Music Therapy in Mental Health For Illness Management and Recovery

Music therapy in mental health
for illness management and

recovery
Music therapy
in mental health for
illness management
and recovery
Michael J. Silverman, PhD, MT-BC

University of Minnesota
1
1
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Preface
Purpose
The purposes of this monograph are multifaceted. The overarching purpose is to focus
on a cognitive behavioral and psychoeducational music therapy approach to illness man-
agement and recovery with adult psychiatric consumers specific to clinical group-based
practice within the United States. Other goals of this monograph include informing ad-
ministrators of music therapy, providing theory-based approaches to psychiatric music
therapy, educating music therapists concerning related literature outside the profession,
stimulating research and employment, and influencing legislative policies. Perhaps the
most essential purpose of this text is to encourage both critical thought and lifelong learn-
ing concerning issues, ideas, and concepts related to various intersections between mental
illness and music therapy. My hope is that readers use the Socratic method to engage with
the material presented in this text and develop and refine their own theoretical under-
pinnings and philosophies. Critical thinking and lifelong learning have been—and will
likely continue to be—essential aspirations in higher education. Moreover, contempo-
rary views concerning evidence-based practice rely heavily upon the clinician’s ability to
think critically (Rubin, 2008), seek a breadth of contradicting and confirmatory evidence,
implement metacognition to monitor thoughts throughout processes, and synthesize
knowledge to make informed clinical decisions relevant and applicable to idiosyncratic
contextual parameters. Thus, in sections of this text, I deliberately present various aspects
of an argument, sometimes without a conclusion. My intention is that readers will engage
with the material and base their own decisions on sound theory, research, values, and
evidence specific to their own distinct contextual parameters. Respectful deliberation of
various multifaceted sides of an issue with colleagues can lead to new ideas, perspectives,
and insights.
As theory-based research can enhance understanding how and why music therapy
might benefit psychiatric patients, how and why music therapy can be effective (Robb,
2012) certainly warrant discussion in the contemporary era of evidence-based practice,
where it may appear that a premium is placed on parallel group studies and quantitative
methods. Outcome studies comparing interventions with placebos are undoubtedly im-
portant and necessary. However, outcome studies do not adequately address purported
mechanisms responsible for change (Kazdin & Nock, 2003). Rather, outcome studies typi-
cally address if there was a difference between groups (although this is an essential aspect
of most experimental research). The music therapy profession requires evidence integrat-
ing multiple ways of knowing as well as various research paradigms in order to imple-
ment new research findings into clinical practice (Bradt, Burns, & Creswell, 2013). Thus,
during my outcome-focused effectiveness research, I have been borrowing, adapting,
vi PREFACE
conceptualizing, developing, and continually refining theory-based and clinically derived

models in an attempt to explain how and why psychiatric music therapy functions within
the conceptual parameters of illness management and recovery, cognitive behavioral ther-
apy, and psychoeducation. However, as Dumont (2011) noted, process research concern-
ing psychotherapeutic mechanisms of change is still being conducted and will likely not be
fully understood without a sophisticated grounding in neuroscience.
Chapters 4 through 7 describe theories for conceptualizing psychiatric music therapy
for illness management and recovery from a cognitive behavioral and psychoeducational
philosophical orientation. However, it is first necessary to understand the social prob-
lem, contextual frameworks, theoretical underpinnings, and parameters in order to better
conceptualize these theories. Thus Chapters 1 and 2 were designed to expediently orient
readers to contemporary cognitive behavioral and psychoeducational psychiatric treat-
ment for illness management and recovery and thereby provide a context for theoretical
and clinical applications described in later chapters. Please note that Chapters 1 and 2 do
not provide definitions of common mental illnesses or an overview of all the numerous
psychological treatments available, as readers likely have already studied and encountered
these subjects. Chapter 3 was written to expediently orient readers to past and contempo-
rary psychiatric music therapy. Administrators who are not familiar with music therapy
may find sections of Chapter 3 helpful. Chapters 8 through 14 were designed to provide
readers with clinical applications of psychiatric music therapy, highlighting contemporary
in-patient practice and treatment, research-based interventions, the research literature,
and evidence-based practice specific to an illness management and recovery approach.
Chapter 14 concludes with questions and conjectures concerning the future of psychiatric
work and how these developments may affect psychiatric music therapy clinical practice.
As with most theories, these conjectures are still being developed, shaped, and refined.
I would contend that these ideas are the result of reading literature within and outside
the music therapy literature base, clinical practice, supervision, university teaching, and
continuous and ongoing research lines. As a music therapy educator at a Research I insti-
tution, I maintain my clinical work in psychiatric settings in order to continually collect
effectiveness and outcome data on the interventions I use. I believe these ongoing clinical
experiences help inform my teaching and research and, in turn, lead to theory-based ap-
proaches. In each music therapy session, I witness seemingly magical (for lack of a better
word) phenomena and I do my best to articulate these happenings to my students. I am
grateful to my undergraduate and graduate students for listening to my verbal thought
processes (rambling and tangential as they may be) as I attempt to describe my percep-
tions of what exactly happens in psychiatric music therapy and how and why mechanisms
of therapeutic change function in the music therapy process. Thus, many of my ideas are
a direct result of years of clinical practice, observing the phenomena of psychiatric music
therapy, and attempting to articulate these mechanisms to my students. My premises are
largely a result of ongoing clinical practice—for these, I am forever indebted to the patients
I treat. These patients continue to educate me and I appreciate their fortitude and under-
standing of my learning curve. It remains a privilege to work with them.
PREFACE vii
Jargon and defining psychiatric music therapy

Regardless of field or profession, jargon is an important topic for communicative pur-
poses. Researchers have noted that the term patient remains “controversial” (Green et al.,
2014, p. S3) for some stakeholders and service users; nevertheless, this term remains com-
mon in clinical practice as these people are often actual patients in a hospital. In an attempt
to alleviate this concern, Green and colleagues (2014) recommended the terms consumer
and service user to describe this clinical population. While there have been many terms
used to describe people in psychiatric treatment, throughout this text I will use the follow-
ing terms interchangeably to describe people diagnosed with mental disorders unrelated
to aging that do not include the autism spectrum or attention deficit disorders: people
with mental illnesses and mental disorders, psychiatric consumers, psychiatric patients,
clients, persons with severe or serious mental illnesses, and patients. While these terms
are rather general and far from ideal, they are perhaps an improvement over past jargon.
Auspiciously, we no longer refer to inpatients with psychiatric diagnoses as lunatics at an
asylum. My hope is that terminology continues to evolve and we are eventually able to use
terms that are sensitive, accurate, descriptive, inoffensive, and diminish and extinguish
public, perceived, and internalized stigma. Meanwhile, it is essential for those who are
knowledgeable of and sensitive to mental illness to educate the public and advocate for this
often-disenfranchised clinical population whenever possible.
Philosophical and contextual underpinnings

Although my experiences as a psychiatric music therapist have been diverse, the majority
of my current clinical work takes place in short-term and acute-care, group-based inpa-
tient locales. Moreover, most psychiatric music therapists in the United States treat psy-
chiatric consumers in group-based settings (Silverman, 2007; Thomas, 2007). Certainly,
mental health services in different countries can vary considerably (Lawrence, Bradshaw,
& Mairs, 2006) and readers are urged to examine contextual parameters that might influ-
ence various music therapy approaches, treatments, and interventions. Most of the patients
I treat have diagnoses including major depressive disorder, bipolar disorder, schizoaffec-
tive disorder, schizophrenia, various forms of anxiety, substance abuse disorders (both
co-occurring or as a primary diagnosis), as well as co-occurring personality disorders.
These patients are typically inpatients for three to seven days. Comorbidity is frequently
present and complicates diagnoses, treatment planning, therapeutic programming, and
research. Additionally, as contemporary evidence-based practice (Boyle, Delos Reyes, &
Kruszynski, 2005) supports treating psychiatric disorders and substance abuse concur-
rently (commonly known as integrated dual-disorder treatment; see Chapter 10), I address
these issues simultaneously during clinical practice. Thus, the patients I work with are not
the “worried well” but are experiencing major crises, represent a danger to themselves or
others, and require supervised inpatient hospitalizations in a secure setting. Based upon
the type of facility where I treat patients, the type of patients I treat, the patients’ needs, and
philosophical orientations of the practitioners on the units, I use a cognitive behavioral
viii PREFACE
and psychoeducational model of music therapy in which I emphasize illness management

and recovery skills to prevent psychiatric relapse and promote psychiatric recovery. I favor
cognitive behavioral therapy and psychoeducation because they are congruent with my
values, morals, personality, data-based approach, desire to generalize skills from thera-
peutic to real-life settings, and the philosophical approaches of the acute-care facilities
where I provide treatment. If I specialized in other clinical settings, such as working with
distressed adults living in the community who did not have major psychiatric diagnoses
and were seeking insight, self-actualization, or greater meaning and fulfillment, my philo-
sophical orientation toward treatment would likely be different. During patient-centered
care, patient need and circumstance—as well as the supporting research literature—should
dictate treatment approach and philosophy.
Please understand that I do not discount other psychotherapeutic theories or negate
their worth. I teach these concepts to university students annually and carefully articulate
when, where, how, and for whom various therapeutic approaches can be effective. In fact, I
enjoy these lectures much more than the seemingly cut-and-dry cognitive behavioral ther-
apy and psychoeducation lectures. Moreover, I tend to agree with Mansell, Carey, and Tai
(2013) as well as with Mahoney (1991), who wrote, “The person of the therapist is at least
eight times more influential than his or her theoretical orientation and/or use of specific
therapeutic techniques” (p. 346). Regardless of orientation, the therapist can be crucial
to facilitating client change. Neuroscience may never fully explain how or why therapy
is effective. Humans are complex and dynamic beings thus necessitating therapists to be
flexible, even within a particular psychotherapeutic orientation. However, as patient need
should directly correspond with patient care, and as the literature base suggests that even
brief cognitive behavioral therapy and psychoeducation can be effective for promoting
illness management and recovery, I will not attempt to further defend my orientation to
clinical treatment that promotes functional illness management and recovery skills and
knowledge. Unfortunately, tribalism will likely continue regardless of how thorough an
argument I make.
Caveats
As with most academic work, it is important to identify limitations and caveats. In the case
of this text, failure to do so could be unethical and potentially harmful to music therapy
clients. Thus, in the interest of full disclosure, examples and clinical anecdotes from this
work are limited to group-based music therapy for adults in the United States for people
with major psychiatric disorders not related to aging, autism spectrum, or attention defi-
cit disorders. As patients diagnosed with eating disorders are often treated at specialized
locales, treatment of these patients is not addressed. Readers interested in music therapy
to treat people who have eating disorders are advised to read Siegel (2007). In a similar
manner, military service veterans are primarily treated at Veterans Affairs (VA) hospitals
and not in the public facilities where I have worked (and continue to work). While I have
forensic music therapy experience, these patients have unique legal issues complicating
PREFACE ix
treatment and outcome. Readers interested in applications of music therapy in forensic

psychiatry are advised to consult Hakvoort and Bogaerts (2013), Hakvoort, Bogaerts, and
Spreen (2012), Kaser and Bullard (2007), Reed (2000), and Thaut (2008). As music thera-
pists in the United States tend to work in inpatient settings where treatment referral is
often programmatic (i.e., based on unit) rather than by individual or by specific disorder,
music therapy with personality disorders is also not addressed in this book. (This is an
important topic, however, and scholarly works concerning music therapy and personality
disorders would constitute welcome—and necessary—additions to the literature base.)
Co-occurring personality disorders are not uncommon and complicate diagnoses and
treatment in crisis stabilization facilities, where the admitting diagnosis and criteria are
typically related to life-threatening psychiatric symptoms. Additionally, personality dis-
orders typically require long-term outpatient therapy. Although this topic unquestionably
warrants discussion, there is currently a shortage of psychiatric music therapy outcome
research specific to personality disorders.
Readers should also be aware that many psychiatric music therapists in the United States
practice group-based music therapy (Silverman, 2007; Thomas, 2007) and work to address
functional illness management and recovery skills within the programming and frame-
work of their facilities. Thus, examples and theories presented in this text are cognitive
behavioral and psychoeducational and may not generalize to insight-oriented music ther-
apy, music therapy in other countries, or individual forms of music therapy. While some
concepts may generalize, others may not generalize to readers’ idiosyncratic contextual
situations. Indeed, although concepts and realities may be far from ideal, clinical circum-
stances typically dictate research design, treatment methods, dose, and outcome assess-
ments (Nathan, Stuart, & Dolan, 2000).
Clinical context is of utmost importance and, after working for a number of years within
the parameters of a multiplicity of mental health care settings in the United States, I have
found substantial variance between psychiatric facilities. There can even exist sizeable dis-
crepancies between different units within the same facility. Thus, context can shape clinical
practice. Moreover, each psychiatric hospital is distinctive and offers diverse types and
levels of treatment. Non-music therapy psychoeducational and therapeutic programming
must be taken into account to determine how best to use music therapy to augment treat-
ment, reduce recidivism, and promote illness management and recovery.
For example, some hospitals provide talk-based psychoeducational sessions to specifi-
cally address coping skills. In these sessions, patients learn about various coping skills and
when, where, how, and why to use them to manage stress and other symptoms of mental
illness. In the case of these hospitals, perhaps music therapists might not focus solely on
coping skills, but rather reinforce the concept as a type of secondary—or tertiary—edu-
cational treatment area to promote illness management and recovery. These music thera-
pists might better serve psychiatric patients by focusing on identifying supports in the
community and how best to use these supports during times of heightened distress to
prevent psychiatric relapse. This is not to imply that a discussion of coping skills with a
music therapy session should be purposely discounted or avoided. Within the session,
x PREFACE
patients can discuss coping skills as a secondary objective. Moreover, seeking supports
in the community may constitute a method for coping, and it is vital that music thera-
pists make these types of generalizations explicit for patients. In other facilities, the music
therapist might be the sole therapist/educator responsible for a coping skills group therapy
session, in which the primary objective is to enhance knowledge and use of healthy cop-
ing skills. In these facilities, music therapists might provide a coping skills group therapy
session but use music therapy to address this topic. Thus, I recommend that psychiatric
music therapists have a comprehensive understanding of the facility’s psychotherapeutic
and educational programming to best conceptualize how music therapy can be used to
augment treatment. While reading and studying a psychiatric facility’s curricula may be
time-consuming and tedious, it will allow music therapists to find the optimal ways to im-
plement treatment within the facility, ideally resulting in improved, cohesive, and holistic
patient-centered care to augment illness management and recovery.
This text will likely be most effective for students who already have a basic understand-
ing of mental disorders, human responses to music, and a variety of music therapy philo-
sophical orientations and approaches, interventions, and research. Thus, a university
abnormal psychology class, psychology of music class, and core music therapy courses
might be appropriate prerequisites for this book. Familiarity with Gfeller and Thaut’s
(2008) well-crafted chapter on music therapy in the treatment of behavioral-emotional
disorders will provide a baseline level of understanding and contextual framework for
the current monograph. Readers might also benefit from studying Darrow’s (2008) book
on music therapy before they use the current text so they are well aware that a cogni-
tive behavioral and psychoeducational approach is merely one of many approaches to
contemporary psychiatric work. Please be aware that this monograph is not intended to
be a “cookbook” to “spoon-feed” readers concerning how to conduct psychiatric music
therapy for illness management and recovery. While some of these issues are addressed,
readers interested in the process of music therapy—including detailed explanations of re-
ferral, assessment, goals and objectives, observation, music therapy strategies, treatment
plans, implementation, evaluation, and termination—should consult Hanser (1999).
Congruent with a cognitive behavioral approach, my intent is to enable readers to develop
their own approach to be independent and competent therapists. Furthermore, this text
was written for a diverse group of psychiatric music therapists interested in illness man-
agement and recovery—some with considerable experience in psychiatric music therapy
and others who may be new to the field or population. Thus, experienced practitioners
may find theoretical chapters more interesting and derive less benefit from sections con-
cerning assessment and documentation. However, assessment and documentation are
essential and were included for music therapy students. Some sections of the book—
including parts of the chapters concerning evidence-based practice and research—may
not be specific to psychiatric music therapy and can generalize to other aspects of the
profession. Whatever one’s purpose is in reading the current text, readers are encouraged
to critically engage and apply the material to the unique contextual parameters of the fa-
cility in which they work.
PREFACE xi
Differences between research and clinical practice

There are numerous differences between clinical findings derived from research protocols
and actual clinical practice. Scholars have repeatedly articulated the well-established gap
between research and clinical practice (Anderson & Adams, 1996; Hollon et al., 2002; Ten-
Have, Coyne, Salzer, & Katz, 2003). Although results of treatment during research studies
may be robust, it does not necessarily mean that this effective treatment will be imple-
mented in similar settings or even continued at the current one (Lin et al., 1998; Schoen-
wald & Hoagwood, 2001; Wells et al., 2000). The lack of generalization and continuation
of beneficial research effects is unfortunate. Therefore, it is important to understand some
of the contextual differences between research and clinical practice. Clinicians need to be
aware that researchers conducting experiments purposely use as much design control as
possible in an attempt to control confounding variables and enhance internal validity. This
may limit a therapist’s clinical creativity in an attempt to preserve clinical control and fidel-
ity of the independent variable and research design while improving external validity. This
type of tightly controlled session may even be perceived as unethical (and lackluster) to an
experienced clinician. However, the use of manuals, scripts, decision trees, and protocols
can help provide the design control necessary for high quality replicable research but still
enable the clinician to help the client in a competent and flexible manner. Thus, “internal
validity (adequacy of the research design) and external validity (generalizability of the
results) involve tradeoffs” (Westen, 2006, p. 161). Scripts and manuals can also promote
treatment fidelity and replication, both important aspects of high quality experimental re-
search (for a more detailed description of manuals, please consult Chapter 14).
Music in psychiatric music therapy

The purpose of this book is not to heighten the musicality of psychiatric music therap-
ists, although this critical issue undoubtedly warrants discussion. Stated plainly, music
therapy cannot occur without music. Music is a mandatory component of music therapy
(Bruscia, 1998) and can provide the structure within a session or function as a prompt or
contingency to elicit a desired response or behavior. Regardless of how it is used, music
is the crucial component of music therapy. While other psychosocial professionals can
certainly help psychiatric patients using music, the functional, deliberate, structured, and
prescribed use of music differentiates music therapists from other specialists. Thus, in the
United States, it is imperative to recognize the MT-BC (Music Therapist-Board Certified)
credential that distinguishes music therapists from those who may use music but lack the
formal academic and clinical training a board-certified music therapist has completed.
While the use of music is obligatory for music therapy to occur, music itself may not be
enough to achieve the desired therapeutic outcome. Live music can be used to establish
rapport and develop the therapeutic alliance. As most people can “play” recorded music
devices, it is becoming increasingly necessary to use live music whenever possible, poten-
tially differentiating music therapists from other clinicians. Certainly, there are situations
in which recorded music may be superior, more appropriate, and even more therapeutic
xii PREFACE
(Silverman, 2009). However, I recommend that each music therapy session should contain
at least some live music in order to develop rapport and working alliance and differentiate
music therapy from other treatment modalities.
Moreover, music therapy cannot occur without high quality music. Music therapists
should use only live music of the highest aesthetic level possible. Poor musicianship on the
part of the music therapist may hinder treatment and result in reduced working alliance,
ineffective treatment, and thus an undesirable or diminished therapeutic outcome. If a
music therapist is not confident, competent, and comfortable with live music, she or he
may devote more attention to the music itself and the client can receive less of the thera-
pist’s attention, which may negatively impact therapeutic presence and subsequent out-
come. This may result in a client perceiving the music therapist as inauthentic. Moreover,
most people listen to music that they would consider to be high quality—listening to low
quality music for enjoyment seems preposterous (with the exception of supporting novice
musicians at concerts and recitals). Thus, in order to be used successfully in a therapeutic
context, live music must be provided at the highest aesthetic level possible by a therapist
who is fully engaged and present with her or his patients.
Music is also imperative in the training of psychiatric music therapists. To become music
therapists, students must typically first demonstrate musical competencies in a variety of
areas. After continued study of music and how it can be used in therapeutic settings, the
student can learn how to apply and integrate music in prescribed and therapeutic contexts.
However, if the music becomes a distraction to the therapist due to lack of technical and
musical ability, this could hinder music therapy treatment. The music in music therapy
should facilitate clinical work rather than hinder it.
Use of this text

I am too realistic to naïvely suppose that this book represents vacation reading. Addition-
ally, although this text focuses on a cognitive behavioral and psychoeducational model of
psychiatric music therapy to promote illness management and recovery, readers should
be aware of other models of psychiatric music therapy. This book can be used as a course
adoption to accompany lectures on psychiatric music therapy specific to illness manage-
ment and recovery. Thus, questions for review and discussion conclude each chapter. If the
book is used as an adoption for a psychiatric music therapy course, I would encourage in-
structors to include creative accompanying assignments. Possible supplementary assign-
ments include the following:
◆ Debating in-class or online about current events related to mental health or about
chapter review questions.
◆ Reading an “anti-psychiatry” or “anti-psychology” book (Chapter 2).
◆ Creating in-services for administrators of psychiatric facilities (Chapter 8).
◆ Role-playing and videorecording interventions (Chapter 9).
◆ Designing studies using qualitative, quantitative, and mixed-method paradigms
(Chapter 12).
PREFACE xiii
◆ Viewing a film concerning mental illness and discussing potential media influences
and effects as well as public, experienced, and internalized stigma.
◆ Reading a mental health memoir.
◆ Reading a self-help book.
◆ Reading about psychiatric current events in the media or in the non-music therapy sci-
entific literature.
◆ Composing open-ended questions based on chapter content for peers to research, an-
swer, and debate.
Conclusion
This text is a result of continuous clinical work, numerous revisions of a graduate-level psychi-
atric music therapy course, and ongoing discussions with students, administrators, academ-
ics, and clinicians. I encourage readers to approach this book—and all academic work—with
an open mind and to critically engage in a wide array of scientific literature, especially from
other philosophical orientations. I hope this work facilitates greater interest in evidence-
based clinical applications and research in psychiatric music therapy for illness management
and recovery so all psychiatric patients will have access to high quality music therapy services.
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TenHave, T. R., Coyne, J., Salzer, M., & Katz, I. (2003). Research to improve the quality of care for
depression: Alternatives to the simple randomized trial. General Hospital Psychiatry, 25, 115–123.
Thaut, M. H. (2008). Group music psychotherapy in correctional psychiatry. In W. B. Davis, K. E. Gfeller,
& M. H. Thaut (Eds.), An introduction to music therapy: Theory and practice (3rd ed., pp. 247–259).
Silver Spring, MD: American Music Therapy Association.
Thomas, C. (2007). Music therapy and acute care psychiatric treatment. In B. J. Crowe & C. Colwell
(Eds.), Music therapy for children, adolescents and adults with mental disorders (pp. 125–132). Silver
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Rubenstein, L. V. (2000). Impact of disseminating quality improvement programs for depression in
PREFACE xv
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American Psychological Association.
Contents
1 The social impact, prevalence, and contemporary short-term treatment

of mental illness 1
2 Pharmacological and psychosocial treatments for people with mental
illnesses 18
3 An overview of music therapy as a psychosocial intervention for psychiatric
consumers 53
4 Continuum model of music and therapy within music therapy 71
5 Educational music therapy for illness management and recovery 78
6 Therapeutic mechanisms in psychiatric music therapy 103
7 Transdiagnostic theory for group-based psychiatric music therapy 119
8 The process of psychiatric music therapy 136
9 Interventions in psychiatric music therapy 168
10 Music therapy for co-occurring psychiatric and substance misuse
disorders 201
11 Psychiatric music therapy with diverse client populations 218
12 Research in psychiatric music therapy 235
13 Evidence-based practice and decision making in psychiatric music
therapy 266
14 Future treatments for psychiatric consumers: Advances, models,
and the potential relevance of psychiatric music therapy 287
Glossary 305
Name Index 315
Subject Index 321

Detailed Table of Contents
1 The social impact, prevalence, and contemporary short-term treatment

of mental illness 1
Social impact of mental illness 1
Prevalence 2
Other health problems for psychiatric consumers 3
Economic implications 4
Brief etiology 5
Brief hospitalizations 5
Brief and time-limited treatments 6
Single-session treatment 7
Contemporary psychiatric treatment for acute care patients 9
Contemporary psychiatric treatment for patients with severe and chronic
mental illnesses 9
Implications for music therapists 11
References 12
Questions for review and discussion 17
2 Pharmacological and psychosocial treatments for people with mental
illnesses 18
Introduction 18
Psychotropic medications 18
Medications as a primary treatment 18
Anti-medication movement 20
Medication noncompliance 22
Electroconvulsive therapy 24
Importance of psychosocial interventions 24
Comparing psychotherapies and the Dodo Bird Verdict 26
Music therapy ramifications of the Dodo Bird Verdict 28
Cognitive behavioral therapy 28
Reviews of cognitive behavioral therapy research 31
Schizophrenia and psychosis 31
xx Detailed Table of Contents
Bipolar disorder 32
Depression, anxiety, and panic disorders 32
The future of cognitive behavioral therapy 33
Illness management as a psychosocial treatment 33
An overview of illness management 33
The impact of illness management 35
Illness management research 36
The recovery concept 37
References 42
3 An overview of music therapy as a psychosocial intervention
for psychiatric consumers 53
Introduction 53
History of psychiatric music therapy 55
Contemporary psychiatric music therapy 59
Funding psychiatric music therapy services 61
Music therapy in long-term psychiatric treatment 63
Music therapy in acute care psychiatric treatment 63
Group psychiatric music therapy 64
Diagnoses in psychiatric in music therapy 65
Contemporary objectives in psychiatric music therapy 65
References 67
4 Continuum model of music and therapy within music therapy 71
Guiding questions 71
Related music therapy literature 72
Continuum model explained 74
References 77
5 Educational music therapy for illness management and recovery 78
The function of psychiatric music therapy 78
Approaches to music therapy with psychiatric consumers 78
Symptom reduction 78
Educational music therapy for illness management and recovery 80
DETAILED TABLE OF CONTENTS xxi
Neurocognitive functioning in mental illness 86

Prodromal, residual, and recurring symptoms 87
Coping skills 92
References 97
6 Therapeutic mechanisms in psychiatric music therapy 103
Introduction 103
When might psychiatric music therapy be effective? 103
For whom might psychiatric music therapy be effective? 105
What characteristics of the therapist facilitate change? 106
Why might psychiatric music therapy be effective? 106
Cognitive factors 108
Affective Factors 110
Behavioral factors 112
Music therapy applications 114
References 115
7 Transdiagnostic theory for group-based psychiatric music therapy 119
Introduction 119
Problems with diagnoses 119
Introduction to transdiagnostic theory 121
Applying transdiagnostic theory to music therapy 122
Clinical example 126
Limitations 128
Alternatives to transdiagnostic theory 129
Transdiagnostic theory implications 131
References 132
8 The process of psychiatric music therapy 136
In-Services 136
Referral 142
Assessment 143
Treatment planning 147
Objectives 149
xxii DETAILED TABLE OF CONTENTS
Developing rapport and therapeutic alliance 150

Problem solving as a collaborative approach 154
Assignments outside of the therapy session to facilitate
generalization 155
Collecting data to systematically measure progress 156
Documentation 158
Evaluation and community reintegration 160
Supervision in psychiatric music therapy 160
Scheduling 162
References 163
9 Interventions in psychiatric music therapy 168
Introduction 168
Songwriting 170
Three approaches to songwriting 174
Structuring songwriting interventions 175
Fill-in-the-blank songwriting 175
Lyric replacement songwriting 176
Free composition songwriting 179
Suggestions for facilitating songwriting interventions 179
Lyric analysis 179
Recreational music therapy interventions 183
Rhythm-based interventions 183
Take one, pass one 184
Rhythm train 185
Pass/bounce, 2, 3, 4 . . . 185
Facilitated group drumming and percussion 185
Rock opera for assertiveness training 186
Rockumentaries 188
Music and art 189
CD about me 189
Scribble art 189
My song 189
Orff-based and narrative-based music therapy interventions for adult
psychiatric consumers 190
DETAILED TABLE OF CONTENTS xxiii
Improvisation 190
Therapeutic music videos 196
References 196
10 Music therapy for co-occurring psychiatric and substance misuse
disorders 201
Introduction 201
Social Problem 202
Separate care 203
Integrated dual-disorder treatment 203
Practicing integrated dual-disorder treatment 205
Characteristics of patients with dual disorders 207
The twelve steps 208
Music therapy and integrated dual-disorder treatment 208
Associations between music and substance misuse 212
References 214
11 Psychiatric music therapy with diverse client populations 218
Introduction to multiculturalism 218
Other types of diversity 224
People who are LGBTQ 225
People with disabilities 226
Multicultural music therapy literature 226
Multicultural music therapy clinical training 228
References 230
12 Research in psychiatric music therapy 235
Challenges and complications 235
Lack of psychiatric music therapy studies 236
Qualitative research in psychiatric music therapy 236
Quantitative research in psychiatric music therapy 238
Future psychiatric music therapy research 238
Theory in music therapy research 253
Suggestions for psychiatric music therapy research 254
xxiv DETAILED TABLE OF CONTENTS
Reporting guidelines 256

Application to psychiatric music therapy 257
References 258
13 Evidence-based practice and decision making in psychiatric
music therapy 266
Introduction to evidence-based practice 266
Evidence-based practice and music therapy 268
Levels of evidence 269
Randomized controlled trials 270
Systematic reviews 271
Meta-analyses 272
Psychiatric music therapy systematic reviews and meta-analyses 272
Other research paradigms in evidence-based practice 274
Selected psychiatric music therapy research using non-RCT paradigms 275
Applying the five steps of evidence-based practice to psychiatric music
therapy 276
Differentiating evidence-based practice terminology 276
Six established evidence-based treatments for psychiatric consumers 278
The future of evidence-based practice in psychiatric music therapy 278
References 281
14 Future treatments for psychiatric consumers: Advances, models,
and the potential relevance of psychiatric music therapy 287
Introduction 287
Manuals 287
Quartered classification system and the dual-factor model of mental
health 291
Precision and personalized medicine based on molecular biology 292
Rational drug design 293
Future psychiatric music therapy models, relevance, and concerns 295
Community-based psychiatric music therapy 295
Wellness model 296
Neurological model 297
DETAILED TABLE OF CONTENTS xxv
Areas of concern in psychiatric music therapy 297

Importance of MT-BC and licensure 298
Compassion fatigue, burnout, and self-care 298
Predicting the future of psychiatric music therapy 300
References 301
Glossary 305
Name Index 315
Subject Index 321

Chapter 1
The social impact, prevalence,

and contemporary short-term
treatment of mental illness
Social impact of mental illness

Mental illness continues to be a major societal problem that cannot be ignored. It is un-
acceptable and intolerable to marginalize this group of healthcare consumers and ignore
their needs, preferences, values, and concerns. People with mental disorders deserve qual-
ity interventions using holistic treatment models to address all aspects of health so they
can live in the least restrictive environments of their choice. Additionally, the general pub-
lic has misconstrued opinions of mental illness. In a descriptive study concerning gun
policy and mental illness, researchers identified a number of misconceptions about mental
illness (see Box 1.1).
The authors also found that in most cases people had more positive views concerning
mental illness when they had direct personal experience, a close relationship with, or con-
tact with a person diagnosed with a mental illness (Barry, McGinty, Vernick, & Webster,
Box 1.1 Discrimination and Misconceptions Concerning

Mental Illness
◆ Respondents believed that people with serious mental illnesses are more dangerous
than members of the general population.
◆ Participants indicated they were unwilling to have a person with a mental illness as
a neighbor or coworker.
◆ Only 58% of participants perceived discrimination against people with mental ill-
nesses as a serious problem.
◆ Only 56% of participants believed that people with mental illnesses could get well
and return to productive lives with treatment.
Data from Colleen L. Barry, Emma E. McGinty, Jon S. Vernick, and Daniel W. Webster, After Newtown—
Public Opinion on Gun Policy and Mental Illness, The New England Journal of Medicine, 368(12), pp. 1077–1081.
Doi: 10.1056/NEJMp1300512, 2013.
2 MENTAL ILLNESS
2013). Thus, the public’s misunderstanding of mental illness perpetuates stigma, delays
treatment for those who desire or require it, and hinders social progress for this disenfran-
chised group.
Prevalence
Mental illness is a solemn and, unfortunately, extensive social dilemma. Each year, approx-
imately one in four adults are diagnosed with a mental disorder (Kessler, Chiu, Demler,
& Walters, 2005). When these statistics are applied to the 2004 U.S. Census residential
population estimate for people aged 18 and older, it equates to approximately 57.7 million
people (National Institute of Mental Health, 2006). Other researchers have investigated
different classifications and severities of mental illnesses specific to the United States: Kes-
sler and Wang (2008) noted that 40% of those with mental illness have mild forms of
their respective illnesses, while 37% have moderate forms, and 22% have serious forms.
However, the majority of the mental illness crisis afflicts 6% of the population who are
diagnosed with a serious mental illness (Kessler, Chiu, et al., 2005). These severe disorders
are not only common in the United States, but also frequently occur in other countries.
Moreover, it is not unusual for a person to be diagnosed with more than one mental dis-
order at a given time as approximately 45% of persons afflicted with a mental disorder
are comorbid; that is, they meet criteria for two or more disorders (Kessler et al., 2005).
Typically, the severity of the disorder is strongly related to comorbidity. Comorbidity can
obscure diagnoses, and psychiatric and psychological treatments can be further compli-
cated, hindered, and longer in duration.
Approximately 2.4 million American adults, or 1.1% of the population aged 18 and
older, have schizophrenia (Regier et al., 1993). Another 20.9 million American adults who
are age 18 and older have a mood disorder (Kessler, Chiu, et al., 2005). Of the mood dis-
orders, bipolar disorder, sometimes referred to as manic depression, affects approximately
5.7 million American adults aged 18 and older each year (Kessler, Chiu, et al., 2005). Angst
(1998) indicated that bipolar spectrum disorders can affect up to 8% of the population.
Major depressive disorder (also known as unipolar depression) affects approximately 15
million American adults each year (Kessler, Chiu, et al., 2005) and is more common in
women than in men (Kessler et al., 2003). Depressive disorders typically co-occur with
anxiety disorders as well as substance abuse and dependence (Kessler, Berglund, Demler,
Jin, & Walters, 2005), complicating both diagnosis and appropriate and effective treatment
methods. Although researchers specifically indicated that depressive disorders are both
major sources of personal distress and social disability (Ormel et al., 1994), all serious
mental illnesses cause tremendous amounts of stress, stigma, disability, and represent a
societal crisis that humanity is forced to address.
Persons with mental disorders face a multitude of social, emotional, and financial prob-
lems. Often, suicide is the end result of the depression and complicated emotional and
behavioral problems experienced by people with mental illnesses. Kleespies, Deleppo,
Gallagher, and Niles (1999) found that between 90 and 93% of adults who had successfully
Other health problems for psychiatric consumers 3
completed suicide had a major mental disorder. In 2002, approximately 11 out of every
100,000 people committed suicide in the United States (Kochanek, Murphy, Anderson,
& Scott, 2004) and more than 90% of these persons had a diagnosable mental disorder
(Conwell & Brent, 1995). Although more men die via suicide than women, women at-
tempt it two to three times as often as men (Weissman et al., 1999). Vieta (2003) specifi-
cally noted the high suicide rates during the depressive phase of bipolar disorder and the
need for timely interventions. Thus, mental illness is a prevalent problem that society must
confront. If untreated, enormous consequences, such as suicide and compromised quality
of life, may occur.
Other health problems for psychiatric consumers

Researchers have also found that many people with serious mental illnesses do not seek
any healthcare (Wang et al., 2005). Concerning those who do seek and use it, few people
in the public mental health care system receive what might be considered high-quality
psychiatric healthcare (Aron et al., 2009). This problem is further complicated with other
aspects of health. Unfortunately, people with severe mental illnesses are rarely identified
as at-risk and are underserved concerning social determinants of health, including life
expectancy (Shrestha, 2006). People with mental illnesses are more than twice as likely
to smoke cigarettes and more than 50% more likely to be obese than the rest of the pop-
ulation (Compton, Daumit, & Druss, 2006; Coodin, 2001; Daumit et al., 2003; McElroy,
2002). Cardiovascular disease is the primary cause of death for people with serious mental
illnesses. People with severe mental illnesses have mortality rates two to three times higher
than the overall population in the United States (Colton & Manderscheid, 2006; Druss,
Zhao, Von Esenwein, Morrato, & Marcus, 2011; Saha, Chant, & McGrath, 2007).
People with severe mental illnesses can die 15–25 years earlier than people without (Col-
ton & Manderscheid, 2006; Morgan et al., 2003). In the United States, adults living with
serious mental illnesses die approximately 25 years earlier than other Americans (Man-
derscheid, Druss, & Freeman, 2007). Researchers have noted that a large proportion of the
early mortality experienced by psychiatric consumers can be associated with preventable
causes (Miller, Paschall, & Svendsen, 2006; Radke, Parks, & Ruter, 2010). Additionally,
physiological illnesses can result in mental disorders. For example, people with diabetes
have double the risk for depression (Sherrer et al., 2011). Some of these complications are
the result of psychotropic medications that can cause weight gain via increased appetite
and high caloric intake. Stigma associated with mental illness may also be a factor resulting
in low participatory levels in mainstream physical activities (Hinshaw, 2007; Thornicroft,
Brohan, Rose, Sartorius, & Leese, 2009). Additionally, low socioeconomic status results
in reduced access to healthy foods as well as a lack of reasonably priced places to exer-
cise (Agerbo, Byrne, Eaton, & Mortensen, 2004; Dipasquale et al., 2013; Hudson, 2005).
Thus, there is a dire need for psychosocial practitioners and researchers to holistically
treat all aspects of the person, not solely limiting care to merely psychiatric or physiologi-
cal concerns. Others have noted that implementing a collaborative care model—in which
4 MENTAL ILLNESS
primary care and mental health providers work together to deliver effective treatments
within primary care settings—for people with depression would save the Medicare system
approximately $15 billion annually (Unutzer, Schoenbaum, & Harbin, 2011). More specif-
ically, researchers who implemented a behavioral weight loss intervention for overweight
and obese people with severe mental illnesses found significantly reduced weight over an
18-month period (Daumit et al., 2013).
Economic implications
Due to the complexities and seriousness of mental health treatment, the supervision
and care of psychiatric consumers have been—and continue to be—extremely expensive
(Gadit, 2004). As mental health institutions employ psychiatrists, psychologists, nurses,
pharmacists, social workers, therapists, and unit staff, operating costs are typically exceed-
ingly high. Many of these institutions are inpatient facilities and thus operate 24 hours/
day, providing comprehensive around-the-clock care for patients but increasing costs sub-
stantially. While most scholars and administrators agree that psychiatric care is expensive,
Insel (2008) noted how challenging it is to estimate exactly how expensive psychiatric care
may be. These difficulties result from not only the direct costs of care, but loss of income
from being unable to work, expenses for social supports in the community, and indirect
costs associated with a chronic disability often beginning early in the adult stages of life.
Scholars have underestimated both the costs and the burden of mental illness on pro-
ductivity and health throughout the world for a number of years. As the prevalence of
psychiatric disorders is so outsized, it inflicts a huge cost on society (Kessler et al., 1994).
Mental illness is responsible for over 15% of the burden of disease in countries that have es-
tablished market economies, a statistic greater than the disease burden caused by all types
of cancer (Murray & Lopez, 1996). Mental disorders are the leading cause of disability for
people aged 15–44 in the United States and Canada, with major depressive disorder being
the single leading cause of disability for this group (World Health Organization, 2004).
Although appraisals vary, Soni (2009) noted a cost of $57.5 billion for mental health care
in the United States during 2006—a figure equivalent to the costs associated with cancer.
Insel (2008) estimated serious mental illnesses cost more than $100 billion in United States’
healthcare expenditures. Additionally, loss of earnings related to serious mental illnesses
cost approximately $193 billion and disability benefits cost $24.3 billion, thus totaling more
than $317 billion spent on serious mental illnesses in 2002. The World Health Organization
(WHO, 2011) reported that mental illnesses are the leading causes of disability-adjusted
life years worldwide, accounting for 37% of healthy years lost from noncommunicable
diseases. In this report, the authors estimated that the global cost of mental illness was
approximately $2.5 trillion in 2010, with two-thirds of the estimate representing indirect
costs. The authors also estimated that by 2030, this cost would reach $6 trillion. Specifically,
depression accounts for approximately one-third of this disability (WHO, 2008).
Social security disability income (SSDI) and supplemental security income (SSI) are
responsible for funding a large part of mental health–related expenses and treatment in
Brief etiology 5
the United States. People with serious mental illnesses represent the largest diagnostic cat-
egory of those receiving SSDI and SSI payments from the U.S. federal government (Jonas
et al., 2011). Each year, approximately 48 million people receive SSDI and SSI at a cost of
over $100 billion (Marini & Reid, 2001). Persons diagnosed with a psychiatric disability
account for 26% of these 48 million people and encompass the single largest diagnostic
category of beneficiaries. Additionally, persons with severe mental illnesses are the pri-
mary diagnosis category for 10–20% of claims in the disability insurance industry, costing
$150 billion each year (Wagner, Danczyk-Hawley, & Reid, 2000). Although there is often
considerable variance between Medicare and Medicaid programs by state, these programs
provide funding for more than 30% of all behavioral health services (Mark, McKusick,
King, Harwood, & Genuardi, 1998).
Concerning specific types of mental illnesses and the costs associated with them, Wyatt
and Henter (1995) indicated that bipolar disorder alone costs the United States $38 billion
annually. The authors found that of this total, $17 billion was a result of diminished or lost
productivity while $8 billion was a result of lost human assets linked with suicide. Since
the data for this scientific investigation were collected in 1991 and the article was not pub-
lished until 1995, it is highly probable that these costs have substantially increased.
Aside from high costs of mental illness, there are serious clinical risks associated with
delayed treatment for persons with psychiatric illnesses (Kelly, Dunbar, Gray, & O’Reilly,
2002). Prolonged distress, legal problems, increased morbidity and self-destructive behav-
ior, and physical assaults represent some of the consequences of delayed psychiatric treat-
ment (Whitty & Devitt, 2005). Thus, the costs of mental health treatment are incredibly
high but are outweighed by the costs of treatment absence or delay. Additionally, financial
costs associated with mental health treatment lead to increased healthcare costs for all
people, regardless of diagnosis (Rice & Miller, 1998; Simon, Ormel, von Korff, & Barlow,
1995). Although personal distress, compromised quality of life, and potential harm or loss
of life cannot be as easily measured quantitatively as financial impact, these issues are crit-
ical and cannot be ignored.
Brief etiology
Brief hospitalizations
Due to the high financial costs of hospitalization, multiple and complex issues of persons
with severe mental illnesses, and advancements in pharmacotherapy, psychiatric patients
are often hospitalized on inpatient status for only a few days before they are discharged
(Black & Winokur, 1988; Wells & Phelps, 1990; Winston & Winston, 2002). In fact, the
National Association of Psychiatric Health Systems (2002) indicated that mean length of
inpatient psychiatric hospitalizations declined from 25.6 days in 1990 to 10 days in 2000.
In the United States, health maintenance organizations (HMOs) have also advocated
for shorter inpatient hospitalizations and briefer treatments in an attempt to lower costs
associated with mental health care. Additionally, many insurance companies implement
limitations on mental health services in an effort to control costs. Restricted insurance
6 MENTAL ILLNESS
benefits often constrain the number of therapy sessions allotted as well as more longitudi-
nal and comprehensive treatments (Nathan, Stuart, & Dolan, 2000). Unfortunately, even
when needed, longer-term treatments may not be available for many patients with mental
disorders. Health authorities, hospital governing boards, HMOs, and insurance compa-
nies carefully observe economic parameters including duration of inpatient hospitaliza-
tion, number of treatment sessions, health outcomes, and client satisfaction. In an attempt
to contain expenditures, these agencies typically focus on accountability and decreasing
costs. From business and expense-savings standpoints within a capitalist society in the
United States, a reduction in recovery time not only improves clients’ overall functioning
but reduces costs which results in lower overall healthcare spending (Dobson & Dobson,
2009) and maximized profits. Therefore, many facilities focus on expediently augmenting
inpatients’ illness management and recovery skills in order to return people to the com-
munity and avoid extended and expensive inpatient treatments.
Brief and time-limited treatments

Due to the aforementioned issues contributing to a contemporary emphasis on short
treatment models, brief, also known as time-limited, interventions for persons who are
mentally ill have become relevant and consequential. Various authors have noted the clin-
ical usefulness and practicality of brief therapy. A noteworthy advantage of this treatment
type is costs are kept at a minimum, making treatment affordable for a greater number
of consumers. Moreover, even within traditionally lengthy psychotherapy, Symrnios and
Kirkby (1993) found that long-term psychodynamic therapy is not necessarily better ther-
apy when compared to similar types of brief interventions in a controlled study. In review
articles, researchers have supported the use of brief and time-limited therapy, noting it is
becoming increasingly popular with a diverse range of clinical populations because of its
effectiveness and practicality (Hill, 1992; Lambert & Cattani-Thompson, 1996). Research-
ers have noted that the effects of brief counseling appear to be relatively long-lasting when
compared to longer types of therapy (Symrnios & Kirkby, 1993).
Specific to substance abuse and addiction, experts have noted that treatment dose can be
unrelated to outcome and that enduring behavior changes can occur within the confines
of relatively brief interventions (Miller, 1998). While the literature does indicate that out-
comes for clients who receive interventions are better than for those who do not receive in-
terventions (Miller et al., 1995), if a brief intervention of one to three sessions is compared
with more intensive treatment, there tends to be a lack of differences in short- and long-
term treatment outcomes (Bien, Miller, & Tonigan, 1993). Specific to substance abuse and
addiction, Miller (1998) noted the importance of brief interventions but also articulated
the lack of understanding concerning how and why brief interventions may be effective:
The optimal procedures for triggering these shifts are only beginning to be discovered, and it may
be that relatively brief interventions can suffice to trigger at least some of these transitions. It is pos-
sible that a triggered transition between certain stages is a sufficient catalyst for an ongoing process
of change, which could account for some of the sharp deflections in behavior observed with brief
interventions. (p. 167)
Brief etiology 7
Single-session treatment
Single-session therapy is the most frequently used treatment duration type and the ulti-
mate version of the brief therapies (Talmon, 1990). Cameron (2007) noted that single-
session psychotherapy has become a mainstream and pragmatic approach over the last
several decades. Single-session treatment is a result of both a reduction of resources and
an increased demand for services (Bloom, 2001, Campbell, 1999). Kaffman (1995) noted
that practitioners and researchers have challenged the belief that therapy must be pro-
tracted and lengthy. Thus, the change in ideology from time-unlimited interventions to
time-limited interventions has resulted in the most extreme example of brief treatment:
Table 1.1 Components of Talmon’s (1990) Single-Session Therapy
Component Brief description

1. Starting the session Greetings and introductions to establish working alliance. The
therapist briefly takes the patient’s history and emphasizes that
change and helpful solutions are possible. The therapist might
determine the patient’s therapeutic expectations and use questions
such as “What is the problem?” or “How can I help you?” to initiate
dialogue.
2. Search for a therapeutic focus The therapist identifies the focus and presenting problem to
help the patient feel less confused and overwhelmed. The focus
should contain initial steps for a workable solution. The therapist
encourages the patient’s autonomy and self-determination.
3. Working with metaphor The therapist formulates an image or metaphor that might
generalize past the presenting problem. The metaphor is based on
the patient’s language and experiences. The therapist and patient
initiate working toward possible solutions.
4. Practicing solutions Use experiential work to practice possible solutions to reinforce
the desired change. “The ‘talking cure’ becomes the ‘doing cure’”
(p. 88).
5. Strengthening The therapist investigates the patient’s support for implementing
the solutions. If ambivalence occurs, the therapist acknowledges the
ambivalence and continues to support the patient.
6. Attempted final intervention The therapist delivers final feedback by empowering patient and
reiterating what the patient and therapist determined would be the
best solutions. The therapist emphasizes self-determination and
capacity for change.
7. Last-minute issues The therapist asks the patient for any last-minute issues. If a patient
identifies another problem, the therapist might note that this
problem might be solved in a similar manner as the therapeutic
focus or presenting problem, thus using the therapeutic momentum
established in the session.
8. Follow-up The therapist or another team member may conduct follow-up
interviews to determine how the patient is doing.
Data from Moshe Talmon, Single-Session Therapy: Maximizing the Effect of the First (and Often Only) Therapeutic
Encounter, John Wiley and Sons, 1990.
8 MENTAL ILLNESS
a single treatment session (Bloom, 2001). Talmon (1990) noted that single-session thera-
pists might employ a plethora of techniques as long as they are specifically tailored to the
client and her or his idiosyncratic needs.
Bloom (2001) and Talmon (1990) clarified that single-session psychotherapy is not a
condensed version of traditional therapy. Rather, in single-session therapy, change is con-
strued as an inevitable aspect of existence and patients need therapists’ assistance only for
relatively brief periods (Watzlawick, Weakland, & Fisch, 1974). Thus, therapists provid-
ing single-session treatment typically take a leadership role to help identify and prioritize
problems, explore potential solutions, develop new approaches (Campbell, 1999), and
promote action and change (Bloom, 2001; Talmon, 1990). The therapists’ goals typically
involve enhancing motivation, readiness for change, empowering patients, inspiring hope
and autonomy, and helping patients identify resources and alternatives (Talmon, 1990).
Techniques might include noting that change is possible, identifying a problem to focus on
within the session, attentive listening (Talmon, 1990), offering advice, and reframing and
normalizing the presenting problem (Campbell, 1999).
In a text concerning single-session therapy, Talmon (1990) identified eight compo-
nents of single-session therapy that are depicted in Table 1.1. Although there is no datum
Box 1.2 Talmon’s (1990) Helpful Attitudes for Single-Session

Therapy
1 This is it.
2 View each and every session as a whole, complete in itself.
3 All you have is now.
4 It’s all here.
5 Therapy starts before the first session and will continue long after it.
6 Take it one step at a time.
7 You do not have to rush or reinvent the wheel.
8 The power is in the patient.
9 Never underestimate your patient’s strengths.
10 You don’t have to know everything in order to be helpful.
11 Life is full of surprises.
12 Life, more than therapy, is a great teacher.
13 Time, nature, and life are great healers.
14 Expect change. It’s already well under way.
Data from Moshe Talmon, Single-Session Therapy: Maximizing the Effect of the First (and Often Only)
Therapeutic Encounter, John Wiley and Sons, 1990.
CONTEMPORARY PSYCHIATRIC TREATMENT FOR PATIENTS WITH SEVERE AND CHRONIC 9
supporting use of these components, these eight components may be helpful to struc-
ture and facilitate single-session treatment. While Talmon developed these components
for use during individual therapy, these concepts can be generalized to group-based
treatment.
In his single-session therapy text, Talmon (1990) also identified 14 items for a check-
list of what he termed “helpful attitudes” (p. 134) for therapists practicing single-session
therapy (see Box 1.2).
As single-session treatment is considerably different from traditional psychotherapeu-
tic approaches, researchers have investigated single-session treatment effects in different
manners consistent with the philosophy and brief format. Although there are limitations
and problems within the scientific literature base, “these studies tentatively suggest that
desirable client-level outcomes are achieved following single session psychotherapy”
(Cameron, 2007, p. 246). Bloom (1981) also noted that not only are single-session ther-
apy encounters common, but “their therapeutic impact appears to be underestimated”
(p. 180). Although single-session therapy may not be ideal, it may be the reality as contex-
tual parameters typically dictate treatment.
Contemporary psychiatric treatment for acute care patients

People are often hospitalized on inpatient units when they display changes in mental
status that threaten the safety of themselves or other people. This type of care is typi-
cally provided on short-term, or acute care and crisis stabilization, inpatient psychi-
atric units of general hospitals or specialized psychiatric facilities (National Center
for Health Statistics, 2010). Between 1970 and the mid-1990s, the number of these
acute care services has grown in accordance with the reduction of long-term psychi-
atric services (Geller, 2009; Sharfstein & Dickerson, 2009). Specifically, the decline in
psychiatric inpatient length of stay for adult patients was more pronounced in govern-
ment-reimbursed than privately reimbursed care (Blader, 2011). Blader (2011) found
that increased hospitalization rates were offset by shorter durations of inpatient care,
resulting in stable statistics concerning overall days of inpatient care. Thus, psychiat-
ric patients are being hospitalized more frequently for shorter durations but patients’
overall number of days within inpatient facilities over time has not changed. Addition-
ally, due to the nature of psychiatric emergencies, patients are often admitted to the
emergency room of a medical facility before they are transferred to an acute psychiatric
care facility (Blader, 2011). This dual admission also contributes to increases in costs
and delayed treatment.
Contemporary psychiatric treatment for patients with severe

and chronic mental illnesses
Severe, or serious, mental illness (SMI) is a social concern that demands attention in
the United States and around the world. It is a “broad term that is used to separate the
‘mad’ from the ‘sad’” (Dickey, 2005, p. 3). Often, people with SMI require hospitalization
10 MENTAL ILLNESS
regardless of the specific type of diagnosis or diagnoses. Although it would likely facilitate
securing financial resources and treatment efforts by providing a mutually agreed upon
definition of the term, there is still a sizable debate concerning how to operationally define
SMI (Dickey, 2005).
Despite pharmacological advances and evidence-based psychosocial treatments, the
census of people with SMI has remained constant (Frank & Glied, 2006). Additionally, be-
cause of diminished cognitive and social functioning levels due to their intense symptoms,
many of these people are homeless or incarcerated. People with SMI have some of the low-
est rates of employment of all disability groups; approximately 30% of adults who are single
and homeless have an SMI (Burt, 1992; Burt, Aron, Lee, & Balente, 2001; Teplin, 1990).
Fortunately, treatment for people with SMI has improved considerably from the days
when they were hospitalized on the back wards of public mental hospitals and received
ineffective and often painful therapies (Deutsch, 1948). Today, many people with SMI are
not hospitalized for as long and almost all obtain some type of treatment (Frank & Glied,
2006). People with SMI often receive financial assistance through their medical insurance
and through federal insurance programs. Instead of being forced to live in state institutions
located far from urban centers, people with SMI often live in communities of their choice.
Although psychiatric illnesses are among the leading causes of morbidity in society, con-
sumers diagnosed with these disorders are still not receiving adequate care (Murray &
Lopez, 1996; Wang, Berglund, & Kessler, 2000; Young, Klap, Sherbourne, & Wells, 2001).
Unfortunately, public health interventions for the treatment of mental illness in the United
States are still underdeveloped (Wells, Miranda, Bruce, Alegria, & Wallerstein, 2004). In
fact, authors of studies conducted in the 1980s and 1990s indicated that only a minority of
persons with anxiety and depressive disorders in the United States had actually received
treatment in the last year (Wang et al., 2000). During the 1980s, researchers found that
only 19% of persons with an active mental illness had received any treatment in the past
year (Robins & Regier, 1991), while in 1990, only 21% received professional treatment
(Kessler et al., 1994). Regrettably, an even smaller proportion of mental health consumers
have received treatment that is considered by experts to be sufficient. Only 7% of persons
with major depression received treatment that researchers deemed minimally adequate
(Katz, Kessler, Lin, & Wells, 1998). Also, many psychiatric consumers are underdiagnosed
and therefore do not obtain the care they need. This may lead to additional and unneces-
sary personal distress (Kunen, Niederhauser, Smith, Morris, & Marx, 2005) and higher
incidence of suicide and homelessness. Despite newer medications and advancements in
various types of treatment methods, recidivism remains extremely high (Langdon, Yaguez,
Brown, & Hope, 2001; Rabinowitz, Mark, Popper, & Slyuzberg, 1995).
Another problem for mental health consumers is the considerable gap between research
and practice in psychiatric settings (Anderson & Adams, 1996; Hollon et al., 2002; Ten-
Have, Coyne, Salzer, & Katz, 2003). Barriers to the establishment of newer and empirically
supported treatments include a lack of partnership between researchers and clinicians,
inadequate characteristics of the organization/workplace, difficulty in learning new clini-
cal techniques, and absence of knowledge and skills (Tarrier, Barrowclough, Haddock, &
McGovern, 1999). An additional concern is that, even when treatment practices prove
effective during vigorously controlled research trials, these treatments are often discontin-
ued after the scientific studies conclude (Lin et al., 1998; Schoenwald & Hoagwood, 2001;
Wells et al., 2000). Moreover, research interventions and assessments are often designed
by experts in research and sometimes do not reflect the concerns and values of adminis-
trators, consumers, and providers (Wells, Miranda, Bruce, Alegria, & Wallerstein, 2004).
Reasons for these discrepancies may involve forces both inside and outside the healthcare
system (Institute of Medicine Committee on Quality of Health Care in America, 2001).
Managed insurance care is another issue further complicating current psychiatric care
in the United States. Although newer classes of medications have become available for use
and may have fewer side effects, financial constraints still can deter treatment. Moreo-
ver, as larger percentages of the U.S. population are covered under managed insurance
care, primary care doctors are frequently being given the responsibility of mental health
care (McFarland, 1994). Often these physicians are not specifically trained in prescribing
psychotropic medications. Unfortunately, the impact of these changes is unknown and
current data are necessary as many studies evaluating and describing patterns and deter-
minants of mental health care treatment are outdated (Wang et al., 2000).
There are a number of issues that still complicate and impede current psychiatric care.
Although scientific investigations may find effective treatment methodologies, these inter-
ventions are often discontinued after data collection. Additionally, even when consumers
are receiving treatment, it is often inadequate. These consequential troubles warrant ad-
ditional attention and investigation as psychiatric consumers should be given priority to
high-quality care.
Implications for music therapists

The current mental health care environment continues to change with advances in phar-
macotherapy, technology, innovative and evidence-based treatments, and changes in poli-
cies (e.g., mental health parity and changes in healthcare regulations). Many psychiatric
consumers are staying as inpatients for shorter durations, both in the private and public
sectors (Frank & Glied, 2006; Thomas, 2007). Music therapists have been challenged to
address this change and to “rethink and redevelop our conceptual models of treatment”
(Thomas, 2007, p. 125). Congruently, Cassity (2007) used Delphi methodology to predict
that future psychiatric music therapists would emphasize brief treatment models. Other
non-music therapy scholars have noted, “Public mental hospitals have lost their custodial
character and, like other institutional providers, primarily offer a setting for the provision
of acute care services” (Frank & Glied, 2006, p. 78). Thus, consistent with contemporary
mental health care, brief treatment models and single-session psychiatric music therapy
research investigating issues pertaining to illness management and recovery are becoming
increasingly essential in order to remain congruent with contemporary clinical practice
and provide the best possible treatment within the idiosyncratic contextual parameters of
psychiatric care.
12 MENTAL ILLNESS
Box 1.3 Chapter 1 Main Ideas

◆ Mental illness remains a prevalent and costly social dilemma; people with mental
disorders are a marginalized and disenfranchised clinical population.
◆ In addition to psychological problems, psychiatric patients also face a multitude of
physical health problems.
◆ Although diverse treatment models exist, patients are often hospitalized for rela-
tively brief periods.
◆ While many treatments have been effective in clinical trials, these treatments are
often not used in contemporary clinical practice.
◆ Advancements in medications, treatments, and brief and time-limited treatment
have forced music therapy clinicians to adapt to a new care model to augment the
likelihood of illness management and recovery.
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Questions for review and discussion

1 What might be some potential reasons that the number of people diagnosed with psychiatric disorders
has remained relatively constant over time?
2 What factors in the contemporary mental health care system might contribute to brief inpatient
hospitalizations?
3 Why might physical health problems (including diabetes and obesity) of psychiatric consumers be
ignored?
4 How might music therapists work with psychiatric consumers to educate them concerning physical
health and to prevent physical health problems?
5 What are some negative stereotypes or biases concerning mental illness? How has past and modern
media perpetuated the stigma against mental illness?
Chapter 2
Pharmacological and psychosocial

treatments for people with mental
illnesses
Introduction
Although a single or uniform approach to treating psychiatric patients might simplify this
multifarious social problem, a “magic bullet” treatment does not exist. Even with advances
in genetics, neurology, etiology, and psychopharmacology, scientists have yet to identify or
develop a “one-size-fits-all” intervention or treatment milieu for persons diagnosed with
mental illnesses. Moreover, uncertainty remains concerning the exact causes of mental
disorders; relying solely upon a biological explanation may be futile without accounting
for sociocultural and psychological interactions. Unfortunately, a century’s worth of study
concerning schizophrenia has not resulted in a cause of the disorder (Insel, 2010). Thus,
without a thorough and exact understanding of the causes and roots of mental illness, is it
even possible to design effective pharmacological and psychosocial treatments?
A thorough discussion of the numerous psychiatric medications is beyond the scope of
this book due to the high prevalence of polypharmacy, consistent medication advance-
ments, highly idiosyncratic responses, and a lack of biomarkers concerning effects. Read-
ers are encouraged to familiarize themselves with common medications at the “mental
health medications” website of the National Institute of Mental Health (2012), the “com-
monly prescribed psychotropic medications” website of the National Alliance on Mental
Illness (2012), and Houghton and Smeltekop (2005).
Psychotropic medications
Medications as a primary treatment
Current psychiatric practices are often under the auspices of the medical treatment model.
The use of medication to treat patients with various psychiatric disorders is frequent and
continues to rise (Barbui & Tansella, 2005). New generation antipsychotic, antidepressant,
and mood-stabilizing medications have increased pharmacological options for patients
and prescribers and, most importantly, these drugs have similar benefits and fewer side ef-
fects than previous medications. While working with patients who have mental disorders,
music therapists are encouraged to support psychiatrists, pharmacologists, nurses, and
their medical-based decisions. The music therapist’s role is to work collaboratively with
the patient and the treatment team to develop a rationale for taking medications as pre-
scribed, identifying how medications can help patients reach their goals, coping with and
communicating potential side effects, improving communication concerning positive and
negative medication effects, and identifying advantages and disadvantages of prescribed
medications and medication noncompliance.
Unfortunately, even when medications do produce observable and measureable benefits
for patients diagnosed with mental disorders, psychopharmacology is not without conse-
quences. When inducing a calming effect, the drugs can reduce clients to a state nearing
stupor. Possible side effects of antipsychotic medications can include constipation, dry
mouth, muscle rigidity, tremors, and blurred vision. Gelenberg (1991) noted that tardive
dyskinesia—a muscle disorder causing uncontrollable grimacing and lip smacking—also
represents a debilitating side effect. Unfortunately, tardive dyskinesia is not treatable by
other drugs as most side effects are. Gelenberg (1991) estimated that between 20% and
30% of individuals taking antipsychotic medications had tardive dyskinesia.
Although some scholars have identified side effects as the most common reason for
medication noncompliance (Weiss et al., 1998), others have not replicated this finding
(Scott & Pope, 2002). In a descriptive study, researchers asked psychiatric consumers di-
agnosed with schizophrenia about their subjective reasons for medication compliance or
noncompliance (Loffler, Kilian, Toumi, & Angermeyer, 2003). Participants noted that the
main reason they were compliant with their neuroleptic treatment was the perceived ben-
efit. Using correlation techniques, the researchers found a positive relationship between
medication compliance and positive attitudes of the therapist and patients’ significant oth-
ers concerning pharmacological treatment. The authors noted that side effects were the
main reason consumers were noncompliant with their medications. The researchers found
that other reasons for noncompliance were the lack of insight into the disease and a lack
of acceptance of the necessity of neuroleptic treatment. Moreover, the authors found that
there was no significant difference concerning compliance between participants who re-
ceived conventional versus second-generation antipsychotic medications.
Even with the advent of atypical antipsychotic medications and other advances in
pharmacological treatments, there are still many psychiatric consumers who find little
to no benefit from medications. Researchers who conducted a meta-analysis noted that
the effectiveness of newer antipsychotic medications is less than previously thought. The
meta-analysis of 12,649 patients in 52 randomized controlled trials found no evidence
that atypical antipsychotic medications were better tolerated or more effective than con-
ventional antipsychotic medication (Geddes, Freemantle, Harrison, & Bebbington, 2000).
From 20%–40% of people with schizophrenia received little or no relief from antipsychotic
medication (Tamminga, 1997) and approximately 30% of patients with schizophrenia still
experienced psychotic symptoms even when they were compliant with their antipsychotic
medications (Kane, 1996). Researchers who conducted investigations in the 1970s and
1980s reported similar results, thus questioning whether the then newer medications were
more effective than conventional psychotropic medications (Curson et al., 1985; Harrow
& Silverstein, 1977; Silverstein & Harrow, 1978). However, while newer medications may
20 Pharmacological and psychosocial treatments
not be as effective as previously hypothesized, they often have fewer side effects than older
pharmacological treatments.
In a book concerning the origins of mental illness, Claridge (1995) wrote of the overre-
liance upon pharmacological interventions and how it can result in poor clinical outcome
as well as social marginalization:
Such use of drugs ought to be merely the first step in reaching out to the person, in order to identify
and nurture areas of psychological strength. But it rarely is, the organic model of psychosis mostly
dictating an exclusive reliance on drugs, often in higher doses than is necessary; this in turn causes
deficits that may themselves be mistaken for signs of psychosis, initiating a downward spiral of
apathy and despair—and confirming the public perception of the mad as dements. As a result, the
seriously mentally ill remain among the most marginalized, least respected members of our society.
(pp. xix-xx)
In an article concerning experimental medicine, Insel (2012) noted that physicians

widely prescribe pharmacological interventions for people with mental disorders but the
treatment effects associated with these medications are insufficient. As developing a new
medication can cost in excess of $2 billion (Munos, 2009), takes approximately 15 years
(Dimasi, 2001), and results in failure in 95% of cases (Dimasi, Feldman, Seckler, & Wilson,
2010), there has been diminished research and development activity concerning innova-
tive neuroleptic treatments for psychiatric consumers. In a profit-driven capitalist society
such as the United States, it may be difficult for pharmaceutical companies to convince
their shareholders that there is adequate evidence and financial incentive to develop medi-
cations for psychiatric consumers. Additionally, the science behind drug development is
still in its relative infancy as there remains a lack of knowledge concerning biological proc-
ess targets. Moreover, even if the medications do seem to result in symptom alleviation,
there is still uncertainty concerning how these treatments affect neurological processes
and why they may be effective (Insel, 2012).
Anti-medication movement
Psychiatry has expanded, largely based upon a biomedical model wherein prescribers use
pharmacotherapy as a “panacea” (Double, 2002, p. 900) for a myriad of problems. There
are numerous well-articulated concerns concerning the sole reliance upon pharmacolog-
ical treatments. Rose (2003) argued that healthcare practice in Europe and the United
States has become dependent upon commercially produced pharmaceuticals. Specific
to nursing practice in mental health treatment, Lakeman and Cutcliffe (2009) made the
case against what they termed “pharmaco-centrism” (p. 199), noting pharmaco-centrism
is based more on successful drug company marketing than scientific evidence. Other
authors have written that the general public has not only become reliant upon pharma-
cotherapy, but that the boundaries of treatable illnesses have expanded markets for new
products (Moynihan, Heath, & Henry, 2002). Rose (2003) noted that the increased avail-
ability of psychotropic medications, the increased awareness of mental disorders, and the
“medicalization” of normal life have resulted in expanded sales and consumption of anti-
psychotic and antidepressant medications in many Western countries. Barbui and Tansella
(2005) went so far as to write, “Nowadays doctors ask themselves a reason for not prescrib-
ing, while years ago they used to think about good reasons for prescribing,” and that “pre-
scriptions have progressively become almost automatic answers to patients’ symptoms”
(p. 140). These scholars further recommended that doctors develop more comprehensive
treatment plans for their patients, including established and effective psychological and
psychosocial treatments.
In the early 1960s, Thomas Szasz helped initiate an “anti-psychiatry” movement. Propo-
nents of this movement questioned the medical model of mental disorders, arguing that
people did not have mental disorders but rather behaved in ways deviating from societal
norms. Concerning other models of mental illness, Freudians believed neuroses resulted
from psychological disturbances. Social psychiatrists conjectured that psychosis was a re-
sult of a person’s conflict with her or his environment, and mental disorders represented
a reaction to an oppressive society (Whitaker, 2010). Proponents of the anti-psychiatry
movement argued that as new drugs are invented, pharmaceutical companies create mar-
keting campaigns and diagnostic categories are expanded. It seems that in order for poten-
tial consumers to seek and purchase the product, the disorder itself must first be marketed
and “sold.” Whitaker (2010) noted that as psychiatric medications actually create chemical
imbalances in the brain, the patient’s brain adapts to the medications and the patient is
unable to function without her or his medication, thus creating a lifelong customer for
pharmaceutical companies. Moreover, patients are typically prescribed additional drugs
to compensate for adverse effects, creating the need for multiple drugs (i.e., polyphar-
macy). Citing a multitude of research studies and rising statistics concerning costs associ-
ated with contemporary psychiatry, Whitaker (2010) made a compelling case against the
medical model of mental illness, and noted that although psychoactive drugs may allevi-
ate short-term symptoms, many drugs have adverse side effects and negative long-term
consequences.
Double (2002) noted that reliance solely upon drug treatment in a biomedical context is
troubling as psychiatric interventions—in the form of pharmacological treatments only—
may be used as a means to solve common personal and social problems. Double argued
that everyday problems have been “medicalized” by psychiatry and that pharmacotherapy
discourages self-responsibility that, in turn, further aggravates the underlying difficulties
faced by the person. Moreover, the biomedical approach might encourage and perpetu-
ate tendencies to believe that people do not have the power to do anything proactive or
productive concerning their psychiatric diagnoses. Although the biomedical approach is
undoubtedly important, it is not without theoretical drawbacks: Sole reliance upon the bi-
omedical model may downplay personal responsibility to health and coping.
While considerable money has been made from people who are sick, Moynihan, Heath,
and Henry (2002) noted that additional capital can be made from healthy people who be-
lieve they are sick. Noting that there are potentially limitless amounts of wealth to be made
from people who are healthy, many authors have attacked the pharmaceutical industry
with accusations of “disease mongering,” or medicalizing ordinary life. Disease mongering
is the expansion of treatable illnesses in order to broaden existing markets for people who
provide treatments (Illich, 1990; Payer, 1992). Heath (1999) noted that pharmaceutical
companies have medicalized people’s distress. Thus, “disease mongers” can downplay the
importance of coping strategies and limit self-confidence and self-efficacy in the ability
to solve problems in a nonmedical manner (Payer, 1992). The sole focus on chemically
oriented solutions to solve problems and interpersonal conflicts can divert attention from
nonpharmacological and modestly cost-effective psychosocial interventions. Therefore,
authors have noted that pharmaceutical companies market and promote diseases so con-
sumers seek medications from their prescribers. One result of this is that the costs of the
new medications—marketed and targeted toward people who are essentially healthy—
may threaten the viability of publicly funded universal health systems (Gilbert, Walley, &
New, 2000).
Medication noncompliance
Although researchers have reported nonadherence in nearly every division of medicine, it
is consistently one of the greatest challenges in treating persons with mental illnesses. The
consequences of nonadherence can be suicide, homelessness, and reoccurring patterns
of multiple hospitalizations (Corrigan, Liberman, & Engel, 1990; Meichenbaum & Turk,
1987). Despite advances in research and technology, authors have noted that psychiatric
consumers’ compliance with prescribed neuroleptic medications is often more the excep-
tion than the rule (Bellack, 2006; Kane, 1983; Van Putten, 1974). Nonadherence rates can
range from 20% to 50% for all psychiatric consumer groups and is especially a problem
in the treatment of schizophrenia (Fenton, Blyler, & Heinssen, 1997). In fact, as many as
70%–80% of patients diagnosed with schizophrenia are nonadherent with their prescribed
medication treatment regimens (Breen & Thornhill, 1998). Liberman et al. (2005) found
that more than 74% of persons with chronic schizophrenia discontinued medication dur-
ing the first randomized treatment phase of their study. Other researchers indicated that
25%–64% of consumers with bipolar disorder do not fully comply with their medication
treatment (Maarbjerg, Aagaard, & Vestergaard, 1988). Additionally, 30%–97% of patients
with unipolar affective disorders are noncompliant (Pampallona, Bollini, Tibadli, Kupel-
nick, & Munizza, 2002). Researchers who conducted meta-analyses concerning unipo-
lar depression reported that dropout rates for antidepressants are close to 30% regardless
of specific type of medication (Anderson, 1998; Steffens, Krishnan, & Helms, 1997).
Additionally, researchers estimated that 75% of inpatients in a first episode (Corrigan,
Liberman, & Engel, 1990) and stabilized outpatients treated with standard medications
(Kissling, 1992) will be noncompliant. Unfortunately, compliance rates for standard medi-
cations are congruent with those of atypical medications, producing similar results con-
cerning medication nonadherence (Ratakonda, Miller, Gorman, & Sharif, 1997).
Although noncompliance is frequent whatever the specific medication or diagnosis,
there exists tremendous variance in noncompliance studies. The markedly large range of
nonadherence rates is most likely due to discrepancies between various operational defini-
tions and measures used in studies (Colom & Vieta, 2002; Dolder, Lacro, Dunn, & Jeste,
2002). It is essential to acknowledge, however, that nonadherence can also refer to a lack of
compliance concerning psychosocial interventions such as missing appointments, not fol-

lowing therapist’s directions, and not applying appropriate and previously learned coping
skills during times of heightened stress. Thus, psychiatric consumers can be noncompliant
with both pharmacological and psychosocial treatments.
Nonadherence can result in numerous dangerous and costly consequences. Psychiatric
treatment noncompliance can be associated with increased personal, social, economic,
and clinical costs, and is closely related to rehospitalization, relapse, and poor outcome in
patients with severe mental illnesses (Delaney, 1998). For patients diagnosed with bipo-
lar disorder who were classified as irregular users of their medications, the mean length
of inpatient psychiatric hospitalization was thirty-seven days compared to four days for
regular medication users (Svarstad, Shireman, & Sweeney, 2001). This huge discrepancy
in hospitalization duration is evident in both financial and quality-of-life measures as the
resulting differences in hospitalization costs are extreme: $9,701 for irregular medica-
tion users versus $1,657 for regular medication users. Researchers estimated that regular
lithium treatment, often considered the gold-standard mood-stabilizing medication for
bipolar disorder, can save approximately $8 billion per year (Wyatt, Henter, & Jamison,
2001). Moreover, treatment noncompliance is such a serious problem that legal coercion
is sometimes used to encourage consumers to participate in their mental health treatment,
despite a lack of empirical evidence for this controversial method (Watson, Corrigan, &
Angell, 2005). Additionally, nonadherence and its consequences represent such a social di-
lemma that Whitty and Devitt (2005) published an article concerning the advantages and
disadvantages of surreptitious prescribing—knowingly concealing medications in food or
drink—for patients diagnosed with schizophrenia. The authors highlighted the pros and
cons of surreptitious prescribing and noted the many ethical dilemmas concerning this
treatment form. While financial costs resulting from noncompliance are high and typically
easier to objectively quantify, personal consequences and quality-of-life issues for persons
with mental illnesses remain just as important and should not be overlooked due to lack of
objective empirical, available, and quantifiable data.
Researchers have noted nonadherence can be especially common in the treatment and
management of mood and psychotic disorders, as there typically is a lack of insight accom-
panying such diseases (Colom, Vieta, Tacchi, Sanchez-Moreno, & Scott, 2005; Vieta, 2005).
This lack of insight may preclude a perceived need for long-term treatment (Ghaemi &
Rosenquist, 2004; Peralta & Cuesta, 1998). Additionally, rational decision making is often
compromised in psychiatric consumers due to impaired cognitive functioning levels,
further contributing to nonadherence (Colom, Vieta, Tacchi, Sanchez-Moreno, & Scott,
2005). Researchers have suggested that psychiatric consumers diagnosed with bipolar dis-
order have a preponderance of irrational fears responsible for the bulk of preoccupations
with psychotropic medications (Morselli & Elgie, 2003). Additionally, some nonadher-
ent patients have compared taking medication to slavery, fearing dependence and often
considering it unnatural (Colom, Vieta, Tacchi, Sanchez-Moreno, & Scott, 2005). Patients
with bipolar disorder who are psychotic can be more prone to medication nonadherence
than patients who are not psychotic (Miklowitz, 1992). Again, researchers have suggested
that this may be related to cognitive impairment and lack of insight resulting from psycho-
sis (Martinez-Aran et al., 2004). Other factors contributing to pharmacological nonadher-
ence may include public-, social-, and self-stigma, myths (Kleindienst & Greil, 2004), and
the opinions of significant others (Cochran & Gitlin, 1988).
Thus, treatment compliance has continued to be a major problem in the pharmacolog-
ical treatment of psychiatric consumers. Despite advances in medications and treatment
modalities, psychiatric patients frequently discontinue or do not adequately maintain
medication regimens, leading to frequent episodes of relapse and hospitalization. Forcing
compliance is both legally and ethically complex, and the empirical exploration of other
treatment avenues is warranted.
Electroconvulsive therapy
Electroconvulsive therapy (ECT) derived from numerous observations of people who
were depressed. Researchers noted that when people with depression had convulsions,
typically as a result of epilepsy or other causes, that they often felt relief from their depres-
sion (Shorter & Healy, 2007). During the 1930s there were no antidepressants or other
effective pharmacological treatments and many practitioners thus considered ECT as a
better alternative than no treatment. In fact, due to a lack of medications for both de-
pression and bipolar disorder, ECT was considered the most effective treatment by the
late 1950s (Carlat, 2010). Since the development and implementation of ECT, practition-
ers using ECT employ more gentle methods, including anesthesia, and have reduced the
amount of electricity used during the procedure. A typical treatment course for ECT is
three times per week for three to four weeks. In 1999, the U.S. Surgeon General’s office en-
dorsed ECT, citing that during controlled trials, no other technique had better results (U.S.
Department of Health and Human Services, 1999). While ECT can be effective, there are
no data available concerning why it can be effective. Scholars have theorized that seizures
result in simultaneous neuron firing or that seizures seem to change emotional machinery
in the brain (Carlat, 2010), but available data are inconclusive.
Researchers have found that ECT can be effective for the acute treatment of major
depressive episodes (American Psychiatric Association, 2001; Petrides et al., 2001). Al-
though clinicians use ECT as a maintenance treatment for depression, there is a lack of
well-designed randomized controlled trials to support this use (Andrade & Aurinji, 2002).
To date, no publications have noted the possibility of using music therapy as a type of
procedural support for ECT. As anecdotal reports from patients receiving ECT indicate
heightened levels of anxiety, perhaps music therapists could work to educate patients
about the procedure, reduce anxiety, and reorient them to reality after the ECT due to the
side effect of temporary memory loss. It seems this may be a fertile area for future clinical
investigation.
Importance of psychosocial interventions

