for the Study of Music Therapy
History of music therapy
Music therapy, as a term used currently, was established during World War II when congestion in the military hospitals provided motivation for engaging alternative therapies in hospitals (Pratt, 2008, p. 238). The National Association for Music Therapy (NAMT) was structured in 1950 to regulate training and encourage unity among those who were already functioning as volunteers and specialists in music therapy application to patients, mainly in hospitals with recovering veterans (Schneider, Unkefer & Gaston, 2009, p.3). The formation of America Music Therapy Association (AMTA) followed the coming together of both the NAMT and the American Association for Music Therapy in 1998. Currently AMTA is the responsible body for music therapy application in America. Its main function is the development of the therapeutic use of music in special education, various rehabilitation, and community settings. AMTA also registers music therapists.
The application of music therapy interventions on sleep disorders among adults suffering from depression
Music therapy is currently applied as an intervention to those with brain injuries and various mental disorders including depression. According to earlier studies, patients who are in the initial stages of severe craniocerebral trauma show a good response to music therapy based on chordal tones hence the use of music interventions as a stimulus can be used to treat such patients. A report by Jochims (2006) indicated positive results of musical interventions on patients who are in a comatose state and music therapy may help children with severe traumatic brain injuries recover faster from a coma and then rehabilitate them.
The results of a study by Rosenfeld (2009) showed changes in heart rate in children with severe traumatic brain injury after a variety of orientating sounds and vocalizations, and they even regained their speech after singing songs (Rosenfeld, 2009, p.41). Wilson and Pressing (2009) reported that a musician who suffered amnesia caused by a stroke was treated with a componential intervention to cognitive functioning, whereby subjective partitions between anterior and posterior brain structures were avoided and substituted by integrated and purposeful networks that can involve more than one lobe of the brain, by way of cortical and subcortical connections (Wilson & Pressing, 2009, p.50).
When the complete neural pathways and cerebral areas a person’s brain is damaged, language and music are used therapeutically with better effect than when therapists only use language. Several reports from music therapists demonstrate the success of music therapy, even though there is little concrete data available (O’Callaghan, 2009, p.90). An extensive bibliography of the then recent research on music therapy and neuro-rehabilitation in 2008 gives 320 references on music therapy, mental disorders, and cerebral vascular accidents (Coast Music Therapy, 2008). Nayak et.al (2000) contributed a great milestone when they published concrete data which showed that music therapy can improve mood and social interaction among patients who had experienced acute traumatic brain injury and stroke. Lastly, music therapy can be used as a perfect tool for improving the brain’s ability to carry out complex cognitive tasks (Knox & Jutai, 2006).
Music therapy has several different rationales that enable communication among people with diverse theoretical traditions. Music therapy is used in analyzing the theoretical growth of this discipline, while encouraging and stimulating the growth of more complex theories. Such theories are solutions to practical complications; these rationales can be used in connecting the theoretical concepts of this study into an amalgamated idea. The theory of quantum was formulated by Charles Eagle in 1991. This theory gives an opinion on the perception of clinical music therapy based on four principles from quantum physics (Wheeler, 2005). According to Eagle’s theory, the world is founded on four quantum principles—trained music therapists who apply these principles in music therapy interventions are very successful. This psychologist mainly advocated for the therapist’s sound observation and actual participation in the music therapy. In the footsteps of Eagle, music therapy as a discipline has embraced several approaches, one of the most significant and influential approach is: Kenneth Bruscia’s improvisational model of music therapy. This model required that each and every approach used in music therapy must have theoretical orientation (Knox & Jutai, 2006).
This study is based mainly on psycho dynamic orientation, which is the most popular practice in the available literature on music therapy application on adult mental disorders, it formed about 42% of the literature that was reviewed in this study and it is greatly related to an individual understanding. This theory was applied in describing the effectiveness of music therapy, the nature and application of this intervention in adults suffering from mental disorders. Psychodynamic in general represents an approach that has grown from the traditional psychoanalytic practices, that involves behavior interpretation and observation of the client (Kern, Wolery & Aldrige, 2006).
In the context of music therapy application to adults with mental disorders; it involves the interpretation of music choices, responses, composition and physical expression of the adults during a music therapy session. To give more explanation we can take for instance that music choices can be interpreted to represent more than the music taste, it can show the needs and defenses of the person. The instruments preferred by the person can give a symbolic meaning and the way the person plays it can also show the emotional feelings of the person. This psychodynamic approach is used to help the adults with mental disorders in planning their recovery and gauging their recovery progress (Kern, Wolery & Aldrige, 2006). This theory is primarily applied in a situation where music therapy is open to a personal choice of instruments. In this case, the therapist can gauge the adult’s recovery progress based on the advancements of his playing skills. The messages expressed while playing the particular instrument can also be used to understand the past of the mentally disturbed adult much better. The participants’ music choices and behaviors are interpreted through close monitoring of their responses to the music used.
Behavioral approaches were not very strongly represented in the reviewed literature in this study. This is because they are mostly unified with cognitive behavioral therapy (CBT). The behavior approach doesn’t apply in most mental disorders because of the severity these disorders can bring in the people’s behavior (Lambert, 2010). But, in the later stages of healing, behavioral stance can be applied with some learning theories, where the central life of the adult with mental disorder is now not a concern but the concern shifts to raising capability in observable behavior. Behavior can be taken to represent the cognitive understanding or external emotional experiences and in this case the therapist will target the behavior to achieve the desired results. In music therapy, the music is mainly used as an enforcer, at the general level; demonstrating the required behavior implies that the client is able to select an instrument, listen to the chosen music and other musical rewards. On the other hand failure to behave will imply that the therapist will withdraw the music until the client has improved his behavior (Lambert, 2010). The current application of the behavior theory is within a more electric framework, stopping the music is not an alternative, but improvement is the main focus of the music sessions and the clients are closely monitored through observable responses (O’Callaghan, 2009). In between the emphasis on observable behavior and conscious actions is the ground of humanistic theory approaches.
Those using the humanistic approach believe that every person has the potential to grow with an integral tendency (Wheeler, 2005), hence music therapy is classified broadly as a humanistic approach because of the creativity involved in it and this relates to the ideas of Steiner and the anthroposorphic movement in humanistic psychology (Jochims, 2006). Creative experiences are greatly viewed as humanistic approaches and the best example is the free sessions offered in music therapy where the interest of the adult decides the flow of the session.
Review of Research Literature and Methodological Literature
This section will provide information on the existing literature to research done in earlier studies, in relation to the use of music therapy interventions in the treatment of adults with depression. In addition, methods that were used in carrying out the previous studies will be highlighted together with their outcomes.
Review of research on the music therapy among adult with mental disorders
In the investigation carried out by Gold (2007), the objective was to inspect if music therapy improves the symptoms among adults hospitalized with schizophrenia. The outcome of this investigation expressed improvement among the people hospitalized with schizophrenia, after fusing music therapy with the regular routine patient care. The fusion of music therapy and normal care lead to better improvement in symptoms compared with normal care applied alone. This was after 12 weeks of application of music therapy plus the routine care, the observable change in Positive and Negative Syndrome Scale (PANSS) had an entire score from baseline of -9.00 as compared to -2.96 score of applying the normal care alone; and p = 0.045. Further results from this study showed that there was no substantial difference in patient contentment with care and global function between the groups (Gold, 2007, p.77).
An earlier study by Gold et.al (2005) was centered at making a comparison between the effects of music therapy combined with standard care, and standard care alone for treating people with severe mental disorders such as schizophrenia.
After inclusion of four more studies that evaluated the effects of music therapy over the short to medium period mainly between 1 to 3 months. The outcome of the study revealed that a combination of music therapy and standard care was more successful as compared to the use of standard care.
Pavlicevic, Trevarthen and Duncan (2006) also examined the improvisational music therapy and the rehabilitation of persons suffering from prolonged schizophrenia. They found out that patients with schizophrenia showed recognizable difference and improved rating in the Brief Psychiatric Rating Scale (BSRS) at the end of 10 music therapy sessions and encouraged the therapists to raise their level of musical interaction. Silverman (2003) did a meta-analysis on the existing quantitative research data by then, he wanted to evaluate the influence of music on symptoms of psychosis. In his conclusions, Silverman reported that music had confirmed to be considerably effective in relieving and reducing the symptoms of psychosis.