A substantial and often-overlooked problem concerning medications is that they do
not contribute to the development of skills and knowledge necessary for a psychiatric
consumer’s successful transition back into the community (Liberman, 1994). Although
medications may suppress the symptoms of the illness, medications do not prepare in-
dividuals to function competently and productively in society or live in the least restric-
tive environment. Specific to schizophrenia, Insel (2010) noted that while conventional
and atypical antipsychotic medications can reduce delusions and hallucinations, these
pharmacological interventions do not enhance functional recovery. Thus, psychosocial
components are considered integral in the comprehensive and holistic treatment milieu
for persons with mental illnesses. Psychosocial interventions can be a valuable treatment
modality bridging the gap between optimal (i.e., theoretical efficacy) and practical and
functional treatments (i.e., effectiveness) (Colom & Lam, 2005).
When comparing treatment modalities for psychiatric consumers, various research-
ers have suggested that public opinion tends to favor psychological over pharmaco-
logical treatments (Eccles, Freemantle, & Mason, 1999; Frank, 1998; Paykel, Hart, &
Priest, 1998). These diverse psychosocial interventions are now recognized as a critical
component of a comprehensive treatment approach (Department of Health, NHS Ex-
ecutive, 1999). Congruent with the popularity of psychological treatments, research-
ers conducted a large (N = 5,015) descriptive survey study in Germany and found that
psychotherapy is the public’s preferred treatment for mental disorders. Only a minor-
ity of participants noted psychotropic drugs as a first choice treatment (Riedel-Heller,
Matschinger, & Angermeyer, 2005). The researchers suggested that the majority of the
public still does not adequately recognize nor understand the severity of mental illness
as evidenced by the public’s obvious skepticism of pharmacological treatments. Thus,
although the medical model currently dictates much of clinical practice, psychosocial
interventions are a critical component in the comprehensive treatment regimen of psy-
chiatric consumers.
There are numerous psychological treatments available and researchers and clinicians
are continually creating, adapting, and refining novel approaches. Miller, Duncan, and
Hubble (1997) noted that the number of psychotherapy approaches has grown by 600%
since the 1960s. Bergin and Garfield (1994) estimated there were 200 therapy models and
400 techniques. In 2001, Corsini listed 250 different types of psychotherapies while in
2008 he estimated that this figure had probably increased to more than 400. Different
systems were built upon relatively similar foundations but have since continued to ex-
pand (DeRubeis, Brotman, & Gibbons, 2005; Mansell, Carey, & Tai, 2013) into hundreds
of distinctive variations, often with overlapping terminology. For a summary concerning
commonly used music therapy approaches for all clinical populations, readers are encour-
aged to consult Darrow (2008). For a well-written overview of various well-known and
established psychotherapeutic models and how they might specifically be applied to psy-
chiatric music therapy, Scovel and Gardstrom (2005) is recommended. While numerous
approaches might be effective and applicable, the focus of this text concerns cognitive
behavioral therapy and psychoeducation for illness management and recovery due to the
strong literature bases supporting clinical implementation and outcomes in the contem-
porary mental health care system.
Comparing psychotherapies and the Dodo Bird Verdict

Some argue that all bona fide psychotherapies—therapies delivered by a trained therapist
that are based on psychological principles (Wampold, Mondin, Moody, & Ahn, 1997)—
produce generally equivalent outcomes, regardless of their specific components. The posi-
tion has become known as the Dodo Bird Verdict, originating from Carroll’s (1865/1962)
Dodo Bird in Alice in Wonderland. The Dodo Bird issued a competition to other characters
who had been soaked by Alice’s tears. The Dodo Bird instructed them to run around a lake
until they were dry. However, the Dodo Bird neglected to use uniform measures to ensure
a fair contest: there was no starting point, no finish, and the Dodo Bird did not assess how
far each character had run or how long they had run. When asked for a decision concern-
ing who had won the race to be dry, the Dodo Bird replied, “Everybody has won and all
must have prizes.”
Generalizing this concept to psychotherapies, proponents of the Dodo Bird Verdict
maintain that all therapies are “winners” in that they all produce equivalent positive
outcomes. Supporters of the Dodo Bird Verdict maintain that common and nonspe-
cific (Frank, 1961) factors exist—such as having a relationship with a therapist who
adheres to a particular intervention (Budd & Hughes, 2009) and is who is respect-
ful, warm, and maintains high expectations for client change (Wampold, 2007)—and
all psychotherapies produce similar outcomes. Thus, pantheoretical factors result in
a lack of differences between approaches (Duncan, 2002). Critics of the Dodo Bird
Verdict, on the other hand, contend that specific factors and techniques are important
and, thus, psychotherapies are not equivalent. These specific factors are technical ma-
neuvers, based on specific theoretical orientations, that therapists use to elicit desired
responses (Butler & Strupp, 1986). Despite over 30 years of meta-analytic reviews and
position papers concerning the Dodo Bird Verdict, it remains a controversial topic
(Budd & Hughes, 2009).
Rosenzweig (1963) first identified common factors between various types of psychotherapies
and is credited with launching interest in the topic and controversy. Eysenck (1952) reviewed
data and questioned if any psychotherapy was effective for any type of problem. Luborsky,
Singer, and Luborsky (1975) conducted a well-known non-meta-analytic study supporting
the Dodo Bird Verdict. They examined over 100 comparative treatment studies and found
few significant differences. Smith and Glass (1977) conducted the first meta-analysis and
reported small to nonexistent differences between psychotherapies. In 1997, Wampold and
colleagues published a meta-analysis based upon problems other scholars had identified in
meta-analyses supporting the Dodo Bird Verdict (Wampold, et al., 1997). However, Crits-
Christoph (1997) and Howard, Krause, Saunders, and Kopta (1997) criticized the Wampold
et al. study. Crits-Christoph argued that, based upon flaws in the Wampold et al. (1997) meta-
analysis, there should be exceptions to the Dodo Bird Verdict. Specifically, Crits-Christoph
(1997) noted that Wampold et al. included only four studies concerning psychodynamic ther-
apy and no studies concerning family therapy. Another criticism concerned parallel group stud-
ies from which Wampold et al. (1997) attempted to make conclusions: It was argued that these
issues can be resolved only through comparisons of active treatments with control groups. In
response to criticisms, Wampold et al. (1997) contended that the Dodo Bird metaphor should
be substituted “with one involving the flat Earth, a notion that persists in spite of evidence
to the contrary” (p. 226). These arguments resulted in numerous follow-up studies and arti-
cles in attempts to prove and disprove the Dodo Bird Verdict (Carroll & Roundsaville, 2010;
Norcross, 1995; Siev & Chambless, 2009).
Most opponents of the Dodo Bird Verdict are cognitive behavioral therapists (Nathan,
Stuart, & Dolan, 2000). Chambless (2002) respectfully disagreed with the Dodo Bird Ver-
dict, noting studies supporting the verdict contained errors in data analyses, exclusion of
research on many client types, faulty generalization to comparisons between therapies that
had never been made, and the erroneous overgeneralization that average differences be-
tween all treatments for all problems can be assumed to represent the difference between
two treatments for a given problem. Chambless noted that meta-meta-analytic methods
of combining data from all treatment types for all client types are misleading. Advocat-
ing that cognitive behavioral therapy was superior to other treatments for a plethora of
clinical conditions in both children and adults, Hunsley and Di Guilio (2002) noted there
was consistent evidence in treatment outcome and comparative treatment research that
should dispel the Dodo Bird Verdict. Similarly, Crits-Christoph (1997) examined studies
in Wampold et al. (1997) and concluded that cognitive behavioral treatments were in fact
superior to other types of treatment.
In an attempt to better understand the role of researchers’ allegiance in the psychosocial
treatment of depression, Luborsky et al. (1999) conducted a meta-analysis of 29 compari-
son conditions. They found that two-thirds of the variance reported in treatment findings
could be attributed to researcher allegiance. Thus, cognitive therapy researchers and thera-
pists found superior results for cognitive therapy while psychodynamic researchers and
therapists found superior results for psychodynamic therapy. These results confounded
arguments and added a layer of complexity to fundamental questions concerning the com-
parison of psychotherapies and the Dodo Bird Verdict.
Some authors have argued that the randomized controlled trial—the research de-
sign typically used to collect data and compare studies for eventual inclusion in a
meta-analysis—should not represent the objective gold standard for psychotherapy re-
search (Budd & Hughes, 2009). Although the randomized controlled trial certainly has
strengths, other methods can also provide insight into how and why therapies work
(Pachankis & Goldfried, 2007). Chambless and Hollon (1998) noted that if a treat-
ment is found to be effective in a research study—regardless of why it works—and this
positive effect is replicated by multiple independent groups of researchers, then the
treatment is likely to be clinically valuable, and clinicians might argue for using it.
Rosen and Davidson (2003) argued against this rationale, noting that listing proposed
mechanisms of change based on the best evidence available is preferable to ignoring
mechanisms of change in favor of purely outcome-based results. Variability in clients,
treatments, and meta-analyses has enabled the Dodo Bird Verdict to remain a highly
charged and controversial topic. Despite considerable effort on the part of people for
and against the Dodo Bird Verdict, it has not yet been confirmed or refuted (Nathan,
Stuart, & Dolan, 2000).
Music therapy ramifications of the Dodo Bird Verdict

Ramifications concerning the Dodo Bird Verdict are invigorating; the topic continues to
fuel debate. If the Dodo Bird Verdict is true, then policymakers can allocate funding to any
type of therapy. If the Dodo Bird Verdict is false, funding could be rescinded for treatments
without empirical support. Perhaps the continued debate concerning the Dodo Bird Ver-
dict has maintained skepticism concerning talk-based therapies—and even creative, com-
plementary, and integrative therapies such as music therapy. Regardless of their positions
concerning the Dodo Bird Verdict, music therapists should be aware of these controversial
arguments, pros and cons of various points of view, and be prepared to critically advocate
for the profession. Clinicians are advised to examine what researchers have found con-
cerning approaches that are effective for a specific population with a specific presenting
problem and then carefully conjecture potential outcomes. If comparative studies are lack-
ing (which may be the case in music therapy), Chambless (2002) recommended clinicians
could be guided about what they do know about specific treatments for specific problems.
Thus, when asked “Can music therapy help treat a person with schizophrenia?” music
therapists might respond with their own questions based upon context, problems, client
preferences and values, and situation, and explain how treatments compare concerning
effectiveness. Avoiding absolutes remains imperative. A music therapist might respond to
this inquiry by stating:
I would certainly need additional information concerning the particular patient you are attempting
to help. Based upon results of a systematic review and meta-analysis, it seems that music therapy
can be an effective additive treatment for schizophrenia in terms of global functioning. However,
future research is certainly warranted. But to date music therapy does not have any known side
effects, and patients seem to attend sessions and find them therapeutically valuable. At this point—
and similar to other types of psychosocial treatments—we are not sure exactly why music therapy
works or if certain types of music therapy are superior to others for patients diagnosed with schiz-
ophrenia. But available effectiveness data are positive.
Cognitive behavioral therapy

Although no single orientation dominates psychotherapy, Smith (1982) noted that cogni-
tive behavioral therapy is one of the strongest theoretical models; Craske (2010) noted it
is the “most empirically supported psychotherapy” (p. 115). Cognitive behavioral therapy
“occupies a central position in the move toward evidence-based practice” and is thus the
treatment of choice for most mental health problems (Mansell, Carey, & Tai, 2013, p. v).
In a book reviewing psychotherapy research, Roth and Fonagy (1996) noted that cog-
nitive behavioral therapy has the largest literature base of all the psychosocial therapies.
Due to its structured, action-oriented, and time-limited format, Lyons and Rawal (2005)
noted cognitive behavioral therapy has the most promise in research settings. While
cognitive behavioral therapy derived from combining behavioral therapy and cognitive
therapy—separate yet interrelated psychotherapies—the term cognitive behavioral ther-

apy will be used in the remainder of this monograph to describe aspects of both cognitive
therapy and behavior therapy. Supporting this decision concerning jargon, Craske (2010)
noted it was difficult, “if not impossible, to distinguish between cognitive therapy and
CBT” (p. 3). Similarly, Butler, Chapman, Forman, and Beck (2006) noted that cognitive
therapy “typically incorporates behavioral interventions” (p. 19). These separate therapies
have overlapping components and share procedures and mechanisms, focusing on teach-
ing patients functional skills to identify, manage, and alleviate their symptoms as quickly
and efficiently as possible.
Cognitive behavioral therapy alters patients’ thoughts, behaviors, and emotions, as prac-
titioners conjecture that these three components are interrelated in humans. A therapist
using this treatment works to replace maladaptive cognitions, behaviors, and emotions
with ones that are adaptive and functional (Craske, 2010). Therapists work to generalize
skills learned in therapy to patients’ everyday lives and encourage self-monitoring behav-
iors, thus attempting to make patients their own therapists (Butler, Chapman, Forman, &
Beck, 2006). Cognitive behavioral therapists are flexible and typically trained as scientist-
practitioners who use a goal-oriented and systematic process to expediently help patients
reach their goals (Dobson & Dobson, 2009). This psychotherapeutic method is purposely
direct and time-limited in both individual and group settings. There is an emphasis on
measuring changes in cognition, affect, and behaviors as well as setting and attaining real-
istic goals. Cognitive behavioral therapists strive to reduce symptoms by challenging and
altering cognitive distortions and irrational beliefs. These therapists often assign “home-
work” exercises to enable clients to implement and practice new behaviors and general-
ize skills to their living environments. A common goal for cognitive behavioral therapy
patients involves heightened self-awareness and self-regulatory behaviors so that when
future problems occur, they are able to apply techniques learned during therapy and in-
dependently solve their problems and ameliorate their distress as quickly and effectively
as possible. Cognitive behavioral therapists are less concerned with the Freudian or tradi-
tional concept of insight; rather they focus on the acquisition on a set of specific skills to
functionally manage distress.
Cognitive behavioral therapists believe that life events and core beliefs merge and
are therefore integrated within a person’s cognitive processes. A person has automatic
thoughts—and perhaps cognitive distortions—concerning life events that can trigger
emotions and behaviors. Negative emotions and behaviors reinforce core beliefs, and the
cycle of negative cognitions repeats itself. Thus, there is a need to teach patients how to
modify their core beliefs and to change how they perceive life events to have different and
positive emotions and behaviors stemming from automatic thoughts. When describing
these processes to the patient, a cognitive behavioral therapist will use everyday language
while avoiding absolutes and “catastrophizing” to enable the patient to better understand
the treatment process in a rational and logical manner.
A common misperception of cognitive behavioral therapy is that patients are uninvolved
in the process and direction of therapy. Whenever possible, cognitive behavioral therapists
work with patients to collaboratively formulate realistic and idiosyncratic goals, objec-
tives, homework assignments, and methods for evaluating change and therapeutic growth.
In fact, cognitive behavioral therapy originated in Western cultures with an orientation
toward science and a belief in logical positivism. As there tends to be an emphasis toward
individualism in Western society wherein people value choice, control of the future, and
independence, cognitive behavioral therapists encourage clients to set goals, take control,
make choices, and be actively engaged in their treatment (Dobson & Dobson, 2009). An-
other misperception of cognitive behavioral therapy is that it is overly standardized and
assumes one treatment can fit all problems. This is not the case, as cognitive behavio-
ral therapists closely observe and understand each person’s unique presenting problem
(Craske, 2010). Cognitive behavioral therapists work to comprehend the antecedents that
eventually result in a person’s distress and therefore must tailor each intervention to the
person’s idiosyncratic needs.
To further conceptualize cognitive behavioral therapy, Dobson and Dobson (2009) and
Dobson and Dozois (2001) identified three basic principles representative of cognitive be-
havioral treatments (Box 2.1).
Thus, mental health can be a result of an accurate interpretation of the world and adapt-
ing to demands. People with poor mental health experience negative interpersonal and
social consequences due to misperceiving situations and behaving in an incongruent and
inflexible manner with their environments.
Specific to the treatment of mental illness, two components of cognitive behavioral therapy
are its use of the well-known stress-vulnerability model (Zubin & Spring, 1977) and the nor-
malizing rationale (Kingdon & Turkington, 1994). The stress-vulnerability model highlights
that each person has unique psychological, physiological, genetic, and social predispositions
that affects her or his vulnerability to a psychotic breakdown. The normalizing rationale states
that a lack of developed and effective coping strategies can lead to social withdrawal and
Box 2.1 Three Basic Cognitive Behavioral Treatment Principles

1 The access hypothesis: Thoughts are not unconscious or unavailable and thinking
is knowable. Clients receiving the proper training can become aware of their cogni-
tions and if these thoughts are useful or helpful.
2 The mediation hypothesis: The way people perceive a situation can influence their
resultant behaviors and feelings.
3 The change hypothesis: With an understanding of cognitive strategies and result-
ant emotional and behavioral reactions, people can learn to change the way they
respond to events.
Reviews of cognitive behavioral therapy research 31
disengagement. Cognitive behavioral therapy emphasizes collaborative approaches to adap-

tation and coping that, ideally, lead to reductions in symptoms and distress. However, this
psychotherapeutic approach typically works best with people who are reality-based. Patients
who are psychotic or have severe cognitive impairments may benefit from a more behavioral
approach emphasizing cause-and-effect relationships, and by the therapist proactively alter-
ing the environment to reduce situational risk factors that contribute to symptoms.
Another advantage of cognitive behavioral therapy is its applicability in group-based
settings. Although cognitive behavioral therapy was developed primarily for the individu-
alized treatment of mental health problems, group-based delivery models permit greater
access to clinical services. Morrison (2001) found minimal efficacy differences when com-
paring group cognitive behavioral with individual therapy. In a systematic review of group
cognitive behavioral therapy for schizophrenia, researchers found this treatment was more
effective than treatment as usual in reducing social anxiety. However, other researchers
questioned the effectiveness of this treatment due to methodological weaknesses in evalu-
ated studies (Lawrence, Bradshaw, & Mairs, 2006). Lawrence et al. (2006) highlighted the
improved access to services due to group-based formats, but questioned therapists’ train-
ing for this unique treatment, asking if cognitive behavioral therapists working in group-
based settings require advanced training or higher skill levels.
In a brief summary of cognitive behavioral therapy in a monograph concerning mental
health policy, Frank and Glied (2006) noted this psychotherapeutic approach could be
considered as effective as medications for a number of disorders. Due to the overwhelming
desire to control costs in public and private healthcare systems, to an emphasis on clinical
outcomes, and to the desire to implement effective and time-limited treatments, cognitive
behavioral therapy is considered the psychosocial treatment of choice for a number of psy-
chological problems (Dobson & Dobson, 2009). In order to expediently highlight treat-
ment effects, a brief summary of contemporary reviews and studies concerning cognitive
behavioral therapy for common psychiatric disorders follows.
Reviews of cognitive behavioral therapy research

Schizophrenia and psychosis
In a review of cognitive behavioral therapy for schizophrenia, Rathod and Turkington
(2005) indicated that this treatment can be an effective adjunct to antipsychotic medi-
cation for positive, negative, and residual symptoms. Clinicians using cognitive behav-
ioral therapy can improve the prognosis of people diagnosed with schizophrenia through
improved management of symptoms and treatment adherence, thus leading to reduced
relapse. Cognitive behavioral therapy, with the addition of treatment as usual, can have
benefits concerning relapse and functioning for patients with schizophrenia (Jones, Cor-
mac, Silveira da Mota Neto, & Campbell, 2004; Pilling et al., 2002). Researchers have also
found improvements in functioning in comorbid patients diagnosed with schizophrenia
and substance misuse (Haddock et al., 2003). In meta-analyses, researchers have found
significant small-to-moderate effect sizes (Cohen’s d = 0.25–0.54) for cognitive behavioral
therapy for psychosis concerning target symptoms (Wykes, Steel, Everitt, & Tarrier, 2008).
Moreover, positive treatment effects have remained stable over follow-up periods (Lin-
coln, Suttner, & Nestoriuc, 2008).
Researchers who conducted a randomized controlled study of four to six sessions of cog-
nitive behavioral therapy with patients with psychosis found positive results (Kemp, Hay-
ward, Applewhaite, Everitt, & David, 1996). The researchers found statistically significant
differences between groups in dependent measures of treatment compliance, attitudes to-
ward drug treatment, and insight into illness. Researchers conducted a similar study with
74 patients with psychotic disorders. Results concerning attitudes toward treatment and
compliance were maintained at 18-month follow-up (Kemp, Kirov, Everitt, Hayward, &
David, 1998).
Bipolar disorder
Zaretsky, Rizvi, and Parikh (2007) reviewed psychosocial interventions for bipolar dis-
order. The authors noted that “manualized, adjunctive, short-term psychotherapies have
been shown to offer fairly consistent benefits” (p. 14). Specific to relapse prevention for
bipolar disorder, they noted cognitive behavioral therapy, family-focused therapy, and
psychoeducation have the most robust effects and, specific to the treatment of residual
depressive symptoms, interpersonal and cognitive behavioral therapy likely have the most
beneficial effects. In a review of psychotherapies for bipolar disorder, Jones (2004) noted
that cognitive behavioral therapy can positively impact symptoms, social functioning, and
relapse risk. Similarly, Colom and Vieta (2004) noted that psychoeducation and cognitive
behavioral therapy are the psychological interventions of choice to prevent new occur-
rences in people who have bipolar disorder.
Depression, anxiety, and panic disorders

In a review summarizing meta-analytic treatment outcomes of cognitive behavioral ther-
apy for a wide range of psychiatric disorders, researchers found a large effect size (.82) for
adult depression, and noted cognitive behavioral therapy was “somewhat superior” to an-
tidepressants (Bulter, Chapman, Forman, & Beck, 2006, p. 17). Elkin and colleagues (1989)
found empirical evidence supporting cognitive behavioral therapy as a first-line treatment
for acute depressive episodes. Researchers conducting meta-analyses of cognitive behav-
ioral therapy for depression have found positive results (Feldman, 2007; Hollon et al.,
2005). Researchers noted that patients receiving cognitive behavioral therapy had lower
relapse rates than patients receiving antidepressant medications (Hollon et al., 2005) and
better long-term results than patients using medications (Paykel, 2007). When researchers
compared cognitive behavioral therapy with treatment as usual and medication, people
who received cognitive behavioral therapy for depression and anxiety had lower relapse
rates than those in the comparison conditions (Hollon, Stewart, & Strunk, 2006). Perhaps
lower relapse rates were the result of patients learning to alter their thoughts and behav-
iors—and thus to constructively manage, treat, and deal with their problems—instead of
relying on pharmacological interventions for symptom relief. People with panic disorders
can also benefit from cognitive behavioral therapy, as treatment effects are strong and are
maintained over time (Landon & Barlow, 2004; Mitte, 2005). Some 70%–90% of patients
with panic disorders were panic-free after completing a cognitive behavioral treatment
program (Barlow & Craske, 2000).
The future of cognitive behavioral therapy

Cognitive behavioral therapy has not remained stagnant. Rather, this treatment has
evolved from a purely behavioral model and will likely continue to evolve (Craske, 2010).
Norcross, Alford, and DeMichele (1992) used a panel of 75 expert psychotherapists to
predict the future of psychotherapy. The panel ranked cognitive behavioral therapy as the
psychotherapeutic approach most likely to be used in future treatment. The reasons for
this prediction were many, but included cost containment, the ability to provide treatment
to greater numbers of people in need of clinical services, emphasis on problem-focused
and time-limited treatments, third-party reimbursement, and demonstrated effective-
ness. Moreover, according to the American Psychological Association Division 12 task
force, 60%–90% of empirically supported treatments were cognitive behavioral (Norcross,
Beutler, & Levant, 2006). In a meta-analytic review concerning its empirical status, re-
searchers highlighted the durability of cognitive behavioral therapy (Butler, Chapman,
Forman, & Beck, 2006). These investigators noted that the effects of cognitive behavioral
therapy are maintained for substantial periods beyond the cessation of treatment across
many disorders, including depression, anxiety, and schizophrenia. Thus, cognitive behav-
ioral therapy will likely continue to be a driving force in the future treatment of psychiatric
consumers.
Specific to music therapy, in a descriptive study Silverman (2007) found that many ther-
apists indicated they used behavioral treatment approaches. Concerning a cognitive ap-
proach to therapy through music, Bryant (1987) noted that the “cognitive model of music
therapy provides the client with an adaptive, behavioral, framework to assist him or her in
dealing with present, and avoiding future, self-imposed disturbances” (p. 27). In a Delphi
poll using as participants clinical training directors of psychiatric music therapy programs,
Cassity (2007) predicted that cognitive behavioral, cognitive, and behavioral therapies,
respectively, would be used more in the future.
Illness management as a psychosocial treatment

An overview of illness management
Illness management, often referred to as psychoeducation, can be defined as a process in which
an educator attempts to increase the knowledge and illness management skills of a psychi-
atric consumer. Clinicians have used psychoeducation in both healthcare and community
settings. Numerous authors have conducted randomized controlled investigations demon-
strating its effectiveness in prevention and quality improvement in primary care programs in
the United States (Cuijpers, 1998; Munoz et al., 1995; Wells et al., 2000). After a comprehen-
sive review of the literature, Lukens and McFarlane (2004) concluded: “Psychoeducation is
among the most effective of the evidence-based practices that have emerged in both clinical
trials and community settings” (p. 205). Through the psychoeducational process, relevant
information is shared in a bidirectional manner: consumers are active participants and able
to share their unique and valuable personal perspectives during the session. Psychoeduca-
tion can empower the psychiatric consumer by providing a realistic and theoretically viable
approach toward managing the symptoms of the illness (Vieta, 2005).
Throughout the psychoeducational process, participants attend classes as students
rather than patients, experience less stigma (Carson & Brewerton, 1991), and share ideas
and support with the other group members. This model emphasizes instruction—as op-
posed to in-depth and analytic therapy—while promoting social skills, pleasant activi-
ties, positive thinking, and relaxation. These interventions can help people appropriately
cope with their environments and can have a positive effect on the therapeutic process
(Dinkmeyer, 1991). Sometimes illness management involves members of the consum-
ers’ social network, such as caregivers, spouses, family, and friends. The psychoeducation
curricula contain diverse and comprehensive educational interventions administered by
psychiatrists, pharmacists, nurses, case managers, psychiatric consumers, and therapists,
designed to teach psychiatric patients a wide range of knowledge and skills needed for the
management of a serious mental illness (Bisbee, 2000). Patients learn to work collabora-
tively with professionals, cope with symptoms of their mental illness, and reduce their
susceptibility to the disease (Mueser et al., 2002).
Founded upon a biopsychosocial medical model of psychiatric disorders (Vieta, 2005),
psychoeducational methods and content may vary. Nevertheless, psychoeducation can
be appropriate for patients in various stages of their illnesses. Illness management incor-
porates several models and theories, including ecological systems theory, group practice
models, stress and coping models, social support models, narrative approaches, cognitive
behavioral therapy, and various learning theories (Lukens & McFarlane, 2004). It is typi-
cally, but not exclusively, used during group settings and thus may reduce isolation, pro-
mote social skills, and normalize experiences that encompass important treatment areas
for psychiatric consumers.
Illness management developed as a method to teach large numbers of psychiatric con-
sumers the skills and knowledge they needed to successfully live in the community (Bis-
bee, 2000). For a number of years, psychiatrists did not educate consumers in the same
way that general practitioners educated patients without psychiatric disabilities. Possible
reasons for such underemphasis include the following: lack of consensus concerning the
benefits of nonmedical models for explaining psychiatric disabilities and treatments; fear
of frightening or discouraging patients by telling them about their illness; fear that con-
sumers may use the information to act inappropriately and avoid responsibility; fear that
information about the illness will cause consumers to remain in a sick role; belief that
consumers cannot assume responsibility for the disease; and belief that consumers may
not understand the concepts being taught (Bisbee, 1979).
Although many Americans currently use the Internet in their homes for psychoeduca-
tion and research concerning symptoms and treatment (Chang, 2005), in most psychiatric
hospitals the responsibility for providing information to psychiatric consumers falls upon
psychologists, nurses, social workers, therapists, other psychiatric consumers, and teach-
ers (Bisbee, 2000). Characteristic subject matter areas in psychiatric patient education
are the following: avoiding drug use and abuse, stress management, coping and leisure
skills, communication, assertiveness training, increasing quality of life, relapse prevention,
medication, social skills, symptom management, problem solving, self-awareness and ob-
servation, and patient rights and responsibilities. Coping skills training is a fundamental
component of psychoeducational curricula. Researchers have suggested that a positive
coping style may be important for the rehabilitation of psychiatric consumers (Kahng &
Mowbray, 2005). Psychoeducation can be used to educate psychiatric consumers concern-
ing coping skills that can be used during stressful periods (Gispen-de Wied & Jansen,
2002) and can help reduce suicide risk and the alternating between manic and depressive
episodes experienced by consumers with bipolar disorder (Vieta, 2005). Additionally, cli-
nicians can use illness management curricula to teach psychiatric consumers to recognize
early signs of symptom recurrence and how to manage them using effective coping skills,
including seeking treatment.
The impact of illness management

As previously noted, nonadherence to psychiatric treatment is common. Thus it is im-
perative that researchers and clinicians keep this important issue in mind. Some have
suggested that including psychoeducation in routine clinical care may be a way to facil-
itate informing patients of the potential hazards of noncompliance (Colom, Vieta, Tac-
chi, Sanchez-Moreno, & Scott, 2005). In fact, researchers found that a group of patients
with bipolar disorder receiving psychoeducation had higher serum lithium levels than a
control group (Colom, Vieta, Sanchez-Moreno et al., 2005), indicating experimental par-
ticipants were more compliant with their medication regimen as a result of psychoeduca-
tion. Therefore, the researchers considered psychoeducation itself to be a mood stabilizer.
They suggested that standard pharmacological treatments should be accompanied by
group psychoeducation as it increases compliance and thereby improves treatment out-
come. Other researchers have suggested that psychoeducation is an essential component
for enhancing consumer compliance with neuroleptic treatment (Loffler, Kilian, Toumi,
& Angermeyer, 2003).
Nonadherence to psychiatric medications is often exacerbated by a failure to understand
the nature of the disease and the clinical importance of complying with neuroleptic medi-
cations. Therefore, helping psychiatric consumers more fully comprehend their disorders
and the benefits of long-term pharmacological and psychosocial treatments can enhance
adherence. Persuading psychiatric consumers through education that a regular medication
regimen is essential for effective management of the illness is an imperative component of
psychoeducation as improved medication compliance can help to increase treatment ef-
fectiveness (Vieta, 2005). Thus, researchers have encouraged the inclusion of psychoedu-
cation in the treatment of mental illnesses (Lukens & McFarlane, 2004) and have received
support from national policymakers (President’s New Freedom Commission on Mental
Health, 2003). Scientific inquiry has resulted in a large amount of evidence supporting the
implementation of psychoeducational interventions. These programs may improve not
only psychiatric consumers’ knowledge of their illnesses and how to manage them, but
also their quality of life and levels of social and cognitive functioning; further, the pro-
grams may decrease distressful symptoms (Lukens & McFarlane, 2004).
It should be noted, however, that psychoeducation alone is typically considered in-
sufficient for persons with severe mental illnesses. Illness management is an adjunct
treatment; for people with severe mental illnesses, it will often be ineffective without an
appropriate medication regiment. As the medical model dictates current clinical psychi-
atric practice, educational components must therefore complement the pharmacological
treatment aspects to educate patients on how to successfully manage their illnesses. This
model provides a wide range of skills and training to psychiatric consumers so that, when
discharged, they are able to cope with real-world demands in vocational, social, and living
situations (Corrigan & McCracken, 2005). Psychoeducation sets consumers up for suc-
cess by providing them with the knowledge they need to function in the community and
avoid relapse. Therefore, providing educational forms of treatment to inpatient consumers
is an essential component of successful rehabilitation. These educational forms of treat-
ment are becoming increasingly popular for adults with psychiatric disabilities (Mowbray
et al., 2005).
Illness management research

Educating psychiatric patients about how to manage their illnesses is an important aspect
in contemporary psychosocial treatment. The illness management and psychoeducational
literature base is strong, with many randomized controlled investigations documenting
its effectiveness. Due to its acceptance and effectiveness, it has been used with a variety of
populations.
Researchers have used psychoeducation as an active control condition in scientific in-
vestigation testing the effects of functional cognitive behavioral therapy (fCBT) as an in-
dependent variable (Cather et al., 2005). The researchers measured psychotic symptoms
and social functioning in participants who had diagnoses of schizophrenia or schizoaffec-
tive disorder. Participants were randomly assigned to psychoeducation or fCBT groups
who received 16 weekly sessions of treatment. The researchers found that attrition for
both groups was low (7%) and did not differ between groups, thus indicating excellent
tolerability of experimental and control treatments. Additionally, there were no signif-
icant differences between groups concerning symptoms, suggesting the effectiveness of
psychoeducation. The authors noted the use of an active control intervention during a
psychosocial research investigation created a more rigorous comparison for the experi-
mental condition.
Researchers who conducted a comprehensive review of scientific literature, including
data from 40 randomized controlled studies, found that psychoeducation can improve
psychiatric consumers’ knowledge of their mental illness, coping skills training can reduce
the distress of symptoms, relapse prevention curricula can reduce symptom relapses and
recidivism, and behavioral tailoring can facilitate the taking of medications prescribed by
psychiatrists (Mueser et al., 2002). Specifically, psychiatric patients receiving psychoedu-
cation had higher levels of assertiveness and lower levels of fear and anxiety at posttreat-
ment. In another study, participants receiving psychoeducation had lower hospitalization
rates a year after training (Brown, 1980). In a review of literature examining the efficacy
of patient-focused therapies for bipolar disorder, Colom and Vieta (2004) noted that psy-
choeducation and cognitive behavioral therapy are the psychological interventions that
have been shown to be most efficient at preventing recurrences. The authors noted a need
for efficacy studies in which the illness is in its acute phase, but concluded that a mixture
of pharmacotherapy and psychotherapy can permit consumers with bipolar disorder to
attain enhanced symptomatic and practical recovery.
It should be noted, however, that researchers who conducted a review of research con-
cluded that psychoeducation requires frequent repetition to promote treatment compli-
ance among patients diagnosed with schizophrenia (Zygmunt, Olfson, Boyer, & Mechanic,
2002). Providers of psychoeducation should be aware that reiteration of information may
be crucial not only for patients diagnosed with schizophrenia, but also for psychiatric con-
sumers with analogous symptomologies and impaired cognitive functioning (Zygmunt
et al., 2002). Moreover, psychoeducational booster sessions can be helpful for outpatients
and their family members.
Silverman has used psychoeducational models of music therapy in group-based acute
psychiatric work to teach general psychoeducational knowledge (2009), coping skills
(2011b), assertiveness (2011a), to enhance social supports (2013a, 2014), and to reduce
stigma (2013b). Moreover, many psychiatric music therapists use music therapy to address
psychoeducational treatment objectives (Silverman, 2007). As psychiatric patients may
consider music therapy to be an engaging and motivating medium, perhaps psychoedu-
cational approaches to music therapy can enhance attendance and participation in both
in- and outpatient settings.
Readers should be aware that there are numerous similarities—and often considerable
overlap—between cognitive behavioral therapy and illness management. Many cognitive
behavioral interventions begin with an educational component in an attempt to normalize
the presenting problem. Both techniques involve a collaborative working relationship be-
tween the healthcare provider and the patient that is often based on educational principles
and learning theories. Moreover, there is a great deal of overlap between the interventions:
both emphasize awareness of cognitions, behaviors, and affective states and to develop
skills for coping, leisure, and independence.
The recovery concept

The recovery concept is often considered a component of illness management, thus form-
ing the phrase “illness management and recovery.” Often conceptualized as more of an
attitude, philosophy (Green et al., 2014), vision, movement, myth (Whitwell, 1999), or
multidimensional construct rather than a model, it was founded upon the consumer move-
ment and the belief that psychiatric consumers have the potential to recover and maintain
productive and satisfying lives (Bellack, 2006). Authors have emphasized that recovery is
not made up of a specific set of techniques (Green et al., 2014). A consequence of dein-
stitutionalization, the recovery theory may be conceptualized as the antithesis of Kraepe-
lin’s pessimistic view that mental illnesses have deteriorating courses (Warner, 2009). The
recovery concept is a social movement away from the paternalistic and medically influ-
enced mental health system wherein consumers perceive themselves as survivors not of
mental illness but of the mental health system (Sowers, Huskshorn, & Ashcraft, 2004). In
the recovery concept, the consumer does not have a passive role in her or his treatment
as the person is actively engaged and makes care-related decisions. In fact, Manos (1993)
referred to the patient as a “prosumer” (rather than “consumer”) to highlight her or his ac-
tive and assertive role. It should be stressed that recovery does not require total symptom
remission as patients can still recover despite mild to moderate symptoms (Bellack, 2006).
The recovery model tends to conceptualize mental illness as analogous to chronic medical
conditions such as heart disease and diabetes: these conditions may interfere with func-
tioning but they do not define the person from an internal or external perspective.
As practitioners using the medical model perceive mental illness as a physical disease,
recovery would be interpreted as a return to a former state of health. However, the recov-
ery movement has abandoned the medical model in favor of a combination of the rehabil-
itative model and empowerment model of recovery (Andresen, Oades, & Caputi, 2003).
The rehabilitative recovery model notes that mental illness may be incurable but, with
rehabilitative efforts, the person can regain a semblance of the life she or he had before
the illness (Anthony & Liberman, 1992). The empowerment model of recovery notes that
mental illness is a sign of severe emotional distress caused by overwhelming stressors; it
does not have a biological foundation (Ahern & Fisher, 2001).
While symptom remission is relatively straightforward and unproblematic to opera-
tionally define, experts have had considerable difficulty defining recovery (Warner, 2009).
Currently, there is no consensus on how recovery should be best operationally defined or
measured (Slade, 2009), presenting challenges for researchers and clinicians (Loveland,
Randall, & Corrigan, 2005). Part of the difficulty is that some experts perceive recovery to
be a process while others view it as a product, outcome, or clinical endpoint (Ralph, 2005).
Other scholars have noted that recovery should be conceptualized and measured along a
continuum rather than as discrete diagnostic outcomes (Mirowsky & Ross, 2002). There
are also contrasting scientific and consumer-based definitions of recovery, which typically
focus on different factors (Bellack, 2006). Scientific definitions tend to indicate that recov-
ery is an outcome or endpoint concerning a level of functioning that a consumer achieves
and maintains for a predetermined time period. For an informative paper concerning var-
ious scientific and consumer-based definitions of recovery, readers are referred to Bellack
(2006). For present purposes, components of recovery include the points listed in Box 2.2.
Adoption of the recovery model largely resulted from psychiatric consumers who felt
the traditional medical model of mental disorders led to feelings of helplessness and in-
ternalized stigma. Although mental disorders are considered chronic conditions, many
patients do not progressively deteriorate over time and can have productive lifestyles that
Box 2.2 Recovery Components

◆ Establishing hope, meaning, personal identities, and abilities.
◆ Developing motivation to pursue personal and valued goals (Tse, Wu, & Poon,
2011).
◆ Educating consumers about illness management.
◆ Establishing a sense of integrity and purpose (Ralph, 2005).
◆ Challenging the stigma of mental illness.
◆ Shifting locus of control from external to internal (Frese, Stanley, Kress, & Vogel-
Scibilia, 2001).
◆ Providing services during which treatment related decisions are made collabora-
tively with consumers and treatment providers.
◆ Empowering consumers to develop optimal self-efficacy and quality of life (Gud-
jonsson, Savona, Green, & Terry, 2011).
◆ Living independently, participating in work, school, and age-appropriate social
activities that do not require supervision from a professional (Liberman & Kopelo-
wicz, 2002; Liberman, Kopelowicz, Ventura, & Gutkind, 2002).
◆ Being productive and functioning independently.
◆ Acknowledging that relapse is part of the recovery process and not conceptualized
as a failure (Loveland, Randall, & Corrigan, 2005).
◆ Positive adaptation to the mental illness strongly linked with self-awareness (Hogan,
2003).
◆ Facilitating the consumer’s sense of hope, opportunity, and control (Repper &
Perkins, 2003).
◆ Maintaining supportive and satisfying relationships.
◆ Enduring processes of change, discovery, and growth (Stocks, 1995).
include a vocation (Jonas et al., 2011). The recovery model emphasizes choice, empow-
erment, and hope and, rather than focusing on symptoms of mental illness, focuses on
people’s assets and strengths.
While studies vary according to specific time formats and criteria used to define and
measure recovery, recovery from a major mental illness is possible. Although the modal
percentage for recovery was 50%, 20%–70% of people had favorable outcomes, including
symptom reduction, high quality of life, and social functioning in various roles over ex-
tended time periods (Harrison et al., 2001; Harrow, Grossman, Jobe, & Herbener, 2005).
During a long-term research study concerning people with serious mental illnesses, 68%
of participants were functioning at a level that most considered normal (Harding, Brooks,
Ashikaga, Strauss, & Breier, 1987). Other researchers have found positive results con-
cerning recovery from severe mental illnesses (Davidson & McGlashan, 1997; Harrison
& Mason, 1993; Mason et al., 1995). In a paper reviewing the scientific evidence on the
recovery model, Warner (2010) noted that optimism concerning recovery from schizo-
phrenia—often considered the most severe and debilitating mental disorder—is “justified”
(p. 3) and well supported by research data. Warner added that many people with schizo-
phrenia can recover completely or regain good social functioning.
In an attempt to further conceptualize recovery, Ridgway (2001) analyzed four recovery
narratives (Deegan, 1988; Leete, 1989; Lovejoy, 1982; Unzicker, 1989) using the constant
comparative method. The author identified eight common themes (see Box 2.3).
Bellack (2006) highlighted the importance of consumers’ subjective appraisal of their
functioning within a recovery model. Although a professional may perceive a person to be
in recovery via objective scientific indicators (such as the Brief Psychiatric Rating Scale),
the person may still feel distressed from residual symptoms and frustrated over lack of
progress toward their goals; feelings of hopelessness and an awareness of the stigma con-
cerning mental illness may also be evident. Thus, consumer values, beliefs, and perspec-
tives are paramount in the recovery model.
In an attempt to better understand recovery from a patient-centric perspective, An-
dresen, Oades, and Caputi (2003) analyzed published accounts of recovery from people
with schizophrenia and other serious mental illnesses. The researchers identified four
processes of recovery: finding hope, re-establishing identity, finding meaning in life, and
taking responsibility for recovery. The authors identified five stages within the process of
recovery (p. 591; see Box 2.4).
Scholars have noted that psychiatric recovery and music therapy have congruent prin-
ciples (Grocke, Bloch, & Castle, 2008; McCaffrey, Edwards, & Fannon, 2011). Specific
to recovery in a music therapy perspective, Solli, Rolvsjord, and Borg (2013) conducted
a qualitative meta-synthesis to examine psychiatric consumers’ experiences in music
Box 2.3 Recovery Themes

1 Recovery is the reawakening of hope after despair.
2 Recovery is breaking through denial and achieving understanding and acceptance.
3 Recovery is moving from withdrawal to engagement and active participation in life.
4 Recovery is active coping rather than passive adjustment.
5 Recovery means no longer viewing oneself primarily as a person with a psychiatric
disorder and reclaiming a positive sense of self.
6 Recovery is a journey from alienation to a sense of meaning and purpose.
7 Recovery is a complex and nonlinear journey.
8 Recovery is not accomplished alone; the journey involves support and partnership.
Box 2.4 Recovery Stages

1 Moratorium: This stage is characterized by denial, confusion, hopelessness, identity
confusion, and self-protective withdrawal.
2 Awareness: The person has a first glimmer of hope of a better life, a sense that re-
covery is possible. This can be an internal event, or it can be sparked by a clinician,
significant other, or role model. It involves an awareness of a possible self other than
that of “sick person”: a self that is capable of recovery.
3 Preparation: The person resolves to start working on recovering. This stage involves
taking stock of the intact self, and of one’s values, strengths and weaknesses. It in-
volves learning about mental illness and services available, developing recovery
skills, becoming involved in groups, and connecting with peers.
4 Rebuilding: In this stage the hard work of recovery takes place. The person works to
forge a positive identity. This involves setting and working toward personally valued
goals, and may involve reassessing old goals and values. This stage involves taking
responsibility for managing the illness and taking control of one’s life. It involves tak-
ing risks, suffering setbacks, and coming back to try again.
5 Growth: The final stage of recovery could be considered the outcome of the recov-
ery process. The person may not be free of symptoms completely, but knows how to
manage the illness and to stay well. The person is resilient in the face of setbacks, has
faith in their ability to pull through, and maintains a positive outlook. The person
lives a full and meaningful life and looks forward to the future. They have a positive
sense of self, feeling that the experience has made them a better person than they
might otherwise have been.
therapy. The authors identified four areas of user experience and twelve subdomains
(Table 2.1); they noted that music therapy can be a treatment component to help con-
sumers in their personal and social recovery process. Music therapists should be aware
of these important results as clinicians can capitalize on these aspects during treatment.
For example, a client may have not been using guitar playing as a coping skill due to
severe depression. The music therapist can use this information to highlight that being
a musician is part of this person’s identity (i.e., being someone) and that actively making
music can be an effective coping skill that can be implemented on a daily basis to aug-
ment mood (i.e., regaining music). Future music therapy research on this crucial topic
is warranted.
Although difficult to define and empirically measure, recovery is a key component in
contemporary mental health treatment. Researchers have found that recovery from se-
vere mental illnesses is possible. In 2003, the President’s New Freedom Commission on
Mental Health concluded that the mental health system was failing to meet the single
Table 2.1 Recovery Areas of Experience and Subdomains Resulting from Music Therapy
Area of Having a good time Being together Feeling Being

experience someone
Sub-domain • Pleasure and joy • Belonging • Awareness of emotions • Identity
• Freedom and • Teamwork • Expressing emotions • Mastery
relaxation • Social • Emotion regulation • Regaining
• Motivation and hope participation music
Data from Hans Petter Solli, Randi Rolvsjord, and Marit Borg, Toward Understanding Music Therapy as a Recovery-
Oriented Practice within Mental Health Care: A Meta-Synthesis of Service Users’ Experiences, Journal of Music
Therapy, 50(4), pp. 244–273 doi:10.1093/jmt/50.4.244, Oxford University Press, 2013.
most imperative goal of the people it was designed to serve: “the hope of recovery” (p. 3).
Without question, continued research is warranted to better understand how to facilitate
recovery from mental illness.

◆ Despite side effects, noncompliance, and the anti-psychiatry movement, medica-
tions are still the primary treatment for people with mental disorders.
◆ The controversial Dodo Bird Verdict maintains that there are few differences be-
tween different types of psychotherapeutic interventions.
◆ Psychosocial interventions, including cognitive behavioral therapy and illness man-
agement (psychoeducation), can teach patients how to proactively manage their
disorders. Cognitive behavioral therapy and illness management have strong sup-
port in the literature.
◆ Although difficult to operationally define, the recovery concept has gained consid-
erable momentum and has allowed many patients to live and work in communities
of their choice.
◆ Music therapists can adopt cognitive behavioral and psychoeducational approaches
to augment illness management and recovery skills in psychiatric patients.
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1 What are potential advantages and disadvantages of surreptitious prescribing? Is surreptitious pre-
scribing ethically acceptable?
2 What are potential advantages and disadvantages of using legal coercion to increase adherence to
pharmacological and psychosocial treatment?
3 How might capitalism be responsible for arguments against the psychiatry profession?
4 How might mental health care providers use incentives so that psychiatric outpatients would comply
with pharmacological and psychological treatments?
5 Why might funding agencies awarding grants often favor cognitive behavioral approaches?
6 What information might music therapists use to effectively recruit psychiatric patients to attend music
therapy sessions that focus on illness management and recovery? Make a one-page sign to post on
the therapy room door to expediently educate psychiatric patients about why they should attend and
participate in psychoeducational music therapy sessions.
7 Define recovery in your own words.
8 Measuring recovery can be challenging for psychiatric music therapy clinicians. How might a music
therapist break down the concept of recovery and quantitatively measure progress toward recovery as
a clinical objective in an acute inpatient setting?
9 What are some positive and negative stereotypes concerning pharmacological and psychotherapeutic
treatments?
10 How does the contemporary media influence treatments and remedies for people who do not have
diagnosable psychiatric disorders?
Chapter 3
An overview of music therapy

as a psychosocial intervention
for psychiatric consumers
Introduction
There has been a shift in the perception of psychological interventions in the treatment of
adults with mental disorders. These interventions are now recognized as a critical compo-
nent of a comprehensive treatment approach (Colom, 2011; Department of Health, NHS
Executive, 1999). This change was the result of numerous factors, including findings that
newer antipsychotic medications are less effective than researchers had previously thought
(Geddes, Freemantle, Harrison, & Bebbington, 2000). Moreover, even when medications
are effective in alleviating the symptoms of mental illness, they do not necessarily facili-
tate psychiatric recovery as pharmacological treatments do not contribute to the develop-
ment of knowledge and skills necessary for a successful transition back to the community
(Liberman, 1994). As a result of these factors, psychological interventions are considered
essential components of effective and comprehensive mental health care to promote illness
management and recovery.
Music therapy is a psychosocial treatment defined as the clinical use of music interven-
tions to accomplish individualized goals within a therapeutic relationship by a credentialed
professional who has completed an approved music therapy program (American Music
Therapy Association [AMTA], 2012). Music therapy can be considered one of the creative
art therapies and, depending upon the clinical setting and other therapeutic programming,
is often conceptualized as a complementary or alternative therapy. Of all the creative arts
therapies, music therapy has the largest and most sophisticated research base. The AMTA
defines music therapy an evidence-based profession; its members publish in the Journal of
Music Therapy, Music Therapy Perspectives, the Nordic Journal of Music Therapy, the Arts in
Psychotherapy, and other journals specifically tailored to different areas of clinical practice.
In order to practice music therapy, music therapists must complete a program from
a university approved by the AMTA (<http://www.musictherapy.org>) and a clinical in-
ternship; they must pass the Board Certification Exam administered by the Certification
Board for Music Therapists (CBMT; <http://www.cbmt.org>). Students must accumulate
at least 1,200 hours of clinical training before they are eligible to take the Board Certifi-
cation Exam. Successful completion of the exam results in the MT-BC (Music Therapist–
Board Certified) credential. In the United States, CBMT is the only organization to certify
54 OVERVIEW OF MUSIC THERAPY
music therapists. CBMT also monitors continuing education, mandating that board-cer-
tified music therapists receive 100 continuing music therapy education hours every five
years or retake the examination. CBMT has been accredited by the National Commission
for Certifying Agencies (NCCA) since 1986. Although not all states have music therapy
licensure, this initiative has gained considerable momentum due to music therapists work-
ing with legislators at the state level as well as coordinated AMTA and CBMT efforts.
Music therapists are trained to play a variety of instruments, including voice, guitar,
piano, and percussion. Guitar is typically the accompaniment instrument of choice due
to its portability. Music therapists receive instruction in voice, orchestration, conduct-
ing, music history, and music theory. However, music therapists are not only musicians—
they possess strong interpersonal skills essential for being competent therapists (Gfeller
& Davis, 2008) and facilitating therapeutic alliances. These clinicians are also trained in
psychotherapy and counseling, research, acoustics, anatomy, psychology, and the various
disabilities they may encounter in clinical fieldwork. Although music therapists are eligi-
ble for certification (and clinical practice) after completing a bachelor’s degree, many have
graduate degrees in music therapy or related fields.
A common misperception of music therapy is that it is used exclusively to treat mu-
sicians. While clinicians have successfully applied music therapy in this area, more fre-
quently they treat children and adults with mental, emotional, neurological, physical, and
behavioral problems using interventions specifically designed to meet the consumer’s id-
iosyncratic clinical objectives. Another common misperception is that music therapy is
merely listening to recorded music. This simplistic perception is incongruent with the
clinical objectives that music therapists formulate. In psychiatric settings, music listening
may even be contraindicated as it may not support relational abilities (Mossler, Assmus,
Heldal, Fuchs, & Gold, 2012). Additionally, Silverman and Leonard (2012) found psychi-
atric patients had higher attendance, durational attendance (i.e., how long the patients re-
mained in the sessions), and perceptions of treatment during active music therapy sessions
(using interventions including songwriting, lyric analysis, recreational music therapy, and
rhythm-based percussion interventions) than psychiatric patients who participated in ses-
sions where they listened to recorded music (i.e., passive music listening).
Music therapists work in neonatal intensive care units, schools, medical and psychiatric
hospitals, skilled nursing facilities, rehabilitation settings, private practice, and hospices.
Music therapists often co-treat patients with speech therapists, physical therapists, and
occupational therapists. While these professions tend to be discipline-specific in that they
attempt to rehabilitate specific aspects of a client, music therapy is medium-specific: music
therapists use music-based interventions to reach a wide variety of clinical objectives re-
gardless of the clinical setting.
Although music has been historically used for religious and healing rituals, the profes-
sion of music therapy began in a psychiatric setting: people working in Veterans Affairs
hospitals observed the profound calming effect music had on the patients. One of the un-
derlying theoretical mechanisms resulting in therapeutic change is that music, as a creative
process, can encourage self-expression, self-awareness, insight, and can thus enhance a
person’s psychological well-being (Crawford & Patterson, 2007). In the early years of the
profession, music therapists were mostly employed working with people with behavioral
and emotional disorders and cognitive disabilities (Gfeller & Davis, 2008). Today, music
therapists work in many diverse settings and, despite being a relatively small profession,
the field maintains a strong scientific literature base supporting interventions with many
clinical populations (Madsen & Madsen, 1997).
Approximately 20% of respondents to the 2011 AMTA annual membership survey in-
dicated they worked with the mental health population (AMTA, 2011). Although psychi-
atric music therapists can practice at the bachelor’s level, many of these clinicians have
master’s degrees in music therapy or a related field (Silverman, 2007). While these thera-
pists typically work in group-based settings, it is not uncommon for music therapists to
treat psychiatric consumers individually (Silverman, 2007). One of the advantages of hav-
ing a music therapist on staff is that she or he can address a variety of goals and clinical
objectives, including coping and leisure skills, social supports, self-expression, symptom
management, psychosocial and pharmacological treatment compliance, and skills for
community reintegration, illness management, and recovery. Moreover, researchers have
found that music therapy may be a way to engage psychiatric patients with low therapy
motivation in treatment (Mossler, Assmus, Heldal, Fuchs, & Gold, 2012).
In the formulation of clinical objectives, music therapists assess both the strengths and
weaknesses of the consumer. Specifically tailored music-based interventions are then de-
veloped to meet clients’ idiosyncratic objectives. The music therapist collaboratively works
as a member of the interdisciplinary team to develop a treatment plan. Commonly used in-
terventions include songwriting, lyric analysis, improvisation, facilitated drumming, music
and relaxation, and recreational music therapy. Although these techniques have been effec-
tive in meeting consumer objectives, research found no between-intervention differences
(Cevasco, Kennedy, & Generally, 2005; de l’Etoile, 2002; Jones, 2005; Silverman, 2003a,
2008; Silverman & Marcionetti, 2004). From these studies, it seems that music therapy can
be effective but a specific type of music therapy intervention (e.g., facilitated group drum-
ming to improve self-expression) is not necessarily more effective than another (e.g., lyric
analysis to improve self-expression). This finding is congruent with research on various
other psychosocial interventions (Silverman, 2008) and, more generally, with the Dodo
Bird Verdict: different types of therapy are approximately equally effective (see Chapter 2).
However, psychiatric music therapists typically find that their consumers meet clinical ob-
jectives. Silverman (2007) conducted a descriptive survey of psychiatric music therapists to
identify current trends in clinical practice. Respondents estimated that 58% of their con-
sumers met clinical objectives within the last week. Additionally, most music therapists had
high degrees of job satisfaction and felt they had a positive impact on their patients.
History of psychiatric music therapy

Readers interested in thorough and well-written historical perspectives of psychiatric
music therapy are advised to consult Crowe (2007), Davis and Gfeller (2008), Gfeller
(2005), and Tyson (1981). This chapter will provide only a brief orientation to the history
of psychiatric music therapy.
Music has been involved in healing rituals since ancient times. The word “music” was de-
rived from the Muses, who were nine nymphs in Greek mythology. The Muses, daughters
of Zeus and Mnemosyne, presided over the fine and liberal arts. The Roman god Apollo
was the leader of the Muses and the god of music. Interestingly, Apollo was also regarded
as the founder of medicine (Tyson, 1981). The fact that Apollo presided over both music
and medicine may be symbolic of the interrelation of the disciplines. In fact, both Socra-
tes and Aristotle gave music a definitive medical value (Alvin, 1966). Historical texts have
also referenced the therapeutic value of music: in the Bible, Saul’s melancholy disappeared
while David played the harp (Hughes, 1948); in Homer’s Odyssey, the bleeding of Odys-
seus ceased when he heard a magic song sung to him by Autolycus (Gruhn, 1967). In prim-
itive cultures, illness was believed to arise from magical and religious forces or from the
breaking of taboos. In combination with dance or words, priest-practitioners used music
to enhance the magical practices of healing (Sigerist, 1944). Songs were considered to be
effective in exorcising disease and healing wounds. People playing drums, rattles, flutes, or
bells sometimes accompanied the singers (Radin, 1948). With such a long tradition using
music to promote healing, it is quite likely that practitioners used music to treat mental
disorders even before recorded history.
During the Middle Ages, disease was regarded as a punishment for sin. People believed
those who were mentally ill were possessed by demons (Sigerist, 1944). Therefore, many
cruel and harsh measures were used in the treatment of people who were mentally ill, in-
cluding incarceration and abuse (Boxberger, 1962). However, if persons of high standing
were ill, their court musicians wrote special compositions to cure them or at least cheer
them up (Sigerist, 1948). By this time, the Church had assumed the task of molding the
nature and use of music to avoid profane influences on people’s souls. This was an era of
religious medicine. It was believed that musical modes could influence behaviors (Box-
berger, 1961): the Dorian mode was thought to influence water and phlegm, the Phrygian
mode was paired with fire and yellow bile, the Lydian mode with air and blood, and the
Mixolydian mode with earth and bile (Carapetyan, 1948). People also believed that mu-
sical registers were related to the four cosmic elements: the bass was compared with the
earth, the tenor with water, the alto with air, and the soprano with fire (Carapetyan, 1948).
During the Renaissance, music was used to treat madness, despair, and melancholy
(Davis & Gfeller, 2008). Practitioners in France and Italy were among the first to provide
improved treatment to persons who were mentally ill. Mental health workers attempted to
preserve the humanity of those afflicted as large numbers of patients attended hospitals,
lazarettos, clinics, and asylums as retreats. In the eighteenth and nineteenth centuries,
physicians began to categorize mental patients on the basis of their symptoms (Stone &
Stone, 1966). It was during the eighteenth century, however, that the first objective empir-
ical efforts were made to evaluate the effects of music on the body.
In February 1789, an unsigned article in the Columbian Magazine stated some basic
principles that remain even in modern music therapy practice. According to the article,
music can be used for influencing and regulating emotional conditions as well as for af-
fective expression. In 1796, an article appeared in the New York Weekly Magazine summa-
rizing a case study of a French music teacher. The teacher became ill and later developed
severe signs of delirium accompanied by tears, panic, and shrieks. The teacher requested
to attend a concert. During the concert, the symptoms vanished, only to return after it
finished. The client was thereafter brought to many performances and recovered fully in
a week (Heller, 1987). In 1806, Samuel Mathews recommended matching music with the
moods of people who were depressed. In 1874, Whittaker noted that music could bene-
fit mild forms of mental illness. However, early researchers attempting to determine why
music may help people with mental illnesses were hindered by a lack of trained music
therapists (Gfeller & Davis, 2008).
By the 1930s, the goal of music (not necessarily music therapy) programs at psychiatric
hospitals was to improve the mood of inpatients while they were on the wards. Patients
participated in singalongs, creative music work, musicals, dancing, and music apprecia-
tion and music education programs (Van de Wall, 1936). Practitioners believed that music
was an integral part of a “normal” person’s life and it was therefore important to include
music in treatment of people with mental disorders (Meese, 1930). In the mid-1950s, the
effects of tranquilizing drugs increased the usefulness of traditional talk-based therapies
and creative art therapies, including music therapy (Tyson, 1981). Music was no longer
used solely as a mood modifier as it had been earlier. Hospitals began to use a variety of
activities, including music, to encourage clients to socialize and grow as individuals. For
patients who were seriously mentally ill, group music was one of the earliest and safest
experiences in which they could engage with therapists and their peers. Similar to people
without psychiatric diagnoses, psychiatric patients found singing and dancing to be enjoy-
able and could take pride in their group music-based accomplishments.
Altshuler (1948) noticed that when music was played on the psychiatric unit, many pa-
tients who were confused or disturbed tapped, swayed, or nodded their heads in time
with the music. When tempos changed, Altshuler observed that the clients’ behavior also
changed and seemed to correlate with the musical changes. Hence, Altshuler developed
the “iso” principle and musically engaged patients at their initial levels of mood and tempo.
The music could then be systematically modified to bring about a corresponding change
in the client.
Between 1920 and 1950, music therapy was used in many psychiatric hospitals. How-
ever, it was used very differently than it is today. At that time, music was largely for en-
tertainment and life enrichment: Patients played in hospital bands, participated in talent
shows, and attended music appreciation classes (Wilson, 2005).
Even so, changes were on the way. Gilliland (1951) wrote of the development of music
therapy as a profession. Gilliland noted that music proved its worth as a therapeutic me-
dium during World War I, but it was during the Second World War that the greatest progress
was made in military hospitals. Clinicians and administrators in Veterans Administration
hospitals in Kansas noted the influence of music on clients. During this period, patients
who were psychotic were treated with cold packs in tubs of water while listening to music.
The conclusion was that, overall, the presence of music in the hydrotherapy room was
helpful (Aldridge, 1993). Van de Wall (1946) asserted that hospital music programs should
provide programs that were pleasurable and comforting.
Formal university-based training in music therapy did not exist before 1944 (Tyson,
1981). The National Association for Music Therapy was founded in 1950. By 1965, music
therapists were mostly employed in state psychiatric hospitals (Michel, 1965). Music ther-
apists typically received referrals not for therapeutic reasons but because a patient had an
interest or previous experience in music. Michel (1965) found that the majority of music
therapists who responded to his survey were working to identify methods for involving
and evaluating the progress of their patients and music therapy programs.
Michel (1951) studied the sedative effects of music for acutely disturbed patients in a
Veteran’s Hospital. Participants included 32 people diagnosed with schizophrenia of var-
ious types, manic-depressive psychosis, and alcoholism. Michel’s results were impressive:
an observable sedative effect for the ward as a whole when appropriate music was played; a
positive acceptance of the music; an unintended marked development of positive relation-
ships between patients and staff; increased verbalization of feelings and problems that left
musicians, doctors, nurses, and staff excited about the therapeutic properties and potential
of music.
In 1967, Forsdyke presented a paper entitled “Music as Recreation for Mental Patients” at
the British Society for Music Therapy Conference and began to differentiate music activi-
ties for social engagement from music therapy to address clinical objectives. She noted that
the largest diagnostic group in mental hospitals was patients with schizophrenia. Forsdyke
stated that clients with this disorder had a difficult time focusing attention and that passive
listening was often ineffective as clients withdrew into their dreams, delusions, or halluci-
nations. If music therapy was to be successful, it was imperative for the clients to have an
active role in listening and participating. However, skill or talent could not be expected
in order to take part in the music. The standard of performance did not matter to either
the therapist or listeners; thus, music therapy could be considered a process- rather than a
product-oriented treatment modality. Forsdyke also noted that music was capable of allevi-
ating the boredom of the monotonous restriction typical of mental hospitals by creating an
easy and relaxed atmosphere. Forsdyke argued that although music therapy could not cure
the illness, it could facilitate an interest and link with patients’ lives outside the hospital.
In psychiatric institutions, music therapy began to address the clinical needs of World
War II veterans coping with posttraumatic stress disorder (then referred to as shell shock
or battle fatigue). Since then, however, its role has changed dramatically, especially after
the inception and advancement of psychotropic medications in the 1950s. In an article
in the Journal of Music Therapy, Euper (1970) described contemporary trends in mental
health work. Euper noted a lack of an integrated treatment team approach as well as chang-
ing objectives in mental health care delivered by psychiatric music therapists:
None of these forms will permit the loosely organized, attend-if-you-wish kinds of musical activi-
ties that have characterized so much work in large hospitals. Neither will the seasonal stage produc-
tions be very feasible. The rationalizations so often given for music activities (they keep the patient
Contemporary psychiatric music therapy 59
busy and his mind off his troubles; they enliven the otherwise dull ward life; they provide a choir for
hospital chapel services and entertainment for parties) will have to give way to more serious aims,
and results in terms of patient progress will have to take precedence. (p. 25)
Euper was correct in her prediction: Since the publication of this article, the role and func-
tion of music therapy has changed considerably. While music activities may still be part
of the clinical responsibility and job description of psychiatric music therapists, the pro-
fession has evolved in order to keep current with contemporary practice and models in
mental health treatment, including illness management and recovery.
Contemporary psychiatric music therapy

Today, music therapy is an intervention commonly used in the treatment of persons who
have mental disorders. For people who have serious mental disorders, music therapy
typically functions as an additive treatment along with other educational, psychosocial,
rehabilitative, and psychopharmacological interventions. Music therapists can work in
community mental health centers, group homes, day treatment centers, in- and outpatient
behavioral health centers, and state hospitals. An advantage of this psychosocial treatment
is its flexibility as music therapy can be adapted to meet a range of psychiatric and psy-
chological clinical objectives. Psychiatric music therapists are typically well received by
consumers with mental illnesses who rate them highly when compared to other forms of
treatment, programming, and therapies (Heaney, 1992; Silverman, 2006). In psychiatric
settings, music therapists have a variety of titles, including music therapist, activity ther-
apist, rehabilitation therapist, and rehabilitative worker. Music therapists often provide
group music therapy sessions based on a particular topic or subject area, such as the psy-
choeducational modules listed by McGuire and colleagues (2014; see Box 3.1).
Box 3.1 Psychoeducational Modules

1 Recovery.
2 Practical facts about mental illness.
3 The Stress-Vulnerability model.
4 Building social support.
5 Using medication effectively.
6 Drugs and alcohol.
7 Reducing relapses.
8 Coping with stress.
9 Coping with persistent symptoms.
10. Meeting needs within the mental health system.
11. Living a healthy lifestyle.
Researchers have conducted a number of studies concerning the effects of music on the
symptoms of psychosis. A meta-analysis by Silverman (2003b) indicated that music was effec-
tive in suppressing and combating such symptoms. Mossler, Chen, Heldal, and Gold (2012)
conducted a systematic review and meta-analysis concerning the effects of music therapy on
people with schizophrenia and schizophrenia-like disorders. These researchers found that
when music therapy is used in addition to standard care, it can help improve global state,
mental state, and social functioning. The authors noted that in order for music therapy to
be effective, sufficient sessions must be provided by a qualified music therapy professional.
In research trials, psychiatric consumers have favored music therapy. In a descriptive sur-
vey, psychiatric inpatients (N = 27) rated the perceived value of music therapy higher than all
other therapies (Heaney, 1992). In a larger and more recent survey of psychiatric inpatients,
participants (N = 73) answered questions concerning which type of therapy addressed
specific deficit areas most effectively (Silverman, 2006). Results indicated that participants
rated music therapy as significantly more helpful than all other programming. Additionally,
57% of participants noted that music therapy was their favorite class or therapy. Ansdell and
Meehan (2010) found supportive results in a qualitative study with adult psychiatric pa-
tients. The authors studied 19 patients with chronic mental health problems who had com-
pleted at least ten individual improvisation music therapy sessions. The researchers used
interpretive phenomenological analysis with data collected via semi-structured interviews.
Through the music therapy process, participants were able to re-establish music as a coping
skill in their home environments. As psychiatric consumers should be considered experts in
psychosocial programming (Dickey, 2005; Kitcher, 2001; Leff, 2005; National Association of
State Mental Health Program Directors, 1989), having a music therapist on staff at a psychi-
atric facility may be a method for administrators to improve consumer satisfaction ratings.
Although there is considerable variability among facilities, music therapists working
with psychiatric patients are often part of the educational and rehabilitative departments.
Larger facilities may have creative arts divisions that house music therapy programs.
Music therapy programs may also be grouped together with other rehabilitative therapies
(e.g., occupational therapy, physical therapy, recreational therapy, art therapy, and dance/
movement therapy).
A great deal of randomized controlled scientific evidence supports the use of psych-
oeducation with psychiatric consumers (Mueser et al., 2002). These psychosocial inter-
ventions are now commonly used to educate persons with mental disorders concerning
how to effectively manage their illnesses and facilitate psychiatric recovery. Music thera-
pists are often contributing members of the interdisciplinary treatment team. Silverman
(2007) conducted a descriptive study of psychiatric music therapists and found that many
routinely addressed psychoeducational subject matter during their sessions. Silverman
has explored applications of educational music therapy for acute-care psychiatric inpa-
tients, including general psychoeducational knowledge (2009), coping skills (2011c), as-
sertiveness (2011b), social supports (2013a, 2014), and stigma (2013b). Although many
psychiatric consumers have inconsistent attendance during psychosocial treatments (Bel-
lack, 2006), Silverman found that a greater number of acute-care psychiatric inpatients
Funding psychiatric music therapy services 61
attended educational music therapy sessions than talk-based psychoeducational sessions

without music (Silverman, 2009, 2011b, 2011c, 2013b). While these differences did not
reach statistical significance, better attendance may lead not only to better treatment, but
also to greater revenue for hospitals. Another advantage of music therapy is that there are
no known side effects (Tang, Yao, & Zheng, 1994; Ulrich, Houtmans, & Gold, 2007).
Music therapists commonly treat patients with substance misuse disorders. Patients on
a detoxification unit who attended music therapy sessions tended to have slightly lower
craving and higher change scores than patients in a nonmusic, talk-based therapy session
(Silverman, 2011a). In another study, patients on a detoxification unit who received music
therapy had significantly higher treatment motivation than patients in a wait-list control
condition (Silverman, 2012). These findings, coupled with research concerning psychoe-
ducational music therapy for psychiatric consumers, provide empirical evidence of the
effectiveness of psychiatric music therapy in inpatient settings.
Funding psychiatric music therapy services