Ulrich, Houtmans and Gold (2007) did a randomized study examining the additional therapeutic effect of group music therapy for schizophrenic patients, based on the fact that Schizophrenia is one of the most serious mental disorders. When they were carrying out their research, music therapy was introduced as a form of treatment thus the purpose of this study was to examine the effect of music therapy for schizophrenic in-patients requiring acute care. The outcome of this study showed a substantial effect of music therapy after self-evaluation of the psychosocial alignment and undesirable symptoms on the patients. No changes were found in the quality of life of the patients (research participants). In their conclusion, the above researchers noted that musical activity reduces negative symptoms and develops social contact in the patients. Furthermore, the researchers ascertained that positive effects of music therapy could increase the patient’s abilities to adapt to the social environment in the public after being discharged from the hospital (Ulrich, Houtmans and Gold, 2007).
Silverman (2006) did a study to quantitatively evaluate psychiatric patients’ awareness of music therapy and other psycho-educational programs. The results of this study specified that that the sampled patients rated music therapy as considerably more helpful compared to other standardized programs (p < 0.05). Additional scrutiny showed that patients admitted to a psychiatric institution only once regarded their music therapy classes as more supportive as compared to patients who had been admitted numerous times. Furthermore, patients who were minorities regarded programming as more helpful than patients who were Caucasian. The patients regularly rated music therapy as highly effective compared to other standardized programs in solving specific psychiatric discrepancy areas. Also, 57% of sampled patients distinguished that music therapy was their preferred class/therapy.
Finally, researchers at Stanford University School of Medicine, USA examined 30 adults who had been diagnosed with major or minor depressive disorder. The sampled participants were randomly given one of the three, eight-week settings. In the first scenario, the participants were required to listen to music at home, following a weekly home visit by a qualified music therapist. In the second case, the patients were subjected to equivalent practices with moderate therapist assistance. Assistance from the music therapist was in the form of a self-administered program where participants made a weekly telephone call. The third case is where the participants were put on a waiting list and used as a regulator. The outcomes of this study showed that the participants in the first two cases achieved considerably better results than the controls on standardized tests of distress, mood, self-esteem, and depression. These developments were clinically significant to the music therapy researchers; they noted that these benefits were maintained over a nine month follow-up duration (Porter, 2011, p.61).
Review of methodological literature relevant to this study
This section will present various methodologies that were used in the previous researches earlier reviewed in the former paragraphs.
The methodology of the reviewed studies are very diverse, they range from meta-analysis, qualitative to quantitative research. The methodology that will be utilized in this research is closely linked to the one used by Gold (2007). This study applied a good sampling system with discrete distribution and single blind, and then the follow-up period was three months after the music therapy treatment was applied to the patients. The study being carried out in four London hospitals, gave it a base to crosscheck the similarity in four hospitals as a form of validation. The sampled adults had a major diagnosis of schizophrenia or schizophrenia-like psychosis.
Notably, eliminations were tributary diagnoses of organic psychosis or dementia. The main intervention included music therapy by means of a variety of musical instruments as well as reassurance to the adults so as to express their selves which was supervised by a trained, certified, and licensed music therapist. Arguably, the sampled people underwent a weekly individual session of up to 45 min, and additional standard care involving application of social, occupational, nursing care and other activities. This was compared to the standard care for only a period of up to 12 weeks, which is enough time for a sensible study. This is a very relevant methodology for this study, since between the two groups of set ups, there is one group that is purely on music therapy intervention alone; this can give a relatively reliable outcome.
The study also borrows closely on the methodology used by Gold et.al (2005). It had a very effective research strategy that was useful in identifying quantitative data. The researchers examined the July 2002 Cochrane Schizophrenia Group’s Register. They then went ahead and supplemented the data obtained with more information obtained from performing a thorough document search for literature and data from music therapy journals, books and reference lists. In addition, they also communicated with relevant authors, giving this study a high score in accuracy since they were certain and clear with the credibility of the primary data they were analyzing.
All randomized controlled trials were used as the selection criteria that compared music therapy with other psychosocial interventions or standard care for schizophrenia; this was very unique. The data collection and analysis in this study was done after the selected studies were assessed for quality and then data was mined. In addition to the quality assurances, data was omitted in instances where more than 30 percent of sampled participants in any group were missing in the follow up. Non-skewed incessant endpoint data from effective scales were amalgamated by using a standardized mean difference (SMD). If statistical heterogeneity was discovered, treatment approach and drug usage were scrutinized as conceivable sources of heterogeneity. This methodology is relevant to the research mainly because the sources of data to be used should be verified through communication with other authors; extra measures to test for consistency should be used as well (Ther, 2008).
Some methodological aspects of the study done by Silverman (2006) are very useful in the research of music therapy. The researcher examined the effect of four emotionally distinctive types of music (fear, anger, sadness and happiness). It focused on 31 healthy controls (Healthy Control Group) and 14 hospitalized patients with major depressive disorder (Major Depressive Disorder Group). The sampled participants were asked to select emotional descriptors that exactlyconveyed the feelings they experienced. The diversity that this study brought to the music therapy research is very important; it brought all the dimensions of music therapy in terms of what the distinctive types of music are.
The research will also be based on the methodological aspects used in the meta-analysis that was conducted on 19 studies by Silverman (2003). It also shares some methodological aspects used
in the study done by Silverman (2006) and Ulrich et al., (2007).
Synthesis of Research Findings[JW1]
Literature from previous studies done by other researchers have reported a marked improvement in the mental disorder of older adults and middle aged people with atherosclerotic encephalopathy. After undergoing purely 10 music therapy sessions, the patients exhibited a 20 percent improvement (Wilson & Pressing, 2009).
Additionally, music therapy also improved the stimulation of imagination in older adults and middle aged people with atherosclerotic encephalopathy. As the patients listened to the music, several of them experienced a feeling of flowing water, wood, sunlight or the lake and had several other positive experiences. Lastly, under this mental disorder, research proved to have an increased capacity to concentrate among older adults and middle aged people. After undergoing 10 music therapy sessions, the capacity of patients to concentrate had developed by an average of 18 percent (Crowe & Colwell, 2007).
Music therapy also worked well among patients with multiple sclerosis and in the reassessment of previously unaddressed experiences of patients with multiple sclerosis. When the individual experiences were recognized by the patients, including other things, the group reported that the music therapy had an effect of thorough and effective reappraisal of these past experiences. This caused dispersion of the previous mental stress situations and in the long run, the problem of mental disorder was managed (Ulrich & Gold, 2007).
In general, the studies have proven the positive effect of music therapy intervention on adults with various mental disorders. The major application is on group and individual music therapy with already recorded music; this is done with the guidance of a trained music therapist.
Critique of previous research
Music therapy has been expressed in this chapter as an advancing, cost-effective and available intervention for adults suffering from mental disorders like those undergoing symptoms of depression, anxiety and distress. Although Music therapy profession is relatively undeveloped and small in size, the reviewed studies demonstrated that it can be used to manage or treat a wide range of clinical populations diagnosed with mental disorders and other psychological conditions. These findings are very important because they have established a diverse research base for this study and more studies still to come. However, while the profession initiated working with people diagnosed with mental disorders, there is a substantial lack of quantitative research regarding the effects and efficiency of music therapy intervention applied to adults suffering from mental disorders (Leedy & Omrod, 2005).
Music therapist and researchers have testified on this shortage of quantitative information and the trouble in caring out psychosocial research on this intervention (Silverman, 2003). Although available studies have given propositions for future research, none of these studies have given comprehensive suggestions for the methodology and design of thorough high quality randomized meticulous psychiatric music therapy study/research. The crucial question that we must ask ourselves is: in what ways do other psychotherapies achieve their databases and can the music therapy field borrow from their effective methodological best practices, to build up its own literature base? Consequently, as the America Music Therapy Association (AMTA), National Institutes of Mental Health (NIMH) give guidance and mention the treatment to be selected for evidence-based psychotherapy as cognitive behavioral therapy (CBT), though the characteristics of music therapy literature base were analyzed, they should conduct more recent research to come up with recent literature that gives more alternatives.