Experts associated with the World Economic Forum have noted the staggering costs as-
sociated with noncommunicable diseases, such as mental illness. Bloom and colleagues
(2011) noted that mental illnesses are the largest contributing factor to high costs, and
advised governments and corporations to seek low-cost interventions (known as “best
buys”) instead. The authors advised against inaction, noting that failure to act would be
even more costly. As music therapists have salaries comparable with other professionals in
allied healthcare fields, including special education teachers and social workers (Gfeller &
Davis, 2008), Tang, Yao, and Zheng (1994) noted that music therapy is “relatively inexpen-
sive” (p. 38). Thus, music therapy can represent a “best buy” action item that can be used to
help people with mental illnesses function at higher levels, augment illness management
and recovery skills, and remain in the community.
Psychiatric music therapy services can be funded in a variety of ways, often depend-
ent upon the type of facility, mission, patients, and idiosyncratic needs. Some hospitals
fund music therapy within an educational and rehabilitative framework in their operating
budgets. As psychiatric facilities may be required to provide a certain number of thera-
peutic hours each week, music therapy is often categorized as a related service or clini-
cal programming. Hospitals may fund music therapy as part of their “integrative care”
services. Some insurance companies reimburse for psychiatric music therapy services and
hospitals might directly bill patients’ insurance. Medicare and Medicaid often fund psy-
chiatric music therapy. Inpatient mental health facilities might categorize music therapy
as a “related service” or bill using current procedural terminology (CPT) codes. However,
there is considerable variance in billing music therapy services with CPT codes: billing
procedures vary by state, facility, unit, licensure type, and specific role and function of
the music therapy service. Moreover, CPT codes change frequently, often annually. Psy-
chiatric music therapists interested in using CPT codes are advised to consult with billing
and coding departments in their facilities as well as with state websites. The process can
be complicated because each facility typically has different methods for billing. Some psy-
chiatric facilities bill for group-based music therapy using CPT code 90.857, Interactive
Group Psychotherapy. Psychiatric music therapists might consider consulting with their
facility’s billing and coding departments using the information provided by the American
Music Therapy Association [AMTA] (2014, p. 11; see Box 3.2).
Box 3.2 AMTA Reimbursement Methods

◆ The U.S. code lists music therapy as a disease prevention and health promotion
service and as a supportive service under Title 42: The Public Health and Welfare;
Chapter 35: Programs For Older Americans; Subchapters I and III.
◆ Music therapy is listed under the Healthcare Common Procedure Coding System
(HCPCS) Code G0176 for billing Medicare in Partial Hospitalization Programs (PHP).
◆ Music therapy has procedure code 93.84 in the International Classification of Dis-
eases (9th rev.) Manual (ICD-9) used in reimbursement.
◆ Music therapy is listed on the U.S. General Services Administration (GSA) schedule
under Professional and Allied Healthcare Staffing Services: 621-047: Counseling
Related Services (includes Community Counselor; Marriage/Family Counselor/
Therapist; Mental Health Counselor; Rehabilitation Counselor; Social Worker)
(BS); Social Worker (MS); Music Therapist; Art Therapist and Dance Therapist
(Registered DTR).
◆ Music therapists are eligible to apply for the National Provider Identifier system
for billing under taxonomy code 225A00000X, which is included in the category of
“Respiratory, Developmental, Rehabilitative and Restorative Service Providers.”
◆ The Minimum Data Set (MDS) 3.0 assessment tool used in skilled nursing facili-
ties and residential care programs lists music therapy under Section O. Special
Treatments and Procedures, O0400. Therapies, F. Recreational Therapy (includes
recreational and music therapy). This listing provides a vehicle for documenting
physician-ordered music therapy services and validates the inclusion of music ther-
apy as a part of the Medicare Prospective Payment System (PPS).
◆ The National Institutes of Health National Center on Complementary and Alterna-
tive Medicine (NCCAM) website defines complementary and alternative medicine.
Music therapy is included under Mind-Body Interventions.
◆ Music therapy is a related service under the Individuals with Disabilities Education
Act and can be included on Individualized Education Plans if found necessary for a
child to benefit from a special education program.
◆ The Joint Commission and the Commission on Accreditation of Rehabilitation Fa-
cilities (CARF) recognize music therapists as qualified individuals who may provide
services with accredited facilities.
Music therapy in acute care psychiatric treatment 63
Music therapy in long-term psychiatric treatment

Today, music therapists in the United States frequently apply an eclectic approach wherein
they draw from a multitude of theories (holistic, humanistic, cognitive, psychodynamic,
behavioral, and biomedical). Music therapists use medical, environmental, and psychoso-
cial means to relieve somatic distress and to encourage patients to explore more satisfying
and useful styles of social interaction and coping with the symptoms of their illnesses. In
longer-term settings with chronically ill psychiatric inpatients, music therapists design
nonthreatening music-based interventions to bolster self-esteem, motivation, and illness
management and recovery knowledge and skills while encouraging appropriate behavior
(Wolfgram, 1978). When dealing specifically with schizophrenia and psychotic disorders,
music can temporarily assist patients in suppressing hallucinations, redirecting attention
from their problems, and relaxing them (Naukkarinem, 1984). Music therapy can also
be used to re-establish the patient’s contact with reality, open lines of communication,
and provide a means through which the person can learn adaptive patterns for illness
management and recovery to help them function normally and prevent further psychotic
breakdowns (Hadsell, 1974). Congruent with the recovery concept, the music therapist is
also able to assist clients who have psychiatric disorders in developing a philosophy of life
that they find more fulfilling (Scovel, 1990). Arnason (1993) noted that music is helpful
in bringing some psychotic clients from a preoccupation with the past to an active stance
in the present.
Music therapy in acute care psychiatric treatment

As noted in Chapter 1, inpatient hospitalizations are becoming briefer in duration. Music
therapists have adjusted their treatments accordingly to meet the idiosyncratic needs of
acute-care patients. Rather than focusing on longer-term goals such as self-esteem and
enhancing musicality, most contemporary music therapists in acute-care treatment set-
tings teach functional skills to patients to prevent additional psychiatric hospitalizations
and recidivism as well as promote illness management, psychiatric recovery, and rehabil-
itation. As the overarching goal for patients is to live in the least restrictive environments
of their choice, music therapists can work with patients to prevent relapse, link medication
compliance and adherence with personal goals, develop healthy coping and leisure skills,
enhance problem-solving abilities, and motivate clients to use community supports.
Specific to brief and time-limited acute care treatment settings, music therapists might
consider the life of the therapy to end at the conclusion of the session. Thus, it is vital to
bring appropriate verbal and musical closure and resolve any “unfinished business.” Music
therapists practicing within a cognitive behavioral framework might assign homework
(or tasks to be completed outside of music therapy sessions for psychiatric inpatients) at
the conclusion of the session. In these tasks, music therapists can make the illness man-
agement and recovery issues addressed during the session into a behavioral assignment,
such as actually using a coping skill or making a coping-skills card while still on the unit.
In order to increase the likelihood of attending future sessions, music therapists reinforce
patients for attending and participating in the session. Concluding the session with an up-
beat live singalong (e.g., “Don’t Stop” by Fleetwood Mac) can be encouraging for patients,
leaving them with a positive message related to the theme of the session. Another tech-
nique to leave patients with a sense of optimism and community is to instruct each group
member to compliment the person on their left. Similarly, within a music therapy session,
patients can state “one thing you can do today that will make tomorrow better.” Whatever
specific question or task the therapist chooses to use as a question to bring closure to the
session, it relates to the theme of the session and is derived from the theme of the session.
Additionally, the music therapist leading the group can model the behavior by first sharing
and disclosing something she or he can do today to make tomorrow better.
Group psychiatric music therapy

Most psychiatric music therapists in the United States provide group-based treatment
(Silverman, 2007; Thomas, 2007). This may be due to group formats allowing a greater
number of patients access to music therapy treatment. Group therapy is also more cost-ef-
fective than individual therapy. The size of the group depends on a number of factors, in-
cluding age of the patients, level of functioning, diagnoses, comorbidity, setting, treatment
objectives, therapist experience, degree of participant participation, and facility character-
istics. Group size should not be too large—researchers found that smaller groups had less
attrition than larger groups in a study of group therapy for depression (Bright, Baker, &
Neimeyer, 1999).
As healthcare costs have risen, group therapy can be a cost-effective, practical alter-
native to traditional individualized therapy. Authors have indicated that group therapy
can be as effective as individual therapy (Bednar & Kaul, 1994; Fuhriman & Burlingame,
1994; Toseland & Siporin, 1986). In a meta-analysis concerning group and individual ther-
apy modalities for the treatment of depression, Neimeyer, Robinson, Berman, and Haykal
(1989) found equally efficacious outcomes, even when comparisons were made by thera-
peutic orientation.
Group therapy also allows patients to interact with their peers. These peer interactions
may be ideal for enhancing illness management and recovery as they can facilitate a num-
ber of therapeutic mechanisms, including universalization, modeling, and vicarious learn-
ing. For example, although a music therapist may not have personal experience with what
it feels like to be stigmatized due to having a psychiatric diagnosis, other group members
may be able share their unique experiences in coping with and dealing with the expe-
rienced and internalized stigma often associated with psychiatric disorders. The music
therapist does not necessarily need first-hand experience with this feeling in order to help
the patient. Rather, the music therapist can direct the question back to the group members
who can offer the patient problem-solving suggestions, coping skills, and suggestions as
to useful community resources. In some situations, a patient may be more likely to accept
advice from a peer than the therapist, especially if that patient does not feel the therapist
can relate to what she or he is feeling or thinking. Group interventions also can provide
opportunities for social interaction in a nonthreatening environment structured by the

music therapy intervention. Due to the nature of psychiatric disabilities, social interaction
is often an important treatment area.
Certainly, some of the complexities concerning group-based treatment include various
levels of participation and addressing idiosyncratic and individualized treatment objec-
tives within a group context. Although a music therapist may be providing group-based
treatment, clinical objectives are still idiosyncratic and individualized. In order to address
a particular patient’s objective, a therapist might ask him or her to elaborate on specific lyr-
ics within a lyric analysis song. Thus, while a music therapist is conducting group therapy,
it does not imply that all group members share the same clinical objective. The psychiat-
ric music therapist strategically interacts with individual group members and can design
situations wherein an individual group member has the ability to meet her or his clinical
objective within a group-based format.
Diagnoses in psychiatric in music therapy

Psychiatric music therapists can expect to treat a variety of diagnoses, as well as comor-
bidities, within a group therapy session. Most psychiatric facilities are arranged by level of
care and supervision required (i.e., acute care versus chronic or long-term care) and not
by specific diagnosis. Thus, a psychiatric music therapist will likely treat patients who have
varied disorders, along with co-occurring disorders, within the same group therapy ses-
sion. Using transdiagnostic theory (Chapter 7) while working with groups can enable the
music therapist to focus on illness management skills related to pathologies and transcend
individual group members’ specific disorders.
Cassity and Cassity (1994) surveyed directors of music therapy clinical training con-
cerning assessments and treatment. Specific to adult male patients, respondents primarily
treated psychotic disorders, affective disorders, substance abuse, personality disorders,
anxiety disorders, and adjustment disorders. Specific to adult female patients, respond-
ents primarily treated psychotic disorders, personality disorders, affective disorders, sub-
stance abuse, adjustment disorders, and anxiety disorders. If one is not in favor of using
the transdiagnostic theory for group-based psychiatric music therapy (see Chapter 7), it
may be a worthwhile research endeavor to conduct a similar descriptive study to collect
data concerning what diagnoses contemporary psychiatric music therapists are treating in
both acute- and chronic-care settings.
Contemporary objectives in psychiatric music therapy

Contemporary psychiatric music therapy practice has evolved to remain congruent with
advances in science, technology, and treatment. In a descriptive study of psychiatric
music therapists, Silverman (2007) found many psychiatric music therapists were using
psychoeducational objectives in their treatment: 76.1% of those who responded to the
survey indicated they had addressed coping skills as a consumer objective during the
last week (Silverman, 2007). Coping skills education and counseling is a fundamental
component of the illness management and recovery curriculum. Other results from the
survey indicated participants noted they had focused on other psychoeducational areas
such as decision making (60.9%), leisure skills, (58.0%), problem solving (52.9%), sub-
stance abuse (42.0%), symptom management (32.6%), mental health knowledge (29.7%),
and community reintegration and resources (both 19.6%). However, medication man-
agement, a basic component of the psychoeducational curriculum, was the least noted
objective area focused on within the last week by psychiatric music therapists (10.1%). It
is unclear why such an essential area of treatment received so little attention, especially
when music therapists frequently addressed other areas of illness management and re-
covery. It may be that nurses, psychiatrists, or pharmacologists provide medication inter-
ventions; medication management may fall outside the job responsibilities of psychiatric
music therapists. Future research is certainly warranted concerning this important as-
pect of treatment.

◆ Music has long been used in healing practices.
◆ Music therapy is a flexible psychosocial intervention that psychiatric consumers
tend to favor.
◆ Although the music therapy literature base is small when compared to cognitive
behavioral therapy, music therapy can be an effective adjunct treatment modal-
ity for a number of dependent measures. (Readers who are specifically interested
in music therapy research for psychiatric consumers are directed to Table 12.1 in
Chapter 12.)
◆ Many psychiatric music therapists are working in acute-care settings where they
provide group-based treatment focused on augmenting illness management and re-
covery knowledge and skills.
◆ Music therapy for illness management and recovery is as effective as psychoeduca-
tion on a variety of measures in randomized controlled clinical trials. Due to its
unique and creative medium, music therapy for illness management and recov-
ery may engage and motivate patients to attend, engage, and actively participate in
sessions.
◆ Changes in healthcare policy and advances in neuroscience will likely force psychi-
atric music therapists to continually adapt approaches to appropriately address new
treatment models.
◆ By continuing the strong tradition of scientific inquiry, adapting to continuous pol-
icy changes, scientific advances, and rigorous academic and clinical training, music
therapists will likely have a continued and even heightened role in treating people
with mental disorders.
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1 How has psychiatric music therapy changed and evolved over time?
2 What are three patient-centric advantages of group-based psychiatric music therapy?
3 Without using music therapy specific jargon, how might you describe music therapy to an administrator
of an acute-care inpatient psychiatric unit?
4 Although brief hospitalizations and acute-care inpatient treatment may not be optimal, they may be the
reality. What are three potential advantages and disadvantages of briefer inpatient hospitalizations?
5 In designing therapeutic music therapy programming, why should the practitioner be familiar with the
existing therapeutic and educational milieu?
6 How might group-based music therapy for acute-care psychiatric inpatients be structured to incorpo-
rate individually tailored psychoeducational objectives?
Chapter 4
Continuum model of music

and therapy within music therapy
Guiding questions
What is music therapy? How does it work? What does a typical session look like? Bruscia
(1998b) devoted an entire book to some of these inquiries, and music therapy profession-
als have probably faced this barrage of questions for years. Likely, this arduous task will
continue. These questions are difficult to answer due to the breadth of populations music
therapists serve and various interventions music therapists use to address idiosyncratic
clinical objectives. Moreover, these questions may be further complicated when a person
agrees that music is therapeutic—in fact, this person “actually performs music therapy”
on herself or himself daily “with an iPod.” As music therapy is not a domain-specific treat-
ment or a specific intervention, describing the profession can be problematic. Physical
therapy, speech therapy, and occupational therapy are larger professions and tend to be
more domain-specific. Thus, these therapists likely face fewer questions than music thera-
pists do. Music therapists use music therapy, which is an intervention- or medium-specific
practice. Regardless of population and clinical objective, music therapists use music as the
medium to address client deficit areas. Additionally, even within similar clinical popula-
tions, music therapists might use different interventions depending upon the consumer’s
strengths and objectives.
What exactly is psychiatric music therapy? How does music therapy work with psychiatric
patients? Can you diagnose a patient based on his or her music preferences? Some patients
or observers of music therapy might comment that psychiatric music therapy contains a
great deal of music but does not necessarily seem therapeutic (e.g., guitar lessons to pro-
mote emotional expression for a person diagnosed with schizophrenia). Thus, is it really
music therapy? Other people might observe that there is a high degree of verbal counseling
and verbal processing but relatively little music (e.g., lyric interventions to promote change
for patients on a detoxification unit). Thus, it is really music therapy? Is there—and should
there be—a balance between music and therapy in psychiatric music therapy? How much
music should be integrated into the session to consider it music therapy? How much ther-
apy should be integrated into the session to consider it music therapy? Is there an optimal
ratio between music and therapy within music therapy? Should there be a balance between
music and therapy within music therapy?
Music therapy students often draw attention to these uncertainties during their aca-
demic and clinical training. Indeed, as students progress through the sequenced music
72 CONTINUUM MODEL OF MUSIC THERAPY
therapy role-play scenarios in Standley and Jones (2008), these questions frequently be-
come a challenge. During the initial, highly music-based interventions, students may ask:
“Is this really therapy? Am I helping the participants enough? I feel like I’m just doing
music. Is that okay?” After students advance to the later role-plays, they may ask, “Am I
using enough music? How can I incorporate more music into the session and accomplish
the objective? Is this still music therapy? How much music do I need for this intervention
to be considered music therapy?” There are likely no absolute answers for these inquires.
However, several authors have proposed taxonomies in an attempt to better explain how
separate aspects of music and therapy might function within music therapy.
Related music therapy literature

In 1974, Hadsell published a paper concerning a sociological theory and approach to
music therapy with adult psychiatric consumers. She noted that a music therapist might
use more music when a patient is functioning at a lower level, relying solely on the qualities
of the music for communicative interactions. She wrote that the music itself may function
as a non-threatening means to help reach and engage the patient. After rapport and trust
have been established, other types of music therapy interventions can be used. Thus, for
persons who are more psychotic, using music as the primary mode of therapy can facili-
tate communication and interaction. However, later in the treatment process, when overt
psychotic symptoms may have dissipated, the therapist might use less music, thus provid-
ing increased opportunities for verbal interaction and therapy.
Wheeler (1983) categorized music therapy for adult psychiatric clients into three types:
music therapy as activity therapy, insight music therapy with re-educative goals, and in-
sight music therapy with reconstructive goals. These categorizes are briefly summarized
in Table 4.1 and are brilliantly effective for describing how music therapy might function
with adult psychiatric consumers. It would seem that music is used less when insight and
Table 4.1 Wheeler’s (1983) Continuum of Music Therapy Procedures for Adult Psychiatric Patients
Wheeler (1983) Category Brief Description Clinical Example

Music therapy as activity Goals achieved through Group-based recreational music
therapy music-based interventions therapy to increase attention span,
rather than through insight communication, and socialization
Insight music therapy with Music is used to elicit emotional, Group songwriting about reasons
re-educative goals cognitive, and/or behavioral to stop using drugs and maintain a
reactions necessary for therapy sober lifestyle
Insight music therapy with Music techniques are used to Music improvisation to elicit
reconstructive goals elicit unconscious material and unconscious reactions to the
worked through to reorganize experience to develop insight
the personality
Data from Barbara L. Wheeler, A Psychotherapeutic Classification of Music Therapy Practices: A Continuum of Proce-
dures, Music Therapy Perspectives, 1(2), pp. 8–12. doi:10.1093/mtp/1.2.8, Oxford University Press, 1983.
Related music therapy literature 73
reorganization of the personality is the central goal, whereas it is used more when therapy
is activity-based and the chief goal does not concern insight. In determining these catego-
ries, Wheeler noted that she drew upon Wolberg (1977), who also developed a three-tiered
taxonomy: supportive therapy, re-educative therapy, and reconstructive therapy.
Bruscia (1998a) developed a four-part taxonomy for describing levels of music therapy
engagement. This taxonomy is of particular interest and relevance as Bruscia described
what might be conceptualized as ratios between the amounts of music and verbal dialogue
in music therapy. Table 4.2 depicts this well-articulated and thought-provoking model.
Bednarz and Nikkel (1992) categorized music therapy for the treatment of young adults
diagnosed with mental illness and substance abuse into different delivery modes. In this
informative paper, the authors described how different interventions could be used de-
pending on the consumer’s stage of treatment (engagement, crisis intervention, stabili-
zation, active treatment, and recovery). Bednarz and Nikkel identified five intervention
types; these interventions are depicted in Table 4.3.
While Wheeler’s and Bruscia’s models are innovative, frequently cited, and enlightening,
some may consider them to be absolute. Moreover, psychiatric music therapists anecdo-
tally note that the ratio of music to verbal therapy tends to fluctuate both within and be-
tween sessions. Therefore I propose a combination of Wheeler’s (1983) continuum model
and Bruscia’s (1998a) taxonomy. In the proposed continuum model of music and therapy
(see Figure 4.1), music and therapy are distinct but interdependent. Music therapy cannot
exist without music; nor can it exist without therapy. This continuum model recognizes
that in music therapy, there is always music and, likewise, there is always therapy, although
Table 4.2 Bruscia’s (1998a) Four Levels of Engagement
Bruscia Level of Engagement Brief Description Clinical Example

Music as psychotherapy Issues in therapy worked through Improvisation without verbal
by listening to or creating music processing
Section 1.01 Minimal or no
verbal discourse
Music-centered psychotherapy Issues worked through by Improvisation followed by
listening to or creating music verbal processing
Section 1.02 Verbal discourse
used to guide, interpret,
or enhance therapeutic outcome
Music in psychotherapy Music and verbal discourse Lyric replacement songwriting
intervention: patients write
new words to existing song
Verbal psychotherapy with music Mostly verbal Discussion of song lyrics
Section 1.03 Music in tandem without patients actively
to facilitate or enrich, but music making music
not necessary
Data from Kenneth E. Bruscia, An introduction to music psychotherapy. In Kenneth E. Bruscia (Ed.), The dynamics of
music psychotherapy (pp. 1–15). Gilsum, NH: Barcelona Publishers, 1998.
Table 4.3 Interventions for Young Adults with Dual Diagnoses
Interventions Brief Description

Music discussion Talking about the role of music in life
Music instruction Learning musical skills
Participatory group Making music in a group format
Music listening Structured listening activities
Expressive music Focusing on insight and feelings
Data from Linda F. Bednarz and Bob Nikkel, The Role of Music Therapy in the Treatment of Young Adults Diagnosed
with Mental Illness and Substance Abuse, Music Therapy Perspectives, 10(1), pp. 21–26, doi:10.1093/mtp/10.1.21
Oxford University Press, 1992.
Therapy
Music
Figure 4.1: Continuum model

of music and therapy 1 2 3 4 5
in a given session one or the other may not be immediately apparent. There can be a fluid
movement along the continuum within a single therapy session or even within a specific
isolated interaction between therapist and group member or client.
Continuum model explained

The continuum contains quantitative indicators along its horizontal axis in an attempt to
approximate the ratios between music and therapy at a given moment. These quantitative
indicators are purposely far from absolute and exist solely for communicative purposes.
From a levels-of-measurement perspective, these indicators could be considered nominal
but not ordinal or intervallic. Numeric indicators are used to communicate as it is easier
to use a midpoint between numeric indicators (e.g., 4.5 is between a 4 and 5 on the con-
tinuum) than by using midpoints between nominal indicators. The purpose of these indi-
cators is not to articulate what may be more effective for a given client or situation. Rather,
these indicators are descriptive and allow for communicative ease during supervision and
education. In correspondence with music therapy students and colleagues, I have found
these quantitative indicators to be helpful for expediting dialogue and describing the roles
Continuum model explained 75
and ratios of music and therapy within a music therapy session. For example, a student
might meet with her or his music therapy educator to discuss and design a role-play from
Standley and Jones (2008). Toward the later stages of the role-plays, a student might be
concerned with a lack of music and ponder ways to appropriately infuse music into a
seemingly “counseling-heavy” music therapy role-play. This situation may be described as
a “4”: the emphasis is on verbal therapy due to the consumer’s objective at the time. In my
experience, the flexibility and visual and quantitative aspects of the continuum model have
greatly enhanced communication with students.
The music therapy continuum model does not contain intersections at the corners. The
decision to place the ratio lines along the vertical axis rather than in the corners was con-
sciously made because during a music therapy session, therapy cannot exist without music
and music cannot exist without therapy. In a music therapy session, music and therapy
coexist and are both interrelated and interdependent. There is a symbiotic relationship
between music and therapy in music therapy. Regardless of how much of either is used,
music and therapy necessitate each other for music therapy to occur.
For example, in a group session, discussing coping skills during a lyric analysis interven-
tion still falls within the definition of music therapy because music was present in the ses-
sion (the therapist played the song for the patients to establish rapport, initiate therapeutic
dialogue, engage and motivate patients, and stimulate their cognitions). In this example,
music is the antecedent to the therapeutic process. In fact, playing the song could be con-
strued as a type of prompt while the lyrics themselves provide structure for the intervention.
As verbal dialogue is more dominant while the music is emphasized less during the group’s
analysis of the lyrics, this session might be considered a 4 or 5 on the continuum. Another
example might be a facilitated group drumming intervention for adult psychiatric con-
sumers. Here music is clearly more dominant than the verbal therapy. A facilitated group
drumming session may thus be considered a 1 or 2 on the continuum. However, the ensuing
dialogue concerning appropriate and effective communication types may be considered a
4 or 5. Thus, even within a session, the relative amounts of music and therapy can fluctuate.
The continuum model registers such fluctuations both within and between sessions.
Thus, a music therapy session for psychiatric inpatients on Monday might be based on rec-
reational principles and thus emphasizes music (perhaps a 1 on the continuum) to engage
newly admitted inpatients and to develop rapport. However, by Friday, the session might
be more talk-based (perhaps a 4); verbal therapy is emphasized in the discussion of how
to avoid psychiatric relapse, a discussion that grew out of lyric analysis of the song “Don’t
Stop” by Fleetwood Mac. In Friday’s session, the emphasis might fall on music (playing
the song and discussing its musical qualities) or on talk (discussing how the song relates
to healthy coping skills as an alternative to misusing substances to change affective states).
In Silverman’s (2011) description of an assertiveness role-playing protocol for psychiat-
ric consumers, there are certainly fluctuations between the different ratios of music and
therapy within the protocol. Parts of the session are purposely musical while other parts of
the session are purposely verbal. However, the entirety of the session would still constitute
music therapy.
Although the music therapy continuum model was developed to articulate psychiatric
forms of music therapy, I suggest that it may be applicable to other forms of music therapy
treatment. While it was not developed to explain all aspects of music therapy (indeed, such
a model will likely never exist), it may function as a method for music therapists to expe-
diently communicate with one another regarding changing ratios of music and therapy
within and between sessions. Additionally, it might be helpful for explaining to non-music
therapists how music therapists use the interplay of music and verbal therapy. The pur-
posely simplistic and visual aspect of the continuum may be helpful to clearly provide
indicators and describe the interplay of music and therapy within music therapy to people
unfamiliar with music therapy.
Another aspect of the music therapy continuum model is perception. Certainly, a thera-
pist and client may have incongruent perceptions of where they may be on the continuum
at any given moment. Thus, during a facilitated group drumming intervention, a music
therapist might perceive higher levels of music (perhaps a 1 or 2 on the continuum) while
the patient perceives a high level of therapeutic value in the actual drumming (perhaps a
4 or 5 on the continuum). While processing the therapeutic relevance of the drumming
at the conclusion of the session, a therapist may have a high perception of therapy (per-
haps a 4 or 5 on the continuum) while the client may have a lower perception of therapy.
Thus, the therapist and client may have differing—although equally valid—perceptions of
music and therapy throughout the session. These perceptions are fluid and may change
within the session as the specific interventions change. Perceptions of therapeutic and
musical aspects of psychiatric music therapy are certainly areas for future systematic re-
search inquiry.
The purpose of the continuum model is not to describe why music therapy can be ef-
fective. Rather, the purpose is to visually depict the fluid interaction between music and

◆ Although various authors have described ratios between music and therapy within
music therapy, a fluid model is needed to better communicate the ratios and rela-
tionships between music and therapy within music therapy.
◆ The continuum model of music and therapy within music therapy was developed as
a communicative tool to enhance teaching and supervision.
◆ The continuum model is fluid both within and between music therapy sessions.
◆ The continuum model recognizes that both music and therapy occur in music ther-
apy, although one or the other may not be immediately observable.
◆ Quantitative indicators along the horizontal axis are solely for communicative
purposes. The quantitative indicators do not constitute evaluative, comparative, or
outcome-based purposes.
verbal therapy and how music therapy might function within the parameters of psychiat-
ric treatment. Future researchers might investigate how the continuum model can be used
over time with patients and music therapy students, and how music therapy dosage might
affect it.
References
Bednarz, L. F., & Nikkel, B. (1992). The role of music therapy in the treatment of young adults diagnosed
with mental illness and substance abuse. Music Therapy Perspectives, 10, 21–26.
Bruscia, K. E. (1998a). An introduction to music psychotherapy. In K. E. Bruscia (Ed.), The dynamics of
music psychotherapy (pp. 1–15). Gilsum, NH: Barcelona.
Bruscia, K. E. (1998b). Defining music therapy (2nd ed.). Gilsum, NH: Barcelona.
Silverman, M. J. (2011). Effects of a single-session assertiveness music therapy role playing protocol for
Standley, J. M., & Jones, J. (2008). Music techniques in therapy, counseling, and special education (3rd
ed.). Silver Spring, MD: American Music Therapy Association.
Wheeler, B. L. (1983). A psychotherapeutic classification of music therapy practices: A continuum of
procedures. Music Therapy Perspectives, 1, 8–12.
Wolberg, L. R. (1977). The technique of psychotherapy (3rd ed.). New York: Grune & Stratton.

1 Using the continuum model, how might psychiatric music therapy for inpatients with psychiatric diag-
noses be distinguished from traditional psychotherapy without music for outpatients who seek greater
self-awareness and self-fulfillment?
2 For a music therapy session that contains a “heavy” amount of verbal processing, discuss the importance
of the music intervention on the therapeutic process.
3 How did your initial interest in music therapy as a profession relate—or not relate—to the continuum
model of music and therapy?
4 Design a research study to quantitatively and qualitatively determine observers’, music therapists’, and
patients’ perceptions of music and therapy in psychiatric music therapy.
Chapter 5
Educational music therapy for illness

management and recovery
The function of psychiatric music therapy

In a review article concerning music therapy for people with addictions, Mays, Clark, and
Gordon (2008) noted that music therapy is additive—not independent—in the treatment
of substance abuse disorders. I believe the Mays et al. statement holds true in other inpatient
psychiatric locales, as well. Most psychiatric consumers in both acute and chronic inpatient
care settings receive a variety of treatments, of which music therapy is one. Thus, when
music therapy is provided as a treatment for hospitalized adults with severe and enduring
psychiatric diagnoses, music therapy is a complementary and integrative therapy but not an
alternative therapy. Alternative therapies are typically used in place of conventional medi-
cine, while complementary or integrative therapies are used in conjunction with conven-
tional medicine (NCCAM, 2014). As inpatients with severe mental illnesses tend to receive
numerous treatments consisting of pharmacological, psychoeducational, and therapeutic
programming, music therapy rarely exists as an independent or sole treatment modality for
psychiatric inpatients and outpatients who are considered a danger to themselves or others.
Thus, it would seem that music therapy often functions as an additive psychosocial treat-
ment modality for inpatient psychiatric consumers. Certainly, music therapy can function
as an independent treatment in the Bonny Method of Guided Imagery or during existential
or insight-oriented types of music therapy treatment for non-inpatients seeking insight
(sometimes referred to as the “worried well”), but these areas are beyond the scope of this
text. As there is a need for a music therapy model specific to acute-care adult psychiatric
consumers (Carr, Odell-Miller, & Priebe, 2013), and as experts have shifted the focus of
care from symptom control to patient-centered, recovery-oriented care (Green et al., 2014),
this chapter focuses on an educational music therapy approach for illness management and
recovery. The educational music therapy approach for illness management and recovery
may be especially applicable in acute-care and crisis stabilization units, where patients re-
ceive brief treatment emphasizing knowledge and skills to prevent psychiatric recidivism.
Approaches to music therapy with psychiatric consumers

Symptom reduction
How music therapy functions within the overall therapy regimen is far more complicated
and intricate than as an additive treatment (Mays, Clark, & Gordon, 2008). Psychiatric
music therapy can be used in a number of different ways to meet a wide range of clinical
objectives. Music therapists can work to reduce the symptoms of mental illness by affect-
ing indicators such as anxiety (Choi, Lee, & Lim, 2008), affect (Thaut, 1989), depression
(Choi, Lee, & Lim, 2008; Erkkila et al., 2011; Maratos, Gold, Wang, & Crawford, 2008),
auditory hallucinations (Silverman & Marcionetti, 2005), grandiosity, level of social func-
tioning, global state, mental state, and social functioning (Mossler, Chen, Heldal, & Gold,
2012), and quality of life (Grocke, Bloch, & Castle, 2009). Regardless of how long positive
treatments gains are maintained, these are unquestionably important areas for many psy-
chiatric patients. It is certainly hard to argue that even temporary relief from auditory hal-
lucinations or depression is not a worthwhile outcome of music therapy. Moreover, music
therapy can accomplish symptom reduction without pharmacological interventions or
side effects. Indeed, one of the most compelling arguments supporting the use of psycho-
logical interventions when compared to psychotropic medications is the lack of side effects
(Morrison et al., 2004). To date, there are no known side effects from psychiatric music
therapy treatment (Ulrich, Houtmans, & Gold, 2007). Thus, the prescribed use of music
therapy for psychiatric symptom reduction could certainly be considered a positive treat-
ment approach for people diagnosed with mental illnesses.
However, a vital question remains: Can mental illnesses be cured? Cummings (1986)
noted that the notion of a “cure” is the primary concept that has held back psychotherapy.
There is growing consensus that mental illness is a chronic lifetime disorder (Jonas et al.,
2011). Therefore, booster sessions, psychiatric check-ups, and other therapies are likely to
continue intermittently throughout a person’s life (Talmon, 1990) to manage the severe
and enduring disorder. Whether or not music therapy can “cure” mental illness will likely
remain a topic for debate. Meanwhile, conceptualizing illness management and recovery
as primary goals for psychiatric consumers with severe and enduring disorders may be a
more realistic approach.
While it is imperative to relieve psychiatric consumers of their “positive” symptoms
(e.g., hallucinations and delusions), it may be equally essential to teach them how to suc-
cessfully manage their symptoms. This is especially pertinent given the cognitive behavio-
ral approach often used in both acute care and longer-term inpatient psychiatric settings,
where therapists work with groups of patients. As there is no “cure” for mental illness,
educational music therapy for illness management and recovery can empower clients,
support self-efficacy, and better prepare them to independently and successfully monitor
and manage their illnesses. From this standpoint, a music therapist would teach patients
with mental health problems to “be their own therapists” and proactively manage their
illnesses rather than solely structuring sessions to reduce symptoms. In hospital settings
with a biological orientation concerning mental disorders, psychiatric disorders are typi-
cally seen as enduring troubles to be managed over a person’s lifetime (Dobson & Dobson,
2009). Congruently, Hadsell (1974) referenced the importance of helping adult psychiatric
patients cope with social problems and deal with interpersonal relationships during music
therapy treatment. As psychiatric consumers may discontinue music therapy and other
forms of psychosocial interventions once discharged from an in- or outpatient facility, it is
80 EDUCATIONAL MUSIC THERAPY
vital to provide them with the knowledge and skills they need to effectively monitor, man-
age, and ideally recover from their illnesses. In the literature, illness management and
recovery (sometimes referred to as psychoeducation) is considered an evidence-based
treatment for psychiatric consumers (Drake, Merrens, & Lynde, 2005). Music therapy can
be a psychosocial intervention to teach general psychoeducational knowledge (Silverman,
2009), augment knowledge and use of coping skills (Silverman, 2011b, 2011c), teach ap-
propriate assertive behaviors (Silverman, 2011a), provide information about social sup-
ports and perceived social supports (Silverman, 2013a, 2014), and reduce internalized
stigma related to mental illness (Silverman, 2013c). Although there is a need for addi-
tional qualitative and quantitative research concerning psychiatric music therapy for ill-
ness management and recovery, psychosocial experts and initial music therapy inquiries
support its use.
As music therapy can be used to (a) reduce symptoms and (b) augment illness manage-
ment and recovery skills, I propose two separate conceptualizations of psychiatric music
therapy treatment: music therapy for symptom reduction and educational music therapy
for illness management and recovery (see Table 5.1). Neither of these models is superior
as both are important and serve different functions within idiosyncratic contextual pa-
rameters. These models can also overlap and may be based on the perceptions of both the
therapist and client. However, essential factors of the patient, length of hospitalization,
idiosyncratic treatment objectives, programming, and the facility are consequential in
determining where the music therapist will focus her or his treatment efforts. For exam-
ple, music therapists working in acute care and single-session psychiatric settings might
use educational music therapy for illness management and recovery to engage, inspire,
motivate, instill hope, support self-efficacy, enhance pharmacological and psychosocial
treatment adherence, and promote change toward self-directed and collaborative goals.
Although the music therapist should certainly observe patients’ overt symptoms, focusing
on symptom reduction in acute-care settings may not necessarily be realistic or appropri-
ate due to the brief length of stay. Moreover, educational music therapy for illness manage-
ment and recovery shares objectives with various forms of psychosocial rehabilitation,
in which the goal is to help consumers develop the necessary skills to participate in the
community and lead a fulfilling and meaningful life with as little professional support
as possible (Green et al., 2014). Readers should be aware that educational music therapy
for illness management and recovery is a philosophy and not a specific technique. This
philosophy emphasizes autonomy and self-determination, which are congruent with a
patient-centered ideology.
Educational music therapy for illness management and recovery

Although the term psychoeducation is commonly used throughout the illness manage-
ment literature, it typically denotes extended treatment and larger doses, often for pa-
tients with chronic mental illnesses and consumers in outpatient settings. Education is
purposely differentiated from psychoeducation as it is specifically used in acute-care and
crisis stabilization inpatient settings where the treatment dose may consist of only a single
Table 5.1 Approaches to Music Therapy with Psychiatric Consumers
Approach
Music Therapy for Symptom Educational Music Therapy for
Reduction Illness Management and Recovery
Patient problem Symptoms of mental illness: Lack of knowledge concerning
depression, anxiety, lack of how to successfully manage illness.
reality orientation, hallucinations, Requires training in coping skills,
delusions, disorganized thoughts, supports, emotional expression,
abnormal behaviors, and speech, prodromal symptoms, self-
chemical dependency, withdrawal, awareness, assertiveness, and
and lack of insight insight. Identify sources of stress and
positive reinforcement. Work toward
recovery, prevention, and wellness.
Role of music therapist Distract patients from symptoms, Engage, motivate, inspire, instill
orient patient to reality. hope, educate, support self-efficacy,
promote action, and help patients
work toward their self-directed and
recovery-based goals. Support self-
efficacy and potential for recovery.
Function of music Music as primary method for Music is the medium to teach
immediately distracting patients academic and social concepts of
from symptoms, alleviating illness management and recovery.
symptoms, and focusing on a Music can function as the structure,
reality-based experience in music. a prompt or cue to elicit a desired
response, or reinforcement during
interventions designed to heighten
illness management and recovery.
Objectives for treatment Immediate reduction of positive Increase knowledge base and
and negative symptoms, reduce functional usage of illness
distress, increase reality-based management techniques to prevent
behaviors and social and global relapse, manage illness, and
functioning. promote recovery. Enable client
to become “own therapist” by
augmenting self-awareness and
coping skills.
Interventions Based in the here and now, Designed to heighten illness
designed to increase reality management knowledge and
orientation, on-task behaviors, and recovery skills in the present and
distract patient from symptoms. future.
therapy session to a few sessions. The author adopted this differentiation from Murray-
Swank and Dixon (2005), who noted that brief models of family-based psychoeducational
treatment should be distinguished from longer interventions, which are therefore referred
to as family educational programs. This definition does not imply that therapy is nonexist-
ent in educational music therapy and that only education is involved. Therapy—facilitating
cognitive, behavioral, and affective change—purposely remains part of the term as therapy
still occurs in educational music therapy. In his definition of psychoeducation, Colom

noted many aspects congruent with cognitive behavioral therapy:
Psychoeducation could be defined as a patient’s empowering training targeted at promoting
awareness and proactivity, providing tools to manage, cope and live with a chronic condition (i.e.,
adherence enhancement, early warning sign identification, lifestyle, crisis management, communi-
cation), and changing behaviours and attitudes related to the condition. Psychoeducation replaces
guilt by responsibility, helplessness by proactive care and denial by awareness. (p. 339)
However, the primary purpose of educational music therapy for illness management and
recovery is to heighten illness management skills for a successful recovery. Psychoedu-
cational music therapy can certainly occur, but would occur with patients who are more
chronically mentally ill and receive larger treatment doses, often in outpatient settings.
Additionally, the author favors the term educational over psychoeducational as it is less
stigmatizing and may enhance help-seeking behaviors and compliance and adherence to a
mutually agreed upon and collaborative treatment plan.
While it may be convenient to separate the two psychiatric music therapy approaches
into distinct areas, patients’ and therapists’ perspectives of these may overlap. For exam-
ple, while learning about coping skills during a songwriting intervention, the patient may
be distracted from his or her anxiety and depression. Thus, although the music therapist
might have been focusing on an illness management and recovery approach, a second-
ary gain occurred as the patient felt immediate relief from her or his symptoms. Relief
from symptoms can be considered therapeutic, despite it not being the therapist’s prin-
cipal treatment intention. In fact, Silverman (2013b) found participants who were in a
single educational group-based songwriting session had higher quality of life and lower
depression scores than other conditions. In the songwriting condition, participants wrote
lyrics to a blues song concerning life after hospital discharge and identified the importance
of medication adherence, ongoing therapy, social supports, and coping skills. Whether
symptoms return after the music therapy session concludes is an area for future investiga-
tion. Indeed, the lack of psychiatric music therapy studies using a follow-up is alarming
and warrants systematic research attention (Gold, Heldal, Dahle, & Wigram, 2005; Silver-
man, 2008).
A music therapist might fluctuate between the two psychiatric music therapy approaches
to successfully engage a patient in the music therapy intervention depending upon the pa-
tient’s functioning level. A patient who was recently admitted to an acute-care unit and
displays psychotic behaviors may not be able to cognitively process educational psychi-
atric music therapy for illness management and recovery. In this case, psychiatric music
therapy for symptom management might be used first in an attempt to reduce symptoms,
enhance reality orientation, and heighten social and cognitive functioning. After the pa-
tient’s psychotic symptoms have subsided, music therapy for illness management and re-
covery might be more appropriate, depending on the psychosocial and psychoeducational
programming a hospital provides.
One might conceptualize the role and function of the psychiatric music therapist who
is practicing an educational approach to illness management and recovery as providing
an optimal learning and therapeutic environment so that the client can achieve maximal
gains. In this type of environment, patients should ideally feel safe to engage in treatment,
learn, share narratives with their peers, be open to new ideas, and self-disclose. During
educational music therapy for illness management and recovery, the clinician believes
participants possess the knowledge, skills, and ability to remain in the community; the
clinician’s goal is to facilitate group therapy and draw responses from participants using
vicarious learning techniques. The music therapist does not function as an omniscient
leader but rather acts as a facilitator by supporting and encouraging self-efficacy, construc-
tive dialogue, problem solving, learning, and potential for illness management recovery
via structured group-based music therapy interventions. The music therapist, therefore,
should ensure that the environment is free of prejudice, stigma, and negativity. (Chapter 8
describes techniques to increase working alliance and may facilitate the psychiatric music
therapist in providing this type of environment.) Music therapists may use a similar phi-
losophy to Barker’s (1989) concept of trephotaxis in mental health nursing:
Although we may help people to change in some way, we do not change people directly. Certainly,
we do not heal people, or otherwise make them whole. . . . I have come to accept that while help-
ing people always involves change, it never involves a return to previous functioning: it is always a
forward change. I have called this approach trephotaxis, which in the original Greek would mean
the provision of the necessary conditions for the promotion of growth and development. (p. 138)
For the purposes of this monograph, the focus is educational music therapy for illness
management and recovery. Although medications and psychopharmacotherapy are com-
plex and ongoing processes (Miller, 2005), medications have been shown to be a benefit
for many psychiatric illnesses (Janicak, Davis, Preskorn, & Ayd, 1997). Psychotropic medi-
cations can be effective and efficient in reducing both positive and negative symptoms of
mental illness. Most inpatient psychiatric facilities provide immediate pharmacological in-
terventions that can be effective with minimal side effects. Thus, the music therapist might
use an illness management and recovery approach, focusing on motivating the patient to
adhere to medication as prescribed. Connecting and relating the use of psychotropic med-
ications with patients’ own goals will increase the likelihood of compliance (Kemp, Kirov,
Everitt, Hayward, & David, 1998; Miller, 2005). This can be accomplished via music ther-
apy interventions designed to have patients identify their own aspirations and linking the
attainment of these goals to medication—as well as psychosocial treatment—compliance.
Also, after discharged to a home or community living environment, patients may feel
overwhelmed by stressors. Psychiatric music therapists can teach patients to anticipate
and identify potential distressful situations that may function as “triggers” and the skills
needed to cope with psychological stressors in an attempt to maintain wellness and prevent
rehospitalization. Thus, educational psychiatric music therapy for illness management and
recovery does not focus on uncovering or resolving deep psychological problems as one
might when using psychodynamic forms of treatment. Rather, music therapists using this
approach work to immediately enhance functional recovery skills via problem solving to
teach patients how to proactively manage and monitor their illnesses to avoid relapse.
Moreover, as educational music therapy is clinically focused, based upon commonsense
principles, and delivered in a straightforward and group-based manner—similar to psych-

oeducation (Colom, 2011)—it can appropriately and effectively integrate within a medical
model of illness commonly used in the treatment of mental disorders.
Insight, often considered a psychoanalytic concept, remains a key term in psychiatric
and psychological clinical practice. Many contemporary music therapists—even music
therapists who identify with behavioral orientations—report that they work with their
patients to increase insight (Silverman, 2007). Although many definitions and interpreta-
tions exist, from a more general and non-exclusively psychoanalytic perspective, insight
can be defined as the ability to recognize one’s own mental illness (Markova, 2005). The
ability to recognize one’s own mental state and the use of this ability to maintain mental
health and prevent psychological illness could be perceived in either a symptom reduc-
tion approach or an illness management and recovery approach. Certainly, insight might
represent a nondistinct, even transtheoretical area in which a therapist works to meet this
need through the patient’s perspective.
It would seem that the differentiation between music therapy for symptom reduction
and educational music therapy for illness management and recovery might be best deter-
mined after a music therapy assessment, consultation with the treatment team, determin-
ing how the patient responds to initial pharmacological and psychological treatments, and
during the formulation of observable and measurable treatment objectives. During a thor-
ough assessment of the patient, a music therapist can work with the patient to determine
her or his needs and expectations for music therapy treatment. The music therapist should
also consult with the interdisciplinary treatment team to avoid formulating overlapping
and redundant clinical objectives and ensure the music therapy approach will provide the
patient with the best possible treatment.
Topics for educational music therapy for illness management and recovery can be de-
rived from the 11 modules identified by McGuire and colleagues (2014) (see Box 3.1).
The modules are premised on the stress-vulnerability model of mental illness in which
the disorder is conjectured to be affected by psychosocial stressors as well as biological
vulnerabilities.
From an educational perspective, psychiatric music therapists can uniquely design
music therapy interventions to address these important topic areas. McGuire et al. (2014)
noted these modules should be delivered using a combination of motivation-based, edu-
cational, and cognitive behavioral strategies. Due to the supporting literature outside the
music therapy profession, these topics represent fertile areas for music therapy scientific
investigation using a variety of research paradigms. These topic areas are also appropriate
for group-based music therapy, in which patients can learn from one another.
Within an educational—or psychoeducational—approach, the relationship between the
therapist and client should ideally be founded upon trust rather than authority. One of
the advantages of these educationally based approaches is that the pathogenic model of
the relationship between a healing physician and a passive client is avoided. Rather, the
approach is a collaborative partnership based on trust and information sharing (Colom,
2011). As psychiatric music therapists purposely infuse music into the relationship, the
working alliance and trust between the client and therapist may be strengthened. The
stronger relationship between client and therapist may lead to enhanced treatment out-
comes. Thus, the importance of the quality and aesthetic properties of the live music used
by the music therapist cannot be overstated and may contribute to an enhanced sense of
therapist competence (Silverman, 2014) and ensuing patient treatment outcome.
Carr, Odell-Miller, and Priebe (2013) noted that a clearly defined model for acute psy-
chiatric care is needed. Although also appropriate in longer-term inpatient and outpatient
settings, educational music therapy for illness management and recovery may be uniquely
suited for acute-care inpatients. Due to the unique challenges of this brief inpatient setting,
a psychodynamic or longer-term depth-based treatment approach may be contraindicated.
Educational music therapy for illness management and recovery, however, is uniquely
suited to group-based treatment and can be delivered within the temporal parameters of
a single therapy session or acute care. Therefore, integrating Talmon’s (1990) components
(more thoroughly described in Chapter 1) and attitudes of single-session therapy with
McGuire and colleagues’ (2014) topic areas with acute psychiatric music therapy may pro-
vide patients with the knowledge and skills to help prevent recidivism within acute and
single-session psychiatric treatment (Table 5.2).
Table 5.2 Components, Topic Areas, and Attitudes for Educational Music Therapy for Illness
Management and Recovery
Talmon’s (1990) Components McGuire and colleagues’ Talmon’s (1990) Therapist

of Single-Session Therapy (2014) Illness Management Attitudes for Single-Session Therapy
and Recovery Topic Areas (pp. 134–135)
Starting the session Recovery; This is it.
Search for a therapeutic focus Practical facts about mental View each and every session as a
Working with metaphor illness; whole, complete in itself.
Practicing solutions The stress-vulnerability model; All you have is now.
Strengthening Building social support; It’s all here.
Attempted final intervention Using medication effectively; Therapy starts before the first session
Last-minute issues Drugs and alcohol; and will continue long after it.
Follow-up Reducing relapses; Take it one step at a time.
Coping with stress; You do not have to rush or reinvent
Coping with persistent the wheel.
symptoms; The power is in the patient.
Meeting needs within the Never underestimate your patient’s
mental health system; and strengths.
Living a healthy lifestyle. You don’t have to know everything in
order to be helpful.
Life is full of surprises.
Life, more than therapy, is a great
teacher.
Time, nature, and life are great
healers.
Expect change. It’s already well
under way.
Neurocognitive functioning in mental illnesses

Mental disorders may negatively impact memory, executive and neurocognitive function-
ing as well as the learning of new skills (Mueser & McGurk, 2004). For example, many
patients with depression exhibit cognitive impairments (Gualtieri & Morgan, 2008) specif-
ically in the areas of attention, memory, and executive functioning (Heinrichs & Zakzanis,
1998; Lee, Hermens, Porter, & Redoblado-Hodge, 2012). Some people diagnosed with
bipolar disorder experience cognitive dysfunction as well (Martinez-Aran et al., 2000).
Kitagawa and Koyama (2009) conjectured that there are relationships between functional
outcomes and neurocognitive functions in depression. Similarly, Rose and Ebmeier (2006)
suggested that working memory and central executive functions are negatively affected by
major depressive disorder. Patients diagnosed with major depressive disorder tend to per-
form less well on neurocognitive tests than people without major depressive disorder, even
after the depression has been successfully treated with more recent antidepressant medi-
cations (Gualtieri, Johnson, & Benedict, 2006; Porter, Gallagher, Thompson, & Young,
2003; Reppermund, Ising, Lucae, & Zihl, 2009). Researchers have found that verbal work-
ing memory was the most important neurocognitive aspect of predicting vocational out-
come (Kaneda, Jayathilak, & Meltzer, 2009, 2010). Unfortunately, cognitive deficits are
not responsive to pharmacological interventions (Kurtz & Richardson, 2012). However,
researchers have noted that cognitive functioning may also be negatively impacted by anti-
depressant medication (Gorenstein, de Carvalho, Artes, Moreno, & Marcourakis, 2006;
Hindmarch, 2009) and atypical antipsychotics (Torrent et al., 2011).
Heightened anxiety can also impair central executive functioning (Baddeley, 1986).
Englert, Bertrams, and Dickhauser (2011) explained this functioning deficiency via at-
tentional control theory (Eysenck, Derakshan, Santos, & Calvo, 2007). Anxiety hinders
the well-documented limited capacity of working memory, thus creating an imbalance
between the two attentional systems (bottom-up and top-down) that the central executive
controls. Under conditions of anxiety, the bottom-up, stimulus-driven attentional system
dominates because it requires less cognitive capacity than the top-town, goal-driven sys-
tem. The top-down system helps people achieve goals through planned behavior, thus
requiring much cognitive capacity. The bottom-up system is influenced by stimuli and
prevents systematic information processing (Corbetta & Shulman, 2002; Yantis, 1998).
Under anxiety conditions, the bottom-up system negatively impacts inhibition (the ability
to resist distractions from irrelevant stimuli) and shifting (the ability to shift attention be-
tween stimuli) and thus hinders executive functioning.
Craske (2010) noted that stress can sabotage the benefits of cognitive behavioral therapy,
especially in patients who have more severe and complex problems:
One pathway through which severity and complexity may negatively impact CBT is by decreas-
ing the personal resources available for the effort involved in this form of therapy. In other words,
learning new ways of thinking and behaving takes effort. Learning new appraisal strategies is dif-
ficult, even for the person who is not dealing with a psychological disorder, since we all have a ten-
dency to selectively attend to stimuli and information that support our beliefs and ignore or discount
contrary information. Under conditions of elevated distress, these tendencies to be selective become
even stronger. That is, we are all more likely to rely on cognitive “shortcuts” under times of stress;
distorted patterns of thinking are such shortcuts. Alternative modes of information processing that
require greater resource expenditure, such as attending to data rather than to prior expectancies, are
obstructed by high levels of stress (e.g., Ford & Kruglanski, 1995). Learning to behave and think in
a different way and face challenging situations takes even more effort. And yet, this type of resource
expenditure is exactly what is demanded by CBT. Hence, excessively high levels of distress and
stress may impede engagement in the process of CBT, thus possibly explaining why initial severity
and complexity, medical comorbidity, life stressors, and personality disorders are associated with a
lesser or slower response to CBT. (p. 111)
Researchers who conducted a review of studies concluded that psychoeducation re-

quires frequent repetition if it is to be used to promote treatment compliance with patients
diagnosed with schizophrenia (Zygmunt, Olfson, Boyer, & Mechanic, 2002). Clinicians
providing educationally based treatments for patients should be aware that reiteration of
information may be crucial not only for patients diagnosed with schizophrenia, but also
for psychiatric consumers with analogous symptomologies and impaired cognitive func-
tioning (Zygmunt et al., 2002). Educational booster sessions can be helpful for outpatients
and their family members.
Thus, as mental illnesses may negatively impact neurocognitive functioning, psychi-
atric music therapists may be at an advantage over traditional psychosocial interventions.
Music and music therapy may enhance memory, motivation, engagement, cognitive func-
tioning, focus of attention, and on-task behaviors. Due to the diversity within and be-
tween various types of interventions, music therapy may be uniquely suited to diversify the
presentation of educational material that requires repetition. Future controlled empirical
investigations are warranted.
Prodromal, residual, and recurring symptoms

The research base concerning the early detection and treatment of mental illness symp-
toms, also known as prodromal symptoms, has advanced in recent years (Miller et al.,
2003). If patients requiring treatment for mental disorders can be identified during ini-
tial stages of the illness, early intervention can lead to improved prognosis (Ruhrmann,
Schultze-Lutter, Maier, & Klosterkotter, 2005). Scholars and clinicians have therefore noted
that this prodromal period is important from a preventive viewpoint. If the combination of
subthreshold symptoms (i.e., subtle changes in cognitions, affect, and behaviors) and other
risk factors (i.e., previous episodes and genetic risks) are identified and early treatment is
provided, the ensuing course of illness can be changed (Yung et al., 2005). Thus, the early
detection and recognition to reduce the duration of untreated illness has become a world-
wide effort (Hambrecht, Lammertink, Klosterkotter, Matuschek, & Pukrop, 2002).
Moreover, in severe and enduring psychiatric disorders such as major depressive dis-
order, many residual symptoms are also prodromal (Fava, Grandi, Zielezny, Canestrari, &
Morphy, 1994). Authors have noted that relapse prodromal symptoms tend to be similar
to symptoms from the initial affective episode (Fava, Grandi, Canestrari, & Molnar, 1990),
thus highlighting the importance of self-awareness and carefully monitoring symptoms.
Because prodromal, residual, and recurring symptoms may be analogous, clinicians can
intervene in an educational and preventive context. Although studies concerning inter-
vention during prodromal stages have typically had undersized sample sizes and high at-
trition rates, results are encouraging and can provide a valuable praxis for early detection
and intervention for people who are at risk for mental health problems (Cannon, Corn-
blatt, & McGorry, 2007). Without early intervention, consequences can include higher
relapse risks, longer inpatient hospitalizations, higher risks of depression and suicide, re-
duced compliance, and greater burden upon the family (Ruhrmann et al., 2005).
Prodromal symptoms do not always lead to onset of illness (Yung et al., 2005). Prodromal
symptoms can resolve, thus augmenting the importance of successful identification and
treatment of patients in prodromal stages. Early recognition of prodromal symptoms can
create an opportunity for interventions that can suspend, ameliorate, or even prevent the
onset of psychosis (Yung et al., 2005). Yung and colleagues (1996, 1998) developed pro-
dromal work by outlining three symptoms that identified people who had a high probabil-
ity for developing schizophrenia: (a) positive psychotic symptoms that were too brief and
irregular to constitute a fully psychotic syndrome; (b) attenuated positive symptoms and;
(c) a functional decline in the presence of a genetic risk. Bechdolf and colleagues (2005)
differentiated early initial prodromal states (EIPS) and late initial prodromal states (LIPS).
The authors noted that EIPS are characterized by self-experienced cognitive and percep-
tive deficits and a clinical decline in function. LIPS criteria include patients who are highly
symptomatic and functionally compromised.
As cognitive deficits and social and role functioning are costly, debilitating, and often
the clinical features most resistant to pharmacological intervention, psychosocial inter-
ventions during the prodromal and recurring phases of the illness may result in posi-
tive clinical outcomes (Cannon, Cornblatt, & McGorry, 2007). Psychosocial interventions
including cognitive behavioral therapy, treatment of concurrent substance abuse, social
and self-management skills, and multifamily psychoeducational groups can reduce the
severity of the psychiatric illness (Ruhrmann et al., 2005). Bechdolf and colleagues (2005)
noted that cognitive behavioral therapy can be especially useful during prodromal states
as patients accept it, little stigma is attached, and there is no risk of pharmacological side
effects. Cognitive behavioral therapy can have protective effects for residual symptoms
of major depression that may progress to become prodromal symptoms of relapse (Fava,
Grandi, Zielezny, Rafanelli, & Canestrari, 1996; Fava & Kellner, 1991). Additionally, cogni-
tive behavioral therapy may be effective as it represents an “established treatment” (Bech-
dolf et al., 2005, p. s45) for depression and anxiety symptoms that often present during
prodromal and recurring stages regardless of specific psychiatric disorder. Bechdolf and
colleagues (2005) described individual cognitive behavior therapy to target early prodro-
mal psychotic symptoms:
Individual therapy forms the central part of the early intervention programme. A combination of
psychoeducation, symptom, stress, and crisis management modules is adapted to the specific needs
of each client. Although putative prepsychotic symptoms serve as inclusion criteria for therapy, the
interventions are problem-oriented, collaborative, educational and involve the therapist and the
client working together on an agreed problem list. This may also include problems other than basic
symptoms, such as anxiety, depression, family or occupational problems. Apart from the treatment
of the psychopathological symptoms, one major treatment aspect focuses on attributional styles
that underpin symptoms. Psychoeducation and cognitive techniques are used to challenge self-
stigmatization and self-stereotypes, helping the person to protect and enhance self-esteem, and to
come to terms with understanding the illness and pursuing life goals. (p. s46)
McGlashan and colleagues (2007) identified cognitive behavioral strategies for the treat-
ment of help-seeking patients in prodromal or at-risk stages. Although the authors devel-
oped these strategies for people with psychosis and schizophrenia, the concepts generalize
to other psychiatric diagnoses (see Box 5.1).
Consistent with theories supporting the identification of prodromal symptoms, re-
searchers conducted a study to determine the efficacy of teaching patients diagnosed
with bipolar disorder to identify early relapse symptoms and to promptly seek appropri-
ate mental health services and interventions (Perry, Tarrier, Morriss, McCarthy, & Limb,
1999). Although seven to twelve individual treatment sessions conducted by a research
Box 5.1 Cognitive Behavioral Strategies for At-Risk Patients

1 Developing a relationship with the patient.
2 Education about symptoms, their biopsychosocial germination, their frequency in
the population, and their manageability.
3 Avoiding the term schizophrenia and psychosis.
4 Verbally challenging and reality testing delusional thoughts and hallucinations while
generating and testing alternate explanations.
5 Teaching coping strategies such as stress management, distracting attention, and
strategic withdrawal.
6 Normalizing psychotic-like experiences by suggesting that symptoms experienced
are relatively common and are manageable.
7 Reality testing perceptual aberrations and suspiciousness by devising experiments to
test the beliefs held by the patient.
8 Self-monitoring of symptoms to enhance the connection between external events
and emotional states.
9 Modeling insight, judgment, and metacognitive functions for the patient.
Data from Thomas H. McGlashan, Jean Addington, Tyrone Cannon, Markus Heinimaa, Patrick McGorry,
Mary O’Brien, David Penn, Diana Perkins, Raimo K. R. Salokangas, Barbara Walsh, Scott W. Woods, and
Alison Yung, Recruitment and Treatment Practices for Help-Seeking “Prodromal” Patients, Schizophrenia
Bulletin, 33(3), p. 721, doi: 10.1093/schbul/sbm025, Oxford University Press and the Maryland Psychiatric
Research Center, 2007.
Table 5.3 Common Manic and Depressive Prodromal Symptoms
Manic Prodromal Symptoms Depressive Prodromal Symptoms

Increased optimism Cannot get out of bed
Increased self-esteem Disinterest in food
Increased sociability Feeling sad or want to cry
Irritable Feeling tired
Loss of interest in food Interrupted sleep
More goal-directed behavior (activities with a Loss of interest in activity or people
purpose in mind including business calls and home
improvements)
Not interested in sleep or sleeping less Low motivation
Overexcitable and restless Negative thinking
Spending too much Not able to put worries or anxieties aside
Thoughts start to race
Data from D. Lam, G. Wong, and P. Sham, Prodromes, coping strategies and course of illness in bipolar affective
disorder—a naturalistic study, Psychological Medicine, 31(08),pp. 1397–1402, Cambridge University Press, 2001.
psychologist had no significant effects on first relapse or number of relapses with depres-
sion, treatment was positively associated with social functioning, employment, and time
to first manic episode. Lam, Wong, and Sham (2001) studied prodromes and coping strat-
egies of people diagnosed with bipolar disorder. They interviewed 40 participants con-
cerning early symptoms indicating the onset of the illness and coping skills at recruitment
and at 18 months later (Table 5.3). The researchers found that patients were able to reliably
report bipolar prodromal symptoms. Manic symptoms tended to be behavioral while de-
pressive symptoms tended to be more diverse and consisted of behavioral, cognitive, and
somatic symptoms. Other results indicated that participants who used behaviorally based
coping strategies to curb excessive actions during manic prodromal stages had better suc-
cess in not becoming manic. Similarly, participants using behavioral coping strategies ex-
perienced fewer depression relapses. The authors highlighted the need to teach patients
to self-monitor their moods in a systematic manner and to teach patients effective coping
strategies.
Birchwood, Spencer, and McGovern (2000) noted that dysphoric symptoms, including
appetite and sleep difficulties, depressed mood, and social withdrawal, were common pro-
dromal symptoms of schizophrenia. Terming it the “back in the saddle” (p. 95) approach,
these authors developed an individualized and structured approach to identify and man-
age prodromal symptoms. This approach is summarized in Box 5.2.
Although originally developed for schizophrenia, the “back in the saddle” approach
could be applied to a number of psychiatric disorders during individual or group-based
psychiatric music therapy. For example, songwriting may be an effective intervention
in which patients compose original lyrics idiosyncratic to the five stages of treatment to
Box 5.2 Techniques to Identify and Manage Prodromal

Symptoms
1 Engagement and education: During initial sessions, the individual and therapist
work toward understanding the individual’s attitudes concerning her or his illness,
focusing on her or his perception of the risk and controllability of relapse. Psychoe-
ducational dialogue is focused on positive preventive steps to remain well and ways
to prevent psychiatric relapse.
2 Identification of the relapse signature: The goal is to identify general and specific
symptoms that tend to occur in a specified order that serve as early warning signs
of psychiatric relapse. Patients are encouraged to review any noticeable changes in
cognitions, affective states, and behaviors with their caseworkers and families.
3 Development of a relapse drill: Patients construct a three-stage action plan based
upon the severity of prodromal symptoms. During each stage, patients consider
various social supports, psychosocial interventions, and personalized and positive
coping strategies.
4 Rehearsal and monitoring: Information concerning prodromal symptoms and plans
are written for the patient. Monitoring is conceptualized as a shared responsibility
between the individual, the family, and the person providing mental health services.
Behaviors are practiced via role-plays of personalized scenarios of the patient’s re-
sponse to prodromal symptoms. Hypothetical situations are used to discuss poten-
tial problematic situations and methods of dealing with these types of difficulties.
5 Clarification of the relapse signature and relapse drill: Individuals replace previously
used coping strategies, social supports, and psychosocial interventions with more
effective ones learned in treatment. Relapse is thus conceptualized as a positive op-
portunity to refine and improve the response to prodromal symptoms thereby in-
creasing control over the illness.
Data from D. Lam, G. Wong, and P. Sham, Prodromes, coping strategies and course of illness in bipolar
affective disorder—a naturalistic study, Psychological Medicine, 31(08), pp. 1397–1402, Cambridge University
Press, 2001.
identify their early prodromal symptoms. Due to the unique medium of music therapy,
patients might be more engaged, more on task, and learn and remember the information
better if it is presented in music therapy than if it is presented in a traditional talk-based
format. Using refrains in the song composed during songwriting can facilitate the reitera-
tion of essential psychoeducational material in a creative, engaging, motivating, dynamic,
and aesthetically pleasing manner.
Colom (2011), an expert in psychoeducation for affective disorders, noted “both early
warning sign detection and adherence enhancement might be active ingredients of
psychoeducation, but it is their combination together (together with other critical topics) that
makes psychoeducation so efficacious” (p. 339). Thus, educational music therapy for pro-
dromal, residual, and recurring symptoms as well as adherence enhancement may actively
engage participants in help-seeking, treatment, reduce the stigma of mental health interven-
tions, and result in reduced frequency and duration of hospitalizations. Psychiatric music
therapy clinicians may work within an educational framework to teach patients self-aware-
ness and self-identification of prodromal, residual, and recurring symptoms and what proac-
tive actions they may take if these symptoms occur. Psychiatric music therapists can work
collaboratively with patients to identify sources of distress, develop action plans for coping,
encourage active help-seeking behaviors, and normalize experiences. Teaching patients to
identify when they are in high-risk states can have important outcomes for people with men-
tal disorders. Recognizing subthreshold prodromal symptoms and having a predetermined
action plan learned during educational music therapy sessions may reduce the durations of
inpatient hospitalizations by highlighting the importance of seeking professional psychiatric
help and by reducing distressful symptoms. Future research considerations concerning inter-
ventions during the prodromal phase include cost-benefit analyses, psychiatric, psychologi-
cal, and neurocognitive measures (Cannon, Cornblatt, & McGorry, 2007).
Coping skills
Researchers have defined coping as behavioral and cognitive efforts to manage stressful
events (Lazarus & Folkman, 1984). Coping is a central concept in stress research (Lazarus,
2006; Semmer & Meier, 2009). A person’s coping style is a trait characteristic and describes
how a person might typically deal with a variety of distressing circumstances. Lazarus
and Folkman (1984) noted that coping styles can be the result of a person’s disposition,
temperament, and personality factors, including optimism or pessimism and introversion
or extroversion. When individuals encounter stress or stressful events, they use adaptive
coping skills or mechanisms to respond (Folkman & Lazarus, 1980). People are eager to
reduce stressful feelings and thus initiate various types of coping strategies (Lazarus &
Folkman, 1984). Effective coping can allow persons to maintain or even improve their
well-being during challenging or threatening situations (Cunningham, De La Rosa, & Jex,
2008). Coping is a consequential organizational construct used to encompass an excess of
actions individuals can use to reduce or augment unfavorable life events and conditions in
both short- and long-term functioning and the development of mental and physical health
or illness (Skinner, Edge, Altman, & Sherwood, 2003).
Researchers and clinicians have documented several popular stress and coping models.
The stress-vulnerability model (Zubin & Spring, 1977) highlighted the importance of cop-
ing skills for psychiatric consumers. In this model, symptoms of mental illness are due to
environmental stressors. Thus, learning and implementing skills to cope with and reduce
stress can decrease the risk of psychiatric relapse.
Researchers have conceptualized coping as a personality trait or as a situational state
(Endler & Kocovski, 2001). When perceived as a personality trait, coping is a person’s
Coping skills 93
habitual preference to use particular coping strategies during stressful situations. Situ-
ational coping, however, are the actual behaviors in a stressful situation. These behaviors
are the result of an interaction between coping styles and personal and situational charac-
teristics (Endler & Parker, 1994).
Coping can also be dependent upon one’s appraisal of the distressful situation. Chang
(1998) noted that primary appraisal is the individual’s set of cognitions regarding the im-
pact or significance of the distressing event while secondary appraisal is the individual’s set
of cognitions regarding the resources or options for dealing with the event.
It should be emphasized that coping strategies do not always result in a reduction of
perceived stress. Coping strategies can be maladaptive and serve to exacerbate symptoms
(Beasley, Thompson, & Davidson, 2003). These coping strategies are referred to as negative
while coping strategies that reduce the perceived stress levels are positive (Carver, Scheier,
& Weintraub, 1989).
One of the most frequently used conceptualizations of coping is problem-focused vs.
emotion-focused coping (Folkman & Lazarus, 1980). Persons can use problem-focused
coping to modify or eliminate the source of stress. Persons can use emotion-focused
strategies to adjust emotional responses elicited by the stress or the stressful situation. Al-
though this distinction been a popular one, it has been criticized on the grounds of being
too broad (Carver, Scheier, & Weintraub, 1989; Skinner, Edge, Altman, & Sherwood, 2003)
or interrelated (Carver & Connor-Smith, 2010).
Many researchers have studied people’s responses to distress (Skinner, Edge, Altman, &
Sherwood, 2003). Researchers have used a number of terms to describe coping (Carver &
Conner-Smith, 2010). As coping is a complicated, personal, and idiosyncratic construct,
no single coping strategy is efficient across all situations (Thoits, 1995). Moreover, coping
can be mediated by the nature of the stressor itself, the individual’s cognitive appraisal of
the event, personal and social resources available, and the actual coping mechanisms the
person uses to alleviate distress. Despite the need to reach consensus regarding coping
subtypes and dimensions, little progress has been made in this area (Compas, Connor-
Smith, Saltzman, Thomsen, & Wadsworth, 2001). In an effort to assimilate the research
literature, Skinner et al. (2003) categorized more than 400 different coping labels. Some of
the common ones are depicted in Table 5.4.
From a clinical perspective, psychiatric consumers do not necessarily need to be familiar
with the terminology of coping, but they do require knowledge of when, how, and why
to use coping skills in order to proactively and successfully manage their illnesses. For
example, a patient might not know the difference between “cognitive” and “alloplastic”
coping. However, the patient should have a basic working knowledge of different coping
skills to be used in times of stress. Thus, alloplastic coping may be helpful to remove a
person from a potentially stressful situation, while cognitive coping may be effective in
vocational settings. In the author’s experiences, patients tend to have minimal knowledge
of coping. For example, during an educational music therapy session, the music therapist
might ask, “What can we do when we are starting to feel overwhelmed by stressors?” A pa-
tient may respond, “Cope” or “Use our coping skills.” While these responses are certainly
Table 5.4 Coping Strategies and Descriptions
Type of coping Description

Active coping A person uses strategies including fight, escape, or confrontation if the
stressor is controllable or escapable (Keay & Bandler, 2001).
Alloplastic coping A person copes by changing the environment (Perrez & Reicherts,
1992).
Autoplastic coping A person copes by changing herself or himself (Perrez & Reicherts,
1992).
Avoidant coping A person does not deal with problem often resulting in negative
psychological outcomes (Beasley, Thompson, & Davidson, 2003).
Behavioral coping A person sorts outstanding worries and attempts to organize actions
(Lam, Wong, & Sham, 2001). A person takes action to alleviate distress
(Latack & Havlovic, 1992).
Cognitive coping A person evaluates if sources of anxiety are worth worrying about and
distracts her or himself from negative thoughts (Lam, Wong, & Sham,
2001). This includes self-talk and mental strategies (Latack & Havlovic,
1992).
Cognitive behavioral coping A person identifies and changes maladaptive thinking and behaviors
that can create, maintain, and exacerbate stress (Steinhardt & Dolbier,
2008). A person engages in activities to distract self from distress,
schedule and complete small tasks, and attain social support (Lam,
Wong, & Sham, 2001).
Control coping A person uses a proactive approach to manage or alleviate distress
(Latack & Havlovic, 1992).
Disengagement coping A person orients her or his responses away from stressors, cognitions,
and emotions (Compas, Connor-Smith, Saltzman, Thomsen, &
Wadsworth, 2001). A person attempts to escape distress via avoidance
and denial (Carver & Connor-Smith, 2010).
Dispositional coping A person has habitual methods of dealing with distress and these habits
(trait coping) can affect future reactions to new distress (Carver & Scheier, 1994).
Early medical intervention A person visits or consults a physician or takes extra medication as
strategies previously agreed with prescribing doctor (Lam, Wong, & Sham, 2001)
Emotion-focused/emotion- A person uses a palliative effort to deal with or change one’s emotional
oriented coping reaction to distress (Bouchard, Guillemette, Landry-Leger, 2004).
This involves releasing pent-up emotions, distraction, and meditating
to manage or change the emotions that accompany stress. It is
typically used in situations an individual appraises as uncontrollable or
unchangeable (Folkman & Lazarus, 1988; Lazarus, 1993) and can result
in negative psychological outcomes (Beasley, Thompson, & Davidson,
2003).
Engagement coping A person orients her or his responses toward either the source of
stress or toward the cognitions and emotions (Compas, Connor-Smith,
Saltzman, Thomsen, & Wadsworth, 2001). A person attempts to
handle the stressor or emotions using problem- and emotion-focused
strategies, such as support seeking, cognitive restructuring, and
acceptance (Carver & Connor-Smith, 2010).
Coping skills 95
Table 5.4 (continued) Coping Strategies and Descriptions

Escape coping A person stays away from the stressful event, person, or situation
and attempts to not be concerned with the issue (Latack & Havlovic,
1992).
Involuntary or automatic A person uses automated responses that are not under conscious
coping control (Compas, Worsham, Ey, & Howell, 1996).
Maladaptive coping A person uses strategies that may immediately alleviate stress during
the short-term but does not alleviate long-term stress. These may serve
to maintain the disorder or stress as they interfere with learning and the
association between stressors and distress and include dissociation, drug
use, avoidance, escape, staying in bed, and hoping sources of distress
will go away without intervention.
Meaning-focused coping A person attempts to derive meaning from stressful experiences or
demands.
Modifying excessive A person reduces and prioritizes the number of tasks to be realistic
behavior coping strategies (Lam, Wong, & Sham, 2001).
Negative coping A person uses strategies that function to increase—rather than
decrease—stress. These can include escape, self-blame, and worrying.
Passive coping A person is inactive and hoping that distress alleviates without
intervention. This can include immobility or decreased responsiveness
to the environment and usually elicited when stressor is perceived as
inescapable (Keay & Bandler, 2001).
Positive coping A person uses strategies that decrease perceived stress and may include
reaction and situation control, denial of guilt, positive self-instruction,
and minimization.
Primary coping A person attempts to influence conditions or events (Rudolph, Dennig,
& Weisz, 1995)
Proactive coping A person utilizes a positive coping mechanism in which she or he
anticipates or detects potential stressors that may occur in the future
and uses behaviors or cognitions to prevent or modify future problems
before they occur (Aspinwall & Taylor, 1997).
Problem-focused coping A person uses strategies focused on reducing or eliminating the
stressor itself (Folkman & Lazarus, 1988; Suls, David, & Harvey, 1996).
A person might attempt to further understand problem and learn new
skills to manage the problem. This is typically used in situations that an
individual appraises as controllable or malleable (Folkman & Lazarus,
1988; Lazarus, 1993).
Reactive coping The perceived stressor or demand precedes the individual’s coping
response.
Secondary coping A person directs her or his actions toward maximizing fit within current
predicament (Rudolph, Dennig, & Weisz, 1995)
Situational coping A person’s actual behaviors during a specific coping episode (Bouchard,
Guillemette, Landry-Leger, 2004). These result from the interaction
between coping styles and personal characteristics (Endler & Parker,
1994).
Table 5.4 (continued) Coping Strategies and Descriptions

Social coping A person seeks social support from other people including professionals
or non-professionals (Latack & Havlovic, 1992).
Solitary coping A person copes alone without other people (Latack & Havlovic, 1992).
Stimulating coping A person enjoys good feelings and schedules activities for a
strategies (specific to predetermined time period (Lam, Wong, & Sham, 2001).
coping with mania)
Volitional, effortful, or A person uses conscious efforts to manage distress (Compas, Worsham,
controlled coping Ey, & Howell, 1997).
correct, it is the music therapist’s responsibility to further engage the patients in deeper
levels of understanding, application, and problem solving. Thus the music therapist might
respond, “Nice—coping skills are super important! But what are some specific positive
coping skills—things we can do to make ourselves feel a bit better—we can easily imple-
ment while at work?” After identifying a variety of potential coping skills that patients may
be able to effectively implement at work, the music therapist might then ask for specific
coping skills to be used in a home living environment to differentiate how coping resources
and mechanisms differ according to setting. Then, it is the music therapist’s responsibility
to make patients explicitly aware of the outcomes of implementing coping skills by ask-
ing, “How do you feel after using coping skills?” The music therapist should make patients
aware of the affective, cognitive, and behavioral changes that result from successfully using

◆ There is growing consensus that mental illness is a chronic and incurable lifetime
disorder.
◆ Psychiatric consumers require the knowledge and skills to understand, manage, and
recover from their conditions.
◆ Regardless of specific type, psychiatric disorders require long-term education,
understanding, management, and lifestyle changes.
◆ An educational model of psychiatric music therapy focusing on illness management
and recovery may be a dynamic, engaging, and motivating contributor to the con-
temporary treatment milieu for psychiatric in- and outpatients.
◆ Incorporating prodromal symptoms and coping skills into the educational model of
music therapy for illness management and recovery is paramount to provide psy-
chiatric consumers with the knowledge and skill sets necessary to prevent psychi-
atric relapse and facilitate recovery.
Coping skills 97
coping skills. For homework, the therapist might assign patients a task in which they make
coping cards with five behavioral coping skills they can use at work on one side of the card
and five behavioral coping skills they can use at home on the other. The music therapist
might also recommend that patients help with one another’s homework assignments to
increase accountability, the likelihood of completion, and, potentially, vicarious learning.
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1 Why will symptoms of mental illness remain a vital treatment component? Should clinicians and re-
searchers instead focus on cognitions, behaviors, and affective states that maintain the patient’s sympto-
mology? Why and why not?
2 Why might educational music therapy for illness management and recovery represent an effective treat-
ment for prodromal and at-risk people in terms of cognitive abilities that may be hindered by psychiat-
ric disorders?
3 While educational music therapy for illness management and recovery can be intended for acute psy-
chiatric inpatients, how might it be beneficial—and contraindicated—for inpatients who are considered
chronically mentally ill and institutionalized?
4 What are potential difficulties in measuring the treatment effects of educational music therapy for ill-
ness management and recovery in an acute-care inpatient setting?
5 What types of coping skills may be most appropriate for patients in acute psychiatric settings compared
to long-term psychiatric settings?
6 What types of coping skills do you use during times of heightened stress?
Chapter 6
Therapeutic mechanisms in psychiatric

music therapy
We know well that therapy “works,” i.e., is responsible for

change, but have little knowledge of why or how it works.
(Kazdin, 2007, p. 2)
Introduction
Why is psychiatric music therapy effective? Researchers investigating psychotherapy still
“cannot provide an evidence-based explanation for how or why even our most well studied
interventions produce change” (Kazdin, 2007, p. 23). The process of attempting to identify
key “ingredients” in successful therapy has been underway for a number of years. In this
type of reductionist approach, known as treatment dismantling or dissection, researchers
attempt to pinpoint the key components or mechanisms of the intervention that render
treatment effective. Unfortunately, researchers have had little success as studies have shown
equivalent effects between component parts (Kuipers, 2005). Gaudiano (2005) noted that
no researcher has been able to dismantle the components of cognitive behavioral therapy
for psychosis, compare it to another empirically supported psychological intervention, or
identify specific successful therapeutic mechanisms. Thus, based on other psychosocial
therapeutic literature, is it possible to determine effective components of music therapy for
illness management and recovery with adult psychiatric patients?
When might psychiatric music therapy be effective?

A potential response to this question begins with a discussion of attendance, participation,
and desire for change. Dobson and Dobson (2009) noted attendance is prerequisite for
change, regardless of intervention type or philosophical underpinning. Thus, it is unlikely
that music therapy could help a psychiatric patient if that person does not attend a music
therapy session. While this concept seems simplistic, it brings attention to factors that may
contribute to attendance. To encourage attendance, it is imperative for music therapists,
unit staff, and even other patients to advocate for patients to attend music therapy ses-
sions. Therefore, unit staff should possess a basic working knowledge of music therapy. It
is the responsibility of the music therapist to educate staff so they can encourage patients
to attend music therapy sessions. Brief in-services can be an especially efficient method
104 THERAPEUTIC MECHANISMS IN MUSIC THERAPY
for educating and advocating for music therapy (see Chapter 8). Due to high rates of staff
turnover in psychiatric facilities, in-services should be provided often. Music therapists
can also encourage staff to attend or observe music therapy sessions. Engaging patients
in music or dialogue concerning music before the session begins may facilitate patients
entering the room where music therapy will occur. This type of engagement may also fa-
cilitate working alliance and develop rapport. Additionally, as patients may be initially
skeptical of music therapy, music therapists should inform them of what they can expect.
This simple exchange of information may serve to heighten the likelihood of patients at-
tending sessions.
Verbal participation in the music therapy session is voluntary. Certainly, a music therap-
ist should never force a client to participate as this will only hinder the development of the
therapeutic alliance. In a study where the researcher measured the frequency and type of
psychiatric inpatients’ verbal participation, higher amounts of participation in music ther-
apy were not necessary for the patients to perceive educational music therapy as helpful
(Silverman, 2009a). However, this finding was not congruent with participants in the psy-
choeducational no-music active control condition as patients who verbally participated
more found the therapy session to be helpful while patients who did not verbally participate
found the session to be less helpful. Thus, from available music therapy data, it seems that
psychiatric inpatients may not have to verbally participate to perceive therapeutic benefits.
In both self-change and psychotherapy, people often progress through a series of stages.
Researchers developed the transtheoretical model of change to describe the continuum of
change (see Box 6.1).
Box 6.1 Transtheoretical Stages of Change

1 Precontemplation: A person does not perceive benefits to change and therefore is
unwilling to change.
2 Contemplation: A person perceives some benefits to change, but costs associated
with change outweigh the benefits.
3 Preparation/determination: A person perceives more benefits to change than costs
associated with the change, but has not actively changed any behaviors.
4 Action: A person is actually behaving in different ways congruent with change.
5 Maintenance: A person has been in the action stage for six or more months, actively
behaving in ways congruent with change.
Data from James O. Prochaska, Carlo C. DiClemente, and John C. Norcross, In search of how people
change: Applications to addictive behaviors, American Psychologist, 47 (9), pp. 1102–14, doi: 10.1037/0003-
066X.47.9.1102, 1992 and James O. Prochaska, Carlo C. DiClemente, and John C. Norcross, Journal of
Addictions Nursing 5 (1), pp. 2–16, doi: 10.3109/10884609309149692, 1993.
For whom might psychiatric music therapy be effective? 105
These widely accepted stages “were derived empirically from factor and cluster analytic
methods” (Miller, 1998, p. 167). The success of a patient can depend upon the stage of
change she or he has achieved (Prochaska, DiClemente, & Norcross, 1992). In a meta-
analysis of 47 studies, Rosen (2000) found effect sizes of .70 and .80 for the use of different
change processes in the stages of change. Patients in precontemplation and contemplation
stages mostly used cognitive-affective processes while patients in the action and mainten-
ance stages mostly used behavioral processes. Thus, as several cognitive readiness stages
appear to precede overt behavioral changes, change can be subtle and can occur in the
form of cognitive initiation and readiness (Prochaska et al., 1992). Thus, these more deli-
cate changes can be integrated into the process model of treatment (De Leon, Melnick,
Kressel, & Jainchill, 1994; Simpson & Joe, 1993), as focusing solely on overt behavioral
indicators may obscure treatment progress.
A patient can only change when she or he is ready for and desires the change. Although
therapists may be able to increase motivation and treatment eagerness, a client cannot and
will not change unless she or he genuinely wants to change. In cases where a patient does
not want to change, the music therapist might focus on reasons the patient does not want
to change, identifying the patient’s goals, and ask the patient if current behaviors are con-
gruent with her or his goals. Making the patient aware of potential discrepancies between
goals and current behaviors may increase motivation for change as well as increase the
therapist’s understanding of the patient’s reluctance to change.
For whom might psychiatric music therapy be effective?

Researchers have also found a number of predictor variables, or moderators (Kazdin,
2007)—for both the client and the therapist—that may account for some of the variance
in successful therapy and treatment progress. Specific to the use of cognitive behavioral
therapy for major depressive disorder, panic disorder, and generalized anxiety disorder,
researchers conducted a systematic review and found that outcomes were similar across
disorders (Haby, Donnelly, Corry, & Vos, 2006). Despite a small sample size of studies
conducted in non-English-speaking countries, the authors found that studies conducted
in English-speaking countries had stronger effects than studies conducted in non-English-
speaking countries. Perhaps the most important implication was the relationship between
higher levels of initial client problem severity and worse treatment outcomes.
Concerning cognitive behavioral therapy in the treatment of depression, other schol-
ars have found similar outcomes related to illness severity. People with more episodes
of depression had worse outcomes than people with fewer depressive episodes (Hamil-
ton & Dobson, 2001). Castonguay and Beutler (2006) reviewed client variables that pre-
dicted treatment outcome. The authors identified empirically based principles of change
that occurred regardless of philosophical treatment orientation. Financial and occupa-
tional difficulties, being older, having a personality disorder, and having higher levels of
impairment were associated with worse treatment outcome. Lambert (1992) found that
40% of the variance in successful therapy was attributed to client characteristics including
motivation, struggles, and social supports. Other client variables included ego strength,
the ability to identify a focal problem, the capacity to relate, motivation, and the severity of
the problem (Assay & Lambert, 1999).
Silverman (2006) surveyed 73 psychiatric inpatients concerning their perceptions of
music therapy and other educational and therapeutic programming. Although not stat-
istically significant, participants with only one psychiatric admission tended to find edu-
cational and therapeutic programming more helpful than participants with multiple
admissions. Additionally, while between-group differences were not significant, partici-
pants who identified themselves as minorities tended to rate programming as more helpful
than participants who indicated they were Caucasian.
What characteristics of the therapist facilitate change?

There are also therapist variables that may influence treatment. Researchers have found
therapist characteristics associated with positive treatment outcome include warmth, car-
ing, higher levels of empathy, and authenticity (Castonguay & Beutler, 2006; Josefowitz &
Myran, 2005). Congruently, Lambert (1992) noted that approximately 30% the variance
concerning psychotherapeutic outcome was attributed to therapist variables affecting the
relationship, including acceptance, empathy, and warmth. Mansell, Carey, and Tai (2013)
noted that the person delivering the treatment tended to have a greater effect on thera-
peutic outcome than the treatment being delivered.
Researchers have found that the amount of therapist training did not relate to client
treatment outcome (Haby, Donnelly, Corry, & Vos, 2006; Jacobson et al., 1996). Dobson
and Dobson (2009) provided additional context for this potentially misleading outcome
as most data concerning these trends were found in randomized controlled trials. The
therapists who typically provide treatment in these studies are supervised, well trained,
and monitored. Lambert (2005) noted that researchers have conducted comparatively
few studies differentiating treatment outcomes with novice and experienced therapists.
Lambert also articulated that, regardless of the amount of training, specific therapeutic
techniques may result in encouraging treatment outcomes for patients. However, when re-
searchers analyzed data from various clinical sites in the treatment of depression, Jacobson
and Hollon (1996) found evidence that patients at sites with more experienced cognitive
therapists had better outcomes than patients at sites with less experienced therapists. It
would seem that amount of therapist training and expertise remains an area for future con-
trolled and systematic investigation, especially in the music therapy profession in which
there are added layers of complexity due to varying degrees, training, clinical experience,
musicianship, and supervision that individual music therapists may have.
Why might psychiatric music therapy be effective?

Smeijsters (1993) noted that many music therapists believe music therapy is a separate and
distinct type of treatment, and therefore, it should not be described using concepts from
traditional verbal therapy. However, a purposeful exclusion of common verbal therapy
conceptual and theoretical frameworks may prevent non-music therapists from under-
standing exactly what psychiatric music therapy can be, what it might accomplish, and
why it may be effective. The exclusion of common verbal therapy frameworks may also
prohibit music therapy from adopting and modifying successful non-music therapy treat-
ments. It would seem that limiting the music therapy description to only musical events
might not adequately communicate the beneficial results of treatment, which—especially
in the case of cognitive behavioral and educational music therapy for illness management
and recovery—are typically and purposely nonmusical. Thus, describing music therapy
using “borrowed” and established theories from larger and more recognized traditional
therapies may be an effective communicative method. In an attempt to describe music
therapy using borrowed and accepted therapeutic factors, nine commonly acknowledged
and accepted mechanisms for therapeutic change (Corsini, 2008) will be adopted to de-
scribe how music therapy triggers engagement, motivation, participation, change, symp-
tomatic relief, on-task behaviors, learning, and improvement of illness management and
recovery knowledge and skills in psychiatric patients.
The nine therapeutic mechanisms discussed in the remainder of the chapter, however,
are not exclusive. The author acknowledges that other therapeutic factors exist. His-
torically, many authors (e.g., Bloch, Crouch, & Reibstein, 1981; Kelman, 1963; Papanek,
1968; Tawadros, 1956) have spent considerable time and effort researching these factors
and these efforts will likely continue. Of particular relevance, Yalom (1995) identified
12 curative factors in group therapy: altruism, cohesiveness, universality, interpersonal
learning-input, interpersonal learning-output, guidance, catharsis, identification, fam-
ily re-enactment, self-understanding, instillation of hope, and existential factors. Yalom’s
curative factors overlap with features from other systems. Other scholars (Becker, 1972;
Opler, 1957; Tenebaum 1970) have found therapeutic factors similar to those of Corsini
and Rosenberg (1955) and Corsini (2008). Thus, areas of conjecture concerning thera-
peutic factors coincide with and may even subsume other aspects of successful treatment.
Additionally, alterative names or taxonomies for therapeutic factors may exist (Bloch,
Crouch, & Reibstein, 1981). These “gray” areas of overlap are important, and the author
encourages informed, open, collegial, and scholarly discussion of these issues. Here, fac-
tors from Corsini and Rosenberg (1955) and Corsini (2008) will be used, as these factors
are not exclusive to a particular therapeutic philosophy or orientation. Thus, in traditional
talk-based therapies as well as in psychiatric music therapy, these nine factors can be con-
sidered transtheoretical. In what follows, the nine factors will be discussed within an ill-
ness management and recovery framework.
In an attempt to systematically investigate how traditional forms of verbal therapy are
effective for client change, Corsini and Rosenberg (1955) were the first to perform a factor
analysis. On the basis of their results, the authors theorized that there are nine factors that
represent the basic therapeutic change mechanisms (Corsini, 2008; Corsini & Rosenberg,
1955). The authors then categorized the nine factors into three groups: cognitive, affective,
and behavioral. While these factors were identified specifically for verbal therapy, they
also may be used to explain client change as a result of music therapy. These factors are not
intervention-specific, meaning that they may each occur during a variety of different types
of music therapy interventions (e.g., lyric analysis, songwriting, improvisation, recre-
ational music therapy, facilitated drumming). By understanding these mechanisms, music
therapists can purposely use them to enhance clients’ potential for change and learning
during group-based educational music therapy for illness management and recovery.
Cognitive factors
Universalization. Patients’ problems and issues are not idiosyncratic or unique. Clients
can improve when they become aware and acknowledge that other people have similar or
related problems and situations.
As most music therapists in the United States work with psychiatric patients in group-
based settings (Silverman, 2007; Thomas, 2007), clients are able to listen to other group
members’ narratives and understand their situations within music therapy. When patients
share their problems and reasons for being admitted to the hospital, they often realize that
they are not alone and that their situations—while certainly unique—often have shared or
parallel aspects. Patients are able to listen to their peers, who may have similar problems
and situations, often regardless of specific psychiatric diagnoses or reasons for hospitaliza-
tions. Group-based treatment can provide a setting in which clients can understand that
their goals and experiences are normal and experienced by others in the group (Mansell,
Carey, & Tai, 2013).
When psychiatric consumers are in organized group-based therapy sessions such as
music therapy, they have opportunities to interact with each other within structured inter-
ventions specifically tailored to elicit therapeutic dialogues and interactions. It is during
these interactions that they often realize that they have quite a deal in common with their
peers on the unit. When patients realize that other group members share their problems,
they typically become more on-task to one another, listening carefully, attempting to
understand and learn from their peers, and becoming more avid participants in the inter-
vention. Patients often discuss their behaviors, cognitions, or decisions that they acknow-
ledge were not helpful to their situations and experience vicarious learning opportunities
to prevent making similar mistakes and ill-advised decisions.
For example, many psychiatric patients have relapsed and thus started using substances
such as illicit drugs and alcohol again (Connors, Maisto, & Donovan, 1996). In fact, re-
searchers have found that relapse rates can be as high as 80%–90% (Helzer, Robins, & Tay-
lor, 1985; Hunt, Barnett, & Branch, 1971; Polich, Armor, & Braiker, 1981). In psychiatric
settings, patients often discuss past failures concerning remaining sober. Persons who may
be in treatment for the first time have the opportunity to learn about drug abuse, relapse,
and ways to avoid substance misuse. Additionally, people who have overestimated their
abilities to remain sober and underestimated their addictions can describe the challenges
they faced and the techniques they used to help remain sober, even if just for a short while.
These challenges and techniques can represent important vicarious learning opportunities
for other clients. In a similar manner, patients often discuss the consequences of discon-
tinuing prescribed medications; their peers can learn from these narratives, too.
One of the unique aspects of psychiatric music therapy is that universalizations can also
occur related to characters within songs. Patients may relate to the feelings, behaviors, cog-
nitions, or situations of a character in a song during a lyric analysis or songwriting inter-
vention. Patients often note that they can relate to the character in the song and, instead
of verbally articulating aspects of the character within the song, voluntarily—and without
prompting—converse about and project their own unique situations. This may occur even
when the music therapist purposely asks a question concerning the character in the song,
as patients often respond not with an answer concerning the character but concerning
their own situation. These organically occurring moments in therapy can be therapeut-
ically powerful and lead to a discussion of why and how to change specific behaviors and
cognitions.
Insight. Clients tend to feel better when they have heightened awareness of themselves
and others. This superior awareness may help them to have enhanced perspectives con-
cerning their thoughts, feelings, and behaviors.
Regardless of specific music therapy intervention, patients can have insights into their
own thoughts, feelings, and behaviors within a music therapy session. Insight does not
have to be interpreted from a classical psychoanalytic perspective, as people from various
theoretical orientations frequently use the term. As metaphors permeate human thoughts
and relations (Dumont, 2011)—and metaphors may be present in the music or lyrics—
musically induced metaphors might stimulate insight in patients. Referentialist theory
supports musical metaphors in that the meaning in music results from insights a person
makes between the music and a nonmusical event or object (Gfeller, 2008). Additionally,
insights can be induced internally or externally. Internal insights might arise when a pa-
tient has his or her own insight—that type of “aha” moment where an epiphany occurs.
Insight can also occur externally, via a music therapist or peer making an insightful state-
ment about the patient that leads the patient to reflect upon his or her own situation. After
reflecting upon the therapist’s or peer’s statement, the patient can develop an internal in-
sight about his or her thoughts, emotions, or actions.
Insights can also result from the music and thus can be musically induced. For example,
during a facilitated group drumming intervention designed to augment verbal communi-
cation skills, when asked to analyze his playing, a patient might talk about his timid play-
ing. The therapist (externally induced insight) or patient (internally induced insight) may
generalize the timid playing to larger aspects of the patient’s life, such as not being assertive
in home, treatment, or work environments. The music therapist then has an opportunity
to allow the patient to demonstrate how assertive drumming may sound, look, and feel.
After playing assertively on the drum, the patient and therapist can discuss and role-play
how to generalize appropriate assertive playing in home and work environments.
An interesting aspect of psychiatric music therapy is that many song lyrics contain a
great deal of ambiguity. Lyrics may not be direct or concrete and thus allow for a multitude
of potential interpretations. Perhaps lyrical ambiguity leads to deeper thought and even-
tually to self-discovery or insight. Thus, especially for psychiatric patients who are cogni-
tively functioning at relatively high levels, songs that contain indefinite and vague lyrics
may be helpful to promote cognitive processing and decision making. Cognitive process-
ing concerning song lyrics that may be considered indistinct, especially when facilitated
by a music therapist, may lead to conjectures, epiphanies, and self-discovery. However,
in the author’s experience, ambiguous lyrics should not be used with patients who are
chronically mentally ill and are functioning at low cognitive levels: often the severe symp-
toms prohibit the patient from cognitively processing and interpreting the abstract lyrics.
Asking a patient who has severe psychotic symptoms to interpret vague lyrics may lead to
increased confusion, paranoia, and frustration. Thus, songs for lyric analysis interventions
should be chosen using a systematic and thoughtful process (Silverman, 2009b) and based
on comprehensive and patient-centric musical and nonmusical assessments.
Modeling. Purposeful observation of other people can help clients. Clients can model
behaviors and affective states of both peers and therapists.
As patients who genuinely desire to change tend to be engaged in and motivated for
treatment, they also tend to seek effective ways of living. Music therapists can model
healthy living habits, including diet, exercise, use of positive coping skills, adhering to
pharmacological treatments as prescribed, spending time with supportive friends and
family members, wellness, stress management, and balancing and prioritizing responsi-
bilities. While these ideas may be potentially powerful when modeled by the music ther-
apist, they may be even more influential when modeled by a patient’s peers who are also
inpatients at the hospital. As patients typically relate to and understand their peers’ situ-
ations due to aspects of universality, they may perceive that their peers’ behaviors, affects,
and cognitions are more realistic and applicable models than a therapist’s. Thus, by re-
inforcing patients’ positive behaviors, the music therapist can facilitate the use of patients
as peer models.
For example, while a music therapist may indicate that playing the guitar is a healthy
leisure skill for herself or himself, a patient might not have the ability or resources to play
or learn to play the guitar. However, another patient in the group may note that she is in-
volved in her church choir and finds this to be an enjoyable and practical leisure activity.
The music therapist could verbally reinforce this patient for sharing and then indicate that
singing in a church choir also promotes socialization and reduces isolation. For group
members who do not consider themselves religious and thus do not want to participate in
a church choir, the music therapist can ask the group for other healthy leisure skills that
they can use that do not necessarily have a religious component. Asking the group for
input can function to make the therapist appear as less of an expert while respecting the
other patients’ opinions, and uses a psychoeducational, facilitative, and collaborative ap-
proach to problem solving. This approach supports patients’ self-efficacy by recognizing
that patients often already have the answers to many of their problems and are capable of
problem solving and being well.
Affective factors
Acceptance. When the client feels unconditional positive regard, specifically from the
therapist, she or he is more likely to change.
Although it may seem like an obvious aspect for change to occur, patients typically need
to feel accepted by the therapist. While anecdotal evidence suggests that music therapists
generally tend to be accommodating, tolerant, and accepting, unconditional positive re-
gard has been—and will likely continue to be—a relevant aspect of therapy regardless of
philosophical orientation. Thus, in psychiatric group therapy sessions, the music therapist
should be accepting of the patient’s lyrical, melodic, and harmonic suggestions, interpret-
ations of the music, musical and nonmusical choices, and improvisations. As patients may
feel intimidated by the music therapist’s level of musical training and ability, it is especially
important to have unconditional positive regard for the patient’s musicality, regardless of
preference, level of training or knowledge, and performance.
For example, patients often provide lyrical suggestions during group songwriting inter-
ventions that are far too lengthy to fit within a pre-established musical phrase. Instead of
discounting the phrase entirely, a music therapist might verbally reinforce the patient for
the suggestion, noting that the patient’s idea is “exactly what the song needs.” The music
therapist could then write the general idea or theme of the phrase on the board for all
group members to observe, potentially acting as a type of reinforcement for the patient.
(This written lyric can also function as a reminder, cue, or prompt for the music therapist.)
As the patient’s suggested wording is too long for the phrase in the song, the music ther-
apist might ask the group to keep the main idea or theme of the phrase, but condense the
wording to fit within the existing lyrical structure. Thus, the patient might still feel that she
or he contributed to the song although considerable revisions to the original lyrical sug-
gestion were necessary for the final product. The music therapist can then verbally process
the importance for compromise and being flexible with lyrics and generalize these aspects
to psychiatric care on the hospital unit and in the community.
Altruism. Change may result when the client is aware that she or he is the recipient of
the therapist’s (or another group member’s) care. Change can also result from the sense of
providing the care to others and feeling that one is helping others.
Another positive aspect of group therapy is the ability for patients not only to relate to
one another, but to also help each other. While music therapists are typically quite aware of
the “helping high” they may receive while helping others during treatment, patients may
not be as aware of this phenomenon. Thus it is the responsibility of the music therapist to
recognize when a patient helps another patient and to verbally reinforce it, ensuring the
patient feels a sense of accomplishment from the altruistic behavior. As anecdotal evidence
supports the idea that psychiatric patients display altruistic behaviors during music ther-
apy sessions, the music therapist should actively seek, identify, and reinforce these behav-
iors to make sure patients are aware of them.
Music therapists can also model volunteering as an altruistic behavior, coping skill, so-
cial endeavor, and way to “pay it forward” and “give back” to the community. For example,
a music therapist who discloses to psychiatric patients that she volunteers at the annual
walk to benefit research for Alzheimer’s Disease can help patients recognize the many
benefits of this altruistic behavior, such as the immediate affective gain of the “helping
high,” that volunteering can be a coping skill, the benefit to the Alzheimer’s association, a
sense of accomplishment, and the ability to meet like-minded volunteers and enlarge one’s
social network and community for a worthwhile cause.
Altruism frequently occurs in settings for people who have addictions. Often, people
in rehabilitation for substance abuse are interested in eventually becoming a sponsor to
mentor others through their recoveries from addiction. While this can be a wonderful way
to promote altruistic behaviors, the music therapist should also acknowledge the tremen-
dous responsibility of this endeavor. Patients need to have demonstrated a successful and
enduring period of sobriety before they assume the weighty responsibilities associated
with being sponsors for their peers.
Transference. Transference is the emotional bond that forms between the client and
therapist. Bonds can also form between clients in group therapy sessions.
Although the term originated from psychoanalytic and psychodynamic orientations in
which transference was defined as the unconscious redirection of feelings from one person
to another, transference can also be defined in a transtheoretical manner. Regardless of
philosophical orientation to music therapy treatment, a bond develops between the client
and therapist throughout the music therapy process. Many authors have noted the import-
ance of developing a positive rapport and working or helping alliance (see Chapter 8). In
fact, researchers conducting meta-analyses have found a relationship between therapeutic
alliance and clinical outcome in varied types of treatment (Horvath, 1994; Horvath & Sy-
monds, 1991).
Clients often recognize aspects of universality and altruism and may “bond” during
group music therapy sessions. Psychiatric consumers may feel a shared closeness after
musical improvisation or songwriting with the therapist, peers, or even the music itself.
Patients may not have realized they had so much in common with their peers before the
session. During music therapy sessions, patients often learn more about one another and
develop connections via mutual experiences. In these instances, music therapists might
consider assigning “group-based inpatient homework” to be completed at a later point
during the day. Providing follow-up questions on the back of a lyric sheet used during a
lyric analysis intervention can be an effective way to promote patients continuing their
therapeutic dialogue with one another after the session concludes (Silverman, 2009b). A
music therapist may also write follow-up questions or assignments for discussion on a
board after competing a songwriting intervention.
Behavioral factors
Reality testing. Change can be a result of clients experimenting with new behaviors in
the security of a therapy session, especially while receiving support and feedback from the
therapist and peers.
Music therapists can provide psychiatric patients with opportunities to experiment with
novel musical and nonmusical behaviors that can augment illness management and re-
covery knowledge and skills. It may be that musically demonstrating a new behavior is
less intimating and can be used as a successive approximation to an ultimately nonmusical
demonstration of the behavior. Conversely, demonstrating inappropriate or nonhelpful
behaviors during a role-play intervention can highlight the need to discover and im-
plement appropriate and effective techniques. Role-plays are efficient and inexpensive;
psychiatric music therapists use these during their sessions (Silverman, 2007). More spe-
cifically, a researcher used role-plays within a music therapy session (Silverman, 2011) in
an attempt to teach appropriate assertive behaviors to acute psychiatric inpatients.
For example, during a lyric analysis of “Desperado” by The Eagles, patients who are
diagnosed with both a mental disorder and a substance abuse disorder on an acute-care
unit may relate to the character in the song. This organically occurring recognition could
bring forth a discussion concerning how the patients might be ashamed to admit their
hospitalizations and addiction to friends in the community due to the stigma attached to
psychiatric disorders. The music therapist may “pause” the lyric analysis and experiment
via role-play potential methods for interacting with friends despite feeling ashamed of
their addiction. Once patients successfully identify potential methods, the music therapist
might assign inpatient homework assignments to group members. For example, through-
out the rest of the day, each patient role-plays a similar scenario (e.g., discussing addiction
and hospitalization with community members after discharge) with at least three peers on
the unit. The homework assignment may help to desensitize patients toward this type of
interaction with friends in the community and enable them to rehearse and refine their
interaction skills concerning this potentially difficult discussion.
Ventilation. Change can be a result of catharsis. This factor pertains to statements at-
testing the value of self-expression or displaying emotions in a context where a client feels
accepted.
Music therapy can be used for cathartic means such as self-expression and ventilation.
Patients can express themselves musically without the potential intimidation of verbal
interaction or the negative consequences. As recognizing emotions and affective states can
be an important objective for self-monitoring, music may be an ideal medium for learning
about emotions and how to effectively identify, express, manage, and modify them.
For example, a music therapist could facilitate an improvisation session with patients
using the minor pentatonic scale on the guitar or keyboard to assist the patient in recog-
nizing, learning, and expressing their emotions and affective states. Patients could also
select or compose songs or lyrics that represent their moods, struggles, or affective states.
These songs can be used to establish rapport and working alliance and as a stimulus for dis-
cussing and implementing illness management techniques, such as understanding what
emotions require the use of coping skills as well as situational risk factors that precede
negative affective states. Participating in a facilitated drum circle using unpitched percus-
sion instruments may be a nonthreatening intervention for psychiatric patients to appro-
priately ventilate intense feelings.
Interaction. Clients can improve when they are able to admit to the therapist or peers in
the group that they do indeed have a problem.
Patients are unlikely to change if they do not sincerely believe they have a problem war-
ranting the effort required for change. This theory is supported by the well-established
transtheoretical stages of change model. As previously noted, this model explains
professionally facilitated and self-initiated change and often focuses on a progression

through five stages: precontemplation, contemplation, preparation, action, and mainte-
nance (Prochaska & DiClemente, 1986, 1992; Prochaska, DiClemente, & Norcross, 1992,
1993). Thus, depending on what stage of change a psychiatric patient is in, the music
therapist can work toward identifying factors highlighting the need for change and the
advantages and disadvantages of both change and status quo. Once cognitive factors have
been identified, the music therapist can work to make these cognitive factors behavioral
by turning ideas into actions (i.e., work with the patient to implement, use, and practice
the behaviors).
A potential advantage of music therapy is that a patient might relate to a character in a
song. The patient might indicate that the character in the song—and herself or himself—
needs to change her or his behaviors, as status quo behaviors had previously resulted in
rehospitalization due to stopping prescribed medication and psychotherapeutic regimens.
Thus, through a dialogue of why the character in the song needs to change, the patient
indicated that she or he can relate to the character in the song and also needs to change.
Music therapy applications

Psychiatric music therapy can be effective in a variety of ways. Although many researchers
have attempted to determine why therapy might be effective or dismantle aspects of suc-
cessful therapy, these efforts have been consistently unsuccessful. Psychotherapy is per-
sonal, complicated, and dynamic; factors influencing change and outcome are poorly
understood (Morgenstern & McKay, 2007). Some might argue that the lack of know-
ledge concerning effective talk-based therapies parallels the lack of knowledge concern-
ing pharmacologic therapies. A discontented psychiatrist has even described prescribing
medications to psychiatric consumers as “subjective,” “random” (Carlat, 2010, p. 83), and
“guesswork” (p. 92). Music therapists should highlight the lack of side effects from music
therapy (Ulrich, Houtmans, & Gold, 2007) and articulate that they can help psychiatric
patients learn and apply life skills to manage their problems. While medications can be
effective components of illness management, traditional talk-based therapies are also
important to encourage and promote illness management and recovery skills. Perhaps
music therapists will play a greater role in teaching psychiatric patients the importance of
pharmacologic interventions and medication management in the future.
Finally, although psychiatric music therapists may never fully understand how and why
music therapy might be effective for their psychiatric patients, it does not negate the neces-
sity of providing observable and measurable patient outcome data. Additional qualitative
and quantitative research is warranted to determine what exactly makes music therapy
effective (Mossler, Assmus, Heldal, Fuchs, & Gold, 2012). In the contemporary era of
evidence-based treatment, accountability is paramount. While researchers have strug-
gled to provide empirical evidence differentiating treatments, it remains a necessity for
clinicians to conscientiously document their patients’ gains throughout the entirety of the
music therapy process.
Music therapy applications 115

◆ Factors that influence therapeutic outcome can be related to attendance and partici-
pation as well as characteristics of both client and therapist.
◆ Researchers and clinicians have developed numerous taxonomies to describe mech-
anisms responsible for therapeutic change.
◆ Understanding mechanisms of therapeutic change allow the therapist to identify,
program for, and use these factors to enhance therapeutic outcome.
◆ Cognitive factors potentially influencing therapeutic change are universalization,
insight, and modeling.
◆ Affective factors potentially influencing therapeutic change are acceptance, altru-
ism, and transference.
◆ Behavioral factors potentially influencing therapeutic change are reality testing,
ventilation, and interaction.
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1 Explain therapeutic mechanisms in psychiatric music therapy to a person unfamiliar with psychother-
apy and counseling.
2 How might a psychiatric music therapist assign reality testing as an inpatient homework assignment for
a group of patients on an acute psychiatric unit?
3 Although “transference” is often considered a psychoanalytic or psychodynamic term, how could a cog-
nitive behavioral music therapist define and use transference during group-based treatment for illness
management and recovery?
4 What other potential psychotherapeutic mechanisms may exist? Why and how might these terms be
synonymous with the nine mechanisms of change presented in this chapter?
5 How can music itself enhance—or detract from—acceptance?
Chapter 7
Transdiagnostic theory for group-based

psychiatric music therapy
If patients came in neat packages, so could treatments. But

everything we know suggests they do not. (Westen, 2006a, p. 397)
Introduction
For the first time in the music therapy literature base, this chapter applies transdiagnostic
theory to group-based psychiatric music therapy. While the concept of transdiagnostic the-
ory may be relatively simple to conceptualize and apply, the reasons supporting implemen-
tation of this theory into contemporary clinical practice are just as important—if not more
important—than the theory itself. Therefore, while the chapter will detail what transdi-
agnostic theory is, the chapter is designed to highlight and provide a rationale for why
transdiagnostic theory might be implemented in group-based psychiatric music therapy.
Problems with diagnoses

“Accurate diagnosis is the foundation of all medical interventions” (National Research
Council of the National Academies, 2011, p. 41). While this statement is difficult to dis-
pute, clinicians and researchers have long struggled with validity and reliability issues con-
cerning psychiatric diagnoses (Schmidt & Fonda, 1956; Shrout, Spitzer, & Fleiss, 1987).
Although diagnostic reliability measures have improved over time (Grove, Andreason,
McDonald-Scott, Keller, & Shapiro, 1981), they are still problematic and have even re-
sulted in the technical term, “poor diagnostic reliability” (Carlat, 2010, p. 52). Although
intricate, researchers have long noted that improvements in the validity and reliability of
clinicians’ diagnoses might make research more generalizable (Feigher et al., 1972; Spitzer,
Endicott, & Robins, 1978) and clinical practice more effective. The continuous debates re-
sulting from diagnostic disagreements have led to considerable changes of both the Inter-
national Statistical Classification of Diseases and Related Health Problems (ICD) and the
Diagnostic and Statistical Manual (DSM), ultimately resulting in the eleventh edition of
the ICD estimated to be published 2015 and the fifth edition of the DSM published in 2013
(Regier, Narrow, Kuhl, & Kupher, 2009). The process of updating the ICD and DSM re-
quires considerable effort. Taxonomic revisions typically result in debate (Dimsdale, 2010)
and, in the case of the DSM-V, considerable controversy (Frances, 2009; Spitzer, 2008).
120 Transdiagnostic theory
With each revision, the DSM has included more diagnostic categories (Carlat, 2010).
In the first edition in 1952, there were 106 diagnostic categories. The DSM-III, published
in 1980, contained 265 disorders. In the fourth edition, published in 1994, there were 357
diagnostic categories (American Psychiatric Association, 1994). Authors noted that the
historical development of erratic classification taxonomies has actually deterred the ad-
vancement of the social sciences and, in particular, the understanding of psychological
factors that affect mental illnesses (Mansell, Carey, & Tai, 2013). Kutchins and Kirk (1992,
1997) criticized the DSM, noting it “is a book of tentatively assembled agreements” (1997,
p. 28). Others have criticized the DSM’s poor validity and reliability (Caplan, 1995; Sparks,
Duncan, & Miller, 2006). Diagnoses can be imprecise as psychiatric diagnoses are mainly
based upon subjective and potentially biased patient-reported symptom profiles (Evan,
Muir, Blackwood, & Porteous, 2001). Moreover, diagnoses can be inaccurate as they are
based on predetermined symptoms or signs (NRCNA, 2011). The DSM and the ICD may
be modernized in the future as scientists continue to further understand molecular disease
models and precision medicine advances (Mirnezami, Nicholson, & Darzi, 2012).
There are numerous problems with the DSM, far beyond the scope of this chapter. One
of the noted problems, however, is the high frequency of the “not otherwise specified”
(NOS) diagnosis (de Bruin, Ferdinand, Meester, deNijis, & Verheij, 2007; Fairburn &
Bohn, 2005). The overuse of this purposely nonspecific term might lead one to conjecture
that the contributors to the DSM have problems with overspecification. Moreover, the
rate of comorbidity is astonishingly high (Kessler, Chiu, Demler, Merikangas, & Walters,
2005), complicating diagnosis, prognosis, treatment, and generalizability. Additionally,
many symptoms overlap diagnoses (Kendler, Neale, Kessler, Heath, & Eaves, 1992). For
example, “difficulty concentrating” is a component of 16 disorders, including dementia,
attention deficit hyperactivity disorder, bipolar disorder, and schizophrenia. Evans and
colleagues (2001) specifically noted the “wide overlap of symptoms between schizophre-
nia” (p. 35), bipolar disorder, and unipolar depression.
In addition to problems between diagnoses, there are problems within diagnoses.
People diagnosed with schizophrenia have “extraordinary variability” (Claridge, 1995,
p. 153). Thus, clinicians making medical decisions concerning diagnoses have had dif-
ficulty with the precision of this task, especially concerning schizophrenia (Robins &
Guze, 1970). Poor diagnostic reliability is not a new social phenomenon. Psychiatrists in
London diagnosed people with schizophrenia half as much as did psychiatrists in New
York (Cooper et al., 1972). In 1973, Rosenhan published a famous study further negat-
ing the worth of psychiatric classifications. Rosenhan used “pseudo-patients”—who did
not actually have psychiatric disorders—to gain admission to psychiatric hospitals. These
“patients” presented with a single problem, hearing an auditory hallucination of a voice
that said, “empty,” “hollow,” or “thud.” After pseudo-patients were admitted to the hospi-
tal, they discontinued presenting their abnormal symptoms. While most were diagnosed
with schizophrenia, all pseudo-patients received an inappropriate Axis I diagnosis. How-
ever, despite deceiving hospital staff, Rosenhan had not yet concluded his experiment. He
then informed hospital staff that he would attempt to admit additional pseudo-patients
Introduction to transdiagnostic theory 121
within the next three months. During this next phase of the study, the hospital staff sus-
pected that approximately 10% of the 193 patients they had interviewed for hospital ad-
mittance were pseudo-patients. Again, the hospital workers were incorrect as Rosenhan
did not actually send any pseudo-patients to the hospital: all 193 patients were, in fact, real
patients. Rosenhan concluded that psychiatric diagnoses were subjective and did not re-
flect inherent patient characteristics. While Rosenhan’s methods might seem extreme, the
findings of this seminal paper resulted in greater operational definitions in the DSM-III.
Other scholars have written about the difficulties specific to the diagnosis of schizophre-
nia. Glicksohn and Cohen (2000) stated that schizophrenia is characterized by variability
in symptomatology and neuropathology. The adoption of narrow, over-exclusive criteria
has attempted to resolve this dilemma, but the existence of mild and borderline conditions
continue to pose problems for clinicians and diagnosticians (Claridge, 1988). Another
problem in diagnosis is the unpredictable course of schizophrenia. Many clients seem to
constantly change, making it difficult to pinpoint the illness (Dolnick, 1998). Often the
plethora of constantly changing variables presented by clients overwhelms caregivers to
the point of frustration (Neufeld, 1977).
Psychiatric diagnoses can also lead to increased symptomology. Ralph (2005) noted that
diagnoses could lead to despair, especially when diagnoses are accompanied by negative
expectations concerning recovery from an incurable illness. Diagnoses can also lead to
isolation and denial, which may prevent help-seeking behaviors. Being diagnosed with a
major mental illness can be stigmatizing and may function to label the person rather than
describe the behaviors and symptoms associated with the illness. Diagnoses can result in
diminished help-seeking behaviors that may prolong inpatient hospitalizations due to de-
layed treatment and worsening of symptoms. In an attempt to better explain the course of
schizophrenia and minimize stigma, some contemporary theories of schizophrenia con-
ceptualize the illness as a neurodevelopmental disorder with a later-onset psychotic por-
tion (Insel, 2010).
Introduction to transdiagnostic theory

Frustrated with the limitations and problems associated with psychiatric diagnoses, Fair-
burn, Cooper, and Shafran (2003) proposed a rationale for a transdiagnostic theory of
eating disorders. The authors contended that anorexia nervosa, bulimia nervosa, and the
atypical eating disorders (eating disorder not otherwise specified [NOS]) share many dis-
tinctive clinical features. They proposed an individualized treatment approach in which
clinicians do not focus on the specific diagnosis. During the treatment of eating disorders,
these scholars were less concerned with specific diagnoses and more concerned with cog-
nitive, behavioral, and affective features and patterns that maintained the illnesses, re-
gardless of how the illnesses were labeled: “The patient’s specific eating disorder diagnosis
is not of relevance to the treatment. Rather, its content is dictated by the particular psy-
chopathological features present and the processes that appear to be maintaining them”
(Fairburn et al., 2003, pp. 522–523).
While transdiagnostic theory was specific to eating disorders in the above example,
other mental illnesses share distinctive clinical features. In fact, prominent scholars have
noted that psychotic illnesses are often not distinguishable (Claridge, 1995) and accurately
diagnosing a client is a complex procedure (Lave, 2003). As many psychiatric symptoms
can overlap diagnoses (Kendler, Neale, Kessler, Heath, & Eaves, 1992) and as many pa-
tients are polysymptomatic, the line of demarcation separating illnesses from one another
is often indistinct. Moreover, when psychosis or drug use is present, it can be especially
challenging to differentiate diagnoses.
In a book concerning applications of transdiagnostic theory to cognitive behavioral
therapy, Mansell, Carey, and Tai (2013) noted that shared cognitive and behavioral fac-
tors can be responsible for maintaining psychological disorders across all disorders.
Thus, cognitive behavioral therapy (and other therapeutic approaches) may be effec-
tive when used to target shared cognitive and behavioral factors without necessarily
using information about a patient’s specific diagnosis. Harvey, Watkins, Mansell, and
Shafran (2004) identified shared cognitive styles and behaviors across all adult psy-
chological disorders, noting that these shared factors maintain distress regardless of
specific psychological disorder. Although other authors have written about a transdiag-
nostic theory and approach (Corcoran et al., 2008; Ehring & Watkins, 2008; McManus,
Shafran, & Cooper, 2010), work in this area is still far from conclusive and it thus re-
mains theoretical.
Readers might also note the constant and continuous changing criteria and definitions
in the DSM. When the DSM was first published in 1952, homosexuality was considered a
psychiatric illness; it remained so until 1973. Researchers are in the continuous process of
collecting data in an attempt to make the DSM a more valid and reliable diagnostic tool.
While these continuous revisions are a testament to the tenacity of the profession and de-
sire to better help people with mental illnesses, they also lend support to a more broad and
encompassing transdiagnostic theory for use in clinical practice.
Applying transdiagnostic theory to music therapy

Based upon extensive clinical experience in a variety of psychiatric settings, the current
author proposes application of a transdiagnostic theory for the group-based music therapy
treatment of people with mental disorders. This theory places less emphasis on specific
psychiatric diagnoses and heightened importance on the actual treatment of patients and
their pathologies and presenting problems. Clinicians who use this theory recognize that
while all group members are individuals and have idiosyncratic presenting problems and
diagnoses, many group members share commonalities concerning behaviors, psychoso-
cial stressors, symptoms, affective states, maladaptive thinking, problems, and treatment.
Additionally, diagnoses do not necessarily characterize the disturbance that led to hos-
pitalization (Blader, 2011). For example, people are typically admitted to inpatient care
facilities not based on their specific diagnoses, but for a problematic behavior such as ag-
gression, change in mental status, or suicidal ideation.
While a component of educational music therapy for illness management and recov-
ery may include teaching patients about specific psychiatric disorders, educational music
therapy emphasizes transdiagnostic theory. Regardless of specific diagnosis, most psychi-
atric patients require somewhat similar treatment plans to promote successful illness man-
agement and recovery. This treatment plan typically includes adhering to medication as
prescribed, regular therapy, using coping skills, proactively managing stress, using social
supports, and self-monitoring. Thus, regardless of their specific diagnoses, many psychi-
atric patients receive similar treatment. Music therapists working in group-based settings
can address these treatments and skills during educational music therapy to enhance the
likelihood of illness management and recovery. In educational music therapy sessions,
therapists can address patients’ specific psychosocial stressors and work to collaboratively
problem solve. Since many patients share psychosocial stressors and can relate to one an-
other, application of transdiagnostic theory may enhance on-task behaviors, vicarious
learning, and treatment compliance.
Although transdiagnostic theory may be appealing, it will never negate the importance of
diagnosis. Taxonomy of diseases has been—and will likely continue to be—a driving force in
contemporary mental health care (NRCNA, 2011). However, music therapy clinicians using
the transdiagnostic theory place clinical emphasis on pathological features that maintain
the symptoms. In a similar manner, psychiatric inpatient units are not organized by diagno-
sis. Regardless of diagnosis, inpatients are typically assigned to particular psychiatric units
within a hospital based upon functioning levels and level of care and supervision required.
Thus, it would seem that the patient’s unique level of functioning may be a more appropri-
ate way to determine psychiatric therapeutic and psychoeducational programming than
specific diagnosis. Indeed, patients diagnosed with bipolar disorder or schizophrenia can
function on a continuum of higher and lower levels depending on the severity of the symp-
toms and behaviors as well as response to psychosocial and pharmacological interventions.
Transdiagnostic theory might be ideally applied to group-based music therapy treat-
ment of the major mental disorders. Typically, psychiatric music therapists have provided
group-based inpatient treatment (Silverman, 2007; Thomas, 2007). Music therapy treat-
ment groups are often inclusive, programmatic, and unit-based, meaning most or all pa-
tients on a particular unit are eligible to attend sessions. Ideally, group members would be
carefully chosen (Hadsell, 1974), but often all patients on a particular unit are referred to
group music therapy in an inclusive treatment model. Therefore, music therapy referral
and participation are typically not dependent on specific diagnoses. Rather, music therapy
referral and participation often depend on the unit and unit programming where the inpa-
tient temporarily resides. Moreover, inpatient psychiatric units are typically not diagnosis-
dependent, as patients are assigned to psychiatric units based upon behaviors, levels of
symptomology, care and supervision required, and levels of social and cognitive function-
ing. Psychiatric hospitals typically have multiple units that vary according to the level of
patient care that is required. Higher-functioning patients require less supervision; lower-
functioning patients require more. Thus music therapists usually treat groups of psychiat-
ric inpatients according to their levels of functioning instead of specific disorders—which,
given diagnostic complexities and changing courses of illnesses, may even be misdiagno-
ses. Music therapists are not responsible for the actual diagnosis of psychiatric patients.
Since this responsibility falls outside the parameters of a music therapist’s responsibilities,
training, scope of practice, and clinical duties, overemphasizing diagnosis may be inappro-
priate and could even hinder immediate alleviation of symptoms and teaching skills for
The transdiagnostic theory in group-based music therapy treatment may also be evi-
dent in substance abuse rehabilitation. Once medically detoxified, patients and clinicians
in these facilities often do not deal with the idiosyncrasies of a specific drug (e.g., beer
versus whiskey, heroin versus cocaine, or alcohol versus prescription drugs) or differen-
tiate between types of addiction. Instead, clinicians and patients typically recognize that
“addiction is addiction” regardless of the specific substance. In these settings, clinicians
often work to educate patients concerning the dangers of cross-addiction, in which one
addiction is suspended in lieu of another. For example, a patient might remain sober from
alcohol but begins abusing prescription drugs or becomes addicted to gambling. Thus,
use of a transdiagnostic theory may proactively facilitate treatment, recognizing patterns
of pathological behavior rather than focusing too much on specific substances and labels.
As a psychiatric diagnosis can contribute to internalized stigma and increase distress,
clinicians can focus on problematic behaviors and pathologies rather than the diagnostic
terms describing patients’ illnesses. In some of the author’s experiences, patients’ major
distresses may result from psychosocial problems rather than specific diagnoses. (Patients
may, however, feel anxiety concerning stigma when disclosing a mental illness, and are
often frustrated with lack of uniform and consistent diagnoses over time and repeated
inpatient hospitalizations.) Fisher and Ahern (1999) wrote, “The degree of interruption in
a person’s social role can be more important in affixing the label ‘mental illness’ to some-
one than his or her diagnosis” (p. 13). While patients may not necessarily experience dis-
tress related to specific diagnoses, they often experience distress as a result of psychosocial
stressors. Thus, rather than focusing on diagnoses in group-based treatment settings, psy-
chiatric music therapists might focus on problem solving and alleviating distress concern-
ing psychosocial stressors: interpersonal conflicts, vocational and financial difficulties,
and current living and environmental situations. In the author’s experience, many patients
share—or can relate to one another’s—psychosocial problems despite differences in pri-
mary and secondary diagnoses; sharing in turn facilitates universalization, normalization,
group cohesion, and vicarious learning in group-based treatment settings.
Consistent with evidence-based treatment for adults with psychiatric illnesses, music ther-
apists often treat patients for their mental and substance abuse disorders concurrently (see
Chapter 10). Indeed, integrated treatment for both substance abuse and mental disorders is
one of the six established evidence-based treatments for adults with psychiatric diagnoses
as there is much literature supporting this intervention (Drake, O’Neal, & Wallach, 2008).
Often, patients in these sessions may not even have a substance abuse disorder; treatment is
provided regardless in a preventive and wellness-based ideology. Moreover, patients rarely
present with a single disorder (Westen, 2006b) as they commonly have multiple diagnoses
often accompanied by a personality disorder. Alternatively, researchers have found “sub-

threshold” pathology to be prevalent (Fava & Mangelli, 2001). Thus, use of the transdiag-
nostic theory may allow the music therapist to address patients’ presenting behaviors and
problems and their commonalities, thereby potentially enhancing the therapeutic alliance.
Application of the transdiagnostic theory in group-based music therapy practice can
also facilitate universalization, cohesiveness between patients, vicarious learning, mode-
ling, and on-task behaviors. When a music therapist verbally recognizes that many psychi-
atric patients have similar behaviors, symptoms, and concerns—regardless of the specific
diagnoses—patients may begin to realize that they are not unique and that other group
members share their problems. Patients may be more attentive and engaged with the inter-
vention if they perceive that the therapeutic dialogue relates directly to them. For example,
a patient diagnosed with major depressive disorder may be uninterested in a discussion
concerning schizoaffective disorder. However, if a music therapist uses the transdiagnos-
tic theory, the therapist can instead facilitate dialogue concerning shared pathological
features (including depression and anxiety), internalized stigma, coping skills, isolation,
boredom, leisure skills, pharmacological interventions, and potential side effects resulting
from pharmacotherapy. The patient diagnosed with major depressive disorder will likely
be more attentive and engaged if she or he believes the conversation is relevant to her or
his unique needs. Thus, promoting dialogue concerning shared clinical problems and so-
lutions may facilitate the therapeutic mechanism of universalization. As universalization
is a key therapeutic mechanism for cognitive change (Corsini, 2008; Corsini & Rosenberg,
1955), patients may be more likely to engage, be motivated for treatment, and change be-
haviors, cognitions, and affective states if a music therapist uses the transdiagnostic theory.
Another positive aspect of the transdiagnostic theory is that by downplaying the di-
agnosis, the therapist can treat the patient in a more humanistic manner. Abandoning
diagnosis may help to avoid “disease personification”—giving the disease humanlike qual-
ities that can be perceived as insurmountable. If the clinician focuses on cross-diagnostic
commonalities and shared behaviors and clinical features, there can be less discussion and
personification of the disorder, a topic that can be disheartening for patients. Focusing on
symptoms and how they may be more common than specific psychiatric diagnoses may
lead to an increased depth of dialogue concerning the person and how to help that person,
rather than a dialogue concerning the disorder. In this manner, patients will not have to
identify themselves by their diseases; rather, they can identify themselves as people. This
may also result in a reduction of internalized stigma concerning mental illnesses. Labeling
and stigmatization can indirectly lead to sustained illness by negatively impacting self-
concept, help-seeking behaviors, and social outcomes (Markowitz, 2005).
Regardless of diagnosis, when pathologies rather than disorders are emphasized, pa-
tients can relate to one another and even potentially to the clinician. It is more humane
to treat the patient as a person and not force the patient into a pre-established diagnostic
category, often accompanied by stigma. In a well-articulated discussion of patient values
and preferences as they pertain to evidence-based practice in mental health care, Messer
(2006) wrote, “Diagnoses cannot capture the unique qualities and concerns that patients
bring to the clinician nor the specifics of the context in which their problems emerged
in the past and are talking place in the present” (p. 32). Additionally, Clarkin and Levy
(2004) noted that nondiagnostic client characteristics may be more accurate predictors of
psychotherapy outcome than DSM-based diagnoses. In this manner, therapy can be cus-
tomized to improve outcome based on level of functioning, coping style, resistance level,
stage of change, and personal expectations rather than a predetermined nonfluid diagnos-
tic category (Norcross, 2002). Messer provided an articulate and brief explanation: “It is
frequently more important to know what kind of patient has the disorder than what kind
of disorder the patient has” (p. 39). In short, transdiagnostic theory allows the clinician to
treat the person while focusing on the patient’s behaviors, cognitions, affective states, qual-
ities, and problems rather than a focusing on a disease or label.
Clinical example
The example in Box 7.1 is a fictional interaction depicting how a music therapist might use
the transdiagnostic theory with a group of adult psychiatric inpatients.
Box 7.1 Clinical Example of Transdiagnostic Theory

Setting: Adult acute psychiatric inpatient hospital
Patients: six adults with primary diagnoses of major depressive disorder (two pa-
tients), schizophrenia (one), and bipolar disorder (three patients)
Intervention: Songwriting
Group objective: During the 50-minute music therapy session, each patient will in-
dependently identify three healthy behavioral coping skills.
Music therapist: Today, we’ll be writing a song about coping skills we can use when
we’re stressed and having a hard time while living in the community. Let’s start with
identifying some potential healthy coping skills you might use when you are feeling
anxious and you become aware that those negative symptoms are coming back while
you are living in the community. It should help make composing lyrics easier after we
brainstorm together.
Patient 1 (bipolar disorder): I like to go for walks around the lakes.
Music therapist: Perfect! Walking—or any type of exercise—is a great coping skill.
And you can walk around the lakes with a friend and get some good chatting in, too!
Patient 1: I could walk my dog! Even though my dog doesn’t talk back to me, she’s
good company.
Patient 2 (schizophrenia): I don’t think you understand my situation! I can’t just call
people because they think I’m weird and messed up because I have schizophrenia. I’m
locked up in a psych hospital and nobody wants to hang out with me because of my
schizophrenia—they think I’m dangerous and will hurt them and need to be locked up
here at the hospital!
Clinical example 127
Box 7.1 Clinical Example of Transdiagnostic Theory (continued)
Music therapist: Thank you for sharing—this is certainly a difficult situation but
know that I’m glad you brought it up so we can talk about it and hopefully figure out
some methods for coping. Now, you might be the only person in the group diagnosed
with schizophrenia, but we are all here as inpatients in the hospital. And, many of us
might experience some of the same negative feelings, including depression, hopeless-
ness, and stress. Regardless of each person’s “diagnosis,” we all may have some of those
aspects in common. Has anyone else in the group ever felt stigmatized because of their
mental illness or having to come to a hospital like this?
Patient 1: Yep—I have!
Patients 4 and 5 (nodding heads in the affirmative): Yeah . . .
Music therapist: Has anyone else in the group ever felt depressed, hopeless, or
stressed?
Patients 1, 2, 4, and 5 (all nodding heads): Uh-huh.
Music therapist: Okay, I’m seeing some heads nodding in agreement, despite differ-
ent “diagnoses” or “negative feelings.” Thanks for sharing, folks. But I’m not concerned
with particular diagnoses—I’m concerned with you getting out of this hospital and
living the life you want to live. So . . . you aren’t alone in feeling this negative stigma to-
ward mental illness. What are some ways we might be able to cope with stigma or the
negative feelings you have when you feel stigmatized concerning being in a psychiatric
hospital? Let’s write some ideas on the board for our lyrics.
Patient 4: Support groups!
Patient 1: Family-based psychoeducation has helped my family better understand my
illness. My friend also said Al-Anon helped his friend learn about his addiction.
Music therapist: Nice! How does it feel to have family members attending those
sessions?
Patient 1: It feels good. You know . . . supported.
Music therapist: Can you please tell me a little more about support groups and family
psychoeducation?
Patient 1: Well, we all go to this group and chat about how my family can help me. You
know, when I’m cycling and isolating and not doing so good. The group leader, she’s
cool—it’s more like a class about managing all types of illnesses and not really like deep
therapy. We all work together and identify pros and cons of different potential solutions
for dealing with certain problems that come up. It’s better than me trying to tell my
family something. You know, they listen to the instructor better than they listen to me.
Music Therapist: Yes—these are huge assets for you. It sounds like you have an awe-
some group leader who really knows her stuff. And having family support is certainly
another big plus you having going for your recovery. I have some handouts concerning
family-based psychoeducation from NAMI, the National Alliance on Mental Illness.
Let me pass these out for all group members. [Music therapist passes out handouts to
group members.] Now, how can we make support groups to reduce stigma and increase
our illness management skills into lyrics for our song?
In this fictional example, the music therapist was able to redirect the dialogue from a
discussion specific to only schizophrenia toward an issue that all group members had in
common. Use of transdiagnostic theory enabled the music therapist to transcend the pa-
rameters of specific illnesses and redirect the conversation toward shared clinical features
and experienced problems to engage and involve other group members, regardless of diag-
nosis. Instead of a dialogue concerning stigma specific only to schizophrenia, the therapist
redirected the dialogue to stigma for people who have been hospitalized in a psychiatric fa-
cility and coping methods—thus allowing all members to relate and actively participate in
the dialogue. Additionally, concerning family-based psychoeducation, the music therapist
was able to recognize and focus on the patient’s assets and strengths rather than focusing
on a pathologizing condition such as bipolar disorder (also commonly referred to as manic
depression, a more deficit-ridden and potentially stigmatizing term).
Limitations
Limitations concerning applications of the transdiagnostic theory in group-based music
therapy might begin with outpatient groups. Often, outpatient groups—such as Narcotics
Anonymous or Double Trouble (for people with co-occurring mental disorders and sub-
stance misuse disorders)—tend to be more diagnosis-specific. Outpatient group therapy
sessions for people diagnosed with bipolar disorder, alcoholism, or gambling also tend
to be more specific. Thus, considerable care should be applied when using the transdiag-
nostic theory in these more specific types of typically outpatient clinical settings. For the
transdiagnostic theory to be effectively implemented in clinical settings, patients and clini-
cians must recognize that pathologies, cognitions, behaviors, affects, and problem-solving
techniques can be similar, regardless of diagnosis.
Another potential limitation of the transdiagnostic theory is that, for some patients, re-
ceiving a clinical diagnosis may actually provide them with some relief. Unknown or novel
symptoms can be stressful and often patients may become isolated in order to avoid disclo-
sure by keeping the pathologies to themselves. Being diagnosed may actually function as
universalization and normalization in that patients recognize that their disorders are real
and that other people are afflicted with them as well.
Sometimes, diagnoses are required for patients to be eligible to receive access to care,
benefits, or treatment. Access to care is imperative for psychiatric patients, a frequently
marginalized and disenfranchised population, as symptoms tend to worsen when patients
delay treatment. However, patients would still receive care even if a music therapist uses
the transdiagnostic theory in group-based treatment. The patients’ access to treatment
services would not be affected by use of this theory in clinical practice as diagnosing pa-
tients is outside the music therapist’s scope of practice.
As diagnoses have become more reliable over time, it is likely that they will continue
to evolve and become more specific. With advances in science and technology, clinicians
may even begin diagnosing patients based on brain scans, genetic tests, and molecular bi-
ology. It is anticipated that these innovations will eventually result in the ability to specify
Alternatives to transdiagnostic theory 129
molecular pathways that drive disease (NRCNA, 2011). A more sophisticated understand-
ing of molecular pathways might lead to better pharmacological and psychosocial treat-
ments. As symptoms can be difficult to objectively measure and are not necessarily the best
descriptors of disease, healthcare providers often miss opportunities for prevention and
early intervention or misdiagnose patients. Precision medicine, based on the study of mo-
lecular structures, might eventually reveal a new taxonomy for diseases (NRCNA, 2011).
A disease classification system based on molecular biology may offer improved pharma-
cotherapy and psychosocial interventions. Thus, the transdiagnostic theory may be used
more or less frequently in the future due to improved and more accurate diagnoses.
People who use the transdiagnostic theory do not necessarily believe that diagnoses are
of no value. I fully support the importance of systematic classification, as categorizations
are undoubtedly important for scientific inquiry as well as for funding interventions and
treatments. I merely propose that use of the transdiagnostic theory can engage psychiatric
patients during group therapy sessions by emphasizing shared and common pathologies
rather than specific diagnoses. Moreover, insurance reimbursement often requires diag-
noses (Walker, 2006), thus necessitating diagnostic assessment from a mental health pro-
fessional at hospitalization intake. In a similar manner, funding agencies often necessitate
diagnoses to enhance generalizability in quantitative studies. Although music therapists
do not diagnose patients, music therapists using the transdiagnostic theory can change
their treatment foci to symptoms and behaviors rather than addressing diagnoses.
Alternatives to transdiagnostic theory

For clinicians and researchers who choose not to use the transdiagnostic theory, there are
several recommended alternatives. Person-first language (e.g., a person with schizophre-
nia) may negate some of the stigma concerning mental disorders. Similarly, clinicians and
scholars can conceptualize patients as having a diagnosis rather than being (Walker, 2006)
a diagnosis (e.g., a patient diagnosed with schizophrenia). Additionally, in group-based
music therapy sessions, it is often not necessary to use the diagnosis. Instead of referring
to a person with schizophrenia, the music therapist can use the person’s first or preferred
name to promote humanistic and patient-centered dialogue.
In a paper concerning acute inpatient care for psychiatric disorders, Blader (2011)
grouped related diagnoses for purposes of his analysis. Blader noted, “Personality dis-
orders and substance use groups comprised either respective specific disorders” (p. E2).
Additionally, music therapists pursuing funding might consider using Blader’s taxonomy
of diagnoses as grant reviewers are often interested in a particular treatment for a partic-
ular disorder to enhance both internal and external validity. These groups and diagnoses
within groups are depicted in Table 7.1.
Readers should note that the transdiagnostic theory is likely best used during group
treatment contexts. When working with an individual, or an individual with his or her
family members present, more detailed information concerning the specific psychiatric
diagnosis is certainly appropriate.
Table 7.1 Alternative to Transdiagnostic Theory: Blader’s (2011) Categories for Psychiatric
Patients
Category Diagnoses
Depression group Major depressive disorder
Dysthymic disorder
Depression not otherwise specified
Psychosis group Schizophrenia
Schizoaffective disorder
Delusional disorder
Psychotic disorder not otherwise specified
Bipolar group Any bipolar disorder diagnosis
Cyclothymia
Anxiety group Generalized anxiety
Panic
Obsessive-compulsive
Phobic
Separation
Posttraumatic stress
Acute stress
Selective mutism
Social phobia disorders
Anxiety not otherwise specified
Dementia group All specified dementias
Mild cognitive impairment
Conduct problems group Attention deficit/hyperactivity
Oppositional disorders
Conduct disorders
Developmental group Mental retardation
Pervasive developmental disorders
Learning disorders
Psychophysiological disorders group Eating, sleep, and movement disorders
Somatoform disorders
Neuroleptic malignant syndrome
General medical conditions 316 group of the International Classification of Diseases (ICD)
(National Center for Health Statistics, Centers for Medicaid and
Medicare Services, 2006)
Other group Diagnoses in the 290–319 range of ICD
Finally, the trandiagnostic theory for group-based music therapy treatment is a theory
and will likely remain just that—a theory. It represents only one conceptualization con-
cerning group-based treatment for psychiatric consumers and is largely based upon the
author’s personal value system (favoring behaviors over labels that do not help treat the
patient and may be inaccurate, disheartening, and inadvertently perpetuate stigma). Cer-
tainly, systematic investigation is warranted as interested researchers test applications of
the transdiagnostic theory with various clinical populations.
Transdiagnostic theory implications

Perhaps use of the transdiagnostic theory will lead to less emphasis concerning specific
psychiatric diagnoses. Psychiatric diagnoses tend to carry more stigma than medical di-
agnoses. Reasons for this double standard are difficult to understand, but the result can be
internalized self-stigma, which in turn may diminish help-seeking behaviors, delay treat-
ment, and ultimately result in additional social marginalization and diminished quality
of life.
Is the continued use of a pathologizing and deficit-based vocabulary helping those with
mental disorders improve their lives? Might their use inadvertently function as a linguis-
tic ball-and-chain? (Walker, 2006). Insel, the director of the National Institute of Mental
Health, noted that words, language, and jargon may be problematic and unintentionally
lead to inappropriate conclusions or generalizations (Insel, 2012). Writing that deficit-
focused medical and psychological vocabularies based upon disease terminology are not
functioning to facilitate client change or social progress, Walker (2006) noted how the use
of language concerning mental disorders actually creates and perpetuates realities as social
constructs.
When we speak as if someone has a diagnosis or has a “mental illness” we are unwittingly creating
a reality—a reality in which human beings are transformed into the “mentally ill.” When we use
words such as “mental illness,” “schizophrenia,” “symptoms,” “tangential speech,” “clinical this or
that,” “treatment plan,” “assessment”—we are unwittingly bringing forth the entire context, the
hierarchical and paternalistic role relationship together with the sticky morass of pathological and
deficit-based perspectives. (p. 12)
Terms such as bipolar disorder or schizophrenia may inadvertently promote or even per-
petuate public, perceived, and internalized stigma concerning mental disorders. Although
mental illness terms and jargon have unquestionably evolved and improved over time,
perhaps psychiatric diagnoses maintain negative perceptions and stigma. A more edu-
cated, aware, and sensitive public discernment of mental illness is vital to improving treat-
ment options and understanding. Perhaps adoption of the transdiagnostic theory may
lead to a more informed general population where people with mental illnesses experience
less internalized and enacted stigma and are more apt to seek help, adhere to treatment
regimens, disclose their illnesses, advocate for their peers, and educate the public.
Referring to the DSM as the “bible of dysfunction” (Pearsall, 2005, p. 161) may seem ex-
treme. The intention of the DSM’s contributing authors was to help psychiatric consumers

◆ For the first time in the music therapy literature base, this chapter applied transdi-
agnostic theory to group-based psychiatric music therapy. While the concept of
transdiagnostic theory may be relatively simple to conceptualize and apply, the rea-
sons supporting implementation of this theory into contemporary clinical practice
are just as important—if not more important—than the theory itself.
◆ Psychiatric disease classifications have numerous problems, including subjectivity,
relying upon patients’ reported symptom profiles, the perseveration of stigma, in-
creased symptomology, and postponing help-seeking behaviors.
◆ Although diagnoses are unquestionably important, in group-based music therapy,
diagnoses typically do not functionally help patients.
◆ Transdiagnostic theory is a treatment approach in which clinicians do not focus
on the specific diagnosis. Rather, clinicians are more concerned with cognitive, be-
havioral, and affective features and patterns that maintain the illnesses as well as
pathologies and psychosocial stressors that group members share.
◆ Application of transdiagnostic theory may facilitate vicarious learning, on-task be-
havior, and greater engagement during group-based music therapy treatment.
by creating a basic and shared vocabulary and taxonomy. However, the DSM may be per-
petuating stigmatizing labels and inadvertently making psychiatric recovery more difficult.
Observation and classification—the mainstays of the DSM—remain vital components of
science and psychiatric care. Diagnoses will undoubtedly continue to be essential in an
effort to systematically study, classify, and treat mental disorders. However, adoption of a
transdiagnostic theory—in which practitioners focus on functional behaviors to enhance
recovery rather than labeling patients with stigmatizing diagnoses—may serve to promote
humanistic treatment in this often-disenfranchised and marginalized population.
It is important to remember that what we now diagnose as disease and emotional or mental dys-
function were not always there, waiting to be discovered. They are categories created by a sick-
ness-oriented healthcare system and they are as much opinion as fact. Healing requires looking
beyond labels and diagnoses to considering how we are relating with the world. (Pearsall, 2005,
pp. 160–161.)
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1 Have you—or anyone you have known—ever been misdiagnosed? How did this affect your perception
of healthcare? What were some consequences of this misdiagnosis?
2 How might the DSM be potentially misused or misinterpreted?
3 How can transdiagnostic theory be considered a more individualized and patient-centered approach?
4 What are potential limitations and problems of the transdiagnostic theory in grant writing and clinical
research?
5 Why may a music therapy clinician be reluctant to adopt a transdiagnostic theory?
6 Why may a psychiatrist be reluctant to adopt a transdiagnostic theory?
Chapter 8
The process of psychiatric

music therapy
In-Services
Scholarly journals such as the Journal of Music Therapy, the Nordic Journal of Music Ther-
apy, Arts in Psychotherapy, and Music Therapy Perspectives are valuable and effective meth-
ods for educating other professionals about music therapy and advocating for the field.
However, hospital administrators and staff members often may not have access to or do
not have the necessary time to learn about music therapy from scholarly journals. Thus, a
time-efficient, direct, customized, and more personable technique to educate others about
psychiatric music therapy is through the use of in-services. In-services are used specif-
ically for educating people on varied topics including nontraditional services—such as
music therapy—that may augment patient care. Music therapists can design and use spe-
cifically tailored in-services to increase the awareness of the profession for doctors, nurses,
social workers, therapists, administrators, patients, and other staff.
Despite the importance of educating others about music therapy, researchers have con-
ducted and published few studies examining the perceptions of music therapy in-services
in professional settings. Darsie (2009) examined interdisciplinary team members’ percep-
tions of music therapy and its function in a pediatric clinic. Silverman and Chaput (2011)
found a 15-minute in-service to be an effective and efficient technique to educate oncology
nurses and gain support for music therapy research. To date, however, there is no research
specific to psychiatric music therapy in-services. This research would be valuable in better
identifying how to design in-services and how they might influence perceptions of music
therapy specific to psychiatric settings. Continued education and advocacy for psychiatric
music therapy may lead to additional awareness, employment, and services for psychiatric
consumers.
Questions and corresponding suggestions for designing and providing in-services
are provided in Box 8.1. These questions and suggestions are derived from previous ex-
perience, teaching in-service units to university students, and Silverman and Chaput
(2011). Additionally, PowerPoint slides for a brief in-service concerning psychiatric
music therapy for psychiatric hospital staff and administrators are provided. Readers are
encouraged to modify the slides to be congruent with the needs, services, and mission
statement of the facility where they are presenting the in-service. Additionally, readers
are encouraged to continuously advocate for music therapy and educate related profes-
sionals about its therapeutic potential. A single in-service may be effective, but “booster”
IN-SERVICES 137
Box 8.1 In-Service Suggestions

1 Who is your audience? Be sure to use jargon with which attendees are familiar.
2 What is the purpose of the in-service? To obtain employment? To introduce music
therapy to a new unit? To initiate research? To educate new staff members? Estab-
lish objectives and a purpose for the in-service so participants will know the goal of
the presentation and their potential roles in how to accomplish it.
3 Include the academic and clinical training requirements of board-certified music
therapists.
4 Use experiential music therapy interventions with live music in order to demon-
strate musical competencies and differentiate skill sets from other staff members
who may use recorded music in their clinical work. Experiential learning will help
staff members understand music therapy more expediently and accurately by par-
ticipating in short interventions.
5 Use a minimum of four relevant and contemporary research studies, appropriately
cited and referenced. Due to time limitations and already busy schedules, an ex-
haustive discussion of the nuances of these studies is not advised; rather, the pre-
senter should focus on how beneficial results of music therapy treatment might
apply to the particular psychiatric unit. Meta-analytic reviews should be used
whenever possible to expediently provide overall effect sizes.
6 Use a remote controller to change slides.
7 Wear appropriate professional attire.
8 Use participants’ names whenever possible to model therapeutic behaviors that
may engage patients and enhance the therapeutic alliance.
9 Be familiar with the facility’s mission statement and make the presentation congru-
ent with it.
10 Propose music therapy as a way to augment existing services. Music therapy should
not replace any current services as presenting music therapy as a replacement for
an existing treatment may alienate some staff members.
11 Videorecord a trial run of the presentation and watch with peers for supportive and
constructive feedback.
12 In order to make the presentation readable, PowerPoint presentations should use a
white or light background with dark font. PowerPoint slides should be simple, easy
to read, and professional. Be cognizant of the amount of information on each slide.
Participants may devote more of their attention to the slide than to the presenter
if there is too much information on the slide. Outline-based formats using single
words for each bulleted point may keep participants engaged with the presenter
rather than the slides.
138 PROCESS OF MUSIC THERAPY
Box 8.1 In-Service Suggestions (continued)
13 Include aspects of referral, assessment, treatment planning, documentation, ter-

mination, and working with the interdisciplinary treatment team to coordinate
patient care within the presentation.
14 What aspects of the in-service will attendees remember a month later? Include a
unique component to make presentation stand out and be unforgettable.
15 Do not read the presentation. Be animated, dynamic, and engaging to demonstrate
group leadership and facilitation skills and the ability to keep psychiatric patients
on-task during music therapy sessions.
16 As hospital staff are busy and in-services take time away from their assigned work
tasks, keep the presentation as brief and concise as possible.
17 Be sure to include time for questions throughout the presentation and at the con-
clusion of the presentation. If attendees have questions during the presentation,
allow them to ask their questions and attempt to make the presentation an engag-
ing and interactive dialogue. Making the presentation as interactive as possible will
demonstrate and highlight the music therapist’s ability to manage questions, group
dynamics, and “think on her or his feet”—all valuable skills of a person leading
group or individual psychiatric music therapy sessions.
18 Encourage attendees to observe, attend, and participate in music therapy sessions.
19 Provide contact information on the slides and distribute business cards so attend-
ees can follow-up with the presenter.
Music Therapy for Illness Management &

Recovery: A Brief In-Service
University of Minnesota
silvermj@umn.edu
612-624-1091
IN-SERVICES 139
From the patients…

• “Music always put the mind at ease and makes a per-
son feel better.”
• “Awesome! I really loved this group and feel so
much better today. I woke up crabby and now I feel
happy(er).”
• “Most fun, good for concentration and focus and
interaction among patients. Valuable and fun which is
good combo especially while in the hospital.”
Purpose of In-Service
• To introduce music therapy as a psychosocial treatment
for psychiatric patients
• To learn about music therapy training, objectives,
approaches, and interventions
• To learn about selected research findings
What is Music Therapy?