This literature review has analyzed and identified constituents of high-quality quantitative music therapy research for adults with depression. It has also analyzed and identified the variables and other elements of current quantitative psychiatric music therapy research for adults with mental disorders. Thirdly, it has compared the study’s data sets and used them to identify the best methodological designs and variables for this study and future quantitative music therapy research among adults with depression. The next chapter of this paper discusses the methodology of this study; this chapter will give more insight on how this study is going to be carried out.
CHAPTER 3: METHODOLOGY
Purposes of the Study
The main purpose of this study is to gauge the effectiveness of music therapy interventions on sleep disorders among adults suffering from mental disorders. It will also identify the challenges, obstacle and issues in music therapy interventions among adults suffering from depression.
Research Design and Strategy
There are two broad strategies which can be applied in research and they include the phenomenological and positivist research strategy. These two strategies are differentiated based on the following factors: method of formulation of research objective, type of research methods employed, data collection methods and the significance of target respondents in the research process. This research will be based on the phenomenological approach because of the following:
- Data will be collected from the target respondents through administration of questionnaires. In the positivist paradigm approach, the researcher uses prepared information frameworks through which the respondents are evaluated.
- Objectives in this research will be set in a manner that would lead to the understanding of facts on the issue under investigation. This will be accomplished by use of both primary and secondary data collection. In addition, the study will also rely on existing literature review. On the contrary, the positivist approach aims at collection of empirical data.
The study will make use of an approach based on the phenomenological philosophy so as to enable the researcher to gather reliable and valid results. This approach will be used by the researcher to define the beliefs, assumptions and the nature of reality of this research study. The researcher will analyze every situation in its totality. In order to develop and come up with ideas from the target population, induction will be used during the research process. Additionally, the study sample will be investigated over a given period of time and a natural setting will also be used to implement this research. For this reason, a qualitative induction design will be utilized to achieve the study’s objectives (Easterby, 2008).
Site Selection, Target Population and Participant Selection
The study will be located in a Psychosocial Rehabilitation Centers (PSRs). These locations give the study credibility in several ways: first, there is ready support from the psychiatric and trained music therapist in case of any misunderstanding or extreme cases. Since most of the clients are confined in the center, it is easier to make follow ups and attain a follow up percentage above 85 percent. Last is the availability of records that can be used in further evolutions to give this study more meaning. The center must first grant permission to conduct the study in their premises so as to ensure that they are safe guarding the rights of the patients. Suitable consents are sorted to improve the validity of this project. It is important to note that with this study, there are eliminated video and audio recording for data collection, because most of the rehabilitation centers have policies that basically prohibit the use of this data recording method, as a means of protecting the confidentiality of their clients.
To ensure more confidentiality, all participants are recognized by a participant code or pseudonym, and no real names appear on labels of any collected data materials, observation analyses or transcripts. All materials are stored in the social work office, in a locked cabinet used wholly for this study. The population selected focused on adults with mental disorders, who were admitted to the acute psychiatric unit of the PRC. Ages were restricted between 18 to 65 years due to current limitations established by the behavioral health unit (Flick, 2009).
The major participants or target population of this study will be selected by psychological therapists, psychiatrists and patients from selected rehabilitation centers that practice the use of music therapy interventions in the treatment of sleep disorders among people with depression. The researcher is confident that these participants will be in a position to provide reliable and relevant information required in this research because they have experience in matters related to the use of music therapy interventions on sleep disorders among people with depression. The researcher in the study has to be partly employed in the rehabilitation center. The presence of the researcher in all group and individual secessions is normally recognized as a necessary component in effective music therapy study (Flowers, 2009).