• Flexible psychosocial treatment
• Music-based interventions
• Nonmusical goals & objectives
• Consumers do not have to be musicians!
• Variety of consumers
• Referral, assessment, treatment planning, documenta-
tion, termination
Training of Music Therapists

• Minimum of a bachelor’s degree
• Multiple supervised practica during coursework
• 6-month (approximately) clinical internship
• 1200 clinical hours
• Board-Certification Exam (MT-BC)
• UMN music therapy program emphasizes evidence-
based practice
Approaches to Psychiatric
Music Therapy (PMT)
• Borrow from related fields
– Psychodynamic
– Cognitive behavioral
• Group-based
• Short-term for acute-care patients
• Educational MT for illness management and recovery
• Contextual parameters guide practice
Songwriting
• Experiential: Blues songwriting
• Musical structure → lyrical flexibility
• Research
– Knowledge of coping skills and working alliance
with acute psychiatric inpatients (Silverman, 2011c)
– Depression and readiness to change with patients on
a detoxification unit (Silverman, 2011a)
IN-SERVICES 141
Lyric Analysis
• Experiential: “Don’t Stop” by Fleetwood Mac
• Research
– Type and frequency of verbalizations in acute psychi-
atric inpatients (Silverman, 2009)
– “Under the Bridge” Red Hot Chili Peppers rocku-
mentary: change and craving with patients on a
detoxification unit (Silverman, 2011b)
PMT Research
• No known side effects (Ulrich, Houtmans, & Gold,
2007)
• Systematic review and meta-analysis concerning music
therapy and schizophrenia (Mossler, Chen, Heldal, &
Gold, 2012)
– 8 RCTs, N = 483
– Global state, mental state, and social functioning
Conclusion
• Questions?
Thank you for your time!

I look forward to working with you!

612-624-1091
silvermj@umn.edu
References
Mossler, K., Chen, X. J., Heldal, T. O., & Gold, C. (2012). Music therapy for people
with schizophrenia and schizophrenia-like disorders. Cochrane Database of
Systematic Reviews, 12, 1–68. doi:10.1002/14651858.CD004025.pub3
Silverman, M. J. (2009). The effect of single-session psychoeducational music ther-
apy on verbalizations and perceptions in psychiatric patients. Journal of Music
Therapy, 46, 105–131.
Silverman, M. J. (2011a). Effects of music therapy on change and depression on
clients in detoxification. Journal of Addictions Nursing, 22, 185–192. doi:10.31
09/10884602.2011.616606
Silverman, M. J. (2011b). Effects of music therapy on change readiness and craving
in patients on a detoxification unit. Journal of Music Therapy, 48, 509–531.
Silverman, M. J. (2011c). The effect of songwriting on knowledge of coping skills
and working alliance in psychiatric patients: A randomized clinical effectiveness
study. Journal of Music Therapy, 48, 103–122.
Ulrich, G., Houtmans, T., & Gold, C. (2007). The additional therapeutic effect of
group music therapy for schizophrenic patients: A randomized study. Acta
Psychiatrica Scandinavica, 116, 362–370.
in-services will provide necessary reiteration of the material for staff who may already
be familiar with music therapy. As staff turnover in psychiatric facilities is typically high
and problematic (Aarons & Sawitzky, 2006), such booster sessions can also function to
educate newer staff.
Referral
The referral process for psychiatric music therapy services is typically idiosyncratic,
meaning that referral is unit- and facility-dependent. Referral procedures depend
largely on whether a unit offers individual music therapy, group music therapy, or both.
Some psychiatric facilities make music therapy referrals for treatment by unit, mean-
ing that all patients on a particular unit are eligible for group-based music therapy
sessions. In these cases, music therapy functions as a programmatic treatment. Carr,
Odell-Miller, and Priebe (2013) referred to this model as “open ward groups” (p. 3),
although these sessions may take place in a room not physically located on the unit.
Other facilities can have a more individualized music therapy referral process in which
only specific patients meet eligibility criteria for group or individual music therapy ser-
vices. Additionally, depending on the facility and psychotherapeutic and psychoedu-
cational programming offered, some patients may even participate in both individual
and group music therapy.
Depending on the protocol of the facility, referrals may be made by members of the
interdisciplinary treatment team that typically includes a psychiatrist, psychologist, phar-
macist, social worker or discharge coordinator, dietician, nurse, therapist, and teacher. As
Assessment 143
these professionals may not be aware of the potential benefits of music therapy, it is vital
that the music therapist educates them concerning eligibility criteria and benefits of music
therapy. In my experience, treatment team members may believe that music therapy is
most effective or appropriate for patients who are musicians. While music therapy can be
valuable for patients with previous musical experience, music therapists should stress that
music therapy is a process-driven modality and patients do not need to be musicians to
benefit.
Assessment
Similar to referral, assessments are often dictated by facility needs, programming, ser-
vices, and policies. Facilities typically have a number of different staff members who
may conduct distinctive assessments germane to their areas of specialty. Assessments
should be designed according to the unique needs of the facility (Isenberg-Grzeda,
1988) and the requirements of regulatory organizations such as the Joint Commission
on Accreditation of Health Organizations or the Health Care Financing Administra-
tion (Norman, 2012). Specific to cognitive behavioral assessments, practitioners de-
termine problematic behaviors, cognitions, and emotions as well as their functional
relationships with one another. The assessment may include antecedents and conse-
quences as well as environmental stimuli that elicit desired and nonpreferred responses
(Craske, 2010).
Music therapists may conduct a music therapy–specific assessment or a more general
assessment as a member of the interdisciplinary rehabilitative or educational treatment
team. Assessment should not solely focus on pathology but also include subjective
well-being and an understanding of the person’s life goals and how her or his prob-
lems might interfere with the acquisition of those goals. Corrigan, McCracken, and
McNeilly (2005) noted the importance of systematically obtaining the person’s per-
spectives concerning her or his problems. This information can be used to collabora-
tively design appropriate treatment plans and to engage and motivate clients to attend
and participate in music therapy sessions. During the assessment, it is vital that music
therapists measure baseline functioning so they can formulate realistic and attainable
clinical objectives.
The purposes of the music therapy assessment include collecting information about the
client, her or his strengths and weaknesses, presenting problems, and treatment goals, and
also orienting the client to music therapy treatment. During the assessment, music thera-
pists begin to establish rapport and working alliance with patients. Assessments can be the
ideal occasion to ask patients for their own concerns and questions relating to treatment,
music therapy, and hospitalization. It is during the assessment that the music therapist has
the opportunity—and ethical responsibility—to explain music therapy to the client, an-
swer potential questions about music therapy treatment, and attempt to engage her or him
in the music therapy process. If patients have a thorough understanding of music therapy,
they may be more likely to accept it as a viable psychosocial treatment. Assessments may
also include standardized testing and self-reports to obtain quantitative indicators of de-
pression, anxiety, treatment eagerness, pathology, and well-being.
In longer-term settings in which goals may include teaching music skills, music thera-
pists might consider using competency-based music performance assessments with cli-
ents who have previous musical experiences and musical abilities. For example, if a patient
notes that she has basic guitar abilities and has a desire to augment these skills and learn
to improvise, the music therapist might consider having the patient demonstrate her basic
abilities (e.g., “Please play me a song you know really well”) or even a more specific task,
such as requesting her to play a specific scale (e.g., “Please play me an A minor pentatonic
scale with the root on the sixth string”). These competency-based and experiential musical
demonstrations can provide the music therapist with valuable data concerning where to
initiate guitar improvisation sessions with this client. Moreover, it is likely that rapport and
working alliance will develop faster if the patient’s requested music needs and preferences
are assessed and implemented into the treatment as quickly as possible.
Cassity and Cassity (1994) surveyed psychiatric music therapy clinical training direc-
tors concerning assessment and treatment. The authors found that 83% of participants
assessed both nonmusical and musical behavior while 94% of participants indicated they
did not administer standardized tests used by other professionals. Respondents indicated
a need for a standardized activity assessment and a standardized nonmusical behavior
music therapy assessment. However, although standardized assessments would be ideal,
the context and parameters of the facility often dictate what is to be included—and not
included, to avoid redundancy—in a music therapy assessment.
Assessments are also crucial in identifying potential adverse reactions to music or music
therapy. For example, a certain song may remind a client of when a client’s daughter died
at a young age. If the music therapist uses this song in group therapy, the client may have
a potentially negative and even traumatic reaction that might adversely affect other group
members. Thus, knowing what music to avoid is a vital component of ethical, responsible,
and effective psychiatric music therapy practice.
Assessment is an ongoing process. For example, if using self-report measures to quan-
tify patient progress, music therapists should use brief, psychometrically strong tools
that are suitable for repeated measures over time and that are sensitive to change. Just as
there is no standardized format for a cognitive behavioral assessment (Dobson & Dob-
son, 2009), there is no standardized format for a psychiatric music therapy assessment.
Although authors have recommended that assessments be brief (Braswell et al., 1986;
Cassity, 1985), the following sample assessment (Box 8.2) is purposely exhaustive; clini-
cians are recommended to study other facility assessments to avoid redundant questions
(which may hinder the development of rapport and working alliance) and efficiently and
expediently manage clinician and patient time. This information can be gathered through
a combination of chart or medical records review and a face-to-face interview with the
patient.
Assessment 145
Box 8.2 Sample Music Therapy Assessment

General Demographic Information
Last Name:
First Name:
Preferred name:
Patient identification number:
Sex:
Age:
Psychiatric diagnosis:
Medical (nonpsychiatric) diagnosis:
Psychosocial problems:
Number of previous psychiatric hospitalizations:
Voluntary admission: Yes: □ No: □
Legal issues or complications:
Reason for hospitalization and presenting problems:
Referred by:
Reason for referral:
Case manager:
Patient goals during hospitalization:
Cultural/ethnic background:
Self-perceived level of acculturation:
Religion/Spirituality:
Allergies:
Highest educational level completed:
Ability to read: Yes: □ No: □
Employment history:
Employment and vocational goals:
Previous military service:
Current living situation:
History of homelessness:
Preferred learning style:
Learning disabilities:
Assistive devices:
Marital/relationship status:
Children or dependents:
Emergency contact person and phone:
Biopsychosocial Information
Patient definition of health/wellness:
Potential causes of stress/anxiety:
Substance abuse history:
Box 8.2 Sample Music Therapy Assessment (continued)
Substances of choice:
Potential motives, triggers, or high-risk situations that lead to substance abuse:
Perceived consequences of substance abuse:
Medications and pharmacological treatments:
◆ Reasons for using pharmacological treatments:
Talk-based therapies:
◆ Reasons for using talk-based therapies:
Creative arts therapies:
◆ Reasons for using creative arts therapies:
Coping skills in facility:
Coping skills outside facility:
Leisure skills:
Hobbies:
Social supports:
Sleep patterns and habits:
Socioeconomic status:
Prodromal, recurring, and/or residual symptoms:
Family illness history (heart disease, cancer, etc.):
Physical limitations:
Music Therapy Information
Previous music therapy experience? Yes: □ No: □
◆ If yes, preferred music therapy interventions:
General music preferences:

◆ Genres:
◆ Artists:
◆ Songs:
Potential songs, artists, or interventions to avoid during music therapy:
Previous music experiences:
Previous use of music as a coping skill:
Previous experience in other creative arts therapies? Yes: □ No: □
◆ If yes, preferred interventions:
Interest and potential access to recorded music:
Interest and potential access to live music in the community:
Interest and potential access to participation in active music making in the community:
What do you hope to accomplish in music therapy?
Free-Response Questions
What keeps you going on bad days?
What are three words that best describe you?
Treatment planning 147
Box 8.2 Sample Music Therapy Assessment (continued)
How might someone who knows you well describe you?

How have you overcome past problems?
If all your problems were solved, what would your life look like?
What are some past accomplishments of which you are proud?
What motivates you for treatment?
Do you have any feedback concerning this assessment?
Observations During Assessment
Eye contact: Yes □ Some □ No □ Comments and observations:
Side effects: Yes □ Some □ No □ Comments and observations:
Hygiene and appearance: Well-groomed □ Needs improvement □ Disheveled □
Comments and observations:
Affect: Bright □ Minimal □ Flat □ Congruent to situation □
Incongruent to situation □ Comments and observations:
Motor Coordination: High □ Some □ Low □ Comments and observations:
Verbalization Frequency: High □ Some □ Minimal □ Comments and
observations:
Speech: Reality-based □ Spontaneous □ Tangential □ Overtly psychotic □
Pressured □ Comments and observations:
Orientation:
◆ Person □
◆ Place □
◆ Time □
Additional comments and observations:
Treatment planning
Treatment planning is a vital aspect of the music therapist’s clinical obligations and re-
sponsibilities. However, treatment planning will largely depend upon results of the as-
sessment as well as the educational and therapeutic programming that the facility offers.
For example, if unit nurses provide educational sessions in which patients learn about
medications and how medication adherence can help them accomplish their goals, music
therapists may choose to design treatment plans around improving knowledge of healthy
coping skills to avoid redundancy with the nurses’ programming. Thus, the music thera-
pist’s contribution to the treatment plan depends on other psychoeducational and psycho-
therapeutic programming delivered by the interdisciplinary treatment team members and
available hospital resources.
Although there are many types of treatment plans idiosyncratic to each facility, a fic-
tional example is used in Box 8.3.
Box 8.3 Sample Treatment Plan

Brief patient summary:
F. is a 46-year-old Caucasian female who was admitted to the hospital due to suicidal
ideation and bizarre behaviors. She presented with a flat affect and made minimal
eye contact. When asked what triggered her depression, she was having “trouble at
work” and was worried about losing her job. F. stated she had been hospitalized three
times in the past for depression, with the most recent hospitalization occurring two
years ago. F. stated she had discontinued therapy with her counselor but was still
taking her antidepressants as prescribed. F. stated that she used to take piano lessons
and enjoyed music, but when she was depressed, she stopped listening to music and
isolated herself in her apartment. F. stated her only coping skill was watching televi-
sion and that additional coping skills would be helpful to her, especially in work and
home settings.
Music therapy treatment:
F. will be offered group music therapy once per day while on the unit. As F. presents
with depression and she stated she wanted help developing coping skills to counteract
her depression, group music therapy will be provided daily to increase knowledge and
use of behavioral coping skills and linking her goals with continued psychosocial treat-
ment upon discharge. This writer will also attempt to engage F. in daily private piano
lessons.
Initial music therapy treatment objective:
F. will be able to identify three positive behavioral coping skills she can use both at
work and in the community at the conclusion of her second music therapy session.
This writer will continue to monitor and additional objectives will be formulated
collaboratively.
Music therapy techniques:
F. will participate in group-based psychoeducational songwriting, lyric analysis, and
recreational music therapy interventions to further develop her behavioral coping
skills repertoire and decrease feelings of isolation. During sessions, this writer will help
F. to identify appropriate behavioral coping skills and negative cognitive processes that
are antecedents of depressive affective states.
Generalization techniques:
This writer will collaboratively formulate written and behavioral assignments with F.
so she can continue to identify and monitor her negative cognitive processes and use
coping skills when feeling distressed. F. will rate her depression severity on a 7-point
Likert-type scale every eight hours and provide descriptors concerning situational
risk factors that increased her depression and techniques she used to decrease her
depression.
Objectives 149
Objectives
In the contemporary era of heightened accountability in healthcare environments, clinical
objectives remain an essential aspect of psychiatric care. Thus, regardless of philosophical
orientation, it is imperative that psychiatric music therapists formulate clinical objectives
using observable and measurable behavioral terms. Objectives should be idiosyncratic
and dependent on type of facility, length of treatment, other psychosocial and psychoe-
ducational programming, strengths and areas for improvement, and patients’ values and
preferences. Including patients (if they are oriented to reality) in the formulation of clinical
objectives will likely engage and motivate them for music therapy treatment. Tryon and
Winograd (2001) highlighted the importance of collaborating with the client to formulate
and agree upon treatment goals in order to maximize probabilities of optional treatment
outcomes. Otto, Reilly-Harrington, Kogan, and Winett (2003) suggested treatment out-
comes are improved with additional input from the client and less input from the therapist.
Dobson and Dobson (2009) made eight recommendations for formulating clinical objec-
tives for use during cognitive behavioral therapy (see Box 8.4).
Clinicians also might consider being flexible with objectives. Often, patients may meet
objectives quickly or may not demonstrate any observable or measureable progress toward
achieving the objectives. In these cases, music therapists should consider modifying ob-
jectives so the patient can make observable and measureable progress and objectives are
neither too easily accomplished nor too difficult to achieve.
Music therapists should avoid using music jargon in the formulation of their treatment
plans and objectives so other treatment team members can interpret treatment and pro-
gress. For example, if music therapist and the patient set an objective for a patient to play a
two-octave ascending and descending A minor pentatonic scale (root on the sixth string)
from memory on the guitar using alternating picking, the treatment team may have dif-
ficulty understanding the objective or how music therapy is being used to help the patient’s
Box 8.4 Recommendations for Clinical Objectives

◆ Be collaborative with patient and treatment team.
◆ Set an initial goal that is likely to lead to an immediate reduction of distress.
◆ Make sure the client knows how to measure change and assess outcome.
◆ Be specific; avoid vague goals.
◆ Goals can be set to increase something positive or decrease something negative.
◆ Goals can be categorized into cognitive, behavioral, affective, interpersonal, and en-
vironmental realms.
◆ Use the SMART acronym to facilitate collaborative goal setting (specific, measure-
able, achievable, realistic and relevant, and time-limited).
◆ Goals may be measured in the immediate, short-, medium-, and long-term.
Box 8.5 Educational Goals and Objectives for Illness

Management and Recovery
Examples: Educationally Based Goals and Objectives in Psychiatric Music Therapy
Practice to Augment Illness Management and Recovery
Patient: 34-year-old male with bipolar disorder on an acute-care inpatient psychiatric
unit; admitted during recent manic episode
Goal: Increase illness management and recovery knowledge and skills
Immediate-term educational objective (inpatient):
◆ Within the group-based music therapy session, patient will identify and verbalize
three positive behavioral coping skills for use as an outpatient.
◆ Within the group-based music therapy session, patient will identify three reasons to
remain on his medication as prescribed.
Short-term educational objective (inpatient):
◆ Patient will identify and verbalize three social supports in the community after three
music therapy sessions.
Long-term educational objective (outpatient):
◆ Patient will attend ten family-based music therapy educational sessions with at least
one family member within six weeks of hospital discharge.
functional illness management and recovery skills. Thus, the music therapist might frame
the objective in the treatment plan to help improve frustration tolerance (i.e., number of
self-defeating comments made during the music therapy session) or cognitive ability (i.e.,
remembering instructed material including strings, frets, fingers, positions, and notes).
See Box 8.5 for more examples.
Developing rapport and therapeutic alliance

The therapeutic alliance, also known as working alliance, is the quality and strength of the
collaborative relationship between the person receiving therapy and the person providing
it (Norcross & Lambert, 2006). Researchers have investigated this relationship in clinical
studies because of consistent links between measures of alliance and therapeutic outcome
(Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000). Researchers have regularly
found that the stronger the alliance, the greater the therapeutic change (Horvath & Bedi,
2002; Orlinsky, Ronnestad, & Willutzki, 2004); qualitative evidence indicates that posi-
tive relationships can facilitate engagement and foster recovery (Priebe, Watts, Chase, &
Matanov, 2005). There has also been consistent evidence that working alliance can be an
important predictor of treatment retention (Meier & Donmall, 2006) and better short- and
long-term outcomes in patients with severe mental illnesses (McCabe & Priebe, 2004).
In a meta-analysis of individual psychotherapy for adults, researchers found that weaker
alliance was associated with premature discontinuation of therapy (Sharf, Primavera, &
Diener, 2010).
Although the relationship between the client and the therapist is not considered a pri-
mary component or necessity for change in cognitive behavioral therapy, the relationship
is still important (Craske, 2010). In fact, cognitive behavioral therapy is typically more
effective when delivered by a therapist who is warm and empathetic (Keijsers, Schaap,
Hoogduin, & Lammers, 1995). Additionally, treatment outcomes can be improved by a
positive alliance as it enhances the perceived value of reinforcement from the therapist,
which can result in increased client engagement and motivation (Craske, 2010).
There is a great deal of literature supporting the relationship between working alliance
and successful counseling outcomes (Al-Darmaki & Kivlighan, 1993; Carroll, Nich, &
Rounsaville, 1997; Connors, DiClemente, Longabaugh, & Donovan, 1997; Goering, Wa-
sylenski, Lindsay, Lemire, & Rhodes, 1997; Kivlighan & Shaughnessy, 1995, Kokotovic &
Tracy, 1990; Mallinckrodt & Nelson, 1991), regardless of treatment orientation (Hor-
vath & Symonds, 1991). Researchers who conducted a meta-analysis established a rela-
tionship between therapeutic alliance and clinical outcome in varied types of treatment
(Horvath & Symonds, 1991). It should be noted, however, that the client’s perception of
working alliance is more strongly correlated with successful therapeutic outcome than
the therapist’s perception (Bachelor & Horvath, 1999; Busseri & Tyler, 2004; Connors
et al., 1997; Horvath & Symonds, 1991; Luborsky, 1994).
Specifically, a strong working alliance has been associated with improved outcomes with
various clinical populations such as cocaine dependence (Carroll, Nich, & Rounsaville,
1997), personality disorders (Hellerstein et al., 1998), and depression (Castonguay, Gold-
fried, Wiser, Raue, & Hayes, 1996). Horvath (1994) conducted a meta-analysis and found
that the working alliance was related to positive outcomes in counseling with the average
effect size being .26. Additionally, the severity of the client’s symptoms did not affect work-
ing alliance (Horvath, 1994). In a related investigation, Duncan, Miller, Wampold, and
Hubble (2010) noted that 80% of positive treatment outcomes were a result of the client
believing in the therapist’s ability.
Bordin (1979, 1980) is credited with developing theories of working alliance. He be-
lieved that the alliance was a joint feature of the treatment relationship between the
therapist and client and represented the chief ingredient of client change. This relation-
ship was built upon three components: (a) the quality of the interpersonal bond between
therapist and client; (b) the client’s agreement with the therapist that the therapeutic tasks
address her or his problems; and (c) the agreement on treatment goals (Hatcher & Gil-
laspy, 2006). Due to a sense of ownership concerning collaboratively formulated objec-
tives, it was theorized that the working alliance makes it possible for the client to accept
the counseling progression (Horvath & Symonds, 1991). Although Bordin’s theory was
developed mostly through knowledge of psychoanalytic literature on alliance, contem-
porary working alliance theories apply to all types of helping relationships regardless of
orientation (Hatcher & Gillaspy, 2006). Thus, despite being founded in psychoanalytic
roots (Freud, 1912/1958), working alliance is considered a transtheoretical concept in
the contemporary literature base (Castonguay, Goldfried, Wider, Raue, & Haynes, 1996).
Bordin (1994) noted that the working alliance was not a specific intervention but rather
may facilitate the use of various counseling interventions, making it functional across
theories (Lustig, Strauser, Rice, & Rucker, 2002).
Concerning working alliance in the treatment of consumers in substance abuse treat-
ment, there is evidence that working alliance is one of the most reliable predictors of out-
come and retention (Meier & Donmall, 2006). Scholars and clinicians have noted that
working alliance is essential for behavioral change in patients with addictions (Dansereau,
Joe, & Simpson, 1993). In a study of various therapies in the treatment of alcoholism, work-
ing alliance was predictive of sobriety at one-year follow-up (Connors, DiClemente, Car-
roll, Longabaugh, & Donvoan, 1997). The relationship between the counselor and client
may be the most consistent predictor of positive change (Fuhriman & Burlingame, 1990;
Strong, Welsh, Corcoran, & Hoyt, 1992). Researchers have found that during treatment
intake, client motivation correlates with therapeutic relationship (Simpson, Joe, Rowan-
Szal, & Greener, 1997). De Leon (1995) and Simpson (1993) indicated that the therapeutic
relationship between counselor and client facilitates treatment retention. Simpson, Joe,
and Rowan-Szal (1997) found treatment engagement (operationally defined as counseling
session attendance and mutual ratings of counselor-client relationship) to be an important
variable. Researchers have noted that working alliance and rapport are important compo-
nents of effective treatment as the therapist helps the client change perceptions of addic-
tion, drug use, and lifestyle (Joe, Simpson, & Broome, 1999).
In a paper concerning mediators and mechanisms of change in psychotherapy research,
Kazdin (2007) argued that the relationship between working alliance and therapeutic out-
come could be conceptualized as a timeline problem. Kazdin suggested that early in the
treatment process, patients may feel symptom relief. As a result of the symptom relief, pa-
tients form a positive alliance with the therapist. Thus, perhaps working alliance is not nec-
essarily responsible for improved symptoms as there is no datum concerning the timeline
of these variables. From an educational music therapy perspective, working alliance may in-
crease as patients learn knowledge and skills to facilitate illness management and recovery.
As working alliance is such an important aspect of the treatment, it is vital that music
therapists begin to develop the therapeutic relationship as soon as the assessment and
treatment process initiate. To date, there is some psychiatric music therapy research con-
cerning working alliance. In two separate posttest-only randomized music therapy stud-
ies using an active control group receiving talk-based verbal therapy or psychoeducation,
there was a slight tendency—although not significant—for experimental participants re-
ceiving music therapy to have higher working alliance scores than their counterparts in the
nonmusic active control conditions (Silverman, 2009a, 2011). In a related investigation,
Silverman (2014b) found acute-care psychiatric inpatients who participated in a live lyric
analysis session had higher trust in the therapist scores than patients who participated in a
recorded lyric analysis session. Future research is warranted concerning working alliance
as a dependent measure.
The following nonexhaustive list (Box 8.6) includes techniques music therapists can use
to positively influence working alliance and therapeutic rapport.
Box 8.6 Techniques for Developing Working Alliance

◆ Play live age-appropriate music and initiate music as patients enter the therapy room.
◆ Use active and engaged listening techniques in an attempt to understand patients’
unique discernments of their perceived presenting problems.
◆ Be sympathetic when appropriate.
◆ Acknowledge and validate the weight and gravity of the patient’s situation and
circumstance.
◆ Have unconditional positive regard and respect for the patient.
◆ Emphasize that it is not the client that constitutes the problem; rather it is the behav-
iors, emotions, and cognitions that are the problems (Craske, 2010).
◆ The therapist does not have to be an expert in alleviating distress but rather collabo-
rates with the client to develop potential solutions to solve and manage her or his
problems.
◆ To enhance self-efficacy and working alliance, empower the client to decide pros
and cons of both status quo and change or potential solutions to problems.
◆ Ask for, accept, and implement feedback from the patient when appropriate.
◆ Ask only a single question at a time that is brief, direct, and open-ended (Mansell,
Carey, & Tai, 2013).
◆ Use self-disclosure and modeling techniques when appropriate.
◆ Be transparent and realistic concerning what the client and therapist might accom-
plish during music therapy.
◆ Use clients’ preferred names whenever possible.
◆ Use high amounts of varied and specific verbal and nonverbal reinforcements.
◆ Incorporate humor in an appropriate manner but avoid sarcasm.
◆ If a patient describes an interpersonal conflict in the session, ask the group for po-
tential solutions and immediately role-play potential scenarios with the patient.
◆ Be sensitive to clients’ nonverbal communication as well as the nonverbal commu-
nication of the therapist.
◆ When asking questions to elicit interaction, discussion, and problem solving, avoid
framing questions in the negative. Rather, frame questions in manners that inspire hope
and self-efficacy. For example, instead of asking, “How might relationships with fam-
ily and friends been damaged as a result of a mental illness?” ask for specific behaviors
using a positive context: “What are behaviors we can use to repair relationships with
family and friends that have been potentially damaged as a result of a mental illness?”
◆ Avoid absolutes by using open-ended questions with many possible responses, such
as “What might be some inexpensive social leisure skills for you and a friend?”
Problem solving as a collaborative approach

Problem solving is a cognitive process in which people attempt to find suitable solu-
tions for problems (Perla & O’Donnel, 2004). Readers should be aware that while cog-
nitive behavioral therapists frequently use problem solving in a general format, some
scholars consider problem solving to be a stand-alone treatment (Chang, D’Zurilla, &
Sanna, 2004; D’Zurilla & Neza, 2006). In a meta-analysis, researchers have found that
problem-solving therapies can reduce mental health problems (Malouff, Thorsteinsson,
& Schutte, 2007). Some authors have conceptualized problem solving and improving cli-
ents’ problem-solving skills as primary counseling objectives (Gelatt, 1989; Husband &
Platt, 1993). Experts in the counseling literature have even categorized the counseling
process as a cooperative problem-solving activity (Dixon & Glover, 1984; Fretz, 1982;
Heppner, 1978; Heppner & Krauskopf, 1987). Specific to acute care, researchers have
found that brief problem-solving treatment methods can be successful methods to treat
psychiatric consumers quickly. During brief problem-solving treatment in acute psy-
chiatric treatment, Dowrick and colleagues (2000) recommended that clinicians follow
three main steps (Box 8.7).
In family-based psychoeducational programs for people with schizophrenia, Falloon
and colleagues (1984) identified six essential steps for problem solving. These steps can be
used with a variety of consumers in various settings and readers are encouraged to gener-
alize the problem-solving steps to their own clinical practice (Box 8.8).
Box 8.7 Three-Step Problem Solving

1 Associate patients’ symptoms with their problems.
2 Define and clarify problems.
3 Attempt to solve the problems in a structured method.
Box 8.8 Six-Step Problem Solving

1 Define the problem and goal.
2 List all possible solutions.
3 Discuss advantages and disadvantages of each potential solution.
4 Choose the solution that best fits the situation.
5 Plan how to carry out the solution in detail.
6 Review the implementation of the solution.
Assignments outside of the therapy session to facilitate generalization 155
Assignments outside of the therapy session to facilitate

generalization
It is common practice in cognitive behavioral therapy to make “homework” assignments
so clients can practice new behaviors and generalize skills learned in therapy to different
environmental contexts. Homework assignments can take place during inpatient or out-
patient treatment. During inpatient treatment, homework assignments can occur between
music therapy sessions. Silverman (2009b) suggested music therapists give the lyric sheets
during lyric analysis interventions to clients. The music therapists can use the back of a
lyric sheet for homework assignments related to the analyzed song and theme or clinical
objective of the session. In a similar manner, music therapists can write homework assign-
ments on lyric sheets given to patients after songwriting interventions.
Music therapists may also assign patients homework assignments in which they collect
data on themselves to practice self-monitoring behaviors. In these types of assignments,
music therapists can have patients track behaviors, cognitions, and affective states includ-
ing anxiety, depressive or dysfunctional thoughts, interpersonal conflicts, behaviors they
are proud of, and frequencies of occurrences of behaviors to be increased or decreased. In
the following session, the music therapist “checks in” with patients concerning their assign-
ments. Moreover, music therapists can encourage patients to support one another and be
involved in their peers’ assignments. For example, a music therapist might ask a patient to
give three compliments to peers on the unit each day and ask the peers to document the suc-
cessful completion of this assignment when it occurs. Anecdotal evidence suggests clients
appreciate these concrete assignments as well as the peer accountability and involvement.
When assigning homework, music therapists should make tasks reasonable, as task dif-
ficulty is inversely correlated with homework compliance (Conoley, Padula, Payton, &
Daniels, 1994). Additionally, music therapists should include the client in the formulation
of the assignment as a client is more likely to be compliant with the assignment when she
or he participates in the formulation of the task (Robinson, 2003). Westra, Dozois, and
Marcus (2007) noted that client acceptance and understanding of the treatment rationale
and expectancy for change are also predictors of homework compliance. The list in Box 8.9
Box 8.9 Suggested Homework Assignments

1 Make a list of at least ten things you have accomplished in your life of which you are
proud.
2 Develop a coping card that has at least five positive behavioral coping skills. Keep
your coping card in your wallet or purse and use a coping skill every time you
experience anxiety or a negative affective state. Start practicing using your coping
card and coping skills while on the unit. If a coping skill is ineffective at relieving
distress, use another coping skill from your card.
3 Give three people on this unit a compliment today and write down their reactions.
Box 8.9 Suggested Homework Assignments (continued)
4 Thank three staff members today, explaining why you are appreciative of them. Doc-
ument their reactions and your current feeling after you express your appreciation.
5 Create three potential ideas for topics to write a song about during tomorrow’s
music therapy session.
6 Identify three songs that represent you or your current situation. Bring a list of
these songs to tomorrow’s music therapy session.
7 Identify three songs that motivate or inspire you in your current situation. Bring a
list of these songs to tomorrow’s music therapy session.
8 Role-play the following scenario with three peers today: You are at the grocery store
and see a neighbor who is more of an acquaintance than a close friend. This person
asks, “Where you have been?” (You had been on inpatient status at the psychiatric
hospital.) After the role-plays, journal concerning what statements worked well
and what statements did not work well.
9 Make a list of all the people you would like to make amends to as a result of sub-
stance abuse.
10 Make a list of advantages and disadvantages of attending substance abuse meetings
(such as Alcoholics Anonymous or Narcotics Anonymous) after you are discharged
from the psychiatric facility.
11 Make a list of local support groups and where and when these groups meet.
12 Make a list of the tasks you will accomplish on the day you are discharged from the
hospital.
13 Make a schedule for your week and include the following: relaxation time, time
devoted to physical exercise, time with friends, time for employment or vocational
duties, time with family, time with a therapist or counselor, and time for proactively
and reactively coping with stress and the demands of life.
14 When you have an automatic negative or pessimistic thought, write down the fol-
lowing: the situation, the thought, emotions that accompany the thought, and rate
the intensity of those emotions on a 9-point scale (with 1 representing no intensity
and 9 representing very intense). Also write any behaviors that result from the au-
tomatic thought and the pros and cons associated with those behaviors.
includes homework assignments music therapists can use in psychiatric care settings to
augment illness management and recovery.
Collecting data to systematically measure progress

In The New Music Therapist’s Handbook, Hanser (1999) provided a thorough and articulate
explanation of a data-based approach to music therapy. With heightened accountability in
Collecting data to systematically measure progress 157
the contemporary psychiatric healthcare environment, it is vital that music therapists use
a data-based approach to observe, measure, and document client progress. Thus, Hanser’s
approach applies to educational music therapy for illness management and recovery for
psychiatric consumers. Without objective, measureable, and replicable data, music thera-
pists cannot be accountable for their services, especially in times of limited funding and
increased cost-saving measures. Therefore, measuring baseline behaviors is a vital compo-
nent of the assessment in order to determine potential treatment effects over the course of
treatment. Specific to acute-care settings, the music therapist should measure aspects of the
patient during each session and document these observations in the patient’s medical chart.
Music therapists can use Likert-type, semantic differential (using bipolar adjectives on
ends of same continuum), and visual analog scales to measure progress within a session
(using the same scale as a pre- and postintervention measure) or between sessions (using
the same scale across multiple sessions). Using the same quantitative scale as both a pre- and
posttest measure, music therapists can efficiently collect quantitative data for inclusion in
the progress notes. These scales can be used in written or oral formats, depending upon the
context of the unit, patients, and therapy session. Although a 1–10 scale is frequently used in
many facilities for a variety of measures, some people prefer to use an odd-numbered scale
that includes a midpoint. The examples in Box 8.10 differentiate these measurement types.
Having patients complete self-assessments using one of these three types of scales can
promote self-monitoring and self-awareness skills. The music therapist should encourage
patients in generalizing these skills to other relevant settings both in the hospital and the
Box 8.10 Sample Likert-type, Semantic Differential,

and Visual Analog Scales
Example: Likert-type scale
Please rate your current anxiety on a scale of 1–9, with 1 representing “no anxiety” and
9 representing “high anxiety.”
1 2 3 4 5 6 7 8 9
No anxiety Some anxiety High anxiety
Example: Semantic differential scale

Please rate your current anxiety on a scale of 1–9, with 1 representing “calm” and 9
representing “high anxiety.”
1 2 3 4 5 6 7 8 9
Calm High anxiety
Example: Visual analog scale

Please make a mark on the scale that represents your current level of anxiety.
0———————————————————————————————————————9
No anxiety Some anxiety High anxiety
community. Moreover, these techniques can be used to collect quantitative psychological data
while the music therapist focuses on educational types of data (such as patient-identified or
used coping skills or social supports). Using a combination of psychological and educational
goals may help provide the music therapist with a more complete and holistic perception of
a patient’s health and may also facilitate working alliance, as the patient is aware of the music
therapist’s multifaceted goals and genuine desire to help numerous aspects of the patient.
Psychiatric music therapists can also collect data based on behaviors and verbalizations
in the session. If a patient’s objective is to identify appropriate coping skills in the com-
munity, a music therapist might purposely ask this patient about various coping skills in a
group songwriting intervention concerning “life after discharge.” The therapist would then
document the patient’s response in the treatment notes, noting the specific types of coping
skills the patient identified.
Documentation
Documentation is typically another element that varies across facilities. Some facilities use
checklists for documentation while others use a more narrative and descriptive format. More-
over, many facilities use electronic records. The music therapist will have to adapt to whatever
type of documentation the facility uses. However, despite variability across facilities, there are
typically many consistent elements. These elements can include the use of objective language,
the term “as evidenced by” to augment objectivity and client behaviors, affect, progress toward
clinical objectives, and observations of potential side effects of pharmacological treatments.
In cognitive behavioral therapy, verbalizations are considered valid data points (Craske,
2010). Craske (2010) noted that cognitive therapists—such as Beck and Ellis—observed
patients’ self-statements and beliefs and that these statements and beliefs played important
roles in behavioral and emotional responses. Thus, patients’ verbalizations can and should
be included in documentation. Such verbalizations can be measured quantitatively. For
example, if a patient verbalizes that biking and reading are coping skills, the music thera-
pist can document that the patient verbalized two coping skills—as well as the specific
coping skills to provide detail for the treatment team—during the session. In acute-care
inpatient settings, patients often may not behaviorally demonstrate these coping skills, but
their verbalizations should be conceptualized as authentic data points.
Data in treatment notes should always be as objective as possible. While including sub-
jective data can also be helpful to the treatment team, subjective data should be followed by
the term “as evidenced by” to provide objectivity and emphasize patient behaviors. For ex-
ample, a music therapist might document: “Patient seemed to enjoy music therapy session
as evidenced by bright affect, being engaged in the songwriting process and spontaneously
contributing lyrics for the song, and thanking the music therapist at the conclusion of the
session without prompting.” Moreover, including patient quotes can also be helpful data
for the treatment team. A music therapist might document that a patient stated her cop-
ing skills were reading, journaling, and “spending time with my family at the playground.”
The list in Box 8.11 includes items to observe in music therapy sessions and to potentially
include in progress notes. Box 8.12 is an example of a progress note.
Documentation 159
Box 8.11 Behaviors to Observe and Include in Progress Notes

◆ Potential medication side effects (e.g., tremors, lip-smacking, continuous thirst or
drinking, lethargy).
◆ Affect.
◆ Social interactions with the therapist, staff, and peers.
◆ Spontaneous conversation.
◆ Eye contact.
◆ Degree of participation with and without prompts.
◆ On-task and off-task behaviors.
Box 8.12 Sample Free Text Progress Note

Example: Free Text Progress Note
Patient arrived promptly to music therapy session on July 2 and stayed for entire du-
ration of 45-minute session. Patient’s affect was bright throughout the session as evi-
denced by smiling and laughter and made eye contact with music therapist and peers
when appropriate. Patient actively participated in lyric analysis of “Runaway Train” and
met immediate objective by identifying three social supports in the hospital (room-
mate, nurse Agnes, and “Kay the mental health tech”) and four social supports outside
the hospital (wife, sister, therapist, and pastor). Patient stated he had difficulty sleeping
as his “mind races” while he lies in bed trying to sleep. The group worked collaboratively
to formulate strategies for sleeping and patient stated (a) exercise and (b) not checking
e-mail before sleeping might help him calm his thoughts. No side effects were observed,
although patient did say he felt “a little sleepy, like my coffee didn’t work today—it’s
probably my body getting adjusted to the higher dose of medication,” as the doctor has
recently increased his medication dosage. Patient oriented to time, place, and person.
Patient did not require prompts to participate in session and was on-task throughout
the session. Patient made eye contact when verbally engaged with music therapist and
peers. Patient stated he was looking forward to discharge in three days and was working
with his social worker to set up regular outpatient meetings with his therapist. Patient
thanked music therapist at conclusion of session without prompting. Music therapist
gave patient homework assignment to identify and write down two support groups in
the community in which he can regularly participate in after discharged. Music thera-
pist will continue to monitor.
Evaluation and community reintegration

Evaluation of treatment will vary by facility and hospital regulations. In the formal
treatment evaluation, the music therapist should consider including the points listed in
Box 8.13.
Focusing on the use of cognitive behavioral therapy for outpatients, Dobson and Dobson
(2009) opposed the term “termination,” noting that “completion” of therapy—in which a
client solves her or his problems and has reached her or his goals—is a more appropriate
term. Psychiatric music therapists are urged to use similar jargon as other related helping
professionals in their facilities.
Termination of therapy or inpatient hospitalization can be the result of a client meeting
her or his goals. In most psychiatric hospitalizations for patients with serious and endur-
ing mental disorders, patients are not necessarily discharged when they meet their music
therapy objectives. Rather, patients are discharged once the treatment team decides that
they are no longer a danger to themselves or others, and an appropriate living situation is
available. In some cases, termination can even be a result of limited insurance coverage
(Hanser, 1999).
Although patients can be excited to be discharged from inpatient psychiatric facilities,
therapy termination and community reintegration can be a difficult process. Patients often
experience heightened anxiety knowing they will no longer be supervised and they may
have to confront stressors that brought them to seek inpatient care in the first place. Music
therapists can work to help patients proactively plan for hospital discharge. Questions to
help initiate this dialogue might include those listed in Box 8.14.
Supervision in psychiatric music therapy

Supervision is a vital component of all professional fields. Specific to therapy and coun-
seling, Dobson and Dobson (2009) noted the importance of peer support, supervision,
and even personal therapy. Persons (1989) noted that it could be useful for cognitive
Box 8.13 Items to Include in Treatment Evaluation

◆ Written summary of objectives patient met and did not meet.
◆ Graphs and tables to expediently highlight quantitative and qualitative indicators of
behavioral, cognitive, and affective change.
◆ Number of music therapy sessions the patient attended (i.e., treatment dose).
◆ Number of music therapy sessions the patient could have attended (i.e., potential
treatment dose).
◆ Goals and clinical objectives for outpatient music therapy treatment or outpatient
nonmusic therapy treatment.
Supervision in psychiatric music therapy 161
Box 8.14 Questions to Ask Patients During Discharge

Planning
◆ What will you do first after you are discharged from the hospital?
◆ How and when are you going to use music after hospital discharge?
◆ What challenges do you anticipate facing and how are you going to deal with those
challenges and the stress of those challenges?
◆ What are specific coping skills can you use when you are stressed at work and at
home?
◆ Who can you seek support from when overwhelmed by stressors?
behavioral practitioners to implement cognitive behavioral techniques on themselves.

For music therapy supervision, readers are advised to consult Forinash (2001) and Odell-
Miller and Richards (2009).
In a descriptive study of psychiatric music therapists, 90.6% of participants indicated
they did not have a music therapist as a supervisor (Silverman, 2007). Moreover, when psy-
chiatric music therapists did receive supervision, it was infrequent. Some 85% of respond-
ents indicated they received formal clinical supervision less than once a month. However,
70% of respondents indicated they trained practica students and 58% noted they trained
interns. Over 67% of respondents indicated they had completed a music therapy intern-
ship in a psychiatric setting. These statistics, coupled with data from the AMTA concern-
ing a consistent percentage of psychiatric music therapists since 1998, leads to additional
questions. If such high numbers of psychiatric music therapists are training student music
therapists, why is the population of psychiatric music therapists not increasing? While
there are many possible reasons for this consistent percentage (job cuts, retirement, inter-
est in other populations, location of employment), these numbers, coupled with the high
amount of job satisfaction and lengthy timespan of employment at psychiatric institutions
(Silverman, 2007), warrant systematic inquiry.
Silverman (2014a) conducted a descriptive study of supervision of psychiatric music
therapists. The most frequent responses concerning theoretical orientation were humanis-
tic and cognitive behavioral. Most participants had earned a master’s degree and indicated
that they received supervision from psychologists, music therapists, recreational therapists,
and unit supervisors, in that order. Respondents indicated they enjoyed supervising all
types of supervisees, but felt it most difficult to supervise other professionals and music
therapy interns. Respondents rated the importance of boundaries, ethics, counseling skills,
and music skills most important and research least important. Emerging themes from
qualitative responses primarily concerned self-care, boundaries, music and music therapy,
and transference or countertransference. Future research identifying the unique practice
of psychiatric music therapy supervision is warranted to provide the best possible training
and continuing education and support for this group of clinicians. Additionally, contin-
ued research concerning music therapy supervision would likely help the field continue to
develop, grow, retain board-certified music therapists, and lead to best practice for music
therapy consumers.
Scheduling
Scheduling psychiatric music therapy services is largely a function of the facility and its
mission. In order for inpatients to have a multitude of therapeutic and educational pro-
gramming throughout the week, it is common for psychiatric music therapists to provide
Table 8.1 Sample Schedule
Monday Tuesday Wednesday Thursday Friday

8:00–9:00 Treatment team Treatment team Treatment team Treatment team Treatment team
meeting meeting meeting meeting meeting
9:00–10:00 Unit 1: Unit 1: Unit 1: Unit 1: Unit 1:
Coping skills Community Medication Co-occurring Leisure skills
supports and symptom disorders
management
Express yourself! Bring your own Shake it! Get Harmonica Recreational
song ready to move! lesson music therapy
11:00–12:00 Assessments, Assessments, Assessments, Assessments, Assessments,
documentation, documentation, documentation, documentation, documentation,
and treatment and treatment and treatment and treatment and treatment
planning planning planning planning planning
12:00–1:00 Lunch Lunch Lunch Lunch Lunch
1:00–2:00 Individual MT Individual MT Individual MT Individual MT Individual MT
Relaxation group Music and art Percussion Sing-a-long Music bingo
ensemble
3:00–4:00 All staff meeting Volunteer Supervision Music therapy Professional
supervision team meeting development
and case & literature
presentations consultation
4:00–5:00 Assessments, Assessments, Assessments, Assessments, Assessments,
documentation, documentation, documentation, documentation, documentation,
and treatment and treatment and treatment and treatment and treatment
planning planning planning planning planning
Unit 1: Acute-care inpatient psychiatric unit (average length of stay: three to seven days)
Unit 2: Intermediate care inpatient psychiatric unit (average length of stay: seven days to two months)
Unit 3: Long-term care unit (average length of stay: two months to three years)
Scheduling 163

◆ In-services can be an efficient way to educate other professionals concerning music
therapy.
◆ Referral and assessment are vital parts of the treatment but vary according to the
music therapist’s facility or unit.
◆ Even in group-based music therapy, treatment planning and clinical objectives are
highly individualized and based on the comprehensive assessment and recommen-
dations from the interdisciplinary treatment team.
◆ Due to strong relationships with treatment outcome, developing working alliance is
a vital aspect of psychiatric music therapy.
◆ Collaborative problem solving with group members may enhance working alliance,
participation, and vicarious learning.
◆ Mutually agreed upon homework assignments can augment therapeutic gains
within and outside the session.
◆ Data collection, documentation, treatment evaluation, and professional supervi-
sion are essential components of contemporary clinical music therapy practice.
evening and weekend programming. Evening and weekend sessions might include
greater numbers of inpatients. In these cases, recreational music therapy interventions
tailored for larger numbers of participations are appropriate. A hypothetical example of
a music therapist’s schedule is shown in Table 8.1. The music therapist provides daily ses-
sions on three units (all patients on the unit are referred to group music therapy) as well
as individual music therapy (patients require a specialized referral for individual music
therapy).
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1 What are the differences between Likert-type and semantic differential scales?
2 How might a psychiatric music therapist incorporate live music into an in-service based upon imple-
menting music therapy research on a new psychiatric unit?
3 What therapeutic change mechanisms might enhance working alliance via live music?
4 Identify three homework assignments that facilitate generalization of behavioral coping skills from a
music therapy songwriting session to life outside psychiatric unit.
5 Why might psychiatric music therapists who do not use supervision perceive it as less important than
psychiatric music therapists who do?
Chapter 9
Interventions in psychiatric music

therapy
Introduction
There are numerous interventions available to psychiatric music therapists to help patients
reach their clinical objectives. The purpose of this chapter is not to provide a set of specific
or tailored music therapy session plans, but rather to act as a catalyst to stimulate contem-
plation, inspiration, and innovation concerning commonly used interventions (including
songwriting, lyric analysis, and recreational music therapy) and less frequently used ones
(including “rhythm train,” “rockumentaries,” and “rock operas”) specifically for psychiatric
music therapists who have less clinical experience. Psychiatric music therapists frequently
use songwriting and lyric analysis interventions (Silverman, 2007, 2009a); the author has
based most of his research on these interventions in an attempt to represent contempo-
rary clinical practice. Thus, greater attention is given to group-based songwriting and lyric
analysis to depict how illness management and recovery can be integrated into them.
Although receptive music therapy interventions (such as patient-preferred, live music
listening) can be engaging, active music therapy interventions designed for psychiatric
board-certified music therapists are emphasized in this chapter. As psychiatric music
therapy treatment should be individualized to the recipient and her or his unique needs
within the contextual parameters of the recipient’s facility, highly structured session plans
may not necessarily generalize to all psychiatric consumer populations or settings. Rec-
ognizing that there is considerable variance in application of music therapy techniques,
orientations, patients, programming, therapist experience levels, and facilities, readers are
encouraged to customize ideas and concepts to their own clinical practice. In an attempt
to facilitate evidence-based decision making, this chapter draws from results of contempo-
rary psychiatric music therapy research and clinical practice and focuses on active music
therapy interventions for group psychiatric treatment, in which participants are involved
both musically and nonmusically to reach nonmusic clinical objectives related to illness
management and recovery.
Although researchers have found various music therapy interventions to be effective for
psychiatric consumers, to date it does not seem that a particular intervention is more effec-
tive than another intervention (Silverman, 2008). A number of researchers have compared
music therapy interventions with various psychiatric patients (Cevasco, Kennedy, & Gen-
erally, 2005; Jones, 2005; Silverman, 2003; Silverman & Marcionetti, 2004; Thaut, 1989) and
have not found statistically significant between-intervention differences. As participants
INTRODUCTION 169
in these studies were not randomized to treatment groups, there is a need for randomized
controlled research to compare different music therapy interventions. From the available
literature, it seems that different music therapy interventions are equally effective. The lack
of between-intervention differences is congruent with the Dodo Bird Verdict (see Chapter
2). Perhaps common factors within music therapy interventions are shared (i.e., music and
a supportive therapist) and represent the active and effective ingredients. It may be that
music therapy intervention preferences are individualized to each patient, but difficult to
methodically measure in group music therapy sessions. Unfortunately, systematic investi-
gation of music therapy intervention preferences for groups of psychiatric consumers is a
complicated process due to various group dynamics and, if results are consistent with the
Dodo Bird Verdict, efforts to undertake this research would likely not yield fruitful results.
However, in today’s era of heightened accountability and evidence-based practice, future
research is warranted to determine intervention preferences for psychiatric consumers,
especially during individual music therapy.
Music therapy may be inherently enjoyable. Although this statement often incites de-
bate, the author contends that psychiatric music therapy interventions can and should be
pleasant for consumers. Currently, it seems that psychiatric patients tend to favor music
therapy (Heaney, 1992; Silverman, 2006). From a cognitive behavioral perspective, it
would seem that psychiatric consumers would be more likely to attend and actively en-
gage in music therapy sessions if they found them to be enjoyable. Thus psychiatric music
therapists might attempt to design interventions that are both therapeutic (or educational)
and enjoyable. Clinicians should not shy away from interventions that are perceived by pa-
tients as “fun.” Rather, clinicians use these interventions but employ different terminology
and jargon when communicating with administrators, other clinicians, and members of
interdisciplinary treatment teams. A clinician could describe these interventions as engag-
ing, motivating, and enhancing attendance and participation through active participation
within a reinforcing and dynamic social context. These terms might better substantiate
music therapy clinical treatment effects, especially to other members of the interdisci-
plinary treatment team who may not be entirely familiar with psychiatric music therapy
practice and who may misconstrue music therapy as a nonessential treatment that is solely
“fun” for patients.
It is vital for music therapists to process the intervention and ensure patients are mak-
ing appropriate and necessary transfers and generalizations. For example, a music thera-
pist might use a rock-and-roll bingo game as a recreational music therapy intervention
to increase knowledge of social and leisure skills for acute psychiatric inpatients. While
the patients may enjoy the intervention, it is the music therapist’s responsibility to make
the nonmusical educational generalizations explicit. Patients may be unaware of how the
social and leisure skills used in the bingo game relate to social and leisure skills outside the
hospital environment, including participating in a choir, self-care, attending concerts with
friends, and having regularly scheduled social and leisure activities to reduce stress and en-
hance quality of life. Herein lies the importance of the music therapist explicitly processing
the educational material to be learned. This verbal processing to ensure psychoeducational
170 INTERVENTIONS IN MUSIC THERAPY
gains for illness management and recovery is also important for administrators and other
hospital staff who may be unaware of the nonmusical benefits of music therapy. While
these generalizations may be more obvious with some lyric analysis and songwriting inter-
ventions, they may be less obvious with other interventions based on active music making.
Intervention design and construction is a challenging, rewarding, and ongoing endeavor.
Readers are encouraged to be tolerant in the construction, development, and the continual
refinement of their interventions. In my experience, the music therapist’s implementation
of interventions typically becomes more effective with experience and the ability to “work
out the kinks” over time. Thus, ideas and concepts in this chapter result from numerous
and repeated trials of various interventions. Similar to how therapists gain skills and prog-
ress over time, interventions also improve with supervision, reflection, accommodations,
adaptations, input from clients, and repetition.
In a report concerning patient-centered care for psychiatric consumers, Green and
colleagues (2014) defined patient-centered care and service delivery intervention. These
principles can be applied to music therapy interventions and guide clinical practice, ed-
ucational topic areas, and collaborative decision making. The authors defined a patient-
centered intervention for people with serious mental illness as
an organized process of care or service delivery that is directed by the person receiving services.
Care and services are delivered collaboratively, attentively, and compassionately, with providers
as partners who understand and respond to the person’s perspectives, culture, and concerns. The
delivery process is structured to educate, inform, guide, and assist the person to be a knowledgeable
consumer of the services relevant to attaining the person’s self-defined needs, goals, and outcomes,
taking into account the person’s individual circumstances.
All individuals, including those who have been diagnosed with a serious mental illness, have the
right to direct their own care. People who are limited in their ability to direct their care as a result
of acute symptoms or legal constraints should be provided with the support necessary to make as
many care-direction decisions as possible. If a person is unable to make informed choices about his/
her care, providers will rely on historically expressed preferences and values and, when available,
psychiatric advance directives and designated surrogates to maximize the person’s participation
in decision making about services and treatment. Care decisions made for persons when they are
unable to direct their own care should be based on the premise that such decisions will enable those
persons to make future choices about their care. Care and services provided to service users should
take into account available scientific knowledge and the resources of the service system. (p. S8)
Songwriting
Songwriting is a common intervention used in psychiatric music therapy (Silverman, 2007)
and can enable patients’ unique voices, narratives, ideas, and concerns to be heard. This ther-
apeutic process may enable patients to experience relief, validation, and joy (O’Callaghan
& Grocke, 2009). Some advantages of clinical songwriting include a flexible structure and
opportunities for self-expression, creativity, and ownership of an original musical compo-
sition. Another clinical advantage of songwriting is the ability to be innovative in meeting
patients’ clinical objectives. In psychiatric settings, composing songs directly related to a
clinical objective can be an engaging and motivating break from the typical monotony
Songwriting 171
of psychoeducational or talk-based sessions. For example, during randomized controlled

trials, group-based songwriting interventions were used to teach acute-care psychiatric
inpatients about coping skills (Silverman, 2011e), stigma (Silverman, 2013b), and facili-
tate change in patients on a detoxification unit (Silverman, 2011b). The researcher wrote
blues songs with patients about coping skills, stigma, and change, respectively. These direct
songwriting approaches were appropriate given the brief treatment settings and acute-care
patients’ objectives within the illness management and recovery framework.
The therapeutic value of songwriting includes both the actual musical product as well as
the process of creating an original music composition. During the interactive and dynamic
compositional process, the music therapist can use questions to stimulate therapeutic dia-
logue. For example, during a group-based blues lyric replacement songwriting session
with acute psychiatric inpatients, the author facilitated lyrical composition of a two-verse
song. The first verse concerned issues patients might worry about after discharge when
living the community. Using the blues allowed the patients to identify problems by voicing
their concerns, which were then used as lyrics in the creative narrative of the first verse.
The second verse concerned potential solutions and cope with the worries identified in the
first verse. The patients composed the lyrics shown in Box 9.1.
Box 9.1 Blues Lyrics Addressing Problems and Solutions

Verse 1
1 When people ask me
2 Where I’ve been
3 Ask the same question
4 Over and over again (I chord)
5 Cease the interrogation
6 Bring an end to it (IV chord)
7 I don’t want to see no more drug-using friends (V and IV chords)
Verse 2
8 Watching the sunrise
9 Kickin’ it with friends
10 Making good choices
11 And making my amends (I chord)
12 Whether it’s biking
13 Or writing this tune (IV chord)
14 I choose to be happy . . . rather than blue! (V and IV chords)
Box 9.2 Therapeutic Dialogue Within Songwriting (1)

Lines 1–6: “Wow—these are cool lyrics! Nice job! With a quick show of hands, who
anticipates dealing with people asking us where we’ve been after we get out of here
as something that we might relate to? [Three patients raise their hands and nod their
heads in agreement.] Okay . . . so what can we say to people who ask us these types of
questions?”
The therapist asked questions related to composed lyrics to stimulate problem solving
and further therapeutic dialogue in the songwriting session. In the present example, the
therapist used the dialogue shown in Boxes 9.2 and 9.3 to engage the group in therapeutic
dialogue.
Thus the music therapist first verbally reinforced the group for their initial lyrical contri-
butions. Reinforcements can further engage patients and motivate participation as some
patients may be hesitant to offer lyrical suggestions. Then the therapist worked to incorpo-
rate universality by recognizing that many group members might have similar concerns,
although unique personal situations certainly exist. The music therapist then facilitated
dialogue to determine potential solutions with the patients. This led to an interesting
discussion differentiating responses between patients who want to be honest with (such
as close friends and family members) compared to people with whom patients were not
necessarily comfortable sharing their psychiatric hospitalization (such as neighbors and
co-workers who may be considered more acquaintances than friends). To practice making
responses to these types of inquires, the music therapist then role-played different situa-
tions with patients.
The music therapist was able to facilitate problem solving concerning potential solu-
tions to this predicament. Patients noted that going to a movie or meeting at a coffee shop
(that does not serve alcohol) would be nonusing situations where they could enjoy their
friends’ company. If patients identified a potentially negative situation such as a bar, the
music therapist could ask the group for potential consequences of behaviors, which allows
patients to identify—rather than the therapist identify—potential negative results. Some
patients questioned that if this friend is still using, especially within close proximity to
the patient, is this friend really a friend? These questions led to therapeutic dialogue and
additional role-plays to practice potential responses and behaviors in a safe and nonjudg-
mental environment.
Box 9.3 Therapeutic Dialogue Within Songwriting (2)

Line 7: “Hmm . . . this can certainly be a tricky situation. Let’s imagine that one of your
good friends still uses drugs and asks you to hang out. What might you say to this
person?”
Songwriting 173
Techniques
• CBT EMT • Solution
for Illness • Problem identification
Management & identification • Creative
Recovery Engagement
• Motivational
Figure 9.1 Depiction of highly Interviewing Process &
Approach
structured blues songwriting Product
for illness management and
recovery
During the second verse, the music therapist worked to facilitate dialogue concern-
ing coping and leisure skills. To initiate the conversation, the music therapist first asked,
“What are some potential coping skills that might make us feel better when we are feeling
anxious or depressed?” The music therapist wrote all patient responses on the dry-erase
board to serve as a sort of “lyric bank” for use in composing lyrics for the second verse.
Additionally, writing a patient’s response on the board may function as reinforcement.
Figure 9.1 is a visual representation of highly structured blues songwriting for illness man-
agement and recovery in which problems and solutions are identified within the lyrics of
the song, as explained in the previous paragraphs. This model depicts how the approach
(cognitive behavioral therapy and educational music therapy for illness management and
recovery) influences the techniques utilized within the intervention (problem identifica-
tion and motivational interviewing) that ultimately lead to the process and product (solu-
tion identification and creative engagement) within highly structured blues songwriting.
Another clinical example of blues songwriting involved increasing hope for psychiat-
ric recovery. The music therapist initially asked for motivators concerning why patients
wanted to recover from their psychiatric illnesses. The music therapist wrote patients’ sug-
gested motivators on the board to function as a lyric bank. After patients identified 8–15
potential motivators for psychiatric recovery (including family, friends, employment,
working toward self-directed goals, being a positive role model, and spending time with
pets), the therapist asked patients to use the lyric bank to create the first verse of the two-
verse blues song concerning motivators for psychiatric recovery. After the group com-
pleted the first verse, the music therapist asked patients to identify what they had to do
for recovery. Identifying motivators for recovery in the first verse facilitated engagement
and participation in identifying the “how” aspect of recovery in the second. Again, the
therapist wrote patients’ suggestions for how to recover on the board. After patients identi-
fied 8–15 potential ways to facilitate psychiatric recovery (including taking medications as
prescribed; making, keeping, and attending therapy sessions; positive behavioral coping
skills; and avoiding drugs and alcohol), the therapist had patients use the lyric bank to cre-
ate the second verse of the two-verse blues song concerning how patients can recover from
their illnesses. Throughout the process, the music therapist facilitated educational dia-
logue concerning concrete and practical motivators for recovery (verse 1) and behaviors
Box 9.4 Blues Lyrics Addressing Motivators and Techniques

for Recovery
Verse 1: Motivators for psychiatric recovery
1 Tired of them med lines
2 Ain’t got no shower curtains
3 Regain my clean time
4 Staff is always observing (I chord)
5. Chewin’ on coffee
6 Sick of them green beans (IV chord)
7 I’m missing my family
8 I just wanna go on home. (V and IV chords)
Verse 2: How to facilitate psychiatric recovery

1 Gotta make my appointments
2 And keep on my meds
3 Let go or resent
4 And make time for my family and friends (I chord)
5 These are the rules
6 To keep from the blues (IV chord)
7 I got them station . . .
8 I got them station 10 blues. (V and IV chords)
that facilitate recovery (verse 2). Some lines were humorous or contained metaphors. For
example, one group wrote “The Shoelace Blues” as psychiatric patients on the unit were not
allowed to have shoelaces due to safety precautions. The patients noted that the shoelaces
symbolized health, wellness, freedom, and independence. Readers should be aware that in
measures (not lines) seven and eight of the blues progression, there is only music and no
lyrics. This section containing music without lyrics can serve to allow the song to “breathe”
a bit and remain stylistically and aesthetically intriguing. In a related session, the patients
composed the lyrics shown in Box 9.4.
Three approaches to songwriting

There are numerous approaches to songwriting. The author recommends interested readers
consult Baker and Wigram’s (2005) thorough and first-rate text concerning clinical song-
writing for additional information. Readers interested in songwriting are also advised to
consult articles by Baker, Wigram, Stott, and McFerran (2008, 2009) and Thompson (2009).
In an attempt to facilitate immediate clinical success, psychiatric music therapists using

songwriting often choose from one of three methods: fill in the blank, lyric replacement,
or free composition. These approaches vary in the level of structure necessary to facilitate
both musical and clinical success. These three approaches can be tailored for both group
and individual music therapy.
It is imperative that songwriting interventions capitalize as much as possible upon the
music during the composition process. Playing the song—and hearing it—will likely fa-
cilitate becoming “lyrically and musically unstuck.” Certainly, being “stuck” can be a useful
therapeutic predicament for participants as it requires problem solving, patience, flexibility,
creativity, and compromise to become unstuck. However, using as much music as possible
enables clients to hear the evolving product and may stimulate ideas and creativity. When
teaching songwriting interventions to music therapy students, the author typically advises,
“Play your way out of trouble,” meaning that when the group is having difficulty making deci-
sions or has “writers’ block,” playing and singing what is already written can be helpful. Also,
psychiatric music therapists may find visual components facilitate songwriting interven-
tions. Writing lyrics on a dry-erase board, notating the music, identifying rhyme schemes,
and numbering the lines provide patients with a visual representation of the composition.
Structuring songwriting interventions

The amount of structure used in songwriting can influence musical and clinical success.
Music therapists working with clients who are lower-functioning and may have chronic
and severe mental illnesses can use a higher degree of structure in order to facilitate musi-
cal and clinical success. Fill-in-the-blank songwriting may be appropriate for people who
are currently functioning at a lower cognitive level due to severe and chronic mental illness.
With psychiatric patients functioning at higher cognitive levels, less musical structure may
be necessary. Thus, for some acute-care patients, lyric replacement provides enough au-
tonomy to engage, stimulate, and maintain interest but enough structure to ensure clinical
and musical success. See Table 9.1 for a depiction of structure in clinical songwriting.
Fill-in-the-blank songwriting
This is a highly structured intervention in which the music therapist (or clients) selects
a song and removes certain key words. Music therapy recipients can then choose their
own words to complete missing lyrics. The harmonies, melodies, and most of the original
lyrics remain unchanged, providing a high degree of structure for the patients to ensure
musical and clinical success. When needed, music therapists provide prompts for patients
concerning a specific type of word (e.g., “We need a verb here for an action . . . what verbs
might work?”). Due to the high level of structure within this specific type of intervention,
fill-in-the-blank songwriting can be successfully implemented with patients who are func-
tioning at lower cognitive levels. If patients are able to read, each patient can complete the
lyrics independently, allowing for greater individualization of musical compositions when
working with a group setting. Although all patients may write a song based on the same
fill-in-the-blank worksheet, each patient’s song will be different. This technique can also
Table 9.1 Three-Level Depiction of Structure in Clinical Songwriting
Type of Songwriting Level of Structure Cognitive and Social Functioning Level

Fill in the blank High structure Low cognitive and social functioning levels
• Patients with chronic and severe mental illnesses
• Can be completed within a single session
Lyric replacement Medium structure Medium cognitive and social functioning levels
• Acute care and brief treatment
• Can be completing during multiple sessions for
patients with severe mental illness
• Can be completed within a single treatment
session with patients in acute-care settings
Free composition Low structure High cognitive and social functioning levels
• Acute care and brief treatment
• Often requires multiple treatment sessions due
to variety of autonomy, choices, and decisions
be used during group settings in which the music therapist leads the group in composing
a single song, thus necessitating and addressing group-based decision making, compro-
mise, and working together for a common cause. Regardless of how the song is composed,
patients should have the opportunity to either perform it or hear it performed.
Two examples of fill-in-the-blank songwriting are given in Boxes 9.5 and 9.6.
Lyric replacement songwriting

Less structured than fill-in-the-blank songwriting, in the lyric replacement intervention
the music therapist (or clients) selects a song (foundation song) and helps clients to change
most or all of the lyrics. Thus music therapy recipients use their own words to rewrite the
song lyrics. The harmonies, phrases, and melodies do not change, providing structure for
the patients. Due to the high level of structure, lyric replacement songwriting can be used
with patients who are functioning at lower cognitive levels and with patients who are func-
tioning at higher cognitive levels in high turnover, acute-care settings. In many acute-care
settings, the therapist may not have patients for multiple sessions and therefore wants to
complete a song in a single session to ensure musical and therapeutic closure. Some music
therapists refer to lyric replacement songwriting as “piggybacking.” The therapeutic and
educational dialogue focuses on the construction of the lyrics while the foundation song
provides the musical components and structure. Music therapists should be highly mindful
Box 9.5 Example 1: Fill-in-the-blank Songwriting

“What a Wonderful World” as foundation song:
a. Fill-in-the-blank songwriting
1. I see _____ of _____, _______ too
2. I see them ______, for ____ and ____
3. And I think to myself
4. What _______________
Box 9.6 Example 2: Fill-in-the-blank Songwriting

“I Wanna Talk About Me” as foundation song:
Fill-in-the-blank songwriting
1. We talk about your _____ how your _____ is a _____
2. We talk about your _____ and your _____ when it _____
3. We talk about the _____ you’ve been having with your _____
4. About your _____ and your _____ and your __________
5. We talk about your _____ and the places that you’ve been
6. We talk about your _____ and the _____ on your _____
7. The _____ on your _____ and the _____ in your _____
8. And God knows we’re gonna talk about your _____
9. You know talking about you makes me smile
10. But every once in a while
CHORUS:
11. I wanna talk about _____
12. Wanna talk about _____
13. Wanna talk about _____
14. Oh _____
15. What I _____, what I _____, what I _____, what I _____, what I _____
16. I like talking about _____, usually, but occasionally
of the musical elements in order to best facilitate the song composition. Illness management
and recovery can be addressed by writing lyrics about specific topics (such as coping and
the importance of medications and therapy) or having to include certain keywords from a
designated “lyric bank” within the song (such as medication, coping skills, and supports).
Box 9.7 gives an example of a song composed through lyric replacement, using “Coun-
try Roads” as the foundation song. Throughout the intervention, the music therapist can
stimulate therapeutic dialogue concerning how to facilitate discharge, happenings to look
forward to upon discharge, motivating factors to be compliant with medication and ther-
apy, how to take medications and how they can be helpful, appropriate coping skills, causes
of potential stress, skills learned in the hospital, and emotions concerning discharge.
Due to the high degree of structure within a 12-bar blues progression, clinical songwrit-
ing in this style can be an example of lyric replacement. Blues can be effective for clinical
songwriting as it functions to let patients complain or “vent” and thus identify problems
they may be experiencing. Complaining via a structured blues narrative can function as a
type of catharsis. The music therapist can compose the blues song such that problems are
identified in the first verse and potential solutions to those problems appear in the second
verse (see Blues Example 2 and the section on problem solving in Chapter 8). Table 9.2
gives two examples of 12-bar blues lyrics composed during an educational music therapy
research study attempting to reduce acute-care psychiatric patients’ perception of mental
Box 9.7 Example 3: Lyric Replacement Songwriting

Foundation song: “Country Roads”
1 Almost discharged . . . from the hospital
2 Going home soon . . . can’t wait to see my puppy
3 Take my meds . . . as Doc told me
4 Use my coping skills
5. When I’m feeling stressed.
CHORUS:
1 Going home . . . to my family
2 To my dog . . . my own bed
3 So excited . . . with my new skills
4 Going home . . . can’t wait.
Table 9.2 Examples of Stigma Blues Songwriting
Stigma Blues Example 1 Stigma Blues Example 2

Verse 1 Verse 1
1 They think we’re crazy 1 Stigma ain’t no good
2 They think we’re nuts 2 Bipolar ain’t contagious
3 Well take that stigma 3 So step outside your mind-frame
4 And shove it up your butts. (I chord) 4 And see that we aren’t dangerous. (I chord)
5 It doesn’t matter 5 It’s just a diagnosis
6 What you think (IV chord) 6 Just another label (IV chord)
7 I got them stigma . . . I got them stigma blues. 7. Ain’t gonna bend . . . I’m fighting them stigma
(V and IV chords) blues. (V and IV chords)
Verse 2 Verse 2
8 Normal is just a setting 8 I’m going to NAMI
9 On your washing machine 9 Education is the key
10 They think we’re insane 10 Gotta get my supports
11 Or just plan mean. (I chord) 11 To teach my family. (I chord)
12 Ain’t sortin’ laundry 12 It’s just a diagnosis
13 Ain’t black and white (IV chord) 13 Just another label (IV chord)
14 I got them stigma . . . them stigma blues. 14. Ain’t gonna bend . . . I’m fighting them stigma
(V and IV chords) blues. (V and IV chords)
Lyric analysis 179
illness stigma (Silverman, 2013b). Again, readers should be aware that in measures (not
lines) seven and eight of the blues progression, there is only music and no lyrics to remain
stylistically authentic to the blues genre.
Free composition songwriting

In this intervention, there is almost no structure; clients are responsible for both the music
and lyrical components. Clients make decisions regarding rhythms, melodies, harmonies,
dynamics, instrumentation, and lyrics. Music therapists using this method typically have
advanced musical competencies in order to provide musical choices that meet patients’
creative needs and requests. Due to the low level of structure within this intervention, it can
be used with higher functioning patients as a longitudinal intervention (i.e., an interven-
tion that takes longer than one 50-minute session to complete). Providing visual and aural
components, such as musical notation to visually depict melodies and harmonies and play-
ing them frequently, can facilitate musical and clinical success in this type of songwriting.
Suggestions for facilitating songwriting interventions

Box 9.8 provides a list of suggestions concerning clinical songwriting interventions for
psychiatric music therapists.
Lyric analysis
Psychiatric music therapists often implement lyric analysis interventions (Silverman, 2007,
2009a) to address a variety of clinical objectives. Silverman (2009c) used a lyric analysis
of “Don’t Stop” (recorded by Fleetwood Mac) to teach illness management skills to acute
psychiatric inpatients and found patients made more in-depth and personalized verbaliza-
tions during the lyric analysis condition than during the verbal psychoeducational active
control condition without music. In an attempt to determine what songs music therapists
used for various clinical objectives, Silverman (2009d) conducted a descriptive study of
psychiatric music therapists’ use of lyric analysis interventions. “Lean on Me” was the most
commonly used song while change was the most frequently cited clinical objective. In-
terested clinicians are directed to Standley and Jones (2008) for a list of songs, organized
by counseling topic. Ideally, these interventions should begin with live music and then
proceed to a conversation concerning the song and how patients may relate to, perceive,
or interpret the lyrics. However, there are situations and circumstances in which recorded
music may be superior, more appropriate, and even more therapeutic (Silverman, 2009d).
During lyric analysis interventions, patients can be encouraged to share their perspec-
tives of what the lyrics mean. The music therapist’s questions can be direct or indirect. For
example, in a scripted lyric analysis of “Desperado” performed by The Eagles with patients
on a detoxification unit, Silverman (2009b) used the following dialogue to directly encour-
age discussion: “Lines 5 and 6 read: ‘These things that are pleasing you can hurt you some-
how.’ What are some things that can both please and hurt us at the same time?” This led
to a discussion of immediate benefits of drugs and alcohol in which participants were also
Box 9.8 Suggestions for Facilitating Songwriting

Interventions
◆ Brainstorm with patients by asking for musical and lyrical ideas and writing pa-
tients’ suggestions on a dry-erase or chalk board.
◆ When the group becomes “stuck” on a lyric, play the entire phrase or verse.
◆ When attempting to determine lyrics for music, sing the melody on “la” so clients
can hear the musical phrase.
◆ Number the lines or phrases to provide structure and to make it easier to skip over
and return to later.
◆ Use rhyme schemes to prompt patients for lyrics: “Okay, we need lines two and four
to rhyme—what rhymes with ‘meds’?”
◆ When the group becomes stuck, remind them that songwriting is a difficult and
complicated process and reinforce them for what they have already created.
◆ Give patients a written copy of the lyrics and music at the conclusion of the session
and provide follow-up questions or homework on the back of the paper.
◆ Record the song for the patients.
◆ Perform the song for unit staff with the patients.
◆ Initiating therapeutic songwriting is often the most difficult aspect of this interven-
tion. Be open to all patients’ verbalizations to demonstrate the ease of creating lyrics
and music.
◆ Avoid absolutes by asking patients questions using nonabsolute terminology such
as “may,” “might,” or “can”: “What lyrics might work here? What are some possible
suggestions that might work? We can always change it later if you prefer. Let’s brain-
storm . . . what are some big ideas that could potentially work?”
◆ Use a picture as a theme to initiate the songwriting process.
◆ Ask patients questions regarding preferred genre, topic, and emotional content of
the song.
◆ If a patient provides a lyrical suggestion that is too long for the musical phrase, rein-
force the patient for her or his idea. Then ask the group to help determine the overall
theme of the patient’s suggestion to “boil it down” and arrive with a phrase that fits
the existing musical structure.
◆ If there is a disagreement in the group concerning a musical decision, vote concern-
ing potential outcomes.
◆ Be aware of copyright issues.
Lyric analysis 181
able to note the long-term problems resulting from misuse of these substances. Patients
also noted that these lyrics could also be interpreted as relationships, gambling, shopping,
eating, relationships, and sex. Thus, lyrics can be used in a direct manner to stimulate dis-
cussion and therapeutic dialogue.
Psychiatric music therapists do not necessarily have to use lyrics in a direct manner;
rather, they can use them as a therapeutic springboard from which to ask related questions
in an indirect manner. During a scripted lyric analysis of “Don’t Stop,” Silverman (2009c)
used the following questions to initiate dialogue: “Let’s look at the first line of the song.
This line reads ‘If you wake up and don’t want to smile.’ What are some reasons that we may
have woken up but not wanted to smile?” This led to a discussion concerning problems
patients might be experiencing, including anxiety; lack of motivation; frustration over
their inpatient hospitalization; depression; apathy; and physical, emotional, spiritual, or
psychological pain. Patients often noted the importance of having a positive attitude and
making the most of the days and their inpatient hospitalizations, even if they did not wake
up smiling. Thus the music therapist indirectly derived a question from lyrics but directly
related the question to patients’ experiences to stimulate constructive dialogue concerning
Another frequently occurring phenomenon in lyric analysis interventions is the use of
third-person to first-person dialogue. During lyric analysis interventions, a music ther-
apist can ask questions about the character(s) depicted in the song using third-person
dialogue. However, patients often respond to these questions using first-person dialogue
concerning themselves. Thus, instead of answering questions about the characters within
the song, patients spontaneously reveal their own experiences, thoughts, and feelings
without prompts from the therapist. These responses are often personalized and insight-
ful. The author does not consider these to be projections as the patient answers a different
nonthreatening question in a more personal manner. Therefore lyric analysis can be an in-
direct, nonthreatening way to encourage therapeutic dialogue concerning patients’ unique
situations. Additionally, patients often relate their own feelings, thoughts, or behaviors
with characters in the song. Referencing characters in songs can be an effective technique
to stimulate therapeutic dialogue without asking potentially threatening, combative, or
invasive questions. Instead, the music therapist can ask patients questions about the song
or characters and let the patients use third-person to first-person dialogue in order to talk
about their idiosyncratic experiences.
Although certain songs may not necessarily translate well for live music sung by the
music therapist and accompanied on acoustic guitar or keyboard (e.g., songs by Tool or
The Black Eyed Peas), live music is recommended for lyric analysis interventions when-
ever possible. The live music may function as a type of musical offering or gift as well as
self-disclosure from the therapist. After the music therapist plays a song live for psychiatric
patients, the consumers may be more apt to disclose personal and therapeutic material and
dialogue after the music therapist made herself or himself vulnerable by self-disclosing
emotion and musicality while playing the song. In a randomized controlled trial, Silver-
man (2014) found that patients in a live music lyric analysis intervention of “Runaway
Train” had higher ratings of the therapist’s competence than patients in a recorded lyric
analysis of the same song. Due to the use of scripts and manuals in this study to control ex-
traneous variables, these significant between-group differences heighten the importance
of the music-based competencies of psychiatric music therapists. Future research is war-
ranted that explores the impact of live versus recorded music on other aspects of the cli-
ent’s experience of music therapy, including working alliance, verbal participation, on-task
behavior, and progress toward educational and clinical objectives.
While vague or abstract lyrics enable patients to make numerous subjective interpreta-
tions, I have had clinical success with acute-care and higher functioning patients using
lyrics that may be considered vague. For patients who are more chronically mentally ill,
however, vague lyrics may not be as successful due to their ambiguity. When working with
patients who have longer-term inpatient hospitalizations and who may be displaying more
psychotic or delusional behaviors, lyrics that are more direct or concrete may facilitate
therapeutic dialogue. This concept warrants empirical investigation.
Noting that songwriting can enable clients to self-express, O’Callaghan and Grocke
(2009) conducted lyric analyses of patient-composed songs. Analyzing lyrics can enhance
music therapists’ empathy for their patients. Thus, songwriting and lyric analysis interven-
tions have many commonalities and can sometimes be used interchangeably. For example,
patients can analyze song lyrics from a song they composed. Conversely, patients can re-
write a song used during a lyric analysis intervention.
Box 9.9 presents suggestions for lyric analysis interventions derived from Silverman
(2009b).
Box 9.9 Suggestions for Facilitating Lyric Analysis

Interventions
◆ Use high quality live music.
◆ Assign some sort of task to consumers during the song to keep them engaged and
focused during the playing of the music (e.g., identify a favorite phrase in lyrics, an
emotion that consumers may have, a problem similarity between the character in
the song and the consumers).
◆ Begin the analysis by emphasizing that there are no wrong answers.
◆ Number the lines of the song so group members can easily refer to specific lyrics.
◆ Group phrases carefully to avoid giving consumers too much lyrical information at
a time.
◆ Use large, boldface font.
◆ Give lyric sheets to consumers at the conclusion of the session.
◆ Type reflective questions on the back of lyric sheets for homework assignments that
are related to the clinical objective and themes in the lyrics.
Rhythm-based interventions 183
Recreational music therapy interventions

Recreational music therapy can be an enjoyable modality to engage and motivate clients
to attend and actively participate in sessions. These interventions can also be referred to as
music therapy games (Silverman, 2005). However, using “games” as a descriptor may inad-
vertently depreciate their value and therapeutic impact, especially when communicating
with people who are not music therapy professionals. While it is imperative that music
therapists address clinical objectives during recreational music therapy interventions, the
interventions should also be enjoyable so that patients attend and participate in future
sessions. Due to the noninvasive nature of recreational music therapy, it may be ideal for
establishing therapeutic rapport and working alliance. Additionally, psychiatric music
therapists who are working evening or weekend shifts may be responsible for greater num-
bers of patients in group therapy sessions. Recreational music therapy interventions can
often be successfully implemented with larger groups of patients.
Music therapy researchers have studied recreational music therapy interventions with
psychiatric patients. In a one-group, pre- and posttest design, Silverman and Rosenow
(2013) found a single recreational music therapy session immediately improved the mood
of acute-care psychiatric inpatients. The researchers used ten different group-based rec-
reational music therapy interventions in the study: musical hot potato, name that tune,
music jeopardy, TV theme songs, music wheel of fortune, junk band percussion (a percus-
sion ensemble using buckets, rods, and other nontraditional instruments), art and music,
a music and dice game, complete the lyrics, and music-based charades. All recreational
music therapy interventions were effective but no intervention was more effective than
another.
Table 9.3 provides group-based recreational music therapy interventions for adult psy-
chiatric patients derived from Silverman (2005).
Rhythm-based interventions
Due to their accessibility and inclusive nature, rhythm-based interventions (that do not
utilize pitches) can immediately engage psychiatric patients in a music therapy interven-
tion. In a randomized controlled study measuring effects of music therapy on anxiety and
meaning in life, Silverman (2011d) described two brief rhythm-based interventions for
use with adult acute psychiatric patients. Anecdotally, patients (as well as staff) actively
participated in these interventions as evidenced by heightened affect, verbal disclosure,
and participatory behaviors without prompting. These interventions were used to develop
rapport and therapeutic alliance in an acute-care psychiatric setting. Following these
rhythm-based interventions, the clinician implemented a lyric analysis intervention to ad-
dress the psychoeducational objective of social supports both in and outside the hospital.
Thus, the rhythm-based interventions were designed to establish trust, rapport, working
alliance, and participatory behaviors before moving toward a more educational interven-
tion involving social supports. Three examples of rhythm-based interventions are given in
the following paragraphs (Silverman, 2011d, pp. 82–83).
Table 9.3 Group-Based Recreational Music Therapy Interventions
Recreational Music Therapy Brief Description

Intervention
Hot potato Players toss ball while music plays, when music stops, player
with ball answers question about music, artists, and illness
management and recovery including medications, coping skills,
and supports.
Name that tune Players identify song or artist, earn points.
Music relay races Set up stations, player has to complete task (such as play
instrument, sing song, identify positive coping skill) at each
station as part of team.
Music with pictures Player draws picture of song, artist, or instrument while team
members guess what player is drawing.
Music trivia Players answer music-based trivia questions.
Music charades Player acts out song/artist while team members guess.
Music bingo or “singo” Player identifies songs on bingo card.
Music board games Players roll dice and answer psychoeducational and music-based
questions, sing, or dance, depending on where they land on board.
Rhythmic games Players toss/bounce ball to peers on beat.
TV theme song games Players identify popular TV show based on theme song.
TV music games Players participate in TV music game (such as Music Jeopardy,
Music Wheel of Fortune).
Musical chairs Players participate in competitive chair elimination game.
Simon says Players follow peer’s music-based directions and can be
eliminated from game.
Blindfolded One volunteer is blindfolded and team plays “hot/cold” with
communication game instruments to direct player to object.
Complete the lyric game Players are given song lyrics and have to identify next lyrics in song.
Music sports games Structure “name that tune” game with popular sports (such as
baseball, football, basketball). Player with correct response gets to
shoot a basketball or bowl to earn points for team.
Take one, pass one

The RT [researcher-therapist] arranged participants standing in a circle and passed out
egg shakers. Participants began with an egg shaker in their open left hand. The RT then
instructed “take one,” and participants grasped their egg shaker with their right hand. As
the RT instructed “pass one,” participants passed the egg shaker to the participant on their
right’s left hand. This process was continuously repeated and tempos were increased. The
RT then reversed the directionality (i.e., starting with the egg shaker in the right hand
and passing to the left). (Thank you to Michael Marcionetti, MT-BC, for sharing this
intervention.)
Facilitated group drumming and percussion 185
Rhythm train
The RT then led a “rhythm train” intervention with the egg shakers. The RT improvised a
simple four-part rhythm (such as shake, shake, pass the egg shaker around your head, shake).
Participants were asked to play the rhythm with the RT (rhythm #1) until all participants
demonstrated successful playing. Then the RT asked if any participants would like to create
their own four-part rhythm (rhythm #2). Once the group was able to successfully play the
new participant-created rhythm, the RT led rhythm #2 four times, then rhythm number #1
four times. The RT continued to add to the “rhythm train” using reverse chaining techniques
until all participants who wished to compose a rhythm had an opportunity to lead the group.
The RT encouraged patients to compose a new rhythm but did not force them to do so.
Pass/bounce, 2, 3, 4 . . .
In this intervention, patients are seated in a circle. The music therapist establishes a four-
beat ostinato on a drum and instructs the patients to pass one ball on the word “pass,” stated
by the therapist during beat one. The other beats (beats 2, 3, and 4) are played in order to
entrain patients and improve rhythmic accuracy and likelihood of successfully passing the
ball on the correct beat. Once the patients develop confidence and competence, the music
therapist can increase the speed of the drumming and also can call a “switch” in which
patients pass the ball in the reverse direction. After patients have developed competency
at the “pass” intervention, the music therapist can switch the intervention to “bounce” in
which patients have to bounce the ball on beat one to each other. Basketballs and kick balls
work well for this intervention. Multiple balls can be used to challenge patients after they
have demonstrated success with a single ball.
Facilitated group drumming and percussion

Facilitated drumming interventions can be used for a variety of psychotherapeutic objec-
tives. Drumming can be used with persons who are diagnosed with mental illnesses to
increase self-esteem and create a feeling of accomplishment (Friedman, 2000). Slotoroff
(1994) used drumming and cognitive behavioral methods to address issues of power in
an experimental and symbolic manner. Watson (2002) found that improvisational drum-
ming was able to release emotions, provide relaxation, ease social interaction, decrease
headaches and muscle tension, and provide enjoyment for sexual offenders. Longhofer
and Floersch (1993) noted that a drumming ensemble complemented goals of psychiat-
ric rehabilitation such as self-determination and empowerment. Although the researchers
were confident that drumming increased the psychiatric outpatients’ self-esteem, unfor-
tunately no quantitative data was provided.
The author has had clinical success using percussion interventions with psychiatric in-
patients. To increase self-awareness, emotional recognition, and communication in group-
based settings, a patient can play how she or he currently feels on a percussion instrument
while other group members guess the emotion. Psychiatric music therapists interested in
facilitated group drumming are encouraged to consult Marcionetti (2009) and Matney
(2007) and apply these techniques to their unique clinical settings.
Rock opera for assertiveness training

In an attempt to teach appropriate assertive behaviors to acute-care psychiatric inpatients,
Silverman (2011a) designed a “rock opera” intervention. The scenarios used in this inter-
vention are in Table 9.4 (see also Box 9.10 for a possible protocol). Role-playing scenarios
from the research study are also included. The rationale and procedure for the rock opera
intervention may be described as follows:
The RT [researcher-therapist] then facilitated a brief dialog concerning assertiveness, its defini-
tion, and why it was important in the context of a psychiatric hospital. Participants were asked to
discuss a rationale for the importance of assertive behaviors, especially as a psychiatric inpatient
(during the beginning of the session) and as a discharged person living in the community (at
the end of the session). The RT explained that certain music talked about being assertive and
introduced Bob Marley’s “Get Up, Stand Up.” The RT facilitated a brief dialogue about how the
lyrics concerned appropriate assertive behaviors and taught the participants to sing the song,
accompanying them on the guitar. The RT then explained that the group would be participating
in a “type of rock opera, where you’ll get to act out certain situations in an assertive manner and
then we’ll all sing the chorus of ‘Get Up, Stand Up.’” Role-playing scenarios [Table 9.4] were
then introduced individually and participants were able to volunteer to act out patient or staff
roles. Scenarios typically lasted one to three minutes and were followed by a feedback session
that typically lasted between one and two minutes. Between scenarios, the RT led the group in
singing “Get Up, Stand Up” during the chorus of the rock opera. After each role-play, the re-
searcher provided coaching, verbal reinforcement, and asked for peer reinforcement concerning
effective assertive behaviors. These are common components of assertiveness training as noted
Table 9.4 Role-Playing Scenarios for Rock Opera Interventions
Scenario Participant 1 Role Participant 2 Role

1 Patient slept through meal, is hungry Patient on unit Mental health worker
2 Patient is having a dispute with other patient Patient on unit Mental health worker
3 Patient has headache and wants medication to Patient on unit Nurse
alleviate headache
4 Patient has a verbal dispute with mental health Patient on unit Nurse
worker
5 Patient experiencing side effects from medications Patient on unit Psychiatrist
6 Patient experiencing high degree of anxiety Patient on unit Psychiatrist
7 Patient wants to go home to live independently Patient on unit Social worker
instead of to group home for a mandatory 28 days
8 Patient is having to remain on unit but wants to Patient on unit Social worker
go home
9 Patient has been living in the community, is having Patient living in Case manager
symptoms again, but does not want to go back to community
hospital
10 Patient’s medications are not working; calls Patient living in Psychiatrist (on
psychiatrist community (on phone) phone)
Rock opera for assertiveness training 187
in the literature (Finch & Wallace, 1977; Gingerich & Mueser, 2005; McFall & Twentyman, 1973;
Rich & Schroeder, 1976). At the end of the session, the RT verbally processed what had taken
place and asked the definition of assertiveness, why it was important at the hospital, why it
was important in the community, and thanked participants for their “good work.” (Silverman,
2011a, p. 378)
Box 9.10 Assertiveness Music Therapy Protocol

Materials: Acoustic Guitar
Time: 30–60 minutes, depending on number of scenarios
Arrangement: Consumers seated around table or in circle
1 Hello song.
2 Define assertive behavior: “What does it mean to be assertive?”
3 Generalize assertive behavior to psychiatric hospital: “Why is it important to be
assertive on the unit? What are some examples of assertive behavior here on the
unit?”*
4 Identify songs that talk about being assertive. “Does anyone know any songs that
talk about being assertive?”
5 Introduce “Get Up, Stand Up.” Teach consumers “Get Up, Stand Up” by Bob Marley.
6 Introduce role-playing to practice assertive behaviors. “Today, we will participate in
a type of rock opera, where you’ll get to act out assertive behaviors with unit staff.”
7 Introduce scenario 1 as “Act 1 of the rock opera.” Ask for consumers to volunteer to
act out roles as unit staff and consumers.
8 Sing chorus of “Get Up, Stand Up.”
9 Provide positive feedback and constructive criticism of consumer behaviors during
Act 1, using a 4:1 positive/negative feedback ratio.
10 Repeat steps 6–8 using different scenarios and different consumers.
11 Tell consumers that time has run out and the session has to conclude.
12 Ask consumers if they have thoughts, questions, or comments they would like to
share about the session in which they participated.
13 Provide specific positive feedback concerning consumers’ participation.
14 Generalize assertive behavior toward being an outpatient: “You will all eventually
be discharged. Why is it important to be assertive when you aren’t in the hospital?
What are some examples of assertive behavior in the community?”
*To increase the amount of music used in the session, the author recommends nonver-
bally demonstrating assertive behavior on unpitched percussion instruments and then
having patients play assertively during a musical conversation. See Cassity and Cassity
(2006) for other assertiveness interventions (Silverman, 2011a, pp. 393–394).
Rockumentaries
“Rockumentaries” can be an effective way to engage patients via music and discussing
artists and their histories. As there are numerous stories of musicians who have drug
and alcohol addiction and varied success with treatment (e.g., Stevie Ray Vaughn, Eric
Clapton, the Red Hot Chili Peppers), this intervention may be particularly applicable for
psychiatric music therapists working in substance abuse rehabilitation facilities or in inte-
grated dual-diagnosis treatment settings. Rockumentary is a combination of lyric analysis
in conjunction with discussion of the band member’s addiction or journal through ill-
ness management and recovery. The rockumentary example is from Silverman (2011c,
pp. 517–519).
After orientation to the research and explanation of and attaining informed consent, the rockumen-
tary condition began with each participant stating their name and how they were currently feeling
within a 12-bar blues “riff” on the guitar. The RT [researcher-therapist] then distributed lyric sheets
for “Under the Bridge” and “Scar Tissue” and played “Under the Bridge” by the Red Hot Chili Pep-
pers. Participants were encouraged to sing along with the RT if they wanted. The RT then provided
a rockumentary of the Red Hot Chili Peppers, specifically concerning the song “Under the Bridge.”
The rockumentary included information concerning the origin and development of the band; sub-
stance abuse by members of the band; the overdose of the band’s original guitarist, Hillel Slovak;
John Frusciante’s struggles with substance abuse and fame; the band getting sober; Anthony Kie-
dis’s frequent relapses; the writing of “Under the Bridge”; how Kiedis eventually attained and main-
tained sobriety; the band’s success and musicality when sober; and current happenings of the band.
(For more information on the history of the Red Hot Chili Peppers, see Kiedis & Sloman, 2004.)
The RT then facilitated a scripted lyric analysis of “Under the Bridge” focusing on relapse pre-
vention based upon that used in Silverman (2010). The lyric analysis intervention was chosen as re-
search has indicated that lyric analysis is the most commonly used intervention by music therapists
working in substance abuse rehabilitation (Silverman, 2009a). Questions were based from the song
lyrics but were focused on the participants’ personal situations (e.g., questions concerning stressors,
loneliness, isolation, coping skills, supports, and healthy alternatives to using drugs and alcohol).
For example, as family, peers, and friends have been predictors of posttreatment outcomes (Grella,
Hser, Joshi, & Anglin, 1999; Hser, Grella, Hsieh, Anglin, & Brown, 1999; Simpson, Joe, Greener, &
Rowan-Szal, 2000), one set of questions was: “Let’s look at lines one and two. They read: ‘Sometimes
I feel like I don’t have a partner, sometimes I feel like my only friend.’ When you were using, did
you feel like you had friends? Who were you hanging out with? If you have had periods of sobriety,
whom were you associating with then?” Another set of questions was: “Line nine reads: ‘And I never
worry, now that is a lie.’ Why does the singer lie, and then admit it? What are some of the things
you are going to worry about when you are back in the community? What are some things you can
do to worry less?”
The RT focused therapeutic dialogue on triggers for using, action steps to take in the hospital
and once discharged, and coping skills to use after patients were discharged and living in the com-
munity. At the conclusion of the session, the RT verbally reinforced participants for attending and
taking an active role in the session. He introduced the lyrics to “Scar Tissue” and suggested that the
“life of the session continues” in the form of a homework assignment: Talk about the lyrics of the
“Scar Tissue” and complete the questions on the back of the lyric sheet. (These questions included:
“What does ‘scar tissue’ mean to you? What can you do about your scar tissue? How are you plan-
ning on staying clean when you are discharged? Where can you go when you need help being sober
when you are discharged? What are some healthy alternatives to using?”)
My song 189
Music and art

CD about me
Incorporating art in music therapy sessions with psychiatric patients can be engaging
and motivating. Patients can create a “CD about me” in which they design a CD cover
and choose songs or a playlist that currently represent them for inclusion on the CD.
The CD cover should be the same size as a typical CD cover to approximate the task.
Music therapists can request that songs in the playlist are chosen for a specific purpose,
such as relaxation, stimulation, coping, emotional recognition, support, or other psy-
choeducational topic. When introducing the intervention to participants, a pre-made
CD about me to function as a model for participants will likely be helpful. The model
may desensitize patients who may be apprehensive about creating visual art. At the
conclusion of the session, patients can share their creations with peers and talk about
how their projects relate to aspects of their hospitalization, illness management, and
recovery.
Readers using art during music therapy should be aware of the American Music Therapy
Association’s professional competencies and certification board for music therapists’ scope
of practice. It is vital to practice within the music therapy competencies and scope of prac-
tice. Music therapists using art-based music therapy interventions can co-facilitate with
art therapists.
Scribble art
Scribble art can be an engaging modality to let patients be creative and use art in a non-
judgmental manner. Music therapists should first distribute pencils and drawing paper.
With unfamiliar (recorded) classical music playing, ask patients to move their pencils
across the paper with the music without lifting pencil from paper. The therapist can ask for
this task to be completed with patients’ eyes closed, but only if the patients are comfortable
closing their eyes. After approximately 45 seconds, the music therapist instructs patients to
stop moving their pencils and to finish their art using colored pencils or crayons with their
eyes open. Patients can rotate the scribble art to their choosing. Patients then name their
creations, give their creations a theme song, and ask their creations three questions. When
introducing the intervention to participants, it may be helpful to have a scribble art project
completed to serve as a model. The model may desensitize patients who are anxious about
making visual art. At the conclusion of the session, patients can share their creations with
the group. Other group members can answer the three questions each patient asked of her
or his creation.
My song
In order to encourage dialogue and establish rapport and the therapeutic alliance, the au-
thor has used “my song” with acute-care psychiatric inpatients, people on a detoxification
unit, and women in long-term substance abuse inpatient care. In this intervention, the
music therapist distributes small pieces of paper and instructs group members to “Write
down the name of a song that currently represents you” or “Write down the name of a
song that inspires and motivates you.” Patients then fold the paper in half and give it to the
music therapist. The therapist then mixes up the papers and opens and reads one song at a
time. Group members’ tasks are to guess which patient selected each song. The patient who
wrote the song can share why that song is representative of her or him. The music therapist
may play the song or follow up with lyric analysis. Depending on the clinical objective, the
music therapist may direct the patients to write song titles that are motivational or encour-
aging to them or another topic of relevance to the clients. For example, if a therapist asks
patients to write motivational songs, a patient may choose “Won’t Back Down” or “Times
Like These” to represent her or his motivation to recover.
Orff-based and narrative-based music therapy interventions

for adult psychiatric consumers
Although Orff-based and some narrative techniques were primarily designed for chil-
dren, the narrative principles may apply to adult psychiatric patients when used in an
age-appropriate manner. Certainly, Orff has many components that are valuable in psy-
chiatric work, including active involvement, use of quality instruments, and high-quality
music. Additionally, the Orff Schulwerk pedagogy was designed to lead children through
four areas of musical development: exploration, imitation, improvisation, and creation
(Colwell, Pehotsky, Gillmeister, & Woolrich, 2008). When used in an age-appropriate
manner, these techniques can be applicable to adult psychiatric work.
Although no Orff-based psychiatric music therapy research exists, there is some
literature that may generalize to clinical music therapy applications with adult psy-
chiatric consumers. I used a common Orff technique in which I told a story about a
man with mental illness to patients on longer-term inpatient psychiatric units and
acute-care psychiatric units to increase knowledge of illness management and recov-
ery. There were three keywords in the story: depression, coping skills, and felt better.
Whenever I said any of these keywords, certain group members would play their un-
pitched percussion instruments. Throughout the intervention, I would stop and ask
patients psychoeducational questions about the character or issues in the story (see
Box 9.11). In this randomized study, the participants in the narrative condition had
higher knowledge of illness management and recovery scores than participants in an
educational lyric analysis intervention and participants in a wait-list control condition
(Silverman, 2013a).
Improvisation
Improvisation is a widely employed music therapy technique capable of addressing nu-
merous client objectives with psychiatric patients. Psychiatric music therapists have
used improvisation to improve mood state, global state, mental state, and social func-
tioning (Mossler, Chen, Heldal, & Gold, 2012). Music therapists can use improvisation
Improvisation 191
Box 9.11 Music-Based Narrative Intervention

Frank: Music-Based Narrative for Adult Psychiatric Patients
Keywords:
1 Felt better and feel better: shake egg shakers twice
2 Depressed, depression: play rhythm sticks once
3 Coping skill: play tambourine three times
Frank was a 37-year-old pharmacist. He worked at the local pharmacy where every-
one in the small town seemed to know him. He enjoyed his job and didn’t mind going to
work. Frank enjoyed spending time with his friends—they would go and watch sport-
ing events or play basketball. He noticed that if he had been having a bad day and did
this, he felt better. Frank was single but had a child named Mark. Although they didn’t
live together, Mark kept Frank from being depressed because he was such a great son.
Frank liked to go and watch Mark play Little League baseball. He felt very proud of his
son and knew that spending time with Mark was an excellent coping skill.
◆ What is a coping skill?
◆ What are some of Frank’s coping skills?
◆ What are some coping skills you can use here at the hospital?
◆ What are some coping skills you can use in the community?
Although it sounds good right now, Frank’s life hasn’t always been all that great. Two
years ago, Frank became very depressed. He felt alone and didn’t know what to do. He
thought that nobody cared for him and life was not worth living. Playing basketball with
his friends didn’t make him feel better. He didn’t like going to work anymore. He wanted
to stay in bed all day. He lost his appetite and Frank had always been a good eater. Watch-
ing his son play baseball was no longer an effective coping skill. Frank was depressed.
He went to see a counselor whom he talked with once a week. After their talks, Frank al-
ways felt better. He began to realize that simply talking about his problems was a coping
skill. However, after a month of therapy, he began to feel depressed again. Frank’s coun-
selor referred him to a psychiatrist, a medical doctor who could prescribe medication
that, in combination with talk-based therapy, might lift his depression. After meeting
with the psychiatrist, Frank began taking antidepressants. At first, these drugs made him
feel groggy and tired. But after a few weeks, Frank’s depression ceased to bother him.
He felt better. He started to enjoy time with his son, friends, and working. Alas, his old
coping skills were working again! The doctor warned Frank to remain on the medica-
tion and if anything happened or he felt depressed, to call her immediately. Frank con-
tinued to see his counselor once a week. After a year, Frank started seeing his counselor
once every two weeks. Both Frank and his counselor felt this was enough.
◆ What is a psychiatrist?
◆ What were some signs that Frank was depressed?
Box 9.11 Music-Based Narrative Intervention (continued)
◆ What were some things that made Frank feel better when his old coping skills
weren’t working?
◆ What are some common antidepressants?
◆ What are side effects?
Frank’s life was going well. He was spending quality time with his son on weekends,
playing in a basketball league with his friends, and he started dating a nice lady named
Susan. Susan was his age and lived close to Frank. The two enjoyed spending time with
each other watching movies, playing board games, and trying new restaurants. Frank’s
life revolved around his coping skills, which never ceased to make him feel better, no
matter how hard a day at work he had. Frank was also careful to stay on his medication
just as his psychiatrist had prescribed. He remembered how important the doctor said
it was to take at a certain time each day. By this time, Frank was only seeing his coun-
selor once a month. He was certainly not depressed—in fact, Frank was quite happy.
However, one day, Susan came home from work and said she needed to talk with
him. Susan was offered a job far away and decided to take it. She had wanted to move
closer to her parents, who were getting older. Although Frank was heartbroken about
her decision to move away, he kept his feelings to himself. He didn’t want Susan to know
how much it hurt him that she was moving far away. Susan moved away two weeks later.
Frank became depressed once again. His medication didn’t seem to make him feel
better. His coping skills weren’t effective anymore. His friends noticed and tried to get
Frank to come out more often. Frank told them he’d rather stay at home. Frank started
calling in sick to work—he didn’t want to have to deal with his job and the people with
whom he worked. He became more and more depressed. He wasn’t sleeping well ei-
ther. Frank’s counselor became concerned as well. The two worked to find more coping
skills to make Frank feel better. Frank tried bowling with his son, talking with his
friends over a cup of coffee, and writing letters to himself, but nothing seemed to work.
◆ What was the primary stressor that caused Frank’s depression to recur?
◆ What other coping skills did Frank implement?
One day at work, Frank had an idea. If his medication made him feel better the last
time he was depressed, why shouldn’t it work this time? He thought that maybe he
could take more medication to help him. And with Frank working at a pharmacy, this
would be easy to do—nobody would ever know. If it didn’t work, Frank figured he’d stop
and go back to his original dosage.
◆ What is Frank’s mistake here?
◆ Why is it dangerous to self-medicate?
◆ What are some common ways that people might self-medicate?
Frank started self-medicating. He began to feel worse everyday and thought he
should go back to his original dosage. However, Frank didn’t—he kept increasing his
medications hoping they would make him feel better, but he still felt very depressed.
Improvisation 193
After one particularly difficult day at work, Frank decided to try a new coping skill.
After all, nothing else was making him feel better. He had often seen people drinking
to help their depression on population television shows. That night, he went to a bar
and started drinking. He didn’t like the taste, but the alcohol seemed to relax him. It
made him forget about his worries. Frank stayed at the bar until closing time, when the
bartender called a cab for him. Using alcohol as a coping skill isn’t so bad, he thought.
His depression was gone and he was feeling better. He was having a great time playing
pool and meeting new people. But Frank knew alcohol could be addictive. He knew
he had to carefully monitor his drinking. And besides, he thought, I won’t be become
addicted—it won’t happen to me. Frank fell immediately to sleep that night.
◆ Is alcohol a coping skill? Please explain why or why not.
◆ What is wrong with Frank’s thinking?
Frank woke up the following morning and felt awful. His head hurt, his body ached,
and he felt shamed and depressed. But he dragged himself out of bed and went to work
despite feeling so bad. At work he took some pills in an attempt to cure his hangover.
Work was very busy that day, and it seemed as though Frank was constantly running
around to meet his work duties. Finally, 5:00 p.m. came and Frank was finished with
work for the day. Frank was very relieved to get out of work. His head was finally feeling
better. He decided to reward himself by going to the bar and having a drink. After
all, he had met some nice people there last night and one drink couldn’t hurt. Frank
thought this wasn’t a coping skill, but rather a reward for having got through a rough
day at work. However, after his first drink, he decided, “Why not have another? I really
did earn it today!” Once again, Frank stayed at the bar until the bartender called a cab
for him. However, Frank had spent all his cash at the bar and had to give the cab driver
his watch in payment for the ride home.
Frank woke up the next morning feeling awful! He looked around for his watch and
couldn’t find it. He didn’t know where all his money had gone. He had slept through
most of the morning and forgotten to call in sick to work. He couldn’t remember what
had happened the previous night. His head hurt and he was depressed. There were
two messages on his voice mail. One was from his boss at CVS wondering where Frank
was and one was from his son. Frank had forgotten about his promise to attend Mark’s
baseball game last night!
◆ What are some of the consequences of Frank’s drinking?
Frank had never been so depressed. He was not using healthy coping skills. Drink-
ing only made him feel better for a short while. Taking pills at work was wrong and
Frank felt ashamed and worried that he might get caught and fired. Frank called his
counselor and made an appointment for later that day.
Frank’s counselor was very worried. He had never seen Frank look so bad. Frank
looked tired and was certainly depressed. It certainly appeared that Frank’s usual
coping skills were not working. His counselor recommended that they get in touch
with Frank’s psychiatrist. This made Frank feel nervous—he didn’t want to have to use
more medicine to make him feel better. He thought his old doctor might even be mad
at him for coming back for more treatment.
Frank went to see his psychiatrist the next day. They had a long talk. Frank was very
honest about why he was so depressed and told the doctor everything he had been
doing. The doctor listened carefully and she didn’t seem to be mad at Frank. In fact,
she seemed sympathetic and very concerned about Frank’s health. She told Frank he
would do whatever it took to make him feel better. After Frank had told the doctor
everything, the doctor suggested that Frank check himself into a psychiatric hospital.
Frank wondered if this were really necessary. “Are there any other coping skills you
can teach me?” He asked. The doctor noted that a hospital would be best and, while at
the hospital, Frank would learn about coping skills to make him feel better and how
to best manage his depression. Frank followed his doctor’s recommendation and went
home to pack his bags.
Frank was scared about going to a psychiatric hospital. He didn’t even like having
regular check-ups with his primary care physician at the medical hospital! What would
other people think about Frank? All of this to feel better? Was it worth it? True, Frank’s
coping skills weren’t helping him out of his depression. Maybe the doctor was right.
Frank went to the psychiatric hospital and checked himself in voluntarily.
◆ Was anyone else scared about being a patient at a psychiatric hospital?
◆ What can you do about stigma concerning psychiatric illnesses?
Frank was on the hospital unit with 14 other people. Some were younger and some
were older. All of them seemed very nice and supportive of him. In fact, upon arrival,
one female patient walked right up to Frank and said, “This place doesn’t suck all that
bad. The food ain’t great, but the staff do care and you’ll get better. Keep your head up
and go to the groups!” This made Frank feel better and worry less. Frank immedi-
ately met the nurses and doctors, who prescribed him some new medications for his
depression. They explained to him that these meds might make him feel groggy and
tired, but after a few days his body would likely adjust and he would feel better. Frank
also met the “psych techs.” These were staff on the unit who helped with activities, took
vital signs, and helped him out whenever he had a question. They asked Frank why he
was depressed and told him what coping skills they had used to deal with a break-up
or when they were having a bad day. The other patients on the unit were very friendly.
Some kept to themselves, but once Frank engaged them in conversation, he realized
how nice they were. The other patients seemed to understand what Frank was going
through and they didn’t seem to judge him. Some of them said they had been admitted
for depression as well. Frank found that it was easy to relate and talk with them. They
shared stories, coping skills, and meals and Frank started to feel better.
Improvisation 195
◆ Have you found that people on the unit have been supportive of you? Why?
◆ How can you help newly admitted patients?
Frank met with the doctor each day. His depression began to lift and Frank was
f eeling better. In groups, Frank talked about feelings, coping skills, medications, how
to manage his depression. Frank felt very supported in these groups and that everyone
at the hospital was trying their hardest to help him. Frank complied with his medica-
tions, went to groups, and participated in all unit activities. Frank began to feel better
after a few days. The doctor noticed Frank’s change in mood and asked Frank about his
depression. Frank said he was feeling better and believed his old coping skills and
newly learned coping skills could do the trick now that he had his new medication.
The doctor agreed and decided to discharge Frank in two days. The doctor and social
workers made appointments for Frank to see his counselor and were excited to hear
that Frank had been in talk therapy with a person he liked and trusted.
As the doctor had said, Frank was discharged two days later. He went back to work
and everyone was happy to see him. They seemed to understand Frank’s situation and
were very supportive. That night, Frank and his buddies went to see Mark’s baseball
game. His old coping skills were working and making him feel better. Sure, he missed
Susan, but Frank had things to keep him from being depressed. He had been worried
about what people might think of him for having gone to a psychiatric hospital, but
nobody seemed to care. People were just happy to have Frank back in their lives. At the
hospital, Frank learned that approximately 25% of the people in the United States have
a diagnosable mental health problem each year. Perhaps people he knew didn’t care
about his hospitalization because mental illnesses are so common.
In the last few weeks, Frank had gone through quite a bit. He had been overcome
by stressors and needed to take a step back and reconceptualize his life. He had done
things that he normally never would dream of—taking pills, using alcohol, and missing
his son’s Little League games. He was glad his doctor had referred him to the hospital.
Things were much better now and they would stay that way!
◆ Please explain how “Frank can live happily ever after.”
to increase reality orientation, heighten self-awareness, and increase on-task behaviors,

thus increasing social and cognitive functioning. Illness management skills could cer-
tainly be addressed through improvisation, although these data do not exist to date. In
an innovative qualitative study, Ansdell and Meehan (2010) used a Nordoff-Robbins
music therapy approach (Nordoff & Robbins, 1977) to treat 19 patients with chronic
mental health problems. Other authors have used the creative music therapy approach
with adult psychiatric patients (Pavlicevic & Trevarthen, 1989). In these approaches, pa-
tients actively made music with a therapist during music therapy sessions. It is typically

◆ There are numerous interventions available to music therapists to use with psychi-
atric patients.
◆ Using an educational approach for illness management and recovery, music therapy
interventions for psychiatric patients can be educational, therapeutic, and enjoyable.
◆ Various levels of structure can be used to ensure patient success, both musically and
nonmusically.
◆ It is essential for the music therapist to make educational and therapeutic material
explicit for patients so they are able to generalize knowledge and skills learned in
music therapy to other aspects of their lives.
◆ Future research concerning how music therapy interventions may affect psychiatric
patients’ ability to manage their illnesses and recover are warranted.
a nonverbal process and patients do not need previous music experience or expertise.
Throughout the process, a bond is formed through the musical and therapeutic rela-
tionship. Readers interested in applying improvisation to illness management and re-
covery are advised to consult the improvisational music therapy literature base (Beer,
2011; Bruscia, 1987; Crowe, Nolan, & Ierardi, 2007; Leite, Austin, Paker, Rugenstein, &
Crowe, 2007).
Therapeutic music videos

Although clinicians and researchers have implemented therapeutic music video in-
terventions with youth who were at risk (Smith, 2012), pediatric patients undergoing
bone marrow transplantation (Robb & Ebberts, 2003a, Robb & Ebberts, 2003b), and
adolescents and adults during stem-cell transplantation (Burns, Robb, & Haase, 2009),
there is no psychiatric music therapy literature concerning this innovative interven-
tion. However, it seems that therapeutic music video interventions could be adapted
to psychiatric music therapy. Interested readers are advised to consult the aforemen-
tioned sources concerning how to design and implement therapeutic music videos.
This intervention remains fertile for future systematic inquiry specific to psychiatric
consumers.
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1 Why may it advisable for a less experienced music therapist to use greater degrees of structure during
songwriting interventions?
2 Why are heightened musicality and aesthetics vital for successful interventions?
3 How can third-person to first-person dialogue be used to create and enhance a nonthreatening thera-
peutic environment?
4 Design a brief age-appropriate music-based activity using hand-held percussion instruments to develop
therapeutic rapport and working alliance for adult psychiatric inpatients.
5 Design a music therapy intervention using music and visual art to increase knowledge of behavioral
coping skills.
Chapter 10
Music therapy for co-occurring

psychiatric and substance misuse
disorders
Introduction
In a report concerning directions for future patient-centered care for people with
mental illnesses, Green et al. (2014) noted addiction was beyond the scope of their
paper. In a similar manner, reducing music therapy to treat addiction and substance
abuse to the confines of a single chapter of the current monograph would inadvertently
negate the importance of this essential and complicated topic. However, Green et al.
(2014) did dedicate a section of their report to address services for individuals with
dual diagnoses, which guided the current author’s decision to include this chapter. For
a well-written and comprehensive text specific to music therapy and addiction, inter-
ested readers are recommended to consult Aldridge and Fachner (2010). Additionally,
readers concerned with the music therapy research literature pertaining to substance
abuse treatment can refer to the sources given in Table 12.2. Readers interested in the
harm-reduction approach to managing substance abuse and dependence are advised to
consult Ghetti (2004), while readers interested in music-based cognitive rehabilitation
to prevent drug relapse can read Lesiuk (2010). For a well-written overview concerning
music therapy for clients with substance abuse disorders, interested readers can consult
Soshensky (2007).
This chapter is specific to music therapy in the context of dual disorders (i.e., mental
health disorders and co-occurring substance abuse disorders). However, readers should
be aware of many other types of comorbidities, including severe mental illnesses and
personality disorders. For example, it is not uncommon for people with a major men-
tal illness (e.g., bipolar disorder, major depressive disorder, schizoaffective disorder) to
also have a personality disorder (e.g., borderline personality disorder). Additionally, a
person can have a diagnosis of multiple severe mental illnesses. For example, anxiety
and depression are frequently comorbid (Aina & Susman, 2006). This chapter, however,
is written specifically to address the “most common and clinically significant comorbid
disorder in adults with severe mental illness” (Drake et al., 2001, p. 469): co-occurring se-
vere mental disorders involving a major mental illness (including bipolar disorder, major
depressive disorder, schizoaffective disorder, and schizophrenia) and substance abuse or
dependence.
202 MUSIC THERAPY FOR CO-OCCURRING DISORDERS
Social problem
Researchers and clinicians have noted that substance use–related problems (including
abuse and dependence) are common in people living with serious mental disorders (Cor-
rigan, McCracken, & McNeilly, 2005). In a study of inpatient care for psychiatric disor-
ders, Blader (2011) found that substance abuse disorders were the primary comorbidity
of adults who have psychiatric diagnoses. Blader noted that 30.27% of adults with a pri-
mary psychiatric disorder also had a comorbid substance use disorder. Other researchers
have estimated that approximately half the people diagnosed with severe mental illness
develop a substance abuse problem at some point in their lives (Boyle, Delos Reyes, &
Kruszynski, 2005; Regier, Narrow, & Rae, 1990). Other scholars have indicated that the
prevalence rates of substance abuse in this population are 25–35% (Graham et al., 2001;
Mueser et al., 1990; Rosenberg et al., 1998). However, there is debate over this statistic
as the National Association of State Mental Health Program Directors Medical Directors
Council (2007) noted that substance abuse and dependence rates for people with serious
mental illnesses are estimated at between 40% and 70% and are major contributing factors
to early mortality in this population. Although not as recent, researchers who conducted
arguably the most extensive prevalence study concerning substance abuse and people with
serious mental illnesses indicated that the rate is three to five times higher than the general
population (Regier et al., 1990). Regardless of the specific study and resulting statistics,
substance abuse has been—and continues to be—a major dilemma for people with mental
disorders. This abuse has been associated with worse work history (Perkins, Simpson, &
Tsuang, 1986) and higher risk for poor treatment outcomes such as recidivism, height-
ened suicide rates, homelessness, risk of HIV and other infections, aggressive behaviors
and behavioral problems, and worsening psychiatric symptoms (Mercer-McFadden et al.,
1998). Substance abuse can lead to longer and more expensive inpatient rehospitalizations
(Haywood et al., 1995). Moreover, people with dual diagnoses are less likely to be compli-
ant with their medication regimens (Miller & Tanenbaum, 1989), are less aware of their
illnesses, and may have unrealistic attitudes concerning their illnesses and treatment (Al-
terman & McLellan, 1981; Tsuang, Simpson, & Kronfol, 1982). People with co-occurring
psychiatric disorders tend to use more costly services—including emergency rooms and
inpatient care—than their counterparts without substance misuse disorders (Bartels et al.,
1993; Dickey & Azeni, 1996).
It is widely believed that many individuals with dual diagnoses self-medicate with sub-
stances in an attempt to manage their symptoms of mental illness. Thus, clients can deny
or minimize problems related to substance abuse (Test, Wallish, Allness, & Ripp, 1989)
and may believe that the substances are actually responsible for the alleviation of stress
(Drake et al., 2001). Causality of symptoms can be obscured due to the immediate effects
resulting from the chemicals (Mueser, Drake, & Wallach, 1998). This initial form of self-
medication can lead to abuse and addiction (Magura et al., 2003). Although the belief
that psychiatric patients cope with their illnesses via abusing substances is widespread
(Khantzian, 1997), it may not necessarily be accurate. In fact, patients with co-occurring
Integrated dual-disorder treatment 203
disorders and the general population tend to report using substances for similar reasons,
including coping with social anxiety, loneliness, insomnia, and boredom (Mueser, Drake,
& Wallach, 1998).
For individuals with co-occurring psychiatric disorders, diagnoses and treatment are
confounded by the two disorders. Clinicians typically have a more difficult task designing
and implementing effective treatments due to the highly complex needs (Aase, Jason, &
LaVome Robinson, 2008). Additionally, mental illness may be the result of prolonged sub-
stance abuse. Due to differing perspectives concerning what was the primary disorder—
the mental disorder or the substance abuse—clinicians have struggled with what disorder
to initially treat and how to resolve this complicated and interwoven problem.
Separate care
People with co-occurring psychiatric disorders have had considerable difficulty attaining
comprehensive services to meet their unique needs. Traditional services for mental health
and substance abuse have been compartmentalized and ineffective, further complicated
by separate funding mechanisms contending for already inadequate resources (Drake
& Mueser, 2000). The difficulties in attaining adequate and comprehensive services to
treat both conditions are often the result of a facility’s reluctance or inability to treat both
disorders concurrently. Most care systems are compartmentalized and designed to treat
a single disorder at a time. Segregated treatment systems typically do not take the im-
mediate and complex needs of this clinical population into account. Thus, a patient with
diagnoses of bipolar disorder and alcohol dependence may be excluded from addiction
services within one care system and asked to return for addiction treatment after her or
his bipolar disorder is stable or under control (Drake et al., 2001). These barriers can be
a factor of regulatory, licensing, and reimbursement issues, often leading to additional
complications and delayed treatment (Minkoff & Cline, 2004). As treatment systems are
often parallel but separate, it results in fragmented and ineffective care (Ridgely, Osher,
Goldman, & Talbott, 1987).
Integrated dual-disorder treatment

Due to the severe problems associated with people who have mental disorders and who
abuse substances, scholars and clinicians developed integrated dual-disorder treatment
(IDDT). This treatment amalgamates mental health and substance abuse interventions,
often by the same clinician or team of clinicians (Drake et al., 2001). Treatments within this
model have consistent approaches, philosophies, recommendations, and, due to the inte-
gration of all the components, appear seamless for clients. Recovery is defined such that
the individual learns to manage both illnesses concurrently and is able to pursue mean-
ingful life goals (Mead & Copeland, 2000; Torrey & Wyzik, 2000). IDDT is considered an
evidence-based treatment and was the result of dozens of studies initiated in the 1980s in
an attempt to treat mental illness and substance abuse simultaneously in the same location
(Mercer-McFadden et al., 1998). These programs have continuous and aggressive outreach
components, often meeting consumers where they live and spending clinical time in the
community (Boyle, Delos Reyes, & Kruszynski, 2005). IDDT is a time-unlimited treat-
ment and, as such, progress is measured in terms of months and years. Experts recom-
mend individual counseling in IDDT to include motivation enhancement therapy and
cognitive behavioral therapy (Boyle, Delos Reyes, & Kruszynski, 2005) as well as aspects of
cultural competence and sensitivity (Drake et al., 2001). Additionally, professionals have
suggested support groups such as Dual Recovery Anonymous or Double Trouble as these
groups are focused on the unique needs of persons who have multiple diagnoses. Other
types of substance abuse support groups typically do not integrate the cognitive, social,
and behavioral variations associated with mental illness.
Data concerning the effectiveness of IDDT are positive but indicate that consumers im-
prove gradually. Approximately 10–20% of consumers are in remission of the substance
abuse disorder per year. Moreover, after three years in integrated treatment, 40–50% of
consumers have achieved durable abstinence (Drake, McHugo, & Noordsy, 1993).
In order to better conceptualize IDDT, Corrigan, McCracken, and McNeilly (2005)
identified eight principles of IDDT based from a report provided by the Managed Care
Initiative (Minkoff, 2001; Box 10.1).
Box 10.1 Eight IDDT Principles

1 Comorbidity should be expected; people with these disorders are not exceptions.
2 When coexisting disorders are observed, both psychiatric and substance abuse dis-
orders should be considered as primary.
3 Individuals in the population of treatment consumers currently served by any single
program are likely to be in all the various stages of change.
4 When possible, services for people with dual disorders should be provided by in-
dividuals, teams, and programs that are experts in treating both mental illness and
substance abuse.
5 Services should be longitudinal and continuous.
6 Beware admission criteria that exclude people from participating in a program.
7 There should be no formal boundaries to dual disorders treatment beyond which
services do not occur.
8 Fiscal and administrative operations of the program need to yield integrated and
effective programs.
Data from Patrick W. Corrigan, Stanley G. McCracken, and Cathy McNeilly, Evidence-based practices for
people with serious mental illness and substance abuse disorders. In Chris E. Stout and Randy A. Hayes
(Eds.), The evidence-based practice: Methods, models, and tools for mental health professionals, pp. 156–7,
Hoboken, NJ: John Wiley & Sons, 2005.
Practicing integrated dual-disorder treatment 205
Box 10.2 Eight Treatment Principles for IDDT

1 Dual diagnosis is not an exception but an expectation.
2 There is considerable variance in individuals with co-occurring psychiatric and sub-
stance disorders.
3 Hopeful and empathetic relationships within the IDDT model are one of the most
critical contributing factors to success regardless of setting.
4 Case management and care must be balanced with contracting, consequences, con-
tingent learning, empathetic detachment, and expectations specific to each client.
5 Both psychiatric and substance disorders should be considered primary.
6 Addiction and mental disorders can be treated within the framework of a disease
and recovery model with parallel recovery phases (acute stabilization, motivational
enhancement, active treatment, relapse prevention, and recovery). Interventions
are specific to stages of change (i.e., precontemplation, contemplation, preparation/
determination, action, maintenance (Prochaska, DiClemente, & Norcross, 1992)
and stages of treatment (engagement, persuasion, active treatment, and relapse pre-
vention; Minkoff, 1991; Ridgely, 1991).
7 There is no single intervention for people with co-occurring psychiatric disorders.
Thus, treatment should be idiosyncratic to ensure success.
8 Clinical outcome data should be individualized and based upon similar parameters
within treatment interventions.
To further understand IDDT, Minkoff and Cline (2004) noted there are eight treatment
principles for the comprehensive, continuous, integrated system of care model for people
with co-occurring psychiatric disorders. Readers should be aware that these principles
contain similar and even overlapping items as the aforementioned list, thus highlighting
the driving factors within IDDT (Box 10.2).
Practicing integrated dual-disorder treatment

In a thorough summary of IDDT, Corrigan, McCracken, and McNeilly (2005) noted five
essential practices: staged interventions, motivational interventions, counseling, social
support, and assertive outreach. These services must be comprehensive, long-term, and
culturally sensitive, and competent; they are briefly described in Table 10.1.
Boyle, Delos Reyes, and Kruszynski (2005) elaborated on the need for clinicians to provide
hope for recovery. As persons with dual disorders often have multiple episodes of substance
abuse and psychiatric treatment, they may become frustrated and discouraged. Thus, clini-
cians should support self-efficacy by maintaining optimistic attitudes toward patients’ recov-
eries. Developing and implementing methods for rejoicing in patients’ successes can increase
recovery self-efficacy, nurture hopefulness, and enhance self-confidence (Rapp, 1998).
Table 10.1 Five IDDT Practices
IDDT Practice Brief Description

1. Staged Interventions Services need to be staged to correspond with an individual’s
readiness for change. Two popular models for change include the
stages of treatment program and the transtheoretical model. The
stages of treatment (Osher & Kofoed, 1989) include engagement
(no regular contact with healthcare providers), persuasion (contact
with practitioner but no reduction in substance abuse), active
treatment (reduction in substance abuse), and relapse prevention
(no substance-related problems for six months) (Minkoff, 1991;
Ridgely, 1991). The transtheoretical model uses a longitudinal
process and includes six stages: precontemplation, contemplation,
determination/preparation, action, maintenance, and relapse
(Prochaska, DiClemente, & Norcross, 1992; see Chapter 6). Thus,
both models move patients through a systematic process of engaging
and motivating them to change their abuse behaviors.
2. Motivational Interventions People are often not ready to actively participate in services and may
need motivation to help them change their cognitions, behaviors,
and emotions. Clinicians can use motivational interviewing (Miller &
Rollnick, 2002), a combination of behavioral analysis and Rogerian
therapy, to avoid or minimize resistance to change (Sobell & Sobell,
2003). Practitioners can use behavior analysis to identify advantages
and disadvantages of abusive behaviors (status quo) as well as
advantages and disadvantages of change. Miller and Rollnick (2002)
believed a consequential aspect of motivational interviewing is in the
client discovering disadvantages and advantages of status quo and
change rather than the therapist identifying these issues.
3. Counseling Interventions specifically addressing behavioral, cognitive, affective,
and interpersonal skills and supports can help people with dual
disorders manage their multifaceted problems. Interventions can
include coping and social skills training, cognitive reframing, relapse
prevention, and dealing with undesired and negative mood states
(Boyle, Delos Reyes, & Kruszynski, 2005; Marlatt & Gordon, 1985).
4. Social Support Family therapy can be used to help re-establish support connections
and enhance communication. Additionally, patients can use twelve-
step and other self-help programs.
5. Assertive Outreach Intensive case management is essential. It may be necessary to meet
in the person’s home and discuss practical matters including housing,
crisis management, medical care, legal issues, and finances.
Data from Patrick W. Corrigan, Stanley G. McCracken, and Cathy McNeilly, Evidence-based practices for people with
serious mental illness and substance abuse disorders. In Chris E. Stout and Randy A. Hayes (Eds.), The evidence-based
practice: Methods, models, and tools for mental health professionals, pp. 156–7, Hoboken, NJ: John Wiley & Sons, 2005.
In an attempt to better conceptualize individual differences and severities between vari-

ous people with co-occurring psychiatric disorders, experts proposed the four-quadrant
model shown in Table 10.2 (National Association of State Mental Health Program Direc-
tors/National Association of State Alcohol and Drug Abuse Directors, 1998). Individu-
als who have high mental health severity often have a serious mental disorder and thus
Characteristics of patients with dual disorders 207
Table 10.2 Quadrant Model for Co-Occurring Psychiatric Disorders
Quadrant I Quadrant II
• Low mental health severity • High mental health severity
• Low substance disorder severity • Low substance disorder severity
Quadrant III Quadrant IV
• Low mental health severity • High mental health severity
• High substance disorder severity • High substance disorder severity
necessitate integrated care in mental health systems. Individuals who have high substance
disorder severity may receive addiction treatment in the chemical dependency system with
varying levels of integration concerning mental heath capability. For example, individuals
in quadrant I may receive treatment in outpatient or primary care settings while individu-
als in quadrant III may receive the majority of services in the substance abuse system.
Related to the quadrant model, scholars from the American Society of Addiction Medi-
cine created an addiction treatment taxonomy based upon dual diagnoses (Mee-Lee,
Schulman, Fishman, Gastfried, & Griffith, 2001). The authors identified three categories
for persons with dual diagnoses: addiction-only services, dual-diagnosis capable, and
dual-diagnosis enhanced. Addiction-only services are designed for people with primary
substance use disorders who have minimal or no co-occurring mental health problems.
Dual-diagnosis-capable programs are for persons who have relatively stable mental health
symptoms and require substance misuse treatment. Dual-diagnosis-enhanced services are
designed for people with variable levels of psychopathology regardless of acuity or stability
(McGovern, Matzkin, & Girad, 2007). Due to the high frequency of co-occurring psychi-
atric disorders, authors have recommended that all programs should be considered dual-
diagnosis capable (Minkoff, Zweben, Rosenthal, & Ries, 2003).
Characteristics of patients with dual disorders

Understanding characteristics of patients receiving IDDT may help music therapy cli-
nicians design effective interventions to meet these patients’ particular needs. Horsfall,
Cleary, Hunt, and Walter (2009) noted that consumers with both serious mental illnesses
and co-occurring substance use disorders tend to have less motivation to change, are
harder to engage in treatment, have higher treatment program dropout rates, and make
slower progress than people with substance use disorders but no other mental disorders.
Kay, Kalathara, and Meinzer (1989) conducted a study to determine diagnostic and be-
havioral characteristics of psychiatric patients who misuse substances. In this descriptive
study, the authors compared psychiatric patients who abused substances with psychiatric
patients who did not abuse substances according to demographic, diagnostic, and behav-
ioral characteristics. In their literature review, they noted that previous researchers have
found that people with co-occurring psychiatric and substance misuse disorders tend to
be younger, male, from lower socioeconomic strata, and from families with documented
histories of alcoholism or sociopathy. These patients tend to be hospitalized at earlier ages
and more likely to experience recurring patterns of hospitalizations (Carpenter, Mulligan,

Bader, & Meinzer, 1985; Davis, 1984; Richard, Liskow, & Perry, 1985; Shern & Fitzgibbons,
1972; Vardy & Kay, 1983). Results from the Kay et al. (1989) study were generally congru-
ent with previous research: “Substance-abusing psychiatric inpatients were distinguished
from their non-substance abusing peers in that they were younger, hospitalized for briefer
periods, more likely to be diagnosed with personality disorders, and conversely, less likely
to be classified as schizophrenic” (p. 1064). Psychiatric patients with co-occurring sub-
stance misuse disorders appeared less functionally and psychotically impaired but were
more apt to exhibit suicidal, homicidal, destructive, and irresponsible behaviors than psy-
chiatric patients without substance misuse disorders.
More recently, researchers found dual diagnoses are more common in people who have
histories of conduct disorder (Mueser et al., 1999) and people who are homeless, in jail, or in
an emergency room (Galanter, Castendea, & Ferman, 1988). Researchers also noted that dual
diagnoses are more common in people who have families with histories of substance abuse
and dependence (Noordsy, Drake, Biesanz, & McHugo, 1994), and in people who are young,
male, single, and less educated (Cuffel, 1996; Mueser, Bennett, & Kushner, 1995). Thus, music
therapists should be aware of these characteristics and design and program interventions
within a preventive model to educate patients about the dangers of substance misuse.
The Twelve Steps

Due to the popularity of the twelve-step program of Alcoholics Anonymous, music thera-
pists working with patients who have dual diagnoses are advised to be familiar with the
Twelve steps. Although the Twelve steps were originally designed for alcohol treatment,
many people—regardless of the substance they may be addicted to—adhere to or are at
least familiar with this model. In a descriptive study of music therapists working with per-
sons in substance abuse rehabilitation, Silverman (2009) found that 76% of respondents
used the twelve steps as their treatment approach. Additionally, from the author’s clinical
experience, it is common for people with dual disorders hospitalized on inpatient psychi-
atric units to speak of and be familiar with the twelve-step program. Thus, music therapists
who are acquainted with and use the twelve-step program can establish a positive working
alliance by implementing similar recovery jargon and treatment goals (Box 10.3).
Table 10.3 provides some facility types, specific steps, and general goal areas for work-
ing within the contextual parameters of the twelve-step program. As patients often adhere
to this model regardless of diagnosis and setting, treatments may take place in substance
abuse facilities, psychiatric facilities, IDDT facilities, group homes, and outpatient care.
Music therapy and integrated dual-disorder treatment

Although IDDT programs typically result in improved outcomes, they are not widely avail-
able in public mental health settings (Brunette et al., 2008). This is likely because IDDT is a
complex service model consisting of multiple components requiring change at various lev-
els, including the provider, organizational, and environmental levels. Thus, IDDT is often
more challenging to implement than single-component practices (Brunette et al., 2008).
Box 10.3 The Twelve Steps of A.A.

1 We admitted we were powerless over alcohol—that our lives had become
unmanageable.
2 Came to believe that a Power greater than ourselves could restore us to sanity.
3 Made a decision to turn our will and our lives over to the care of God as we under-
stood Him.
4 Made a searching and fearless moral inventory of ourselves.
5 Admitted to God, to ourselves, and to another human being the exact nature of our
wrongs.
6 Were entirely ready to have God remove all these defects of character.
7 Humbly asked Him to remove our shortcomings.
8 Made a list of all persons we had harmed, and became willing to make amends to
them all.
9 Made direct amends to such people wherever possible, except when to do so would
injure them or others.
10 Continued to take personal inventory and when we were wrong promptly admitted it.
11 Sought through prayer and meditation to improve our conscious contact with God,
as we understood Him, praying only for knowledge of His will for us and the power
to carry that out.
12 Having had a spiritual awakening as the result of these Steps, we tried to carry this
message to alcoholics, and to practice these principles in all our affairs.
Reproduced from The Twelve Steps of Alcoholics Anonymous Copyright © 1952, 1953, 1981 by Alcoholics
Anonymous Publishing
Music therapists using the IDDT approach should be aware that they might encompass
a single treatment component operating with a larger and complex system. Music thera-
pists might also need to receive advanced training, such as motivational interviewing (also
known as motivation-enhancement therapy) and facility-specific programmatic services
to implement and provide these services within a larger system. Music therapists might
also consider using the transdiagnostic theory (see Chapter 7) when working with clients
with co-occurring disorders to holistically address their multifaceted concerns.
In a descriptive study of music therapists who work with patients who are chemically
dependent, Silverman (2009) found that 64% of respondents use cognitive behavioral
therapy and dual disorders treatment as their treatment approach. Thus, many music ther-
apists are likely already working within IDDT models. However, due the high degree of
variance between facilities and psychosocial programming, clinical objectives and treat-
ments may differ considerably.
Table 10.3 Potential Music Therapy Goals in the Twelve-Step Approach by Treatment Setting
Treatment Facility/Setting Possible Steps Potential Music Therapy Goal Areas

Detoxification, Acute Psychiatric 1, 2, 3, 4 Motivate for treatment; engage in treatment;
Inpatient distract from withdrawal symptoms and craving;
reduce shame; enhance readiness for additional
in- and outpatient treatment
21-day substance abuse facility, 1, 2, 3, 4, 5, 6 Identify triggers and coping skills; identify
Inpatient psychiatric follow-up care (including meetings and support
groups); reduce shame and guilt; identify pros and
cons of substance misuse and changing behaviors;
identify social supports in the community; develop
self-awareness
6-month facility, Outpatient 4, 5, 6, 7, 8, 9 Implement coping skills; increase frustration
psychiatric care, Group homes toleration; decrease impulsivity; identify
accomplishments; identify problematic
situations and interactions; make amends;
enhance responsibility by following through on
commitments
Living in the community, Group 9, 10, 11, 12 Continue to attend various support meetings;
homes manage addiction; use coping skills; regularly seek
support; become a sponsor
The Twelve Steps are reprinted with permission of Alcoholics Anonymous World Services, Inc. (“AAWS”) Permission to
reprint the Twelve Steps does not mean that AAWS has reviewed or approved the contents of this publication, or that
AAWS necessarily agrees with the views expressed herein. A.A. is a program of recovery from alcoholism only – use of
the Twelve Steps in connection with programs and activities which are patterned after A.A., but which address other
problems, or in any other non-A.A. context, does not imply otherwise.
Music therapists can certainly engage clients with co-occurring disorders during treat-
ment and work to increase their motivation for change. Thus, music therapists should be
familiar with the transtheoretical stages of change (see Chapter 6). As there are a plethora
of songs concerning substance abuse, music therapists may use lyric analysis interventions
to identify consequences of substance misuse and increase motivation for change. In fact,
music therapists working in substance abuse rehabilitation facilities noted that lyric analy-
ses were the most frequently used intervention (Silverman, 2009). Music therapists can
also use educational songwriting interventions to increase knowledge of substance abuse
triggers and coping skills to augment illness management and recovery. For example, the
author has used a two-verse songwriting intervention composed within a single session
for patients on a detoxification unit to directly address triggers and coping skills. In this
intervention, the first verse addressed triggers while the second verse addressed coping
skills. In a related songwriting project on the same unit, the author has facilitated group
songwriting interventions about change in which the first verse concerns why change
(identifying motivators for change and treatment) and the second verse concerns how to
change (identifying proactive change behaviors and cognitions).
The list in Box 10.4 contains treatment areas for psychiatric music therapists who are
working within an IDDT model.
Box 10.4 Music Therapy Treatment Areas for IDDT

◆ Eliminating boredom.
• Planning a full day of activities.
• Structuring and forming positive habits.
• Using lists and calendars to enhance structure within and between various time
periods.
• Implementing accountability measures from sponsors, friends, family, and pro-
fessionals to regain trust.
◆ Reducing isolation.
• Identifying and using professional sources of social support.
• Identifying and using non-professional sources of social support.
• Attending and participating in recovery-oriented meetings.
◆ Values clarification.
◆ Enhancing knowledge and use of coping skills.
• Both individual and social coping skills.
• Scheduling proactive coping skills, such as exercise and relaxation, as a regular
part of each day.
• Coping skills in various environments (at work, at home, in isolation).
• Coping with potential feelings of guilt and shame.
◆ Identifying leisure skills and hobbies.
• Both individual and social.
◆ Finding a job and working (working is considered a motivational step in recovery;
Alverson, Becker, & Drake, 1995).
◆ Coping with and resolving interpersonal conflicts.
◆ Proactively identifying the potential for cross addiction, in which one substance is
suspended for another (a person might remain abstinent from alcohol but starts
abusing prescription medications or becomes addicted to gambling).
◆ Wellness and holistic health.
• Meeting physiological needs including regular exercise, healthy eating, proper
nutrition, and physical activity.
• Meeting spiritual, social, physical, emotional, vocational, financial, and intellec-
tual needs.
◆ Adhering to various medications as prescribed.
◆ Scheduling and prioritizing commitments.
• Having realistic expectations.
• Making appropriate short- and long-term goals.
Box 10.4 Music Therapy Treatment Areas for IDDT (continued)
◆ Re-establishing trust with friends and family.