In research, getting the correct sample is of great significance for the researcher to obtain the correct information and to ensure that the research objectives are properly met with an element of logic and judgment. In this research, it will be essential to seek for specific information from the respondents. Therefore, an appropriate method of sampling will be used whereby the researcher will target only specific people in the rehabilitation centers that will participate in the research process. This will be very necessary in obtaining the relevant data required for this research. There is a high turnover rate and frequent sudden discharge of clients from rehabilitation centers, thus sampling emerges as the study that advances and not pre-selected. Selection measures are established leading to screening participants for the study. These include the presence of already diagnosed mental health condition, the capacity to understand and speak in English, voluntarily admission to the rehabilitation center, and the nonexistence of other active psychotic symptoms. The duration of treatment varies, such as number of sessions attended but the final data analysis will capture only those who have attended more than 12 sessions, for the simple reason that the research which has proven the effects of music therapy can be evaluated after at least 10 therapy sessions (Saunders, 2005).
The study is designed to include the participants’ input through interviews and filling of questionnaires. The procedure involved of the following steps:
1. The psychiatrist, the social worker and the music therapist in the rehabilitation center will screen the adults with mental disorders upon admission to the adult psychiatric unit of the Psychosocial Rehabilitation Centre (PRC). The adults who are allowed to participate in the study must be diagnosed with sleep disorders and depression and then the suitable participants are referred to the researcher.
2. The researcher then conducts an extra informal screening to gauge if the participant meets the standards of the study.
3. Once a potential participant is identified, the researcher meets with the participant and explains to him/her the procedure and purpose of the study.
4. When the consent has been sorted, the patient is incorporated as a participant in the study.
5. Before each session, the researcher creates a session plan with the help of the music therapist and based on the treatment objectives and relevant graph reviews of the participants. A treasured input into this process is also taken from the researcher’s spontaneous logs.
6. 7. After each and every session, the researcher must reflect on what has taken place in the group or individual sessions and make notes on feelings, ideas and thoughts of the participants.
8. Data is collected from the researcher’s reflexive logs and observations during the music therapy sessions. This field data is analyzed after every music therapy session. It is vital to note that this portion of the data is not used to guide the structure of the interviews
9. In case the participants are well off to be discharged by the treatment team, the researcher selects one or two of them and interviews them as they fill the final questionnaire.
10. On completion of all interviews and transcriptions, the transcripts are analyzed.
11. Finally after 12 weeks, the treatment team is interviewed and they will fill the questionnaire for the final data analysis.
The researcher will administer the questionnaires to the target respondents online through electronic mails. The questionnaire will be accompanied by consent forms and introductory letters. The researcher will request the respondents to deliver their feedbacks through emails. On the other hand, secondary data will be gathered by performing a thorough document search in books, journals and magazines that contain relevant information to the question under investigation (Schwab, 2005).
This study will mainly explore a reliable method and instrument of primary data collection, which is the use of semi-structured interviews.
In this method of data collection, the researcher engaged the respondents in live interviews. In preparing the interviews, the researcher used the guide of the crucial stages of interview preparation according to Kvale (1996, p.27).These included the following steps of preparation:
- Thematization: This refers to the adoption of a general theme for the interview and it is guided by the primary research question.
- Designing: This included restructuring of the interview questions and locating the set ups in a manner in which the respondents would find it simple to collect data.
- Actual interview and transcribing phase
- Analysis of respondents’ feedback, verification and reporting
The researcher used similar questions for all the interview sessions in order to ensure that the responses obtained were related. This would also make the process of data analysis much easier. The following are some of the advantages of using semi-structured interviews in this research study (Foddy 1993, p.2):
- Total expression is experienced from the target respondents. Interviews overcame the limitation of total expression experienced from other data collection methods like the use of questionnaires. The researcher was present to give clarifications to the meaning of the questions that were not well understood by the respondents.
- Through the semi-structured interviews, the researcher was able to obtain more information that would otherwise not be obtained in other data collection methods like use of questionnaires. For example, expressions that were inherent in facial expressions and signs were experienced in the use of interviews and they added much more value to the information gathered.
The following are some of the few limitations of semi-structured interviews included the following:
- Some of the respondents exhibit bias by generalizing the interview questions hence leading to a bulky and diverse response. This is disadvantageous because it may interfere with the quality of the responses that could be obtained. In addition, it may also reduce the reliability of the study.