• Following through on commitments and being accountable.
◆ Attending and participating in support groups and self-help meetings.
• Finding and appropriately using a sponsor.
• Finding support groups where one feels comfortable sharing and participating.
◆ Promoting the importance of self-care without guilt and making self-care part of a
daily routine.
◆ Teaching self-monitoring skills to proactively identify and cope with stress and po-
tential triggers for substance misuse.
◆ Attending and actively participating in professional therapy or counseling.
◆ Encouraging family members and friends to attend Al-Anon meetings and learn
about addiction and how they can be a support without inadvertently enabling ad-
dictive behaviors and cognitions.
◆ Taking pride in and recognizing past accomplishments.
◆ Finding and using creative outlets for healthy emotional expression.
◆ Decision making.
• Making rational and informed decisions; avoiding impulsive and emotional
decisions.
Associations between music and substance misuse

Complicating music therapy treatment, people with addictions often associate certain
music with chemical abuse. It is unrealistic to assume that a person can always control
music in the environment. For example, a person may hear a song associated with ad-
diction at work or at a social event. Some patients may even be unwilling to change their
music preferences despite the associations with addiction. Thus, it is the music thera-
pist’s responsibility to educate patients concerning appropriate, effective, and patient-
identified coping skills to use during these high-risk situations. In longer-term treatment
facilities, music therapists can work to change these relationships by coupling the music
with recovery instead of substance abuse. Additionally, music therapists can work to have
patients use “consequence cards” in which each time patients feel the urge to use sub-
stances, they instead withdraw “consequence cards” from their wallets. This consequence
card has patient-identified consequences and negative behaviors, cognitions, and emo-
tions that result from substance misuse. Consequence cards can be replaced with cop-
ing skills cards, depending on the preference of the patient. In this author’s experience,
some patients prefer consequences while others prefer coping skills. Regardless, patients
should make this distinction and choice to facilitate treatment compliance. Patients can
also integrate photos of their family members (or other types of motivational pictures)
on these cards to help motivate them. Regardless of specific treatment intervention, the
music therapist has the duty to teach patients to identify and use appropriate and effec-
tive coping skills during any high-risk periods, even when these situations are musically
induced.
Integrated forms of treatment can be effective and music therapists have the skills and
unique privilege to play an essential role in providing and potentially augmenting this
evidence-based treatment. Descriptive research is warranted to determine what objectives
and interventions music therapists are using within IDDT contexts to address their pa-
tients’ various and multifaceted needs. This research can lead to empirical investigations
and qualitative inquiry to better approximate treatment effects and determine how to most
effectively integrate music therapy into IDDT within existing contextual parameters. As
dual diagnoses are common, this will likely be an area for continued empirical investiga-
tion and clinical practice for music therapists.

◆ Comorbid substance abuse and major mental illness is a major and frequently oc-
curring problem in contemporary healthcare.
◆ Treatments for these disorders have often been separate, uncoordinated, and
unsuccessful.
◆ Integrated Dual-Disorder Treatment (IDDT) is an evidence-based treatment con-
currently integrating the care and treatment of the psychiatric disorder and sub-
stance misuse disorder.
◆ Consumers with both serious mental illnesses and co-occurring substance use dis-
orders tend to have less motivation to change, are harder to engage in treatment,
have higher treatment program dropout rates, and make slower progress than peo-
ple with substance use disorders but no other mental disorder.
◆ Twelve-step programs are popular sets of guiding principles outlining a course of
action for recovery from various types of addiction and substance misuse.
◆ When working with consumers with dual disorders, music therapists should imple-
ment a holistic treatment approach focusing on meeting spiritual, social, physical,
emotional, vocational, financial, and intellectual needs.
◆ Music therapists are responsible for educating patients to identify high-risk situa-
tions and use appropriate and effective coping skills during these periods, especially
when these situations are musically induced.
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inquiry. Archives of General Psychiatry, 40, 877–883.

1 Clinical treatment and care for adult psychiatric patients is often separated and segregated. What are
other examples of segregated clinical and educational practice?
2 What are common reasons that people with psychiatric disorders abuse substances? How might
these reasons be similar to and different from the reasons people without psychiatric disorders abuse
substances?
3 Design a music therapy intervention to teach identification of (a) five situational risk factors for using
substances to modify mood and (b) three positive behavioral coping skills as alternatives to using
substances.
4 Despite a lack of empirical evidence, why is the twelve-step program so widely used?
5 What are five potential music-related leisure skills that do not involve bars or clubs where patients may
be at heightened risk for drinking or drug use?
Chapter 11
Psychiatric music therapy with diverse

client populations
Introduction to multiculturalism
There have been major shifts in the demographics of populations living in the United
States, resulting in diverse and mixed cultural groups. Individuals from these various
groups may be at risk for mental illnesses and can encounter a number of barriers to treat-
ment (Siegel, Haugland, & Schore, 2005). Due to these obstacles and other psychosocial
stressors, people from minority groups are three times as likely to require mental health
services as people from nonminority groups (Sanchez, 1997; Snowden & Clancy, 1990;
Ying & Hu, 1994). These problems are not novel: In 1978, the President’s Commission
on Mental Health identified mental health disparities faced by clients who were consid-
ered diverse. Unfortunately, these disparities have not changed despite advances in clini-
cal practice (President’s New Freedom Commission, 2003; U.S. Surgeon General, 2001).
Moreover, the well-articulated gap between research and clinical practice (Anderson &
Adams, 1996; Hollon et al., 2002; TenHave, Coyne, Salzer, & Katz, 2003) is particularly
problematic for clients from racial and ethnic minorities (U.S. Surgeon General, 2001).
Thus, the disparities in healthcare concerning ethnic and racial groups continue to be a
multifaceted national problem (Satcher & Higginbotham, 2008).
As conventionally noted by scholars in the multicultural counseling field (Paniagua,
1994; Sue & Sue, 1987, 1990), it is essential to highlight that the descriptions of various
cultural behaviors, cognitions, and emotions may not be true for all members in a cul-
tural group or subgroup. Subcultural groups also exist, typically consisting of smaller and
more homogenous units of social organization (Barrera, Castro, Stryker, & Toobert, 2013).
Trimble (1995) noted that the term subculture provided for a heightened level of differen-
tiation and specificity. Differences may certainly exist in aspects of language, family, defini-
tion of mental health or illness, generational status, socioeconomic status, acculturation,
and treatments. Generalizations may be inappropriate and, in a counseling or therapeutic
setting, dangerous to the mental health of the consumer. For example, although the United
States Surgeon General (2001) categorized Chinese Americans and Japanese Americans
into the Asian American group, there are many differences between and within these two
distinct and diverse cultures.
However, regardless of specific identity, groups and subgroups often do share consisten-
cies that have been considered clinically pertinent in assessment and treatment (Paniagua,
1994). Ignoring group traits can potentially hinder treatment and prolong psychosocial
INTRODUCTION TO MULTICULTURALISM 219
distress. Therapy can be more effective if the clinician is aware of general population
characteristics and various cultural tendencies. In an attempt to provide best practice
treatment as expediently as possible, it would seem that it is better to possess basic knowl-
edge of cultural tendencies than to not possess this knowledge. Additionally, regardless
of the individual cultural group, therapeutic rapport can be considered essential for ef-
fective results to occur (Ho, 1992; Sue & Sue, 1990). Understanding cultural tendencies
can facilitate rapport building, especially as minorities frequently engage in time-limited
forms of treatment (Paniagua, 1994; Sue & Sue, 2003). A therapist who is not cognizant
of cultural tendencies may limit working alliance, alienate or offend the client, and dis-
suade the client from returning to treatment or seeking psychosocial services in the future.
Comas-Diaz (2011) noted the significance of positive working alliances between clients
and therapists within cultural praxes: “The development of a therapeutic working alliance
requires cultural congruence between clients’ and therapists’ worldviews” (p. 550). Thus, a
basic knowledge of shared group characteristics may facilitate understanding each client’s
worldview from their idiosyncratic social context.
Table 11.1 provides a brief description of each of the four most prevalent minority
groups in the United States, including general characteristics, family, and religious aspects.
Additionally, guidelines for the first session, ongoing treatment, and recommendations for
counseling and treatment are provided. Table 11.1 represents a brief synthesis of literature
from Paniagua (1994) and Sue and Sue (2003), all experts in multicultural assessment,
treatment, and counseling.
Although characteristics and guidelines are provided in Table 11.1, a brief discussion of
the hazards of overgeneralization is essential. Many people are acquainted with persons
who fall outside the norm of their cultural group or heritage. Each person is an individual
and, while she or he may possess some characteristics similar to those of the major cultural
group, may have other characteristics falling outside what may be considered the cultural
norm. Therefore, to reduce potential inappropriate generalizations that could be unethi-
cal, counterproductive—or even dangerous—in clinical practice, it is imperative for the
music therapist to assess the individual’s idiosyncratic level of acculturation. Acculturation
is a process of adjustment between a person’s own culture and a host culture. Additionally,
the music therapist might assess the level of acculturation of the client’s family, extended
family, caregiver, friends, church, social group, and workplace in order to better under-
stand social contexts as they relate to acculturation.
Regardless of specific group, scholars have found shared characteristics that in turn
lead to recommendations for treatment. Traditionally, experts have considered behav-
ioral approaches to be the most effective strategies for the assessment and treatment of
the four multicultural groups discussed in this chapter (Paniagua, 1994). Behavioral ap-
proaches tend to be brief which can be especially relevant when working with clients from
minority populations as clients are often at heightened risk of premature therapy discon-
tinuation (Barrett, Chua, Crits-Christoph, Gibbons, & Thompson, 2008; Reis & Brown,
1999; Wierzbicki & Pekarik, 1993). Scholars have also suggested a behavioral approach as
multicultural clients typically respond best to techniques that are action-oriented, brief,
220
MUSIC THERAPY WITH DIVERSE POPULATIONS
Table 11.1 Summary of characteristics and therapeutic recommendations
Group Characteristics and Issues Family Religion First Session Ongoing Treatment Therapeutic
Recommendations
African Lower than mean Grandmother often Religion Discuss racial Include church and Make genogram; do not use
American socioeconomic status; raises children; considered differences (except family; provide quick client’s form of language;
primarily live in southern U.S.; nuclear and very in crisis situations); solutions; teach address issues of racial
unemployment; legal issues; extended family important; explore level of assertive behaviors; sensitivity; do not change
shorter life span; lack of important; biological spiritual acculturation; provide provide homework family structure but attempt
health insurance; less likely to and non-biological concrete suggestions assignments to to make it more functional;
have surgery and participate important; role for solution of involve family in determine reaction of
in therapy; becoming flexibility; single problems; include target setting; client to a counselor
increasingly heterogeneous parents; matriarchal; church; screen for determine who lives of a different ethnic
extended family depression and at home background; determine
network substance abuse feelings about counseling;
establish egalitarian
relationship; determine
positive and negative
reactions to racism; assess
positive attributes of client;
determine external factors
related to presenting
problem; help define goals;
use problem-solving and
time-limited approaches
Table 11.1 (continued) Summary of characteristics and therapeutic recommendations
Recommendations
Asian Higher than median income; Emphasis on Holistic view Maintain formal Emphasize brief Assess family’s perspective
Americans, live in urban areas; avoid extended family; of mind and interaction; do not nature of treatment; of presenting problem(s);
Pacific direct eye contact and patriarchical body joke; mention prior educate client determine acculturation
Islanders proximity; high incidences and hierarchical; experience; explain about therapy and conflicts; build rapport by
of shame and guilt that Children’s job is to that a tentative expectations; assess discussing confidentiality;
often lead to anxiety and/ be well behaved solution is possible; potential humiliation conduct a positive assets
or depression; act quiet and and respect parents; emphasize concrete and shame; discuss search; take an active role
passive and avoid offending women and children and tangible goals; duration of treatment; but allow client to choose
others; tend to express less autonomous, acknowledge somatic avoid personalism; specific intervention; use
psychological disorders in assertive and complaints; consider behavioral and family problem- and solution-
somatic terms; often wait, more conforming; the first session a therapy; avoid group focused and time-limited
underuse, or refuse treatment individual crisis; provide direct therapy; social skills approaches; address father
for a number of years; often accomplishments are and specific advise; and assertiveness first; focus on positive
expect medications; large to be shared with do not pry—use more training helpful parenting aspects such as
INTRODUCTION TO MULTICULTURALISM
between- and within-group family general questions modeling and teaching;
differences; little emotionality; when working with
face issues of racism and refugees and immigrants,
discrimination; unique assess living conditions,
problems of refugees and culture conflict, financial
immigrants situation and use case
management to obtain
food, living and community
resources
221
222
MUSIC THERAPY WITH DIVERSE POPULATIONS
Recommendations
American Constitute most common Extended family Mind, body Only ask questions Integrate traditional Assess acculturation level
Indian, group seen in mental has primacy; self is and spirit are that relate to the core healing practices; use and determine cultural
Alaskan health services; most secondary; elders are interconnected problem; tell client a directive problem- identity of client; begin
Native socioeconomically respected; children that history shows solving approach with a client-centered style
disadvantaged group; are encouraged to that they are good with concrete and and gradually provide more
high mortality rate; shorter make their own people and should feel feasible solutions; structure and questions;
life expectancy; sharing is decisions and have proud of themselves; brief therapy with assess problem from
important; time is not viewed few rules; strong client may bring other short-term objectives; perspective of individual,
as a measurement tool as it roles for women; people to session; therapist should family, extended family,
is related to the task; little extended family can listen; avoid taking provide suggestions and tribal community; if
eye contact; firm handshake stretch through the too many notes; in a calm, slow, and necessary, address basic
can represent aggression; second cousin screen for alcoholism concrete manner; needs; screen for domestic
emphasis on working and depression; focus on external violence, substance abuse,
together to achieve goals; assess if client had conflicts; be aware of depression, and suicide;
emphasis on listening not recently moved from political relationships formulate concrete
talking; high risk for diabetes, a reservation; avoid and understand the objectives that incorporate
alcoholism, and obesity; judge discussing medication history of oppression cultural, family, extended
selves in terms of benefit family, and community;
to tribe; confrontation is focus on holistic factors
considered rude; rather than such as mind, body,
act impulsively, observe and spirit; use culturally
modified brief cognitive
behavioral interventions;
evaluate effect in terms
of individual, family, and
community
Recommendations
Hispanic Live in urban areas; 2nd Male is dominant Religion Explore level of Talk about spiritual Use solution-focused
American, largest group in US; social authority in family; considered acculturation; be issues; be more behavioral therapy to
Latino people; often offer gifts; woman acts as very more formal than informal than formal; implement behaviors in
American higher rates of tuberculosis, housekeeper important; informal; understand use proximity; family home environment; avoid
AIDS, and obesity; will not and child-raiser; spiritual; spiritual model and group therapy insight oriented therapies;
seek professional help until family relationship church will be of mental illness; effective; use a engage in respectful, warm
other resources have been paramount; children considered interview father alone behavioral approach and mutual introduction;
exhausted are to be obedient; before concerning family describe counseling; explain
high rate of school professional problems; determine confidentiality; have client
dropout mental what problem is and state presenting problem;
healthcare immediate solutions consider participation of
INTRODUCTION TO MULTICULTURALISM
family; prioritize goals
and problems; determine
positive assets; determine if
a translator is needed; offer
time-limited, solution-based
therapies
223
224 MUSIC THERAPY WITH DIVERSE POPULATIONS
directive, authoritative, concrete, and emphasize focused learning (Boyd-Franklin, 1989;

Walker & LaDue, 1986; Yamamoto, Silva, Justice, Chang, & Leong, 1993). Moreover, mi-
nority clients who strongly identify with their own ethnic group may be more responsive
to action-oriented counseling approaches as they expect to follow therapist recommen-
dations to recover quickly (Parker, 1987; Pedersen, 1989) and find immediate relief from
psychological distress. These patients may view a nondirect therapist as incompetent and
may discontinue treatment as a result. However, regardless of specific client group, sen-
sitivity and competence are paramount (Paniagua, 1994). Additionally, as the variable of
generation can impact acculturation, assessing the individual’s unique levels of genera-
tion and acculturation are imperative for effective treatment (Sue & Zane, 2006; Wer-
ner, Swope, & Heide, 2009). Resnicow, Baranowski, Ahluwalia, and Braithewaite (1999)
recommend that interventions for multicultural clients should be responsive to cultural
practices and worldviews of the subcultural groups for whom the interventions were
intended.
While cognitive behavioral therapy can be effective for many conditions, it may not
always be effective or appropriate with patients who are diverse. Hayes and Imawasa
(2006) noted that cognitive strategies tend to be closely aligned with North American
and European values concerning rational thinking, logic, verbal skills, and cognition.
Solely using a cognitive behavioral approach may inadvertently devalue the role of spir-
ituality that many cultures possess. Additionally, Caucasians typically have a more in-
ternal locus of control while in Asian cultures, events may be perceived as unrelated to
a person’s actions (Craske, 2010). Thus, cognitive behavioral therapists might need to
modify approaches through functional analyses to be successful with diverse clients.
Practitioners must take ethnicity, values, and acculturation into account, especially
when dealing with issues that may be related to assertiveness and collectivism. Pam-
phlets and videos depicting cognitive behavioral therapy can help to educate potential
clients who may be from diverse backgrounds concerning what to expect in treatment
(Organista, 2006).
Other types of diversity

There are also a multitude of other potential groups who may be considered “diverse.”
These include characteristics such as age, religion, disability, sexual preference, gender,
medical condition, geographic location, and socioeconomic status. As Reid (2002) noted
that mainstream psychology tended to focus on a single identity domain, it is important to
understand potential interactions and accumulations between aspects of diversity (i.e., an
older woman who uses a wheelchair and is dually diagnosed with bipolar and borderline
personality disorders). Talmon (1990) noted an important aspect of empowering patients
is to allow their faith and belief systems to guide the therapeutic process. Music therapists
must be cognizant of these demographics, characteristics, and issues and treat each per-
son as an individual, recognizing the unique social contexts informing the lives of their
patients. Thus, assessment remains a key treatment component.
People who are LGBTQ 225
People who are LGBTQ

Clients who are lesbian, gay, bisexual, transgendered, and questioning (LGBTQ) consti-
tute a dissimilar unit within themselves and may represent all variations of gender, socio-
economic class, age, and ethnicity (Brown, 2006). Whitehead-Pleaux and colleges (2012)
noted:
LGBTQ individuals come from all cultures, ethnicities, religions, and ages. There is no single “gay
culture” within the LGBTQ community: there is a wide variety of subcultures. Age, race, ethnic-
ity, religion, regional location in the USA, identity with various counter cultures, gender expres-
sion, gender identity, and orientation can influence how a LGBTQ individual defines and views
her/himself, interacts with the majority culture, develops and maintains relationships and fam-
ily, chooses his/her level of “outness,” and musical preferences. Above all, as with all populations
served by music therapists, it is vital to see the client as an individual first, and then a member of a
culture. (p. 163)
Brown (2006) noted that discrimination and stigma has bound this heterogeneous group
together. Perez, DeBord, and Bieschke (2000) found that this group used psychotherapeu-
tic services at least double the rate that the heterosexual group used psychotherapeutic ser-
vices. Congruently, researchers have found that women and men who are gay were more
likely to abuse substances and have depression and anxiety than women and men who are
heterosexual (Cochran & Mays, 2000; Cochran, Sullivan, & Mays, 2003). However, higher
rates of depression and anxiety in this population are not evidence that homosexuality is
pathological. Rather, these harmful effects are consequences of living in discriminatory,
stigmatized, and even dangerous cultural contexts (APA, 2000). Additionally, men who
are gay have higher rates of adult sexual assault than men who are heterosexual (Balsam,
Rothblum, & Beauchaine, 2005), thus potentially necessitating the use of additional psy-
chotherapeutic services.
Martell, Safren, and Prince (2003) articulated that cognitive behavioral training pro-
grams do not have adequate coursework concerning lesbian, gay, and bisexual issues.
Brown (2006) wrote:
To effectively work with clients who are LGBT, the therapist must be able to avoid making the cli-
ent’s sexual or gender orientation the problem and rather focus on the distress that brings the client
into treatment; at the same time, the therapist must not ignore the salience of the client’s LGBT
identity. The therapist must be able to demonstrate and experience positive regard for the LGBT
client. . . . I would suggest that for LGBT clients the therapist’s capacity for the genuine demonstra-
tion of affirmation will be a larger factor contributing to the outcome of the psychotherapy process,
simply because the therapist then makes the therapy room and process a place safe from stigma,
bias, and discrimination. (pp. 349–350)
Recognizing that music therapists practicing in the United States still require poli-
cies and best practices to provide the highest care quality possible to LGBTQ people,
Whitehead-Pleaux and colleagues (2012) proposed a comprehensive set of best-practice
guidelines as well as recommendations for implementation. These guidelines may also
serve as protections for LGBTQ students, colleagues, and co-workers; readers are strongly
encouraged to familiarize themselves with this valuable literature.
People with disabilities

People with disabilities also constitute a subgroup of people who may seek mental health
treatment. However, the research literature for this population is scant to nonexistent.
Olkin and Taliaferro (2006) were unable to locate any published materials concerning
evidence-based practice and people with disabilities. These authors also articulated the
enormous heterogeneity of individuals with disabilities, including, “age of onset of the
disability, functional abilities, the visibility of the disability, the course of the disability, the
effects on life expectancy, and the presence of other disabilities” (p. 354). Olkin and Talia-
ferro noted risk factors potentially contributing to mental health problems for people with
disabilities may include barriers to housing, employment, social, leisure, and recreational
activities as well as neglect, poverty, sexual and physical abuse, stigma, and discrimination.
Priestly (2001) identified the moral, medical, and social models as the three main mod-
els of disability. While the moral model identifies disability as a manifestation of flaws in
character and morality, the medical model identifies disability as a defect in a bodily func-
tion or system that resides in the individual. The medical model conceptualizes disabling
conditions that result from pathophysiology. Practitioners adhering to this model strive
to cure or treat the condition (Jette, 2006; Weiner, 2007). The underlying framework of
disability studies, however, is built upon the social model of disability. In the social model,
disability is socially constructed and reflects problems in society but not problems in the
person. Practitioners using the social model perceive disadvantages of people with dis-
abilities as generated by society. Therapists using the social model of disability would seek
to work collaboratively with the patient to problem solve, resolve, and cope with social,
legal, economic, and political barriers. Cognitive behavioral interventions would seek to
address, change, and cope with these external problems and work with the client to change
her or his perceptions of these external factors and alleviate distress related to these issues
as quickly and efficiently as possible.
Multicultural music therapy literature

Music therapy researchers have responded to the changing demographic make-up of
the United States. Toppozada (1995) conducted a survey study to identify attitudes and
knowledge of music therapists concerning multiculturalism and found music therapists
did not feel they were adequately prepared to treat multicultural clients during their aca-
demic training. Bradt (1997) also identified a lack of multicultural training in music ther-
apy coursework and addressed some potential ethical issues encountered in multicultural
counseling. Moreno (1988) found that music therapists were ethnocentric in their use of
music and recommended greater diversity and knowledge of world music. Werner, Swope,
and Heide (2009) reiterated the proposal for music therapists to gain greater awareness
and understanding of music across cultures.
Darrow and Molloy (1998) found scant literature concerning multicultural music ther-
apy and noted therapists sought additional training to address this vital competency at
workshops. Chase (2004) published an article about music therapy with people who are
Multicultural music therapy literature 227
gay and lesbian and conducted a review of multicultural music therapy literature (Chase,
2003). Froman (2009) conducted a survey study of music therapists working with Jewish
people in the United States. Consistent with recommendations from other scholars, Fro-
man articulated the limited research on multicultural music therapy and recommended
the need for additional literature.
Although researchers have indicated a lack of training in multiculturalism, music ther-
apy clinicians still work with diverse clients. In a study of music therapists in private prac-
tice, 83.8% of respondents were not bilingual while 60% served populations who did not
speak English (Silverman & Hairston, 2005). In a descriptive study specific to psychiatric
music therapists, Silverman (2007) found that 85.7% of respondents were not bilingual but
58.2% still treated non-English-speaking clients. It is interesting that, despite the potential
differences in demographics and clinical practice between the psychiatric music therapists
and music therapists in private practice in the studies, data concerning the percentages of
music therapists treating non-English-speaking clients were relatively similar.
Professional music therapy organizations have articulated the importance of multicul-
tural training in order to be competent clinicians. The American Music Therapy Associa-
tion (AMTA) recognized the importance of cultural diversity and treatment in a manner
consistent with the individual’s culture in the advanced competencies (AMTA, 2009a),
professional competencies (AMTA, 2009b), and standards of clinical practice (AMTA,
2009c). The Certification Board for Music Therapists also recognized cultural sensitivity
in the scope of practice (CBMT, 2009).
Music therapy organizations are not alone in articulating the need for multicultural
training, competence, and guidelines. In an attempt to assist psychologists in providing
individually tailored treatments to diverse clients, the American Psychological Associa-
tion (APA) adopted guidelines concerning multicultural practice, sexual orientation, and
older adults (APA, 2000, 2003, 2004). Levant (2005) wrote: “Culturally sensitive alternative
treatments in response to a patient’s context or worldview may complement psychologi-
cal treatment” (p. 13). This may be an appropriate venue for music therapy treatment, as
therapists can use music indigenous to the patient’s culture to develop rapport and work-
ing alliance and influence therapeutic change and progress. The APA (2003) also noted the
importance of social, historical, political, and economic contexts and understanding how
these contexts may influence a person’s behavior, cognitions, and affective states.
Contemporary applications for psychiatric music therapy with diverse client groups
include various minority groups as well as refugees. There are a high number of refugees
in the world (United National High Commissioner for Refugees, 2010) and many of these
people migrate to the United States. Refugees could certainly be considered multicultural
and may warrant psychosocial treatment services. Although not considered music ther-
apy, Jespersen and Vuust (2012) found listening to relaxing music improved sleep quality
in refugees. In a study with refugee students attending an intensive English as a secondary
language school, Baker and Jones (2006) used music therapy to decrease externalizing
behaviors such as hyperactivity and aggression in a classroom setting. Unfortunately,
there is scant literature concerning how music therapy can be used for refugees. Music
therapy with refugee populations is certainly a fertile and necessary topic for systematic
inquiry.
While some experts in psychosocial interventions have recommended that the use of
translators and interpreters should be avoided when the therapist and client do not share a
language (Martinez, 1986), it may be necessary in some clinical settings. When interpret-
ers are used, culturally specific guidelines should be consulted to facilitate the most effec-
tive treatment (Bamford, 1991; Gaw, 1993; Ho, 1992; Westermeyer, 1993). Regardless of
client group, the therapist should address the patient and not the interpreter. If interpreters
are to be used in music therapy treatment, it is recommended that the therapist meet with
the client and interpreter and client before the session and discuss music therapy, effec-
tive techniques, and issues to be as culturally sensitive as possible. Additionally, as music
therapy is a much smaller clinical practice than traditional talk-based therapies, clinicians
should provide thorough descriptions of music therapy and what it can and cannot ac-
complish during referral and assessment so clients from diverse cultures have realistic
treatment expectations and can provide informed consent for music therapy treatment.
Specific to music therapy, clinicians should be aware of the function and role of music
in the client’s respective culture. Although a review of this literature is beyond the scope
of this chapter, perhaps music therapy curricula could place greater emphases on world
music during students’ academic training in an attempt to better address this important
competency (Moreno, 1988). A greater emphasis on learning and using multicultural
music—as opposed to classical music—would likely facilitate music therapy students’ un-
derstanding of cultures and the role and function of music within respective cultures.
Multicultural music therapy clinical training

Despite a lack of literature in the research base, multiculturalism remains an important
issue in music therapy academic and clinical training. Young (2009) found that the major-
ity of music therapy internship supervisors in the United States and Canada had supervised
interns from diverse cultural backgrounds. Young suggested that, during supervision,
multicultural issues were not being consistently addressed. Kim (2011) surveyed interna-
tional music therapy students living in the United States and found English proficiency,
neuroticism, and music therapy student academic stress were the most powerful predic-
tors of acculturative stress. Swamy (2011) described a culturally centered approach to su-
pervision with a Taiwanese music therapy student.
While many people may erroneously believe that music is a universal language, music
therapists need to understand major and subtle differences in the uses, roles, and functions
of music in various cultures and subcultures. While all cultures have music, the music does
not necessarily translate cross-culturally. Thus, music constitutes a universal phenomenon
but not necessarily a universal language. Although people may be able to appreciate the
music of another culture, this appreciation does not equate to understanding the role and
function of the music. Psychiatric music therapists need to be sensitive and continue edu-
cating themselves concerning multiculturalism and the music of other cultures.
There are numerous complications in adequately training music therapy students to be

culturally competent. As there a multitude of cultures, requiring students to be aware of all
cultures and their various types of music is simply not feasible or practical, regardless of
degree program. With an emphasis on streamlining contemporary curricula to facilitate
timely graduation amid escalating tuition, there is limited time within academic training
to explore and address such a broad topic at the necessary—or even adequate—depth.
Perhaps music therapy educators might focus on multicultural groups specific to the lo-
cation of their college or university. However, if a student changes location, some of this
culture-specific training may not be as relevant. Training music therapy students to ap-
propriately generalize knowledge and to be culturally competent will likely remain a topic
of considerable importance and debate in higher education. It seems essential to include
opportunities for learning abroad, world music and ethnomusicology courses, as well as
multicultural education specific to music therapy. Of course, multiculturalism itself is not
a problem—it is a wonderful aspect of an increasingly diverse and global world that is to
be both celebrated and championed.
It is important to note that one never arrives at cultural competence. Developing cul-
tural competence and treating patients who are diverse are both lifelong processes and

◆ The United States has become a more socially and culturally diverse country and
people from diverse sociocultural backgrounds are also susceptible to mental ill-
nesses. There are numerous types of diversity including age, ethnic background, re-
ligion, disability, sexual preference, gender, medical condition, geographic location,
and socioeconomic status.
◆ Although generalizations can sometimes be inappropriate, it is important for music
therapists to have a basic understanding of cultural tendencies in order to avoid
alienating or offending diverse clients.
◆ Acculturation is a process of adjustment between a person’s own culture and a host
culture and it is imperative for the music therapist to assess the individual’s idiosyn-
cratic level of acculturation.
◆ Direct behavioral approaches can be effective treatments for diverse populations as
patients may expect immediate relief from symptoms and psychosocial stressors.
◆ In the social model of disability, disability is socially constructed and reflects prob-
lems in society rather than problems in the person.
◆ Music therapists must be aware of the role and function of music in a person’s
culture.
◆ Developing cultural competence and treating diverse patients are ongoing processes
necessitating continuing education, sensitivity, patience, and compassion.
commitments necessitating continuing education (Comas-Diaz, 2011), sensitivity, pa-

tience, and compassion. Culturally competent intervention research is relatively recent
and, as it may detail topics such as inequality, disparity, prejudice, values, and differential
treatment, is often controversial (Sue & Zane, 2006). There is a dire need for research
concerning specific ethnic and racial communities, identifying disparities related to ac-
cess, lack of psychiatric and psychosocial services with limited English-language skills,
and institutional racism (Jonas et al., 2011). These studies should include data concerning
specific subgroups (e.g., Mexican, Puerto Rican, South American), years in the United
States, primary language, and acculturation as well as the causes and risk factors for lack
of services for people who have limited English-language skills (Jonas et al., 2011). Future
research using various paradigms regarding culturally competent music therapy with di-
verse client populations is certainly warranted and necessary as the world continues to
become increasingly diverse and culturally rich.
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1 What is acculturation and how might music therapists assess this factor in adult psychiatric inpatients?
2 Why is it important for psychiatric music therapists to have a baseline understanding of cultural tenden-
cies? What can psychiatric music therapists do to avoid over generalizing these cultural tendencies and
potentially offending or alienating clients?
3 How might group-based psychiatric music therapy treatment facilitate rapport and working alliance
with a diverse patient group? What mechanisms of therapeutic change might be relevant?
4 Within a group setting, how might music therapists use music with diverse patients despite the lack of a
common spoken language?
5 People often fail to acknowledge and work through their biases. What are some of your biases regard-
ing race, ethnicity, religious affiliation, gender expression, sexual orientation, or worldviews? Discuss
strategies to work through your biases with a peer.
6 What challenges do music therapy educators face in attempting to provide a thorough education con-
cerning psychiatric music therapy for diverse clinical populations?
Chapter 12
Research in psychiatric music therapy
Challenges and complications

By definition, every research study involving human participants is inherently biased (Else
& Wheeler, 2010) and blemished (Wampold et al., 1997). There are additional difficulties
in conducting psychosocial research with people diagnosed with mental illnesses. Even in
1972, Millon and Diesenhaus noted that the quantitative, controlled, ethically acceptable,
and objective clinical investigation of psychopathology has many complications, includ-
ing the presence of obscure and unreliable data, choosing between scientifically safe and
clinically significant problems, issues of clinical responsibility and ethics, and complica-
tions of study execution. Methodological problems in psychological research also include
keeping clinicians and research participants blind to interventions (Drury, Birchwood,
Cochrane, & MacMillian, 1996; Kuipers et al., 1997), limited information concerning the
treatment methods (Lecompte & Pelc, 1996), small sample sizes, failure to report treat-
ment changes that may affect outcomes (Kuipers et al., 1997), and complications con-
cerning control conditions (Kemp, Hayward, Applewhaite, Everitt, & David, 1996). Other
problems include controlling confounding issues such as medication differences, various
diagnoses, comorbidity, attendance, treatment milieus, varying personal and social func-
tioning levels, fluctuating degrees of illness and symptomology, data collection restric-
tions, and lack of appropriate instrumentation for measuring mental health change or
stability. Additionally, confidentiality and ethical issues are intricate. Are patients legally
able to provide consent and are they motivated to do so when overwhelmed by psychiat-
ric symptoms and may exhibit a lack of insight into their cognitions, affective states, and
behaviors?
Specific to psychotherapy research, treatments for the majority of disorders tend to be
effective when treatments are tested by investigators and conducted by therapists who be-
lieve in them (Luborsky et al., 1999; Wampold, 2001). Although double-blind studies and
the use of an independent statistician may minimize this influence, this is a confounding
factor and often difficult to control. Thus, designing, implementing, and conducting high
quality music therapy research with scientific quantitative confirmation of effective treat-
ment modalities for mental illness can be complicated, time consuming, and difficult to
control (Silverman, 2008). Moreover, even if research is completed and published, there
tends to be a considerable gap between research findings and clinical practice in psychoso-
cial helping fields (Anderson & Adams, 1996; Hollon et al., 2002; TenHave, Coyne, Salzer,
& Katz, 2003).
236 RESEARCH IN MUSIC THERAPY
Lack of psychiatric music therapy studies

Despite the large number of therapists practicing in this area, psychiatric music therapy
efficacy and effectiveness data are limited. Music therapy researchers have reported on the
lack of quantitative research in this area (Choi, 1997; Euper, 1970; Silverman, 2003b, 2008,
2010a) and the difficulties and intricacies of conducting this type of research (Aldridge,
1993; Silverman, 2008). Another reason for the undersized literature base is that few clin-
ical music therapists are actively engaged in research. In a descriptive study of psychiatric
music therapists, it was found that 74.9% of respondents indicated they did not conduct
research. However, over 50% of participants indicated they had earned a master’s degree
or higher (Silverman, 2007) and had thus likely received research training during graduate
education programs. Other fields interested in psychosocial mental health effectiveness
and efficacy research concerning different interventions and treatments have also had sim-
ilar problems amassing a scientific literature base, although their membership is typically
much larger than the music therapy profession (Silverman, 2008).
Both qualitative and quantitative methods have pros and cons. In a chapter describ-
ing research methods for exploring and assessing recovery from mental illness, Loveland,
Randall, and Corrigan (2005) provided an excellent summary regarding the importance
of how the research questions guide the method and paradigm:
Many methods are available for collecting data in research, each having advantages and disadvan-
tages. No one method or collection of methods is better suited than others for all research (Shadish,
1990). The appropriateness of any method is based on the goals of the research (Cronbach, 1982).
Conversely, the selection of a particular methodology will determine what data can be collected
and, subsequently, what questions can be answered by the research. Furthermore, what is con-
sidered valuable or relevant data also influences the selection of research methods, which, in turn,
influences what is collected. What is considered to be valuable data is influenced by one’s epistemo-
logical assumptions about what constitutes knowledge and how it can be observed and measured
(Guba & Lincoln, 1989). (p. 20)
Qualitative research in psychiatric music therapy

Although data are limited, researchers and clinicians have published a number of psychiatric
music therapy studies. However, many of these studies used qualitative approaches or were
case studies and thus provided information that may not necessarily generalize to other
clients with comparable diagnoses and objectives (Alexander, 1996). Certainly, qualitative
inquiries are a valuable component of the music therapy literature base and provide unique
insights into the treatment process and patients’—and therapists’—experiences. Unfortu-
nately, qualitative research is often inappropriately criticized due to its lack of generalizabil-
ity. Although qualitative research is not specifically designed for generalization, qualitative
studies are essential for understanding unique experiences in treatment and for better con-
ceptualizing mechanisms of therapeutic change in the music therapy process. Kazdin (2007)
noted the importance and relevance of qualitative inquiry in psychotherapy research:
Qualitative research is an approach to the subject matter of human experience and focuses on nar-
rative accounts, description, interpretation, context, and meaning. Among the key characteristics
Qualitative research in psychiatric music therapy 237
is the in-depth study of the phenomena of interest. Individual participants or cases are focused on
intensely to examine processes, meaning, characteristics, and contexts. Qualitative research is a rig-
orous, verifiable, empirical, and replicable set of methodologies that encompasses many different
disciplines and diverse design, assessment, and data-analytic strategies (Berg, 2001; Denzin & Lin-
coln, 2005). In the context of the present discussion, qualitative research might study the process of
therapy, how the patient and therapist experience that process, and what might be critical actions
or cognitions and how they relate to improvements outside of treatment. Qualitative research can
provide a fine-grained analysis by intensively evaluating the richness and details of the process,
including who changes and how change unfolds, and who does not change and what might be op-
erative there. (p. 20)
Research is integrally linked to both reimbursement and financial resources (Simpson &
Burns, 2004). In today’s evidence-based era of heightened responsibility, music therapists
must be accountable for their methods. As the results of qualitative inquiry are not de-
signed nor intended to generalize, these types of data are often not considered as reimburs-
able by insurance companies and other funding agencies (Hanser, 1999; Rogers, 1995).
Moreover, methodology not containing a statement about the probability of the occur-
rence of the phenomenon due to random sources is often dismissed by funding agencies.
Due to the importance of cost-effectiveness and generalization imposed by the capitalistic
healthcare industry in the United States, the foundation of qualitative research within the
mental health field is still not as secure as that of quantitative research (Good & Watts,
1996). Additionally, although qualitative studies can be especially valuable in describing
perspectives and experiences, the systems for appraising qualitative research are still in
their infancy (Harden et al., 2004).
Qualitative studies are undoubtedly beneficial and can be used for education and clinical
training and to better inform quantitative methods. Thus, these studies are an integral part
of the literature base. Jonas and colleagues (2011) specifically recommended that strong
consideration should be given to the potential of qualitative research paradigms for psy-
chiatric consumers. These studies can include qualitative case studies using various meth-
ods, including participant observation, protocol analysis, discourse analysis, conversation
analysis, voice-centered techniques, photographic analysis, diary studies, document anal-
ysis, and computational modeling.
For the reasons previously summarized, quantitative data are not easily attainable with
mental health populations (Silverman, 2008); therefore qualitative research represents a
central part of the solution toward further understanding the phenomenon of psychiatric
music therapy and enlarging the literature base. Additionally, as researchers might initiate
inquiry in a particular area, qualitative research is uniquely suited to best investigate the
breadth and depth of the phenomenon or construct under examination (Melnyk & Cole,
2005). Qualitative research questions are typically designed to investigate how or what can
be valuable in developing theories, providing depth and breadth to experiences within
sociocultural contexts, and better understanding the human experience (Powers, 2005).
Therefore, researchers must carefully consider what method most appropriately addresses
the research question in conjunction with the abilities of psychiatric consumer research
participants to consent to and actively participate in research.
Quantitative research in psychiatric music therapy

The emphasis of the current text concerns an educational approach to music therapy for
illness management and recovery stemming from cognitive behavioral and psychoedu-
cational approaches. Thus, quantitative studies are highlighted in order to provide read-
ers with a brief summary of the generalizable literature base. In order to provide readers
with an overview of quantitative research in psychiatric music therapy congruent with
the purpose of the text, the author located articles using PsycINFO, FirstSearch, ERIC,
other Internet search engines, and the ancestry approach. Studies were excluded from
the analysis if the article “was not in English, it was of poor methodological quality or
there was inadequate description of the participants, intervention, outcomes measures
or the research method” (Evans, 2002, p. 9). All existing quantitative studies (includ-
ing case studies with quantitative data) involving music therapy with adult psychiatric
populations were included. The analysis did not include music therapy articles con-
cerning children or adolescents (see Gold, Voracek, & Wigram, 2004). Combinations
of descriptors and keywords for the search included the following: music therapy and
mental disorder, mental illness, bipolar, schizophrenia, major depressive disorder, depres-
sion, substance abuse, substance disorder, chemical dependence, and psychiatric. Studies
involving music medicine or techniques that were not delivered by a music therapist
were excluded. After articles were identified, they were examined to determine if they
met inclusion criteria.
Quantitative music therapy studies are outlined in Table 12.1 (adult psychiatric patients)
and Table 12.2 (adults in substance abuse rehabilitation). Adults in substance abuse reha-
bilitation were included because they have a psychiatric diagnosis (some type of substance
abuse disorder) and treatments may be similar.
Future psychiatric music therapy research

In a study attempting to determine characteristics of effective therapists, Blatt, Sanislow,
Zuroff, and Pilkonis (1996) noted that it is important to differentiate among therapists
and include therapists’ demographic data in outcome studies. Thus, future music therapy
researchers might consider including these essential characteristics in their studies. While
researchers should explain characteristics of the treatment and therapists in order that
other researchers might replicate the study, investigators should also be sure to include
potential participant variables that may function as covariates or confounding variables.
These variables may include gender, age, race/ethnicity, number of psychiatric admissions,
number of days on inpatient status, admission status (voluntary or involuntary), therapeu-
tic dose (i.e., number of treatment sessions), unit characteristics and programming, and
diagnoses. Also, there may be interactions between these types of patient variables and
treatments as some interventions may be effective for certain patient groups but less effec-
tive for others (Chambless & Crits-Christoph, 2006). Researchers evaluating how music
therapy might affect these dependent measures would unquestionably contribute to the
literature base in a constructive manner.
Table 12.1 Music Therapy Studies of Adult Psychiatric Patients
Author(s), Year Independent Variable Dependent Variable N Diagnosis Design Results

Bunt, Pike, & Wren, 8 sessions of Patient and 6 Pyschiatric in- and Descriptive High attendance, positive comments
1987 improvisational music staff comments, outpatients from patients and staff
therapy attendance
Carr et al., 2011 10 sessions of group- Symptoms 17 Patients with post- RCT; mixed MT group had significant reduction in
based active and associated with traumatic stress methods severity of symptoms and marginally
receptive MT, free post-traumatic disorder significant reduction in depression.
improvisation stress disorder Patients perceived MT as helpful.
Cassity, 1976 Group guitar lessons Peer acceptance, 12 Various psychiatric RCT Significant gains in both dependent
and recital group clients measures
cohesiveness,
and interpersonal
relationships
Castillo-Perez, Listening to classical Depression 79 Low and medium- RCT Music therapy group had less depression

Gomez-Perez, and baroque grade depression than psychotherapy group; doses
Velasco, Perez- recorded music or different as well
Campos, & Mayoral, psychotherapy
2010
Ceccato, Caneva, & Sound Training Attention and 16 Outpatients with Non- Memory and life skills of experimental
Lamonaca, 2006 for attention and memory schizophrenia randomized group significantly higher than control
memory protocol controlled trial group
Choi, Lee, & Lim, Group music therapy Depression, 26 Psychiatric Non- Significant improvements in all measures
2008 anxiety, and inpatients randomized
relationships controlled trial
Cook & Freethy, Contingent hymn Complaining, 1 43 year old Behavioral Contingent music effective, especially
1973 playing talking in a whiny diagnosed with when patient is instructed about
voice, length schizophrenia contingency
of time before and mild mental
reinforcement retardation
239
240
Table 12.1 (continued) Music Therapy Studies of Adult Psychiatric Patients
RESEARCH IN MUSIC THERAPY

de l’Etoile, 2002 Music listening, lyric Symptoms, 8 Adult outpatients 1 group pre- Positive changes in dependent measures
analysis, music with curative factors, with chronic and posttest
other arts media, attitude mental illnesses
improvisation, toward seeking
songwriting, singing, professional
music for relaxation psychological help
Erkkila et al., 2011 Individual Depression, 76 Adults with RCT Music therapy group had greater
improvisational music anxeity, depression improvement in depressive symptoms,
therapy and general anxiety symptoms, and general
functioning functioning at three month follow-up
Eyre, 2011 Therapeutic chorale Participant 16 Chronic mental Descriptive Chorale was valuable to participants
experiences illnesess and positively affected lives (self-esteem,
emotional expression, mood, coping,
routine, and comfort)
Gold et al., 2013 3 months of biweekly Negative 144 Adults with non- RCT MT was superior to treatment as usual
individual resource- symptoms and organic mental for total negative symptoms, functioning,
oriented music 15 secondary disorders and clinical global impressions, social
therapy outcomes low therapy avoidance through music, and vitality
motivation
Gold, Heldal, Dahle, Music therapy 4 studies, Schizophrenia and Meta-analysis Music therapy with standard care can
& Wigram, 2005 266 schizophrenia-like help people with schizophrenia improve
participants illnesses their global state. A sufficient number of
sessions can improve mental state and
functioning.
Gold, Erkkila, & Improvisational Symptoms, 3 studies Inpatients with Post hoc Effect sizes tended to be less favorable
Crawford, 2012 group or individual continuous scale (N = 81, schizophrenia and analysis of 3 among initial participants when compared
music therapy 37, 79) outpatients with RCTs to later participants. The process of
depression implementing trial procedures may
negatively affect therapist performance.

Goldberg, McNiel, & Group music therapy Curative factors 61 Acute psychiatric Descriptive Patients valued both music therapy
Binder, 1988 inpatients and verbal therapy. No between-group
differences in curative factors as ranked
by patients, but therapists found music
therapy had more patient interaction.
Grocke, Bloch, & Songwriting, singing, Quality of life 17 Outpatients 1 group pre- Significant improvement in quality of life
Castle, 2009 improvisation with severe and and posttest measures and interaction anxeity
enduring mental
illness
Grocke et al., 2014 Group-based singing Quality of life, 99 Outpatient with Randomized Significant between-group difference
familiar songs, social enrichment, severe mental embedded- in quality of life and spirituality. Greater
composing songs self-esteem, illness experimental dose was associated with greater
and recording them spirituality, mixed methods treatment gains. Focus group and song
in a professional psychiatric lyric analyses indicated enjoyment,

studio symptoms enhanced self-esteem, and appreciation
Hakvoot, Bogaerts, Individual Numbers of 20 Forensic inpatients Descriptive Similarities in verbal and dysfunctional
& Spreen, 2012 improvisational music matching coping behavior in music therapy sessions and
therapy skills and social on living unit. No similiarities in assultive
dysfunctional behaviors, interpersonal skillls, and
and aggressive positive and negative coping skills in
reactions music therapy sessions and on living unit.
Harris, Bradley, & Hard rock/rap versus Inappropriate N/A Adult inpatients Behavioral More inappropriate behaviors during
Titus, 1992 easy listening/country behaviors at a large state hard rock/rap condition
hospital
Hayashi et al., 2002 Chorus activity, Psychotic 66 Female inpatients Non- Short-term positive change in personal
games and plays symptoms, with chronic randomized relations and sense of participation
using music subjective quality psychoses controlled trial
of life, and musical
experiences
241
242

Heaney, 1992 Survey Self-rated opinion 27 Psychiatric Descriptive Music therapy consistently rated higher
of therapy patients than other therapies
Kahans & Calford, Recitals Attitude change 713 Adult psychiatric Non- Attitude changes toward therapist found
1982 inpatients, nurses, randomized when music was preference of therapist
medical students controlled trial and this was conveyed to the audience
Kwon, Gang, & Oh, 13 group MT sessions Alpha waves, 55 Adults with quasi- MT condition had significantly higher
2013 including singing, cognitive function, chronic experimental 2 relative power alpha waves, improved
playing and listening positive and schizophrenia group design cognitive functioning, more positive
negative behaviors behaviors and less negative behaviors
than control group.
Maratos, Gold, Music therapy 5 studies, Depression Meta-analysis Music is accepted by people who are
Wang, & Crawford, 237 depressed and it can help to improve
2008 participants mood.
Morgan, Bartrop, Improvisation or Positive and 49 Schizophrenia, RCT Significant changes in positive and
Telfer, & Tennant, songwriting negative symptoms schizoaffective, or negative symptoms in experimental
2011 bipolar group; 9.3% decrease in length of stay.
Mossler, Assmus, Individual MT Predictors of 31 Psychiatric clients 1 group pre-, Reproduction techniques may improve
Heldal, Fuchs, & techniques: change mid-, and relational abilities in patients with low
Gold, 2012 production, posttest therapy motivation.
reproduction, and
reception
Mossler, Chen, Music therapy 8 studies, Schizophrenia and Meta-analysis When music therapy is utilized in
Heldal, & Gold, 483 schizophrenia-like addition to standard care, it can help
2012 participants illnesses improve global state, mental state, and
social functioning
Pavlicevic, Individual Musical 41 Outpatients with RCT Music therapy group had significant
Trevarthan, & improvisational music interaction, schizophrenia differences in musical interaction,
Duncan, 1994 therapy psychosis improved clinical status

Peng, Koo, & Kuo, Singing and listening Psychotic 67 Schizophrenia Non- Significant between group differences
2010 (not music therapists; symptoms randomized
nurses) controlled trial
Silverman, 2003a Contingency Combativeness 1 Schizohrenia Case study Contingent songwriting reduced
songwriting and non- inpatient combativeness and non-cooperation on
cooperation unit
Silverman, 2003c Music Symptoms of 19 People with Meta-analysis Music has significant effect on psychosis;
psychosis psychosis no difference between live versus
recorded; passive versus active; classical
versus non-classical; preferred versus
classical
Silverman, 2006 Survey Perception of 73 Psychiatric Descriptive Music therapy rated higher than all other
helpfulness inpatients treatments

Silverman, 2007 Survey Perception of 176 Clinical music Descriptive Music therapists felt they had a postive
helpfulness therapists impact on treatment and helped patients
meet their objectives
Silverman, 2009c Lyric analysis Response 105 Psychiatric RCT Music therapy group made more
frequency and inpatients verbalizations about themselves; music
type, perceptions therapy group tended to have higher
perceptions of treatment
Silverman, 2010b Individual game, Perceptions of 15 Inpatients with Mixed-methods Patients were able to describe what they
team game, music therapy severe mental had done, what the purpose/objective
singalong, lyric treatment illnesses of the session was, and supported music
analysis, songwriting therapy on the unit
Silverman, 2011c Various music Proactive coping 9, 29 Acute psychiatric RCT Although not significant, music therapy
therapy interventions inpatients condition tended to have slightly higher
mean proactive coping
243
244

Silverman, 2011d Percussion State anxiety and 69 Acute psychiatric RCT Although not significant, experimental
intervention and lyric meaning in life inpatients group tended to have lower state anxiety
analysis
Silverman, 2011e “Rock opera” and Quality of life, 133 Acute psychiatric 3 group RCT Although not significant, both
role play locus of control inpatients assertiveness conditions tended to
have slightly higher quality of life and
locus of control than the recreational
music therapy condition. More patients
attended music therapy conditions.
Silverman, 2011f Songwriting about Knowledge of 89 Acute psychiatric RCT Although not significant, music therapy
coping skills coping skills, inpatients condition tended to have slightly higher
working alliance knowledge of coping skills and working
alliance. Music therapy condition had
higher attendance.
Silverman, 2013a Educational music Knowledge of 65 Acute psychiatric 3 group RCT Although not significant, increases from
therapy social supports inpatients pre- to posttest measures.
Silverman, 2013b Psychoeducational Quality of life, 105 Acute psychiatric 3 group RCT Although not significant, songwriting
group songwriting depression, inpatients has most positive quality of life and
treatment depression.
perceptions
Silverman, 2013c Educational Self- and 83 Acute psychiatric 3 group RCT Significant differences in self-,
songwriting about experienced stigma inpatients experienced, and total stigma between
stigma educational music therapy and wait list
control conditions.

Silverman, 2014a Educational lyric Perceived social 96 Acute psychiatric 4 group RCT Significant differences in perceived
analysis support and trust inpatients therapist competence between live and
in the therapist recorded conditions with live condition
being higher. Significant differences
in support from friends between live
and recreational conditions with live
condition being higher.
Silverman, 2014b Educational music Depression, 11 Acute psychiatric 3 group RCT Although not significant, educational
therapy - songwriting satisfaction with patients, inpatients and music therapy condition tended to
life, treatment 21 family their visiting family have slightly higher means than other
perceptions members members conditions. Seven themes emerged from
therapist's treatment notes regarding
family-based music therapy.

Silverman & Active music therapy Attendance 16, 18 Patients with 2 quasi- Higher mean attendance and durational
Leonard, 2012 interventions and durational serious mental randomized attendance in active music therapy
attendance, illnesses pilot studies sessions than in passive music listening
treatment sessions. Higher mean treatment
perceptions perceptions in active music therapy
sessions.
Silverman & Songwriting, Various self-rated 189 Psychiatric 1 group pre- Positive changes in all dependent
Marcionetti, 2004 drumming, lyric measures inpatients and posttest measures
analysis, music
listening, music game
Silverman & Reading, recorded Auditory 7 Psychiatric Behavioral Interactive music making best at
Marcionetti, 2005 music, interactive hallucinations inpatients suppressing auditory hallucinations
music making
245
246

Silverman & Recreational MT Mood 41 Acute psychiatric 1 group pre- Significant positive changes in wide
Rosenow, 2013 interventions inpatients and posttest awake/drowsy, relaxed/anxious, cheerful/
depressed, and friendly/aggressive. No
between-intervention differences.
Talwar et al., 2006 Individual General symptoms 81 Patients with RCT Trend towards improved symptom scores
improvisational MT of schizophrenia schizophrenia in music therapy group
Tang, Yao, & Zheng, Passive listening and Negative 76 Inpatients RCT Significant difference in negative
1994 group singing symptoms, social with residual symptoms, positive social changes
measures schizophrenia
Thaut, 1989 Music group therapy, Self-rated 50 Psychiatric 1 group pre- Significant change in all three dependent
instrumental group relaxation, mood/ prisoner patients and posttest measures
improvisation, music emotion, thought/
and relaxation insight
Ulrich, Houtmans, & Group music therapy Quality of 37 Inpatients RCT No quality of life differences, but
Gold, 2007 - instrument playing life, negative with psychotic significant reduction in negative
symptoms, disorders symptoms in experimental group
psychosocial
orientation
Wen-Ying, Zhen, Group and individual Symptoms 70 Adult inpatients RCT Negative symptom and social disability
Yong-Zhen, music therapy with chronic reduction in experimental group
Hong-Yi, & Bio, schizophrenia
1998
William & Dorow, Contingent Complaints, non 1 Depressed adult Behavioral Decrease in complaints, increase in non-
1983 interrupted music complaints complaints during music condition
Note. RCT = randomized controlled trial; NRCT = nonrandomized controlled trial; MT = music therapy.
Table 12.2 Music Therapy Studies with Substance Abuse Patients

Albornoz, 2011 12 group Self-rated and 24 Adult males ages RCT Significant between-group difference in
improvisational music psychologist-rated 16–60 psychologist rated depression but not in
therapy sessions over depression self-rated depression.
three months
Baker, Gleadhill, & Group music Non-drug induced 24 Adults with 1 group Music therapy facilitated experiencing of
Dingle, 2007 therapy: lyric emotions substance abuse posttest only positive emotions
analysis, songwriting, disorder
improvisation,
singing, listening
Cevasco, Kennedy, Movement to music, Depression, stress, 10 Females in 1 group pre- Decrease in all four dependent measures
& Generally, 2005 rhythm activities, anxiety, anger substance abuse and posttest

competitive games rehabilitation
Dingle, Gleadhill, & Lyric analysis, Attendance, 24 Adults with 1 group High attendance, motivation, enjoyment
Baker, 2008 songwriting, enjoyment, substance abuse posttest only
improvisation, motivation disorder
singing
Hammer, 1996 Guided imagery and Anxiety 16 Adults with and Non Guided imagery and music group had
music and relaxation without chemical randomized significant decrease in anxeity
(30 minutes for 10 dependency controlled trial
weeks)
James, 1986 Survey Self-monitoring 95 Adults in chemical Descriptive Music therapists should provide verbal
scale dependency reinforcement for instrinsic motivation -
treatment scale useful in determining sources of
motivation.
247
248
Table 12.2 (continued) Music Therapy Studies with Substance Abuse Patients

Jones, 2005 Songwriting, lyric Emotional change 26 Chemical 2 music Positive changes in emotional states
analysis dependence therapy
groups, pre-
and posttest
Mays, Clark, & Music therapy 19 studies Patients with Systematic Music therapy additive, not independent.
Gordon, 2008 addictions review Used in group formats. No consensus
regarding treatment efficacy.
Ross et al., 2008 Music and imagery, Psychiatric 80 Dually diagnosed 1 group pre- Music therapy appears to be a
drumming, and symptoms, general and posttest motivational tool
improvisation functioning,
motivation,
music therapy
appreciation
Silverman, 2003b Songwriting, music Self-rated 8–12/group Women who 1 group Positive ceiling effect for dependent
games, lyric analysis, therapeutic were chemically posttest only measures
music and relaxation effectiveness and dependent
enjoyment
Silverman, 2009a Survey Perceptions of 25 Music therapists Descriptive Music therapists felt they had a positive
treatment working with impact upon treatment
patients who have
addictions
Silverman, 2009b Lyric analysis Treatment 66 Adults with RCT Not statistically significant, but music
eagerness and chemical therapy condition had higher treatment
working alliance dependency eagerness and working alliance
Silverman, 2010c Lyric analysis Withdrawal 118 Adults in a RCT Not statistically significant, but music
symptoms and detoxification therapy group had lower withdrawal and
locus of control facility higher external locus of control scores
Table 12.2 (continued) Music Therapy Studies with Substance Abuse Patients

Silverman, 2011a Songwriting Change, 140 Adults in a RCT At immediate posttest, significant
depression, detoxification differences in treatment perceptions.
treatment facility Change and depression tended to be
perceptions slightly better in music therapy condition.
Silverman, 2011b Rockumentary (lyric Change readiness, 141 Adults in a 3 group RCT At immediate posttest, significant
analysis) craving detoxification differences between both music therapy
facility conditions and verbal therapy condition

in contemplation and action subscales.
Although not significant, both music
therapy conditions had lower craving
means than the verbal therapy condition.
Silverman, 2012 Group songwriting Motivation, 99 Adults in a RCT Significant between-group differences in
readiness for detoxification motivation and readiness for treatment
treatment facility
Note. RCT = randomized controlled trial; NRCT = nonrandomized controlled trial; MT = music therapy.
249
There are many research opportunities for psychiatric music therapists. Readers in-
terested in a list of potential dependent measures and contemporary issues in psychiat-
ric music therapy research are advised to consult a literature analysis (Silverman, 2008).
Moreover, researchers should not solely consider quantitative experimental designs as
all research paradigms would constitute a welcome addition to the literature base. Using
mixed-method designs may allow for researchers interested in both quantitative and qual-
itative methods to answer their questions and triangulate data (Bradt, Burns, & Creswell,
2013). Moreover, mixed-method inquiry can be especially insightful as each data set can
be used to further interpret and understand the other data set. Qualitative data can pro-
vide depth to and explain quantitative effects and quantitative data can verify qualitative
findings. Despite the depth of knowledge they might provide, there is a lack of psychiatric
mixed-method music therapy studies.
A research question that merits continued examination is music therapy dosage. The
dose-response effect questions the frequency and duration of treatment required to at-
tain consequential therapeutic change. Hansen, Lambert, and Forman (2002) noted that
symptom alleviation can occur after 13 to 18 psychotherapy sessions, regardless of the
treatment type or client diagnosis. In a related study, Lambert (2007) found approximately
18 sessions are required for 50% of clients to recover in terms of a clinically significant
change on an objective measure. Likely the result of limitations on the number of sessions
and available funding, Hansen, Lambert, and Forman (2002) found the average number of
psychotherapy sessions (dose) was fewer than five. Garfield (1994) found that the median
duration of treatment was between five and six therapy sessions. Thus, from these studies,
it seems that most therapists were unable to provide clients with an adequate treatment
dose for change to occur. Specific to psychiatric music therapy treatment dose, Gold, Solli,
Kruger, and Lie (2009) conducted a systematic review and meta-analysis concerning dose
for people with serious mental disorders. The authors found that, when added to standard
care, music therapy has strong and significant effects on global state, general symptoms,
negative symptoms, depression, anxiety, functioning, and musical engagement. There
were statistically significant dose-effect relationships concerning functioning and general,
negative, and depressive symptoms. However, effect sizes differed by dosage. After doses
of three to ten music therapy sessions, effect sizes were small; after 16 to 51 sessions, effect
sizes were large.
While the value of this study cannot be overstated and the authors should be praised for
their innovative scholarship, readers must be aware of the unique contextual parameters
specific to contemporary clinical practice. For example, as psychiatric inpatient hospitali-
zations have become briefer over time, many patients may not receive 16 or more music
therapy inpatient doses in order to produce large effect sizes. Outpatient psychiatric music
therapy is not as prominent as inpatient music therapy in the United States (Silverman,
2007). Additionally, music therapy is typically group-based (Silverman, 2007; Thomas,
2007) and this important variable (often determined by administrators at the facility and
based upon available funding) may affect dosage and resulting treatment outcome. More-
over, improvisational music therapy is not as common in contemporary inpatient care
Future psychiatric music therapy research 251
practice in the United States as it is in Europe. This is especially true in acute settings,
where the emphasis is on returning patients as quickly as possible to the community with
augmented illness management and recovery knowledge and skills. Additional research
is warranted concerning different types of clinical practice specific to idiosyncratic con-
textual parameters, such as acute inpatient psychiatric care, outpatient treatments, and
potential between-country differences.
As music therapists do not “own” music, other professionals can use music for therapeu-
tic reasons. In the contemporary era of heightened accountability, research is warranted
to determine effects of active music therapy interventions and to differentiate those from
passive or receptive listening interventions. In a meta-analysis concerning the effects of
music on the symptoms of psychosis, Silverman (2003c) did not find significant differ-
ences between (a) recorded music versus live music or (b) active music therapy interven-
tions versus passive listening. These results are alarming; future research is warranted to
differentiate passive music listening from active music therapy treatments. Thus, during
two pilot studies, Silverman and Leonard (2012) attempted to differentiate active and pas-
sive (or receptive) music therapy formats and answer questions related to attendance and
patients’ treatment perceptions. The researchers conducted a series of active group music
therapy interventions (lyric analysis, songwriting, music game, facilitated percussion in-
terventions, and a singalong session) and passive group music listening sessions (recorded
music via iPod) for five days. During the first pilot study, a higher percentage of psychiatric
inpatients on the intermediate care unit attended the active music therapy sessions than
the passive music listening sessions. Concerning treatment perceptions, participants in
the active music therapy condition tended to have slightly higher perceptions of enjoy-
ment and comfort than participants in the passive music listening condition. During the
second pilot study, participants spent more time in active music therapy sessions than in
passive ones. Participants in the active music therapy condition also tended to have higher
perceptions of helpfulness and how much they learned concerning managing their men-
tal illnesses than participants in the passive music listening condition. While this was a
small-scale study and results should be interpreted with caution, depending upon hospital
billing procedures, greater attendance could result in additional funding. Funding from
heightened attendance could potentially support the hiring of a music therapist.
In another investigation of the potential effects of live music, Silverman (2014a) studied
the effects of live educational music therapy on trust and social support during a four-group
posttest-only randomized design. Participants (N = 96) were acute psychiatric inpatients
who were randomly assigned by cluster to one of four conditions: live educational music
therapy (lyric analysis), recorded educational music therapy (lyric analysis), education
without music (talk-based education with the same questions and therapeutic material as
the lyric analysis conditions), or recreational music therapy (rock and roll bingo). The only
subscales resulting in between-group significant differences were friends and competence.
Pairwise comparisons with Bonferroni adjustments for multiple analyses indicated signifi-
cant differences between live educational music therapy and recreational music therapy on
the friends subscale and between live educational music therapy and recorded educational
music therapy on the competence subscale. Participants in the live educational condition
had higher means than participants in comparison conditions. General results tended to
support the use of live educational music therapy, as it may be a psychosocial interven-
tion capable of heightening psychiatric inpatients’ perceptions of social support concern-
ing friends and perceptions of therapist competence. Participants in the live educational
music therapy condition found the therapist to be more competent than participants in
the recorded educational music therapy condition, providing empirical support for music
therapists to be competent musicians. While researchers have been able to differentiate live
music from recorded music in the medical music therapy literature base (Standley, 2000;
Standley & Whipple, 2003), the results were the first to demonstrate differences between
live and recorded music in the psychiatric music therapy literature base. Additional re-
search is needed to differentiate music-based interventions facilitated by music therapists
from music-based interventions facilitated by non–music therapists.
While it may be tempting for researchers to exclusively focus on traditionally impor-
tant quantitative outcome measures such as length of stay, depression, quality of life, and
recidivism, other dependent measures that psychiatric music therapists might target in
contemporary clinical practice warrant investigation. These measures may be predictive
of illness management and recovery, including knowledge of coping skills, coping self-
efficacy, perceived social support, medication management knowledge, reasons for taking
medication as prescribed, stage of psychiatric recovery, knowledge of stressful situations
(i.e., triggers), working alliance, trust in the therapist, perceived therapist competence,
avoiding drugs and alcohol, decision making, hope for recovery, values clarification, and
perceptions of the therapy session. Although these factors may not be conventional out-
come measures, they are important variables that likely influence patients’ ability to man-
age their illnesses.
The future of psychiatric music therapy inquiry is indisputably fertile for many research
questions and corresponding paradigms of inquiry. For example, psychiatric music thera-
pists could investigate psychiatric music therapy through the lens of discovery-oriented re-
search (Bernal & Scharron-Del Rio, 2001). Discovery-oriented research takes place when
an investigator may not have a clear intervention, or is uncertain about the psychother-
apeutic phenomena and processes. It does not test established treatments or hypotheses
but rather attempts to understand treatment process dynamics in the hopes of identifying
variables and treatment strategies to test. Discovery-oriented research makes use of all re-
search methodologies and paradigms. Perhaps discovery-oriented research can facilitate
the understanding of potential therapeutic covariates and how and why psychiatric music
therapy might be effective.
Jonas and colleagues (2011) identified priorities for patient-centered outcomes for
people with serious mental illnesses. Although the authors had anticipated stakeholders
would focus on comparisons of evidence-based interventions and treatment and studies
to address gaps in the literature base, three of the top four priorities focused on how—and
not what—research was conducted. The three priorities centering on how research was
conducted are shown in Box 12.1.
Theory in music therapy research 253
Box 12.1 Research Priorities

1 Developing consensus measurement and outcomes definitions.
2 Improving infrastructure for research, longitudinal studies, new data sets, and new
investigators.
3 Developing comparative effectiveness/patient-centered outcomes research meth
odology.
Reproduced from Dan Jonas, Alyssa J. Mansfield, Pam Curtis, John Gilmore, Lea Watson, Shannon Brode,
Karen Crotty, Meera Viswanathan, Elizabeth Tant, Cathy Gordon, Samantha Slaughter-Mason, and Brian
Sheitman, Identifying priorities for patient-centered outcomes: Research for serious mental illness, p. 11
Research Triangle Park, NC: RTI-UNC Evidence-based Practice Center © 2011, The Authors.
In their report, the authors concluded that a failure to fundamentally change the way
research with patients diagnosed with serious mental illnesses is conducted may prevent
the field from progressing.
Theory in music therapy research

Using outcome-focused research to determine if interventions under evaluation are ef-
fective has been—and will likely continue to be—a substantial part of the music therapy
literature base. However, outcomes-focused research typically only allows researchers
to determine if the proposed intervention was effective on the predetermined depend-
ent measure. Outcome-focused research does not allow for examination of questions
concerning how or why the intervention was effective. Examining mediators of psycho-
social interventions can allow researchers to study not only if the independent variable
achieved the desired effects, but also how the independent variable achieved the effects
(Stanton, Luecken, MacKinnon, & Thompson, 2013). Although cognitive behavioral
therapy has the largest empirical literature base, Craske (2010) noted that there is a need
for methodologically rigorous research concerning mechanisms and mediators of this
treatment. Thus, this type of theory-based research can facilitate both researchers’ and
clinicians’ understanding of the complicated interactions between independent and
dependent variables. Moreover, Kazdin (2007) noted that providing global conceptual
views, such as cognitive behavioral or psychodynamic, is no longer sufficient. Rather,
specific and detailed conceptual models that thoroughly explain processes responsible
for change are needed. Conceptual theory (describing how the mediators are causally re-
lated to the outcome) and action theory (describing how the intervention affects selected
mediators) can provide clear specification for how the intervention affects outcome vari-
ables (Stanton, Luecken, MacKinnon, & Thompson, 2013). Robb (2012) highlighted
the importance of theory-based research in the music therapy profession, noting that
behavioral intervention research is moving away from outcome-focused research toward

a theory-based approach. Gfeller (1987) also noted the importance of theory in music
therapy research:
Because the music therapy profession is primarily concerned with successful treatment outcomes,
theoretical considerations or a mental plan of principles may seem of secondary importance to the
practicing music therapist. The value of theory, however, should not be underestimated. A coherent
theoretical foundation provides a plan of action and a guideline for selection of approach. Without
such a foundation, each therapeutic decision exists in isolation, with no connection to preceding or
subsequent events. (p. 192)
Theoretical frameworks constitute a vital component of qualitative, quantitative, and

mixed-method research. Burns (2012) described theoretical frameworks as follows:
Theoretical frameworks, sets of related constructs that characterize and provide a mental image of
a phenomenon (Peterson & Bredow, 2009), are essential components of research studies and ev-
idence-based clinical decision making that allow for an understanding of potential outcomes, the
underlying processes leading to those outcomes, and potential variables amenable to change via
intervention (Sidani & Braden, 2011). (p. 9)
Burns (2012) noted that in order to develop a framework, researchers need to first fully
describe the problem to be addressed. This includes potential variables that are related
or contribute to the outcome. Then the researcher needs to decide the mechanisms or
processes within the framework that may facilitate change and the content within the
intervention, as well as the delivery format, that must be present to achieve the desired
outcomes.
In an integrative review paper concerning the theoretical rationale for music selection in
oncology intervention research, Burns (2012) articulated how theoretical frameworks can
be responsible for describing the relationship between variables and intervention content.
Although it may be tempting to first design the intervention, the social problem needs to
be conceptualized and contextualized in order to formulate interventions designed to tar-
get social problems and dependent measures. Using theoretical frameworks that clearly
describe relationships between social problems and potential covariates can facilitate the
understanding of what dependent measures may be susceptible to change and the specific
aspects of the intervention that must be present to bring about the change. When these
mechanisms of change within the intervention are identified, clinicians can design inter-
ventions based on client preference, setting, and previous experiences, thus allowing for
clinician flexibility.
Suggestions for psychiatric music therapy research

The list in Box 12.2 is provided as a sort of “research muse” to stimulate critical thinking
and encourage dialogue concerning designing relevant and innovative research question
and studies.
Clinical music therapists interested in conducting research are advised to consult the
treatment team for recommendations concerning how music therapy augments existing
Suggestions for psychiatric music therapy research 255
Box 12.2 Research Suggestions

1 Design studies demonstrating differences between active music therapy inter-
ventions (e.g., songwriting, lyric analysis, and improvisation) and passive music
listening.
2 Design studies demonstrating differences between live music therapy interventions
and recorded music therapy interventions.
3 Design studies that use multiple treatment groups in an attempt to tease out effec-
tive components of music therapy.
4 Design studies in an attempt to determine potential indicators of response to music
therapy treatment (e.g., the more times a patient has been hospitalized the less
likely she or he will find psychosocial treatments helpful [Silverman, 2006]).
5 Design studies to assess if certain music preferences in music therapy affect out-
come measure (e.g., if a patient prefers music by The Eagles, will she or he have a
better therapeutic response during a lyric analysis intervention of an Eagles’ song
than a patient who does not prefer The Eagles?).
6 Design qualitative and mixed-method studies to better determine the depth of par-
ticipants’ experiences in psychiatric music therapy.
7 Design studies to determine if there are outcome differences between participants
who receive group music therapy and participants who receive individual music
therapy as well as the combination of group and individual music therapy.
8 Design studies to determine how music therapy treatment dose effects outcome
measures.
9 Design studies to determine how music therapists might effect patients’ percep-
tions of working alliance.
10 Design qualitative studies to explore and understand individual patient responses
to various music therapy interventions.
11 Design studies to measure and conceptualize staff perceptions of psychiatric music
therapy.
12 Design studies to determine if music therapy in-services for staff affect patient at-
tendance in music therapy sessions.
13 Design studies to determine cost/benefit analyses of psychiatric music therapy.
14 Design studies to measure types and frequencies of patient and therapist verbaliza-
tions during different music therapy interventions.
15 Design studies to measure how co-facilitation might affect patient outcome (e.g.,
a music therapist could co-facilitate group therapy with a pharmacologist to teach
patients about medications).
Box 12.2 Research Suggestions (continued)
16 Design music therapy studies based on established evidence-based treatments for

psychiatric consumers (e.g., incorporate music therapy into an assertive commu-
nity treatment model).
17 Design studies differentiating therapeutic relationships in music therapy with other
types of therapeutic relationships.
18 Design studies to investigate the features of effective psychiatric music therapists.
19 Design studies to compare music therapy as a type of bundled psychosocial in-
tervention (i.e., part of a treatment milieu) to bundled psychosocial interventions
without music therapy.
20 Design studies to enhance psychiatric consumers’ and the public’s knowledge of
mental illness to reduce stigma, prejudice, and discrimination while encouraging
social inclusion.
21 Design studies based upon well-established taxonomies and frameworks from re-
lated fields to guide, define, and describe approaches.
22 Design studies to measure subjective life satisfaction and well-being outcomes in-
cluding quality of life, happiness, and success in education, relationships, employ-
ment, and housing.
psychosocial programming and how research would fit within the clinical paradigm. Cli-
nicians and academics are encouraged to collaboratively work with interdisciplinary re-
search teams to capitalize on different strengths and perspectives.
Reporting guidelines
The clarity and transparency of reporting in research studies is paramount to the synthesis
of research and determining the state of the literature base. The consolidated standards of
reporting trials (CONSORT) statement (Moher, Schulz, & Altman, 2001) was designed
as a guideline to increase the clarity and transparency of reporting in randomized con-
trolled trials. Authors have noted that the use of the CONSORT statement has improved
the quality of reports (Moher, Jones, & Lepage, 2001). Thus, researchers should adhere to
CONSORT guidelines (Schulz, Altman, & Moher, 2010) whenever possible.
There is also a need for increasing the transparency and clarity of nonrandomized con-
trolled trials. Thus, Des Jarlais, Lyles, and Crepaz (2004) formulated the transparent re-
porting of evaluations with nonrandomized designs (TREND) statement.
As music therapy and music-based interventions contain an added degree of complex-
ity, including choice of music and mode of delivery, Robb, Carpenter, and Burns (2010,
2011) formulated a set of guidelines specific for reporting effects concerning music-based
interventions. CONSORT and TREND guidelines, as well as recommendations from
Robb, Carpenter, and Burns (2010, 2011) are not exclusive to psychiatric music therapy
research and should be used whenever possible.
Application to psychiatric music therapy

There is a need for additional high quality research concerning how music therapy can
positively impact psychiatric patients. With an increased emphasis on neurology and
advances in the technology of neuroscience, systematic inquiry concerning how music
therapy affects psychiatric patients from a neurological perspective is a central item on
the research agenda. Partnering with neuroscientists and using technology to determine
how music therapy impacts a psychiatric patient’s neurological functioning may lead to
breakthroughs and more effective treatments. Additionally, as practitioner effectiveness
is influenced by relationship factors and the intervention used (Nathan, 2004), there is a
need to systematically investigate both these factors and how they may influence one an-
other. In today’s evidence-based era, providing both qualitative and quantitative research
is imperative in order to enable more psychiatric consumers to access high quality music
therapy services and understand mechanisms of change in music therapy interventions.
In a summary statement concerning future psychotherapy research, Westen (2006) advo-
cated for the following:
If researchers want clinicians to take their research seriously, they will need to take clinicians seri-
ously. That is, they will need to compare their treatments to treatments as practiced by experienced,
well-paid professionals in private practice, not to no treatment, waitlist controls, worst practice
labeled TAU (i.e., treatment by overworked, often undereducated therapists in underfunded set-
tings), or intent-to-fail conditions (e.g., “supportive” therapy with no theoretical goals carried out
by graduate students who know they are in the non-bona fide treatment condition; Wampold,
2001). They will also need to study patients who resemble patients treated in the community, using
the same exclusion criteria used by competent clinicians in private practice. At this point, if the
goal is to generalize to everyday practice, there is no excuse for continuing to exclude patients
from RCTs for mood, anxiety, eating, or substance use disorders for virtually anything other than
psychosis, mania, or closed head injury. Nor is there any excuse for comparing experimental treat-
ments to anything but what the best clinicians in private practice do.
We have learned enough about internal validity. Now let’s learn something about psychotherapy.
(p. 171.)