- There is also a lack of motivation in the target responses because some respondents would fear that the interviews would interfere with their schedules. To overcome this, the researcher will convince them that the interviews would be short and less-time consuming in order to win their interest and to create a sense of ownership in them regarding the issue under investigation.
The use of questionnaires has been acknowledged by many researchers to be a reliable method (Foddy, 1993). This is because the questionnaires are developed under the guidance of the research objectives to ensure that the questions constructed are relevant to the study. In addition, they are user friendly, inexpensive to construct and administer to the research respondents. Robson (1993) established that a well-developed questionnaire assists the researcher in generating uniform answers from various respondents.
The use of open-ended questions also helps the respondents to put across their observations freely because they do not get restricted in any way. During the construction of the questionnaire, several efforts will be made to connect the questions with literature, to devise and organize the questions in a way that is easy to use and coherent to avoid the inclusion of negative questions (Foddy, 1993). Among the things that the researcher will also put in consideration are the weaknesses that can be encountered while using questionnaires. Such weaknesses include: absence of the respondents which may force the researcher to use unintended people in answering the questions, and inability to evaluate complex views and opinions.
The developed questionnaire will then be taken through various stages aimed at improving its content. The first stage that the questionnaire will be exposed to is the pilot test (Foddy, 1993).
Research Questions and Hypotheses
Five main research questions were considered in this study:
1. What is the role of music therapy interventions on sleep disorders in the treatment of adults suffering from depression?
2. How do adults suffering from depression experience group and individual music therapy interventions?
3. What are the indicating and contra-indicating factors for music therapy interventions on sleep disorders with these adults suffering from depression?
4. How do participants believe music therapy impacts their overall treatment?
There are two key outcomes expected in this study. The first is the overall effectiveness of the music therapy among adult people with mental disorders. The second is the level of effectiveness measured by success rate of music therapy on the same group.
The key hypothesis of this study is:
HO: Music therapy intervention on sleep disorders among adults suffering from depression is very effective.
This will be tested against the alternative:
HA: Music therapy intervention on sleep disorders among adults suffering from depression is not effective.
The qualitative data that will be obtained from this study will be analyzed qualitatively using the appropriate qualitative data analysis methods to derive the significance of the facts and opinions that were expressed by the respondents. Qualitative data analysis methods will be used to analyze the qualitative data that will be collected. Such methods include the use of tables, graphs and pie-charts (Schwab, 2005).
Secondary Data Analysis
The researcher will also rely heavily on secondary data analysis to obtain literature that will be important in the correlation of primary data and already existing or established facts. The secondary data will be obtained from books, research journals, news reports from broadsheets and current affairs magazines. This will play a significant role in providing authenticity, backup and making a comparison to the primary data (Patton, 2002).
In any given research, the major requirement is to guard the welfare and self-esteem of the research respondents. The following are key ethical considerations that have been looked into in this research (Patton, 2002):
- The confidentiality of the information provided by the target respondents will be maintained and the data will primarily be used for research.
- The identity of the respondents will be kept anonymous hence the respondents will not be required to provide their names on the questionnaires.
- The researcher will seek consent from all relevant authorities before the commencement of data collection in order to avoid any legal disputes.
- The respondents will be required to sign a consent form before participating in the study in order to show that they will be taking part in the study at their own will without being coerced.
The expected outcome of this study is presented by category. A very strong positive relationship is expected between music therapy intervention on sleep disorders and depression symptoms. After the analysis of data, various themes are expected to come out consistent to the research purpose and hypothesis. The main categories to be discovered using data analysis and interpretation in relation to the aim of this study are: personal perspective, experience of the music therapy sessions and the effectiveness of music therapy to this group of people. Personal perspectives of the sampled people could include their beliefs, values and history. The experience of the music therapy sessions is expected to include: options, change, connection, triggers, impact, the role of music, and feelings. The calculated percentage of effectiveness of music therapy is expected to be above 60%, and the other sub themes expected are: affirmations, change or shift and transfer or association.
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[JW1]Refer to my comments on the previous version. It doesn’t look like much changed.