◆ Research is a time-consuming and difficult process, especially when studying psy-
chiatric consumers.
◆ There continues to be a lack of psychiatric music therapy studies that may hinder the
development of the profession.
◆ All types of research are important and the investigator’s compelling research ques-
tion should dictate the most appropriate and applicable research paradigm.
Box 12.3 Chapter 12 Main Ideas (continued)
◆ Due to the evidence-based practice movement and reimbursement procedures,

qualitative research is not as established a quantitative research.
◆ There are limitless potential future psychiatric music therapy research studies.
Readers are encouraged to pursue their own unique interests as enjoying the re-
search process may facilitate completion of a finished research product.
◆ Mixed-method designs allow investigators interested in both quantitative and qual-
itative methods to answer their research questions and triangulate data as each data
strand can be used to further interpret and understand the other strand.
◆ Theoretical frameworks are constructs that illustrate the phenomenon under em-
pirical investigation and are considered essential ingredients of research studies.
◆ Investigators should adhere to established reporting guidelines to provide readers
with sufficient detail for replication and expansion.
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1 How might active controls or psychological placebos be used in an attempt to tease out potential
unique effects of music therapy interventions?
2 What potential nonsignificant between-group quantitative differences might represent clinical
relevance?
3 How might it possible to “blind” participants or evaluators to condition and timing of assessment and
evaluation?
4 If conducting single-session treatment studies with acute care psychiatric inpatients, what are potential
advantages and disadvantages of pretests?
5 How might clinical circumstances and contextual parameters dictate research design, treatment meth-
ods, dose, and outcome assessment?
6 If a treatment is more effective than a control condition, is that enough evidence to warrant its use?
Why or why not? What might be considered enough evidence for administrators, patients, scholars,
and music therapists?
7 Is music the specific component—or mechanism of change—that makes music therapy effective? How
might researchers differentiate and dismantle potential effects of the practitioner, music, and therapy?
8 Will efficacy studies generalize to the general population? How can music therapists design efficacy
studies that are more representative of clinical practice? What types of data might music therapists
need to bring these studies to fruition?
9 Are effectiveness studies too general to influence evidence-based practice and the literature base? Why
or why not?
10 Should new interventions be based on contemporary clinical practice, research from related fields,
Delphi polls, or a combination of these components? What are advantages and disadvantages of basing
interventions on these methods and results?
11 Although research is often biased toward randomized controlled trials, how may this approach be
inappropriate for mental health research focused on patient-centered outcomes?
12 How might data from patients’ perspectives be used to enhance clinical services, educate administra-
tors, and design future studies?
Chapter 13
Evidence-based practice and decision

making in psychiatric music therapy
The Nation must have a more effective system to identify,

disseminate, and apply proven treatments or evidence-based
practices (EBPs) to mental health care. Systematic approaches to
bring scientific discovery to service providers, consumers, and
families must be emphasized.
(President’s New Freedom Commission, 2003, p. 72)
Introduction to evidence-based practice

Evidence-based practice (EBP) is the use of a combination of (a) the best research avail-
able, (b) clinical expertise, and (c) patient characteristics, culture, values, and preferences
to make informed clinical decisions that are patient-centered. These three areas are often
conceptualized via a Venn diagram with EBP being the area of overlap between the three
circles. Clinicians and researchers using this approach to healthcare conscientiously inte-
grate the best research evidence with clinical expertise and patient values (Rubin, 2008;
Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). In a related but more patient-
centric model of EBP, Haynes, Devereaux, and Guyatt (2002) did not compartmentalize
practitioner expertise into a separate component of EBP. Rather, the authors noted that
the practitioner merges her or his expertise with (a) the patient’s clinical state and circum-
stances, (b) the research evidence, and (c) the patient’s preferences and actions, and makes
decisions collaboratively with the patient. Thus, in this model, the practitioner is not a sep-
arate entity; instead, the practitioner carefully coalesces the three elements with her or his
expertise in a collaborative partnership with the patient. This model also places emphasis
on the patient’s clinical state and circumstances, thereby acknowledging the importance of
context in making informed healthcare decisions.
EBP “is an approach that enables clinicians to provide the highest quality of care in meet-
ing the multifaceted needs of their patients and families” (Melnyk & Fineout-Overholt,
2005, p. 3). Practitioners base their decision-making processes on interventions for which
researchers have systematically investigated and have consistently found supporting ev-
idence showing improved outcomes for consumers (Drake et al., 2001; Sackett, Straus,
Richardson, Rosenberg, & Haynes, 2000). Rubin (2008) noted that when clinicians are
INTRODUCTION TO EVIDENCE-BASED PRACTICE 267
deciding on a treatment, the use of EBP will “maximize the likelihood that their clients
will receive the most effective intervention” (p. 7). To do so, Rubin noted that practitioners
will use and integrate
(a) the most rigorous scientific evidence available, (b) practitioner expertise, (c) client attributes,
values, preferences, and circumstances, (d) assessing for each case whether the chosen intervention
is achieving the desired outcome, and (e) if the intervention is not achieving the desired outcome,
repeating the process of choosing and evaluating alternative interventions. (p. 7)
EBP should not be conceptualized as a “cookbook”-type approach but it can enable

healthcare providers to impart the highest quality of care (Melnyk & Fineout-Overholt,
2005). Indeed, EBP is flexible in that it attempts to account for diverse clients, circum-
stances, and evolving literature bases. In the absence of relevant literature in the research
base, Shlonsky and Gibbs (2004) noted that the practitioner’s expertise and client’s val-
ues and expectations may be weighted more heavily to make informed clinical decisions.
However, when there is overwhelming empirical support for a particular intervention,
this aspect will be weighted more heavily than the practitioner’s expertise and the client’s
values and expectations (Dobson & Dobson, 2009).
EBP was derived from evidence-based medicine (EBM), which sought to assess the
quality of evidence relevant to the risks and benefits of treatment or lack thereof (Elstein,
2004). Although it may seem that the term EBP has become trendy and overused in con-
temporary clinical practice, the main ideas of EBP are not new (Rubin, 2008) and can be
traced to the beginning of Western medical care with Hippocrates, the Hippocratic oath,
and Florence Nightingale (Hayes, 2005).
Practitioners and researchers developed EBM in an attempt to better provide quality
outcomes based upon existing research (Elstein, 2004; Sackett, Rosenberg, Gray, Haynes,
& Richardson, 1996). EBM founders noted that the judicious use of the best evidence
available is paramount to make informed clinical decisions concerning the care of indi-
viduals. Moreover, EBM instigators articulated the importance of critical thinking, noting
practitioners should not rely merely on statements from medical experts (Sackett, Rosen-
berg, Gray, Haynes, & Richardson, 1996). The term “evidence-based” was first used in
1990 (Eddy, 1990, 2005) while the term EBM first appeared in the medical literature in
1992 (Guyatt et al., 1992). David Eddy, who applied mathematics to practitioner decision
making, was the first to use EBM as a term (Arzin & Goldman, 2005). British epidemiolo-
gist Dr. Archie Cochrane is considered to have founded the evidence-based movement
(Melnyk & Fineout-Overholt, 2005) and is often referred to as the “godfather of evidence-
based medicine” (Arzin & Goldman, 2005, p. 70). Cochrane was an avid supporter of the
randomized controlled clinical trial (RCT). In fact, Cochrane was such an advocate for
using research to improve healthcare that he challenged the public to pay only for care that
had empirical support demonstrating its effectiveness (Enkin, 1992).
EBP has drawn increased interest due to financial constraints and the desire to pro-
vide the highest quality of care possible in a timely and efficient manner (Dobson & Dob-
son, 2009). Healthcare practitioners have a moral (Hancock & Easen, 2004) and fiduciary
268 Evidence-based practice and decision making
responsibility (Roberts & Yeager, 2004) to amass the knowledge concerning the available
literature and apply critical thinking skills to create treatment plans and make informed
recommendations and clinical decisions. Due to heightened accountability stressed in the
healthcare system of the United States (and other countries), increased emphases on eth-
ics and compassionate patient-centered care, financial constraints, and readily available
information on the Internet, there is pressure for practitioners to use EBP (Rubin, 2008).
Melnyk (1999) noted that in the future, third-party payers might provide reimbursement
only for healthcare services whose effectiveness is supported by scientific evidence. If her
prediction is correct, it is vital that music therapists understand EBP and how to critically
assess and use the scientific literature to support their interventions.
Integrating a mental health recovery perspective into clinical decision making and EBP,
Frese, Stanley, Kress, and Vogel-Scibilia (2001) argued that the mental health consumer
should have more influence in decision making as she or he recovers and regains deci-
sional capacity. However, some members of the consumer community have argued that
refusing mental health treatment is a patient’s right and can represent a rational decision
even if that patient is acutely ill (Bellack, 2006). Other authors have suggested that the issue
is not necessarily a black-and-white question, in which patients or clinicians are correct or
wrong. Rather, parties may have differing perspectives based upon their values (Fischer,
Shumway, & Owen, 2002; Shumway et al., 2003). Specific to recovery in severe mental
illness, authors have advocated that EBP incorporates many aspects of the patient’s pref-
erences, including consumer education, shared decision making, consumer intervention
and outcome preferences, choice, autonomy, self-management of the illness, independent
living, social and vocational lives, and quality of life (Torrey, Rapp, Van Tosh, McNabb, &
Ralph, 2005).
Evidence-based practice and music therapy

Many music therapy practitioners and researchers use the term evidence-based. However,
there are relatively few scholarly publications in the music therapy literature base that are
specific to EBP. In a publication concerning music therapy and EBP, Edwards (2005) high-
lighted the fundamental need for music therapists—as well as other types of creative arts
therapists—to present evidence. Edwards wrote articulately concerning approaches to EBP
and types of evidence. Else and Wheeler (2010) published a paper including an overview
of EBP and analyzed systematic reviews concerning music therapy and autism and de-
mentia. They noted the disparities in some music therapy evidence. Recognizing the need
to conceptualize evidence-based music therapy practice in an objective and multifaceted
approach, Abrams (2010) used four epistemological perspectives to develop a framework
concerning evidence-based music therapy practice. Kern (2010) applied EBP and decision
making to music therapy in early childhood. While these articles did not specifically ad-
dress psychiatric music therapy, they are well written and thought-provoking; readers are
encouraged to consult these informative papers for a comprehensive understanding of
EBP and how to apply it to contemporary music therapy practice.
Levels of evidence 269
Levels of evidence
Determining what exactly constitutes EBP can be a time-consuming and complicated pro-
cess. However, this process often begins with the categorization of single studies based
on the research design of each individual study. Concerning the categorization of single
research studies, clinicians and researchers typically conceptualize levels of research evi-
dence as hierarchical. Studies with the strongest levels of evidence are typically at the top
of a pyramid (systematic reviews and meta-analyses) while studies representing weaker
levels of evidence are at the bottom of the pyramid (descriptive, qualitative, and case stud-
ies). As noted by Stevens (2005), there are a plethora of hierarchies and taxonomies of
evidence (e.g., Guyatt & Rennie, 2002; Harris et al., 2001; Levant, 2005; Melnyk & Fineout-
Overholt, 2005; Rubin, 2008). Melnyk and Fineout-Overholt (2005) proposed the hier-
archy depicted in Table 13.1 to appraise evidence from a single study. Moreover, there are
currently numerous protocols, some of which overlap, for the evaluation and categoriza-
tion of individual research reports. These hierarchies differentiate levels of evidence based
on the research paradigm and design of each single study. Readers should note that these
hierarchies do not rate one type of research study as superior than another, provide qual-
ity indicators, or provide a synthesis of results. Rather, researchers and clinicians can use
levels of evidence to show a natural progression of research from a single descriptive or
qualitative study (i.e., the most basic level) to meta-analysis (based upon a systematic re-
view) consisting of only randomized controlled trials (i.e., the most complex level). Levels
of evidence do not evaluate nor synthesize the cumulative literature base for a given clin-
ical population as they are specific to a single study. Readers are encouraged to critically
appraise the quality of each study. Although researchers may have used a randomized
controlled design, it does not necessarily indicate the study has high external validity. The
study could potentially have a weak design, flaws in the method or analysis, or a weak the-
oretical framework.
Table 13.1 Melnyk and Fineout-Overholt’s (2005) Rating System for the Hierarchy of Evidence
Level Description
Level I Evidence from a systematic review or meta-analysis of all relevant randomized
controlled trials (RCTs), or evidence-based clinical practice guidelines based on
systematic reviews of RCTs
Level II Evidence obtained from at least one well-designed randomized controlled trial
Level III Evidence obtained from well-designed controlled trials without randomization
Level IV Evidence from well-designed case-control and cohort studies
Level V Evidence from systematic reviews of descriptive and qualitative studies
Level VI Evidence from a single descriptive or qualitative study
Level VII Evidence from the opinion of authorities and/or reports of expert committees
Data from Bernadette Mazurek Melnyk and Ellen Fineout-Overholt, Making the case for evidence-based practice.
In Bernadette Mazurek Melnyk and Ellen Fineout-Overholt (Eds.), Evidence-based practice in nursing and healthcare:
A guide to best practice, p, 10, Philadelphia: Lippincott Williams & Williams, 2005.
Silverman (2010a) applied Melnyk and Fineout-Overholt (2005) levels of evidence to

the psychiatric music therapy literature base. He found a need for additional randomized
controlled trials (RCTs). As authors conducting systematic reviews and meta-analyses
often use only RCTs due to their potential for external validity, additional RCTs represent
imperative additions for the literature base.
Randomized controlled trials

RCTs are empirical investigations in which research participants are randomly assigned to
either a treatment group or a no-treatment/control group. RCTs are the primary method
for demonstrating a causal relation between treatment and change (Kazdin, 2007). Authors
have also referred to RCTs as the “psychotherapy technology model” as RCTs borrowed
methodology from successful medication efficacy and effectiveness research (Carroll &
Rounsaville, 1990; Wampold, 2001). Many researchers favor RCTs as this design repre-
sents the strongest method for measuring and determining cause-and-effects relation-
ships (Melnyk & Cole, 2005). In RCTs, it is common for the control group to receive some
sort of standard default treatment or for there to be more than two groups (i.e., treatment,
no-treatment, and default treatment groups). RCTs have traditionally had an important
role in EBP as early determination of EBP had simple criteria: two independent rand-
omized controlled trials supporting the treatment’s effectiveness (Chambless & Hollon,
1998). In contemporary practice, however, experts have noted that more stringent factors
are needed to justify EBP.
RCTs are typically considered the gold standard for demonstrating that a treatment is
effective (Leichsenring, Rabung, & Leibing, 2004; Tarrier & Wykes, 2004). RCTs are ap-
plicable not only in psychotherapy research but in other types of EBM, thus signifying
its scientific merit and acceptance. RCTs can provide empirical support for psychothera-
peutic techniques as they compare groups using a treatment group and a control condi-
tion, be it a waiting list, some type of control group, or a placebo group. These types of high
quality trials should lead to more accurate approximation of treatment effects, efficacy, and
approval of the results within the healthcare community (Moher et al., 1995).
As with all types of research, RCTs have inherent weaknesses. Various authors have
identified problems with RCTs. One of the major pitfalls of RCTs (and other published
articles, for that matter) is that, typically, only effective and significant trials are published.
Noneffective trials are rarely published and can thus artificially inflate effect sizes in meta-
analyses. Another weakness of RCTs is that they are typically outcome-based; that is, re-
sults indicate only if there was a between-group difference—they do not address how or
why this difference occurred. These are different and often separate research questions
necessitating a theory-based research approach to identify mediators (Kazdin, 2007). A
mediator is a “construct that shows important statistical relations between an interven-
tion and outcome, but may not explain the precise process through which changes comes
about” (Kazdin, 2007, p. 3). Edwards (2012) wrote eloquently that RCTs can “provide vital
evidence of symptom reduction and behavioral change” (p. 375). Edwards noted, however,
Systematic reviews 271
that RCTs did not include information about how to develop or deliver services and that,
in RCTs, healthcare participants’ opinions were typically ignored.
Additionally, Reed (2006) noted that an overreliance on controlled research may actu-
ally limit the development of cutting-edge treatments that may not have been tested in
large controlled trials but demonstrate strong individual outcomes. A further problem is
that samples in RCTs are often vigilantly screened in an attempt to eliminate potential con-
founding factors. Thus, participants in RCTs may not necessarily represent people in the
community who typically have multiple problems (Beck & Weishaar, 2011) or comorbid
diagnoses. However, Stirman, DeRubeis, Crits-Cristoph and Rothman (2005) found that
participants in RCTs tended to have similar characteristics to those in clinical settings. As
many patients in out- and inpatient settings have more than one diagnosis, other investi-
gators have been studying research participants who have multiple diagnoses to determine
potential generalizations (Brown et al., 2005; DeRubeis et al., 2005). Specific to the psychi-
atric recovery model, RCTs are considered tools for evaluating intervention efficacy but
not for evaluating recovery itself (Loveland, Randall, & Corrigan, 2005). In the current era
of heightened accountability, it is vital that researchers are inclusive and design RCTs rep-
resentative of contemporary clinical practice. Basing RCTs on descriptive studies of con-
temporary clinical practice and partnering with active clinicians may enable investigators
to design interventions that are realistic, practical, and accurately represent contemporary
healthcare trends.
Systematic reviews
As contemporary healthcare decisions should be partially based upon research evidence
from a number of studies, systematic reviews represent an essential component of clinical
practice. As numerous authors have placed systematic reviews at the top of their levels of
evidence, Bero and Jadad (1998) specifically noted systematic reviews represent the best
evidence when assessing intervention effects. Systematic reviews are tools that facilitate
the appraisal, summarization, and synthesis of large quantities of research in a rigorous
and unbiased manner. Systematic reviews do not necessarily include a meta-analysis as a
statistical component. These reviews are a central element to ensure healthcare decisions
and policies are both clinically and cost-effective. Researchers can also use systematic re-
views to identify gaps in the literature base. Researchers conducting systematic reviews
have established protocols for identifying, evaluating, interpreting, and coding data in
studies. These protocols are incorporated into the manuscript so replication is possible. As
a single research study should not be evaluated in isolation to arrive at a decision concern-
ing the status of the cumulative literature base, systematic reviews represent one of the
strongest forms of evidence (Glasziou, Vanderbroucke, & Chalmers, 2004). Additionally,
systematic reviews can be efficient tools for clinicians to make informed clinical decisions
when they are attempting to appraise the evidence base as it requires far less time for clini-
cians to evaluate and use a single systematic review than coalesce multiple RCTs and other
research studies. Scholars have noted that these reviews should also include unpublished
studies in an attempt to reduce publication bias (Anderson & Beck, 2003; Egger, Smith,
& Sterne, 2001). Moreover, the quality of studies within systematic reviews is essential.
Results of systematic reviews are confounded if the primary research literature is of poor
quality (Gilbody & Petticrew, 1999). Thus, only the highest quality studies should be used
in systematic reviews. Ideally, the literature used in systematic reviews should include
RCTs whenever possible.
Meta-analyses
Meta-analyses are specific statistical strategies for combining results of multiple quantita-
tive studies into a single effect size. Although people often use the terms systematic review
and meta-analysis interchangeably, a meta-analysis is an optional statistical component of
a systematic review. Meta-analyses must be based upon systematic reviews to collect quan-
titative data for analysis from the studies that meet inclusion criteria. Thus, a systematic
review does not have to include a meta-analysis but a meta-analysis requires a systematic
review. In an attempt to synthesize results from inconsistent, incongruent, and underpow-
ered psychotherapy effectiveness research studies, Smith and Glass (1977) were some of
the first investigators to use a meta-analysis.
The Cochrane collaboration (<www.cochrane.org>), developed in the early 1990s in
the United Kingdom, provides systematic reviews—and often meta-analyses—concerning
evidence of health interventions. Cochrane reviews provide the “highest levels of evidence
ever achieved on the efficacy of preventative, therapeutic and rehabilitative regimens”
(Sackett & Rosenberg, 1995, p. 632). Studies used in Cochrane reviews are typically RCTs.
Psychiatric music therapy systematic reviews

and meta-analyses
In 2003, Silverman published a meta-analysis concerning the effects of music and music
therapy on the symptoms of psychosis. Overall, results were positive, effect size (d) = +0.71.
However, there were no significant differences between live and recorded music nor were
there differences between structured music therapy interventions and passive music lis-
tening. Based on these results, there is a need to differentiate live music therapy from pas-
sive listening to recorded music. Silverman also found that non-classical music was more
effective than classical music, potentially supporting the need for music therapy students
to receive education and gain clinical competence in non-classical music.
Gold, Heldal, Dahle, and Wigram (2005) conducted a systematic review and meta-
analysis concerning the effects of music therapy for schizophrenia and schizophrenia-like
illnesses. In this study, the authors used four RCTs with a total of 266 research participants.
This Cochrane review was updated in 2012 (Mossler, Chen, Heldal, & Gold, 2012) and
included eight studies and 483 participants. The authors concluded that when combined
with standard care, music therapy can help improve global state, mental state, and social
functioning.
Psychiatric music therapy systematic reviews and meta-analyses 273
In 2008, Maratos, Gold, Wang, and Crawford published a Cochrane review concerning
the effects of music therapy on depression. The authors compared music therapy with
standard care to standard care alone for people with depression. The authors also com-
pared music therapy with other psychological or pharmacological therapies. As this study
was a Cochrane review, only RCTs met inclusion criteria. The authors found five studies
(237 research participants) that met inclusion criteria and noted variations between inter-
ventions and populations but did not conduct a meta-analysis. The authors noted that in
four studies, participants randomly assigned to the music therapy condition had greater
reduction in depressive symptoms than participants assigned to standard care conditions.
The authors also noted low dropout rates from the music therapy conditions, suggesting
people with depression may accept music therapy. The authors highlighted the need for
additional high quality studies concerning effects of music therapy on depression.
Jung and Newton (2009) conducted a Cochrane review of non–medication-based
psychotherapeutic and other interventions for schizophrenia, psychosis, and bipolar
disorder. The authors identified 28 interventions during their systematic search and cat-
egorized them into four categories based on the Joanna Briggs Institute grades of rec-
ommendation: (a) strong support that merits application; (b) moderate support that
warrants consideration of application, (c) not supported; and (d) data that are deemed
inconclusive. Of the 28 interventions studied, four had strong support while five had
moderate support. Music therapy was one of four interventions that the authors graded as
having strong support (Jung & Newton, 2009). Other nonpharmacological interventions
graded as having strong support included assertive community treatment for people with
severe mental disorders, crisis intervention for people with severe mental illnesses, and
psychoeducation for schizophrenia. As music therapy was included as an intervention
meriting strong support along with assertive community treatment and psychoeduca-
tion—both established evidence-based treatments—the results warrant application and
promotion. Moreover, as Jung and Newton’s study was published in 2009, the authors
used the Gold, Heldal, Dahle, and Wigram (2005) Cochrane review that contained data
from only four studies. However, the Gold et al. (2005) Cochrane review was updated in
2012 and included eight studies with 483 participants (Mossler et al., 2012). Thus, while
Jung and Newton (2009) recommended music therapy for psychiatric patients based on
an older review comprised of less data, there is additional evidence suggesting its clinical
implementation.
Currently, there is a systematic review—but not a meta-analysis—concerning music
therapy and substance abuse (Mays, Clark, & Gordon, 2008). In this paper, the authors
compared types of music therapy in the literature base and evaluated the evidence that
music therapy improves outcomes of patients who have addictions. The authors identi-
fied 14 studies that were descriptions of music therapy and five music therapy studies.
Although the authors found no consensus in the literature concerning outcome data and
concluded there was a lack of quantitative evidence-based literature to support music
therapy for addiction treatment, there have since been a number of studies with this clini-
cal population (Baker, Gleadhill, & Dingle, 2007; Dingle, Gleadhill, & Baker, 2008; Ross
et al., 2008; Silverman, 2009, 2010d, 2011a, 2011b, 2012) that might potentially change
the authors’ conclusions if they updated their study (see Table 12.2 in Chapter 12). Addi-
tionally, the authors did not include the music therapy study in which Cevasco, Kennedy,
and Generally (2005) investigated women in long-term addiction treatment. The authors
of the systematic review also noted, “Some residential addiction programs apply music
therapy without a music therapist” (p. 52). From the authors’ conclusions, it seems that
additional coordinated efforts concerning high quality music therapy research—as well as
music therapy advocacy, education, and licensure—are warranted.
Other research paradigms in evidence-based practice

Evidence-based public health also involves the use of non-RCTs (Norcross, Beutler, & Le-
vant, 2006; Victoria, Habicht, & Bryce, 2004). As all types of scientific evidence are relevant
to making informed clinical decisions in EBP, Powers (2005) noted that it is necessary for
clinicians to acquire the ability to appreciate qualitative research as viable evidence. Unfor-
tunately, due to the emphasis on replicable outcome measures and the research hierarchies
traditionally used within EBP, many people have misinterpreted EBP as favoring quantita-
tive research. Concerning this issue, the current author agrees with Rubin (2008). Rubin
noted “that more than one research hierarchy is implicit in the EBP process” and that “for
some questions . . . I’d put qualitative studies at the top of a research hierarchy and experi-
ments at the bottom” (p. 41). Thus, “different research hierarchies are needed for different
types of EBP questions” (Rubin, 2008, p. 56). In the same spirit, Pearson (2002) wrote,
“Best practice should reflect the whole range of evidence available—both quantitative and
qualitative” (p. 21). Fawcett and colleagues (2001) noted evidence should extend beyond
empirical research bases to include personal, ethical, and aesthetic theories.
While experts have noted that evidence derived from systematic reviews and meta-
analyses of RCTs represents the strongest evidence, other factors can influence clinical
decisions. Sometimes RCTs do not exist—or are not practical or ethical (Victoria, Habicht,
& Bryce, 2004)—and, in these cases, practitioners must use other forms of evidence to
make their decisions regarding patient care. Thus, clinicians can also use qualitative stud-
ies, evidence-based theories, patient values and preferences, evidence from opinion lead-
ers, evidence from the patient’s history and assessment, and available healthcare resources
to make comprehensive informed clinical decisions (Melnyk & Fineout-Overholt, 2005).
Pearson (2002) noted the relevance of qualitative research in the process of EBP as it uses
patients’ voices. Other researchers have argued that the healthcare evidence base would be
broadened with the inclusion of qualitative research (Black, 1994; McPherson, 1994; Ong,
1993; Popay & Williams, 1998). Specifically, Barbour (2000) advocated that qualitative
inquiry demonstrates how research addresses questions relevant to practice. By providing
contextualized explanations, qualitative research is better suited to provide in-depth ac-
counts of patient experiences and the contexts in which these experiences occur (Powers,
2005) through the lens of the participant. While quantitative research typically provides
answers concerning if an intervention was superior to a control or comparison, qualitative
Selected psychiatric music therapy research using non-RCT paradigms 275
research can explain unintended consequences and benefits, formulate future research
questions, and may even be “theoretically generalizable” (Barbour, 2000, p. 158).
While there may be an unfortunate tendency for academics and clinicians to consult
only the scientific outcome-based quantitative literature to justify using music therapy for
adult psychiatric patients, a component of EBP is patient values and preferences. Moreo-
ver, experts in psychosocial treatment of patients with mental disorders have noted that
psychiatric patients’ perceptions of treatment should be considered valid. These views are
imperative as various authors have noted that patients with severe mental illnesses are ca-
pable of meaningfully contributing to the development and refinement of various mental
health services (Dickey, 2005; Kitcher, 2001; Leff, 2005; National Association of State Men-
tal Health Program Directors, 1989). Moreover, in a comprehensive report concerning
patient-centered care for people with serious mental illnesses, the authors noted patients
should be active participants in the design and revision of treatment and recovery plans
(Green et al., 2014), which is congruent with EBP and the philosophy of incorporating
patients’ values and perspectives into treatment programs.
Selected psychiatric music therapy research using

non-RCT paradigms
Heaney (1992) published a study in which adult psychiatric inpatients (N = 27) evaluated
the therapies they received. Participants rated music therapy as more pleasurable than art
or recreation therapy. Participants also rated the three evaluated activity therapies (music
therapy, art, and recreation therapy) as significantly more pleasurable than individual psy-
chotherapy, being in a new environment, group psychotherapy, or medication.
Using descriptive methods to compare educational and therapeutic programming in
a study with 73 adult psychiatric inpatients, Silverman (2006) found that patients rated
music therapy as significantly more helpful than other programming. Additionally, 57%
of respondents indicated that music therapy was their favorite class or therapy. After ana-
lyzing data by demographic factors, Silverman found that patients with only one psychi-
atric admission perceived their programming as more effective than patients with multiple
psychiatric admissions. Additionally, participants who identified themselves as minorities
perceived programming to be more effective than participants who identified themselves
as nonminorities.
In a small-scale study, Silverman (2010c) provided five different commonly used group-
based music therapy sessions on an inpatient unit for patients with severe mental illnesses.
To obtain qualitative data, the researcher conducted a brief individual interview with each
participant after the sessions. Analyses of participant interviews indicated that partici-
pants (a) were able to articulate what they had done in the group music therapy interven-
tion, (b) were able to explain the purpose and general group objective of the session, and
(c) supported the use of music therapy on the unit.
Noting that other non-RCT research methods can be sensitive to patients’ perspectives,
Ansdell and Meehan (2010) conducted a unique study in which they analyzed data from
19 adult patients with chronic mental health problems who had completed at least ten in-
dividual improvisation music therapy sessions. The researchers used interpretive phenom-
enological analysis with data collected during semi-structured interviews. Through the
music therapy process, the participants were able to re-establish music as a coping skill in
their home environments. The researchers identified nine themes in the interview data: (a)
benefit from music therapy is broader than symptomatic change, (b) music therapy often
involves reconnecting with a previous relationship to music, (c) music therapy elicits and
works with patients’ “music-health-illness narrative,” (d) in music therapy the qualities of
the “musical” and “therapeutic” dimensions are often experienced as a unity, (e) aspects
of the musical process in music therapy are experienced as distinctive, (f) the therapist’s
role is experienced as an equal “musical companion,” (g) music therapy is experienced as
distinctive in relation to other therapies, (h) music therapy compensates for or alleviates
the experience of illness, and (i) a key benefit of music therapy is its ability to mobilize
“music’s hope.”
Thus, there are non-RCT studies that support the use of music therapy for psychiatric
consumers and represent a valuable component of the literature base that should not
be discounted when seeking evidence to use in clinical decision making. To holistically
understand the process and effects of psychiatric music therapy, various research para-
digms are necessary. Perhaps psychiatric music therapy researchers will use more mixed-
method designs in the future to provide data with external validity and that adequately
depicts patients’ experiences in psychiatric music therapy treatment.
Applying the five steps of evidence-based practice

to psychiatric music therapy
Melnyk and Fineout-Overholt (2005) identified five steps in applying EBP (p. 9). These
steps, with descriptions and applications to psychiatric music therapy, are depicted in
Table 13.2.
Differentiating evidence-based practice terminology

Clinicians and researchers have frequently misused and confused the terms evidence-
based treatment (EBT) and EBP. EBTs are specific interventions that have been repeatedly
proven to be effective via numerous rigorous well-controlled and randomized research
trials. Typically, EBTs have a number of high quality systematic investigations and meta-
analyses that show statistically significant results for specific problems. EBP, however, is
more of a philosophical approach in which a person uses a decision-making process that
integrates the best available research, expert opinion, and individual client characteris-
tics. Thus, an EBT is a specific treatment or intervention while EBP is a philosophical ap-
proach to treatment guided by the collection, interpretation, and integration of research.
Additionally, EBP differs from the term “research use” in that EBP takes the practitioner’s
expertise and patient values and preferences into account whereas research use typically
relies upon results from a single study (Barnsteiner & Prevost, 2002).
Differentiating evidence-based practice terminology 277
Table 13.2 Five Steps of Evidence-Based Practice
Step Description Music Therapy (MT) Application

1. Ask the clinical question Use “PICO” format to ask Rather than ask: “Can MT help
questions patients with schizophrenia?”
• P: Patient population ask: “In patients diagnosed
• I: Intervention of interest with schizophrenia (the patient
• C: Comparison intervention population), how effective is MT
• O: Outcome (the intervention) versus standard
care (the comparison) in social
functioning (the outcome)?”
2. Collect the most relevant First use systematic reviews In searching for evidence
and best evidence or meta-analyses and concerning MT and schizophrenia,
evidence-based clinical use the systematic review and
practice guidelines (see meta-analysis by Mossler, Chen,
Table 1). Consult the Cochrane Heldal, and Gold (2012).
Database of Systematic
Reviews or journals using
relevant keywords in a
systematic search.
3. Critically appraise the Appraise the evidence Mossler, Chen, Heldal, and Gold
evidence by answering: How large (2012) conducted a systematic
were treatment effects? review and meta-analysis of
Did the research approach MT compared to treatment as
appropriately match the usual/standard care using eight
purpose of the study? Were randomized trials. Results indicated
results valid? Were participants participants who received MT
homogenous before randomly had better global state, mental
assigned to conditions? Will state, and social functioning than
results facilitate patient care? control participants. There are no
Does MT have risks or side known side effects from MT (Ulrich,
effects? Houtmans, & Gold, 2007).
4. Integrate all evidence Integrate best available Conduct an individualized MT
with one’s clinical expertise, research evidence with the assessment and determine if the
patient preferences, and other relevant information patient is interested in participating
values in making a practice concerning the patient, in MT treatment. Assess the
decision or change facility, assessment, patient’s values, preferences,
preferences, values, available contextual situation, and past
healthcare resources. experiences. Discuss potential
benefits and risks of MT and
other psychosocial treatments in a
collaborative manner with patient.
5. Evaluate the practice Did the intervention work as Has the patient’s social functioning
decision or change expected? improved? The music therapist
must measure patient change and
collect observable and measurable
data to determine if there were
treatment gains.
Six established evidence-based treatments

for psychiatric consumers
Researchers and clinicians have identified six EBTs for psychiatric consumers. These EBTs
are generally consistent with the illness management and recovery model and are admin-
istered in the context of a collaborative partnership (Bellack, 2006). Silverman (2010b)
briefly described these six treatments and applied them to contemporary music therapy
practice. Due to the strong evidence base supporting these interventions, it would seem
that applying music therapy to these treatments would be a fertile area for various re-
search paradigms and may warrant external funding to support the trials. Readers further
interested in evidence-based mental health practice are advised to read Drake, Merrens,
and Lynde (2005). As there is already strong empirical support for these interventions, it
would seem future psychiatric music therapists could implement music therapy into these
treatments. For example, in assertive community treatment, music therapists could visit
clients and also provide them with a music lesson as well as the typical duties that a non-
music therapist assertive community treatment team member may provide. This innova-
tive approach may engage the clients in treatment; the music could serve as a way to build
therapeutic rapport and working alliance and motivate them to participate. Table 13.3
provides a brief description of the six established EBTs for psychiatric consumers along
with applications to music therapy practice.
The future of evidence-based practice in psychiatric

music therapy
EBP is a complex process that requires critical thinking (Rubin, 2008). Despite positive
outcomes when EBP is applied, only 10% of psychiatric patients receive evidence-based
psychosocial practices (Drake et al., 2001). Additionally, 40% of clinical decisions are not
substantiated by evidence based from research (Gray, 2002). Practitioners who use EBP
cannot blindly accept or conform to what “authorities” tell them. Nor can EBP practition-
ers base clinical decisions solely upon tradition. Lopez (2005) noted that the profession of
music therapy is likely far from an evidence-based method and that music therapy clini-
cians and researchers must meet the rising demand for evidence-based psychotherapeutic
care (Nickel, Hillecke, Argstatter, & Bolay, 2005). Thus, it is essential for music therapy
academics and clinical training and internship directors to continue their strong tradition
of educating music therapy students to be avid consumers of research and imparting the
ability to critically analyze evidence in order to gain the ability to think critically, choose
alternatives, evaluate, and make informed clinical decisions concerning patient care. Per-
haps most importantly, EBP is similar to learning in that they are both lifelong processes. It
is essential for music therapists to regularly ask informed questions, critically engage in the
literature, understand cultural and contextual parameters, educate patients, and involve
patients in clinical decision-making processes. Accountability is—and will remain—a vital
component of healthcare. EBP has important repercussions and ramifications for mental
health practice, reimbursement, education and training, research, and policy (Norcross,
Table 13.3 Six Evidence-Based Treatments for Psychiatric Consumers
EBT Description Music therapy (MT) application

Assertive A time-unlimited intense approach for MT could be used during home visits
Community community mental health as a psychotherapeutic maintenance
Treatment (ACT) delivery designed as an intervention tool, to decrease stress, and to
to help with the large number of increase recreation, coping, and leisure
people living in the community skills. Music therapists could provide
due to deinstitutionalization. ACT music lessons and, while doing so,
works to prevent homelessness and assess the psychosocial progress of
hospitalizations. The primary emphasis psychiatric consumers and report back
of ACT is on home visits to the to the treatment team as a type of
consumer by various members of the maintenance treatment to promote illness
treatment team, thus enabling management and recovery. MT could also
treatment to take place in the be used as a type of diagnostic tool to
consumer’s home and environment assess reality orientation, memory, social
rather than relying on the functioning, and general mental status
generalization of information and during home visits.
skills learned in the hospital to the
community.
Integrated IDDT is a time-unlimited treatment Music therapists can help to identify
Dual-Disorder that resulted from dozens of studies situational risk factors (triggers) for
Treatment (IDDT) that began in the 1980s in an abusing substances, teach different
attempt to treat mental illness and associations with music that had formerly
substance abuse simultaneously in been listened to when using drugs and/
the same location. These programs or alcohol, increase self-awareness,
use continuous and aggressive implement behavioral methods to reduce
outreach components, often meeting cravings, diminish stress, identify and
consumers where they live and facilitate support groups, and determine
spending clinical time in the and implement healthy alternatives to
community. IDDT often includes using. These objective areas could be
motivation enhancement therapy, addressed using various MT interventions
cognitive-behavioral therapy, and (see Chapter 10).
support groups.
Supported The majority of psychiatric consumers Music therapists could complete the
Employment (SE) consider regular employment a central required training and acquire the
life goal. Employment can augment specific skills to become an employment
quality of life. SE is an individualized specialist. Music therapists could
treatment that helps consumers find, design and implement music-based SE
attain, and maintain competitive interventions. In MT sessions, psychiatric
jobs. In order to provide the greatest consumers can potentially learn and
amount of success for each consumer, practice numerous skills that will help
SE often uses coaches, development, them to be successful in an employment
retention, transportation, technology, setting, including reality orientation,
training, and supervision, depending sustained and selective attention,
on the unique functioning level of the sequencing, appropriate interpersonal
working consumer. Psychiatric relations, self-awareness, recognition of
consumers can choose how many others’ emotional states, goal setting,
hours they want to work to prevent problem-solving, as well as higher level
stress and enable the person to social skills of negotiation, compromise,
function at the highest level possible. and teamwork.
Table 13.3 (continued) Six Evidence-Based Treatments for Psychiatric Consumers
EBT Description Music therapy (MT) application

Illness Illness management and recovery is Use an educational approach to
Management a broad set of techniques designed to psychiatric MT to teach patients
and Recovery help individuals collaborate about their illnesses, coping skills, the
with professionals, reduce their importance of medication compliance,
susceptibility to the illness, and and relapse prevention. Various
effectively cope with symptoms. interventions could be used to meet
This model has also been referred these needs, including songwriting,
to as psychosocial rehabilitation, lyric analysis, improvisation, and
psychoeducation, or psychiatric recreational MT.
rehabilitation. Illness management
and recovery resulted from the belief
that psychiatric consumers can be
active participants in their own mental
health care and should be considered
personal experts in their recovery. It
includes psychoeducation, strategies
for addressing medication
nonadherence, relapse prevention
training, and coping skills training.
Family-Based Family psychoeducation involves Music therapists could provide group
Psychoeducation people with mental illness and their sessions to patients and their family
families coupled with mental health members to reduce stigma associated
professionals. The major goals of with mental illness. Family-based MT
family psychoeducation are to prevent interventions could include group music
relapse and promote the reintegration making, role-playing family improvisation,
of persons with mental illness back songwriting, lyric analysis, recreational
into the community at a higher level MT, and group-based music lessons and
of social and occupational functioning. ensemble participation.
This EBT also supports the well-being
of the family.
Medications Medications have shown to be a Music therapists can work with patients
benefit and researchers have to identify short- and long-term goals
documented that neglecting to take and relate how medication can enable
medications as prescribed is both patients to reach their goals. Music
common and can lead to relapse. The therapists might work with psychiatrists
successful use of medications and and pharmacologists using educational
psychopharmacotherapy is a complex approaches to teach patients about the
and ongoing process. It is important function of their medications.
to involve the consumer in the selection
of medication as it has been shown to
lead to better compliance and outcome.
Learning about the consumer’s unique
goals and aspirations and relating them
to the purposes of the medication can
increase compliance. It is vital that
consumers, their families, and physicians
collaborate to identify psychosocial
goals and to manage side effects, risks,
and benefits of medications.

◆ Evidence-based practice is a philosophy of care integrating the best research avail-
able, the patient’s values and preferences, and the practitioner’s expert opinions.
◆ Levels of evidence, based upon the research design, can be used to appraise the sta-
tus of a single study.
◆ Randomized controlled trials are often considered the gold standard for quantita-
tive research; they are empirical investigations in which research participants are
randomly assigned to either a treatment group or a no-treatment/control group.
◆ Systematic reviews are tools that facilitate the appraisal, summarization, and syn-
thesis of large quantities of research in a rigorous and unbiased manner. Systematic
reviews do not necessarily include a meta-analysis as a statistical component.
◆ A meta-analysis is quantitative method, based on a systematic review, for combin-
ing the results of multiple quantitative studies to determine overall effect sizes.
◆ Although there are a number of systematic reviews and meta-analyses in the psychi-
atric music therapy literature base, additional investigations are warranted.
◆ Quantitative inquiry is not the sole model for improving the status of music ther-
apy as an evidence-based practice; patients’ values and preferences are also integral
components.
◆ There are five steps that guide EBP: (a) Ask the clinical question; (b) collect the
most relevant and best evidence; (c) critically appraise the evidence; (d) integrate all
evidence with one’s clinical expertise, patient preferences, and values in making a
practice decision or change; (e) evaluate the decision or change.
◆ Evidence-based treatments are specific treatments that have a strong supporting
research base. There are six established evidence-based treatments for adult psychi-
atric patients that music therapists can implement in their clinical practice.
Beutler, & Levant, 2006) and music therapists need to possess an adequate understanding
of EBP and its jargon to effectively communicate treatment benefits and advocate for con-
tinued implementation of music therapy services.
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1 What are potential areas for music therapy exploration that RCTs cannot systematically measure?
2 When initiating a research line, why might it be beneficial to start at a lower level of evidence?
3 Why might music therapy be considered a patient-centric and evidence-based practice for adult psychi-
atric consumers? Conversely, why might music therapy not be considered an evidence-based practice
for psychiatric consumers?
4 What are creative avenues for psychiatric music therapy clinicians to stay current with research litera-
ture aside from reading music therapy journals?
5 Task: Read a non-music therapy research paper concerning an effective psychosocial treatment for adult
psychiatric consumers and incorporate music therapy into this intervention.
6 How much evidence, and in what format, would you need to use a new pharmacological treatment?
How much evidence, and in what format, would you need to use a new psychosocial treatment?
Chapter 14
Future treatments for psychiatric

consumers:
Advances, models, and the potential relevance
of psychiatric music therapy
He who has hope has everything.

– Arabian proverb
Introduction
The President’s New Freedom Commission on Mental Health (2003) has a lofty yet appro-
priate vision concerning the future of psychiatric care:
We envision a future when everyone with a mental illness will recover, a future where mental illness
can be prevented or cured, a future when mental illnesses are detected early, and a future when eve-
ryone with a mental illness at any stage of life has access to effective treatment and supports essential
for living, working, learning, and participating fully in the community. (p. 1)
Predicting the future of psychiatric music therapy is a complicated and daunting task.
Despite advances in technology, psychological treatments, and psychopharmacology, it
is likely that persons will continue to require inpatient and outpatient care to success-
fully manage and recover from their mental illnesses. Patients will thus still need educa-
tion concerning how to manage their illnesses, reasons to adhere to their medications as
prescribed, the supportive and protective environment of inpatient hospitalizations, and
booster sessions as outpatients to continue monitoring their illnesses and ensuing recov-
eries. The purpose of this chapter is to describe issues and areas of future concentration
with psychiatric consumers, contemporary advances in healthcare, and potential intersec-
tions between psychiatric music therapy and these continued developments. These topics
are informed by patients, clinicians, students, non-music therapy scientific literature, and
contemporary trends in mental health care.
Manuals
Clinicians and researchers can use treatment manuals to describe a detailed set of tech-
niques to treat a specific disorder. Treatment manuals date back to the trend of medical-
izing psychotherapy in the 1960s (Lang & Lasovik, 1963) but, due to the emphasis on
288 FUTURE TREATMENTS IN PSYCHIATRIC MUSIC THERAPY
evidence-based practice, have received considerable attention recently. Manuals are docu-
ments created by researchers in an attempt to facilitate the evaluation, dissemination, and
implementation of evidence-based treatments (Addis, 1997). Therapists using manuals
have considerable flexibility in how they implement treatments, although typical treat-
ment courses are outlined to facilitate the training of the therapists (Chambless & Crits-
Christoph, 2006). Treatment manuals can serve as “beacons” by helping therapists “remain
on course” (Addis & Cardemil, 2006, p. 136). It is important to understand that treatment
is not based on the manual; rather, the manual is considered a supportive and important
component of the treatment (Addis & Cardemil, 2006). In manualized treatments, therap-
ists use the same techniques in a consistent sequence for a relatively standardized number
of treatment sessions. Manuals emphasize what the therapist is expected to do within the
parameters of a therapeutic relationship (Dobson & Dobson, 2009). The structured ap-
proach results in time-limited treatments that are highly focused and idiosyncratic to a
specific disorder.
In a clinical context, the usefulness of manuals lies in their ability to help therapists
examine their adherence to techniques and strategies that facilitate the hypothesized ac-
tive core components or mechanisms of therapeutic change. In research contexts, man-
uals enhance internal validity by describing interventions in such detail that treatment
integrity and fidelity tests can be conducted to document whether or not the independent
variable was successfully implemented in experimental and comparative research para-
digms (Addis & Cardemil, 2006). Manuals can also facilitate the training and supervision
of therapists in specific approaches to psychotherapy (Lambert & Ogles, 2004). The use
of treatment manuals has resulted in more standardized treatments, which in turn has al-
lowed for the more precise study of a treatment (Luborsky & DeRubeis, 1984). In manuals,
researchers and clinicians provide theoretical active-change ingredients so that therapists
will be able to determine whether these components occur in the treatment (Addis &
Cardemil, 2006).
Many scientists perceive manuals as a positive development (Bright, Baker, & Neimeyer,
1999). Manuals are based on theoretical conceptualizations within a particular client
group with certain diagnostic characteristics. Researchers have noted that manualized
interventions can have a high success probability (Dobson & Dobson, 2009) as the man-
uals break down the complicated process of therapy into manageable components (Addis
& Cardemil, 2006). An advantage of manual-based treatments is that they are typically
based from controlled clinical trials. Practitioners’ clinical judgments may be intuitive and
subjective whereas manuals rely on empirically derived evidence (Wilson, 2011).
There are numerous debates concerning the use of manuals. Critics have appropriately
argued against a “one-size-fits-all” approach to therapy. Duncan and Miller (2006) wrote,
“Therapists who do therapy by the book develop better relationships with their manuals
than with clients and seem to lose the ability to respond creatively” (p. 145). Many people
have disapproved of the standardization of manuals claiming manuals limit practitioners’
ability to make clinical judgments (Davison & Lazarus, 1995) and do not make adequate
use of therapists’ skill, creativity, intuition, or clinical judgment (Addis & Cardemil, 2006).
Manuals 289
Another controversy concerning the use of manuals is that they are typically based on a
specific disorder. In manualized treatments, patients with similar diagnoses are treated
with similar manual-based approaches (Wilson, 2011). Due to the disorder-driven con-
text, manuals are forced to rely upon the Diagnostic and Statistical Manual or the Inter-
national Classification of Diseases to determine inclusion and exclusion criteria (Eifert,
Schulte, Zvolensky, Lejuez, & Lau, 1997). (A brief discussion of problems associated with
the DSM and the ICD is provided in Chapter 7.) Thus, if a patient is misdiagnosed, manu-
alized treatments may not result in a desirable therapeutic outcome.
Other critics of manuals have argued that the therapeutic relationship is compromised
in manualized treatments due to the overemphasis on therapeutic techniques (Fenster-
heim & Raw, 1996; Garfield, 1996) and lack of therapeutic flexibility. Addis and Cardemil
(2006) suggested that the word manual itself is inadequate and “mechanistic” (p. 138).
These scholars suggested that terms such as guide, framework, or outline might be more
appropriate by shifting the discussion from manuals to the treatments that manuals are
designed to describe. Moreover, in a book highlighting the importance of theories con-
cerning cognitive behavioral therapy (CBT), Craske (2010) noted that manualization may
unintentionally hinder psychotherapeutic progress:
Lack of CBT competency, even among self-described CBT clinicians, may be additionally attrib-
uted to the overemphasis on training in CBT procedures at the cost of training in CBT principles.
This imbalance may stem in part from the manualization of CBT interventions for various prob-
lems. Whereas manualization is a positive feature that facilities empirical evaluation of CBT and
enhances CBT dissemination, it may have inadvertently encouraged too much focus on procedure
over principle. (p. 4)
Debates concerning manuals will likely continue due to conflicts concerning territory,
decision making, professional identity, and access to funding and resources (Addis & Car-
demil, 2006).
Due to its heightened amount of structure and time-limited focus, cognitive behavioral
therapy tends to be more amenable to manualization than other psychotherapeutic ap-
proaches (Dumont, 2011). Although there are noncognitive behavioral manuals in ex-
istence (Klerman, Weissman, Rounsaville, & Chevron, 1984; Luborsky, 1984), Addis and
Krasnow (2000) found that psychodynamic clinicians had more negative attitudes toward
manuals than cognitive behavioral clinicians. These discrepancies are likely due to the
structured approach to cognitive behavioral therapy that is congruent with the concept of
manuals.
Conceptualizing manuals as a “cookbook” approach to therapy is inappropriate. In an
attempt to provide data concerning the use of manuals, various researchers have studied
manuals and found evidence to support their use. Therapist adherence to manual-based
treatment for the group treatment of depression was associated with greater improve-
ment in clinician-rated symptoms (Bright, Baker, & Neimeyer, 1999). Other researchers
found that the degree to which a therapist adhered to a manual was positively related
to patient treatment outcome (Luborsky, McLellan, Woody, O’Brien, & Auerbach, 1985).
Highly structured manualized approaches can result in better clinical outcomes than
individualized treatments for routine clinical problems (Kuyken, Fothergrill, Musa, &
Chadwick, 2005).
Manuals were not designed to replace sensitive, caring, flexible, and creative therapists.
Rather, manuals are theoretically informed guides that are designed to assist in the dis-
semination and implementation of evidence-based treatments by communicating con-
ceptual and structural boundaries of a given intervention (Addis & Cardemil, 2006). These
boundaries articulate a theory of therapeutic change and the factors underlying or main-
taining a patient’s problem or disorder (Addis & Cardemil, 2006). Kendall, Chu, Gifford,
Hayes, and Nauta (1998) noted therapists still must be competent, flexible, and creative to
effectively use manuals:
Perhaps it goes without saying that a manual requires implementation with good clinical skills. . . .
The rampant misunderstanding of treatment manuals, along with the overzealous assumptions about
the potency of manuals, combined to reaffirm the need to explicitly state that a manual operational-
izes the treatment but practitioners must be able to breathe life into a manual. (p. 197)
If music therapists aspire to be considered evidence-based practitioners in the future,

they will likely have to use manuals, scripts, and protocols, regardless of psychotherapeutic
orientation. Rolvsjord, Gold, and Stige (2005) noted that psychiatric music therapy man-
uals may result in a loss of therapeutic integrity. They skillfully argued that manuals defin-
ing therapeutic principles can be flexibly applied without using a fixed set of techniques,
procedures, or actions. In this informative paper, the researchers presented a rationale for
a music therapy manual for use in a randomized controlled study highlighting the descrip-
tions of the principles and underlying assumptions for resource-oriented music therapy.
Readers are urged to consult this enlightening paper in its entirety to understand the four
types of principles the authors used to describe the manualized music therapy treatment:
(a) unique and essential therapeutic principles, (b) essential but not unique therapeutic
principles, (c) acceptable but not necessary therapeutic principles, and (d) not acceptable
(proscribed) therapeutic principles. Also specific to music therapy, Hillecke, Nickel, and
Bolay (2005) noted that most clinicians used an eclectic mix of techniques and theories.
Thus the use of manuals for music therapy interventions for specific clinical populations
may standardize practice and enable music therapists to achieve more consistent and rep-
licable positive clinical results. Although music therapists may resist movement toward
manual-based treatments, other healthcare providers are moving toward this approach.
Music therapists should note that manualized approaches still respect the client’s individu-
ality and are flexible within a contextual framework.
A potential problem with using manuals in psychiatric music therapy is that manuals
assume treatment is one-to-one. As most psychiatric music therapists in the United States
work in group settings (Silverman, 2007; Thomas, 2007), there will likely be additional
layers of complexity resulting from group dynamics as well as further intricacy concern-
ing various music-based variables and their interactions with client preferences, values,
and characteristics. Due to the degree of structure and emphasis on collaborative problem
solving but not in-depth psychotherapy, group-based educational music therapy for illness
Quartered classification system and the dual-factor model of mental health 291
management and recovery (see Chapter 5) may be particularly amenable to manualiza-

tion. Future research comparing manualized music therapy treatment to nonmanualized
and group-based manualized treatments is warranted. Psychiatric music therapists inter-
ested in using manuals are advised to contact the corresponding author of the study in
which the manual was used.
Quartered classification system and the dual-factor model

of mental health
Traditionally, clinicians have made mental illness diagnoses based upon whether or not a
person met criteria for a mental disorder. In this model, mental health is conceptualized at
one end of a continuum and therefore indicates a lack of mental illness. Jahoda challenged
this absolute concept as early as 1958, writing “The absence of disease may constitute a
necessary, but not sufficient, criterion for mental health” (p. 15). Diener, Lucas, and Oishi
(2002) also believed absence of disease does not necessarily mean a person is mentally
healthy. Moreover, while an individual’s mental illness may have been treated and allevi-
ated, it does not necessarily guarantee mental health (Keyes, 2005; Suldo & Shaffer, 2008).
Recent scholars have therefore advocated for the dual-factor model of mental health. In
this model, clinicians evaluate not only pathology (i.e., an objective measure of symptoms)
but also subjective well-being. As symptoms of mental illness may not be intrinsically
distressing (Mansell, Carey, & Tai, 2013), subjective well-being represents an important
construct; a person may have a symptom but not necessarily be distressed by it. Thus, a
number of mental health scholars have categorized people into four groups (see Table 14.1)
according to levels of pathology and subjective well-being (Greenspoon & Saklofske, 2001;
Keyes & Lopez, 2002; Suldo & Shaffer, 2008).
The dual-factor model of mental health addresses potential discrepancies between path-
ology and subjective well-being. Mental health is conceptualized in a comprehensive man-
ner by integrating the absence of mental illness and high subjective well-being (Doll, 2008;
Greenspoon & Saklofske, 2001; Keyes, 2005; Keyes & Lopez, 2002; Suldo & Shaffer, 2008).
This model emphasizes positive prevention and maintains that incomplete mental health
may be an intermediate stage for people as they progress in their treatments. Thus, the de-
crease of symptoms is a first step in treatment (Wang, Zhang, & Wang, 2011). Clinicians
work to improve subjective well-being after symptom reduction in an attempt to facili-
tate holistic recovery and complete mental health and reduce recurrence. Additionally, in
Table 14.1 Dual-Factor Classification System
Factor Complete Mental Incomplete Mental Incomplete Mental Complete Mental

Health Health Illness Illness
Pathology Low Low High High
Subjective High Low High Low
well-being
order for the dual-factor model of mental health to gain support, researchers will need to
further define and study subjective well-being.
In the treatment of patients using the dual-factor model of mental health, psychiatric
music therapy clinicians cultivate positive factors such as subjective well-being (Weiss-
berg, Kumpfer, & Seligman, 2003; Weisz, Sandler, Durlak, & Anton, 2005). Reducing path-
ology will continue to be an important component, but clinicians should also be aware of
more subjective aspects of well-being. Thus, psychiatric music therapists can focus on leis-
ure skills, socialization, coping strategies, employment, and hobbies—all treatment com-
ponents consistent with the illness management and recovery approach. Teaching patients
functional music skills (e.g., guitar lessons) as leisure and recreational activities may be a
way to increase subjective well-being. Psychiatric music therapy researchers might design
studies based on the dual-factor model of mental health using dependent variables such as
happiness, life satisfaction, state anxiety, affect, and spirituality. Qualitative research para-
digms may provide insight into patient experiences of well-being during and following
music therapy.
Precision and personalized medicine based on molecular

biology
In 2011, the National Research Council of the National Academies (NRCNA) published
a report concerning precision medicine and the potential for new disease taxonomies
(NRCNA, 2011). The committee’s charge was based on new scientific advances in molecu-
lar biology. The NRCNA noted the importance of taxonomy and how molecular biology
could be used to improve taxonomy that could then be used to develop enhanced health
outcomes. With the advancement of data-intense molecular biology, innovations in infor-
mation technology, and healthcare changes, scientists could create a knowledge network
based on vast amounts of data. Patients would be able to contribute to and benefit from a
network stemming from advances in molecular biology. This knowledge network of dis-
ease would function to consolidate and integrate social, clinical, and behavioral data and
could serve to inform the new taxonomy and ultimately result in more individualized—
and thus improved—healthcare.
The proposed new taxonomy is similar to the concept of personalized medicine. The
President’s Council on Advisors on Science and Technology (PCAST, 2008) defined per-
sonalized medicine as
the tailoring of medical treatment to the individual characteristics of each patient…to classify indi-
viduals into subpopulations that differ in their susceptibility to a particular disease or their response
to a specific treatment. Preventative or therapeutic interventions can then be concentrated on those
who will benefit, sparing expense and side effects for those who will not. (p. 1)
Precision medicine is an analogous concept in which the medical treatment is tailored

to the patient’s individual characteristics (NRCNA, 2011). The goal of precision medicine
is to identify a subset of patients who share a common biological disease and who may be
likely to benefit from pharmacotherapy or other interventions. From a pharmacological
Rational drug design 293
perspective, a precision medicine approach would identify patients who would benefit
from certain treatments, minimize side effects, increase compliance, and likely result in
lower costs (NRCNA, 2011).
Although lack of infrastructure and resources will likely delay the development of a new
taxonomy and personalized medicine, advances in molecular biology will inevitably lead
to considerable revisions of the International Classification of Diseases and the Diagnostic
and Statistical Manual. If scientists and clinicians are able to predict a predisposition to
mental illness, music therapists could be more proactive in their approach to the treatment
of mental disorders. Music therapists could treat patients in outpatient facilities and focus
on prevention, prodromal symptoms and self-awareness, wellness, illness management,
identifying symptoms, dealing with stress, and proactive coping and social skills training.
These proactive treatment areas are congruent with the educational music therapy for ill-
ness management and recovery approach.
Due to the recent emphasis concerning biomarkers coupled with newer tools to meas-
ure brain activity and subtle changes in brain matter, scientists and diagnosticians may no
longer have to rely upon overt symptoms to diagnose mental health consumers. Noting that
reconceptualizing schizophrenia may yield hope for prevention and cure, Insel (2010) sug-
gested approaching schizophrenia as a neurodevelopmental disorder with psychosis as a
late—and potentially preventable—stage of the illness. Insel described four stages (risk, pro-
drome, psychosis, and chronic disability) of schizophrenia along with features, diagnoses,
disabilities, and interventions specific to each stage. Although this model was developed
specific to schizophrenia, parts of the model—specifically the psychosocial interventions
designed to target various stages of the disorder—may generalize to other mental disorders.
Rational drug design

Researchers working with computer-based tools have accelerated the process for devel-
oping pharmacological interventions (Mandal, Moudgil, & Mandal, 2009). Data con-
cerning gene expression—analyzed using bioinformatics tools—will likely improve the
process for developing rationally designed drugs. Rational drug design, in which drugs
are constructed based from knowledge of a biological target (Madsen, Krogsgaard-Larsen,
& Liljefors, 2002), will likely decrease the amount of time it takes to develop medications,
reduce toxic side effects, and improve strategies for combination therapies (Mandal et al.,
2009). This type of precision medicine couples clinical-pathological indexes with state-
of-the-art molecular profiling resulting in pharmacological interventions specifically and
precisely tailored to each patient (Mirnezami, Nicholson, & Darzi, 2012).
Genetic analyses will likely resolve inaccurate psychiatric diagnoses that will ideally
lead to better prognosis (Evans, Muir, Blackwood, & Porteous, 2001). Due to advances
in physical maps, annotated sequence, sequence variation, and comparative genom-
ics resulting from the Human Genome Project, scientists will be better able to under-
stand psychiatric genetics and how to develop enhanced pharmacological—and perhaps
even psychosocial—treatments. Genetics can help explain the considerable variation
concerning differential drug response in psychiatric patients (Evans, Muir, Blackwood,

& Porteous, 2001) and may eventually result in pharmacological treatments that are not
accompanied by side effects. A reduction or negation of side effects may increase psycho-
tropic medication and psychosocial treatment compliance. When genetic discoveries lead
to biological innovations, scientists will likely be able to apply rational drug design to op-
timize prescription medications.
Another recent advancement is the National Institute of Mental Health’s Research Do-
main Criteria (RDoC) initiative (Insel & Cuthbert, 2009). The goal of the RDoC is to use
neurobiological underpinnings to characterize psychiatric disorders and identify sources
of homogeneity and heterogeneity within and across individual disorders and interrelated
disorders (Vaidyanathan, Nelson, & Patrick, 2012). The RDoC is related to the converging
biomarker approach and is based upon neurophysiological indicators. The converging bio-
marker approach uses different biological indicators across multiple psychiatric disorders
as referents for neurobiological-based diagnostic phenotypes (Vaidyanathan et al., 2012).
These advances may change how researchers and clinicians classify mental disorders. Ra-
ther than relying on patient self-report, biologists may someday be able to define and diag-
nose psychopathology. Diagnosticians might someday use neural circuitry, rather than
overt observable behaviors and subjective patient reports, to identify mental disorders
(Insel & Cuthbert, 2009). Kihlstrom (2002) recommended that psychology move from a
model based on questionnaires and rating scales to a model based upon objective labora-
tory tests concerning psychopathology.
There are skeptics concerning these types of reductionist approaches as related to psy-
chiatry. Among the dubious, Rose (1995) contended that these approaches do not entail
adequate emphasis on social and cultural influences as they relate to psychiatric con-
sumers. Perhaps music therapists’ roles within these endeavors will be to provide the psy-
chosocial treatment necessary to teach patients how to manage their illnesses based on
social and cultural factors that may be overlooked in reductionist and more biologically
oriented approaches.
Advances in science may not only influence psychopharmacology, but also may influ-
ence psychosocial treatments and how researchers study the effectiveness of these inter-
ventions. If scientists are able to determine biological targets to create specific medications,
perhaps someday they might also identify beneficial components of psychosocial inter-
ventions based on targeted genetic and neurological data. From a psychological perspec-
tive, scientists could biologically identify patients who may be more amenable to certain
treatment approaches. In fact, scientists are already using brain imaging in the form of
functional magnetic resonance imaging to identify people with social anxiety disorder
who may be able to benefit from cognitive behavioral therapy (Doehrmann et al., 2013).
Perhaps scientists may be able to identify ideal candidates for cognitive behavioral music
therapy or psychodynamic music therapy based on neurological structures and biological
responses to music and certain types of psychosocial interventions.
Despite advances in neurology and pharmacology, it is unlikely that inpatient hospital-
izations will be wholly eliminated in the future (Wilson, 2005). While rational drug design
Future psychiatric music therapy models, relevance, and concerns 295
may have the potential to change the landscape of psychopharmacology, it is limited in

that it relies solely upon medications. Rational drug design will not be able to help psy-
chiatric consumers if they are noncompliant with their medications or unmotivated for
improvement. Moreover, rational drug design will never possess the ability to teach func-
tional living skills. Thus, psychiatric music therapists will likely still play a crucial role in
the treatment of patients with mental disorders during the development of their individu-
alized medications. Music therapy clinicians will still work to teach patients how, when,
and why to adhere to their medication regimens, as well as educate them about what the
medications actually do and how they work. Psychiatric music therapists can work to as-
certain patients’ goals and relate how pharmacological and psychosocial treatment adher-
ence can enable patients to reach their goals. Teaching patients functional life skills and
coping skills to manage negative affective states will likely remain an essential task that
psychiatric music therapists—but not medications—can facilitate using an educational
approach to music therapy for illness management and recovery.
Future psychiatric music therapy models, relevance,

and concerns
Community-based psychiatric music therapy
Authors have written about community music therapy programs (Justice & Crowe, 2007;
Pavlicevic & Ansdell, 2004; Soshensky, 2011; Turry, 2005), in which consumers partici-
pate in a music-centered approach as community members in wider social constructs.
Stige (2003) noted that in community music therapy, the practitioner does not work in
the traditional way. Rather, the music therapist tries to involve whole communities and
engage different parts and participants within the system to interact. Soshensky (2011)
noted music therapy in these settings might provide “opportunities for positive psycho-
social outcomes” (p. 23). Due to their social and interactive nature, community music
therapy programs may reduce isolation and can meet sociological and cultural needs in
patients with mental disorders (Justice & Crowe, 2007). As outpatient care seems to be an
increasingly important aspect of contemporary music therapy psychiatric treatment (Cas-
sity, 2007; Silverman, 2012), perhaps a community-based psychiatric music therapy model
will provide the structure and flexibility to engage and retain consumers in a positive, mo-
tivating, success-oriented, and dynamic outpatient treatment. Thus, specific to a psychi-
atric context, music therapists working in outpatient settings would facilitate songwriting,
active music making, music performances, music recording, and making music videos to
meet therapeutic outcomes. Psychiatric music therapists using these interventions to meet
objectives should be cognizant of the importance of measureable behavioral objectives
so that treatment team members are aware of the non-music benefits provided by these
highly music-based interventions.
Resource-oriented music therapy (Rolvsjord, 2004) is similar to community music ther-
apy in that both are based upon active music making in communities. However, resource-
oriented music therapy is based on patients’ strengths and resources and thus supports
patients’ potential for psychiatric recovery. Community music therapy and resource-
oriented music therapy programs may be attractive for both psychiatric consumers and
case managers and may result in greater attendance and participation than traditional
talk-based forms of outpatient psychoeducation and psychosocial treatment. These
community-based models could also serve as booster sessions to augment treatment ef-
fects and monitor outpatients’ therapeutic progress and global functioning.
The psychosocial clubhouse model is designed to empower consumers (referred to as
“members”) as consumers and staff work collaboratively to run daily operations such as
preparing meals, staffing the reception desk, and developing and distributing a newsletter
(Warner, 2009). Lipe and colleagues (2012) studied the effectiveness of an interactive arts
intervention program in a community mental health setting. The authors used a clubhouse
model to increase arts experiences for members while decreasing stress, increasing cop-
ing abilities, and increasing self-care skills. Participants in the arts intervention program
had positive responses; clinicians might use these types of inclusive models to provide
music therapy and other creative arts-based services to outpatients with mental disorders.
Clubhouse models are a fertile area for systematic investigation from a variety of research
paradigms.
Eyre (2011) published an innovative study concerning the “therapeutic chorale” for
persons with chronic mental disorders. Participants were 16 adult psychiatric outpatients
with a variety of psychiatric disorders typical of chronic outpatient care. Eyre noted that
membership and participation in the choir may promote creative opportunities for per-
sonal growth and establishing regular social habits that may result in other benefits. Due
to the success of this program, it seems outpatient performance groups facilitated by music
therapists may be a unique and motivating technique to engage people with mental dis-
orders in continued psychosocial treatment. Based on positive results of this pioneering
study, future research using all paradigms is warranted.
Wellness model
Psychiatric music therapy models have changed and evolved over time. In 1974, Hadsell
noted that as consumers typically receive music therapy during inpatient psychiatric hos-
pitalizations, there is little to do in the way of prevention. However, there is a dire need to
treat all aspects of the person, not solely the mental illness in an intervention-only model.
Psychiatric patients deserve attention to holistic aspects of health, including mental, phys-
ical, emotional, spiritual, intellectual, chemical, dietary, and social health in intervention
and prevention models. In order to achieve well-being for the whole person (Green et al.,
2014), all aspects of the person should receive treatment. As psychiatric patients may be at
greater risk for cardiovascular disease, diabetes, other health-related problems, these top-
ics could be addressed via educational music therapy for illness management and recovery.
Perhaps incorporating a holistic and multifaceted wellness approach to psychiatric music
therapy may help to provide patients with the skills they need to cope and avoid relapse,
prevent hospitalizations, and facilitate recovery. In future practice, perhaps music therapy
Areas of concern in psychiatric music therapy 297
can be used to educate people about healthy lifestyles emphasizing wellness and health,
rather than lack of health. Wellness music therapy may also be applicable in outpatient
settings for psychiatric consumers to prevent relapse and increase help-seeking behaviors.
Aspects of a wellness model of psychiatric music therapy are also congruent with re-
commendations concerning patient-centered outcomes for people with mental disorders.
Jonas and colleagues (2011) noted the need for mental as well as physical health outcomes
for psychiatric consumers, stressing comorbid medical illnesses including diabetes, HIV,
tobacco cessation, nutrition, caloric intake, physical and mental exercise, sleep apnea, and
cardiovascular disease. Educating psychiatric patients about psychosocial stressors that
may trigger negative affective states and cognitions, and treating disorders as early as pos-
sible within the course of the illness, are paramount to reduce recidivism and the duration
of inpatient hospitalization. Moreover, co-facilitating music therapy sessions with psychi-
atric consumers in recovery would use a peer-based model that may facilitate engage-
ment, motivation, and augment outcome. Thus, psychiatric music therapists can use a
more holistic approach to health and wellness, including physical, spiritual, social, and not
focus solely on mental health. These treatment areas are congruent with an educational
approach to psychiatric music therapy focusing on illness management and recovery in
which practitioners treat all aspects of the patient and do not limit treatment to overt psy-
chiatric symptoms.
Neurological model
Thaut (2005) noted that, based on research concerning neurobiological foundations of
music in the brain, music therapy theory and clinical practice are evolving from a so-
cial science model to a neuroscience model. Thus, brain functioning—including how the
brain relates to music perception and cognition—may play an important role in eventually
understanding how and why music therapy can be effective. Thaut (2005) noted that neu-
roscientific advances may enable music therapy to be a central treatment modality rather
than an adjunct or additive treatment modality. Examining the role of brain function-
ing and the brain’s response to music and music therapy may result in exciting treatment
methods individually tailored to a person’s unique neurology. Indeed, advances in cog-
nitive neuroscience and neuropsychiatry may unlock key components of mental illness
concerning pharmacological as well as psychosocial treatments. As a nonpharmacological
intervention, psychiatric music therapy can play a unique role in helping people with men-
tal disorders. Advances in neuroscience will likely augment music therapy researchers’ and
clinicians’ ability to design and implement effective interventions.
Areas of concern in psychiatric music therapy

In an attempt to identify psychiatric music therapists’ potential areas of concern for the
future of psychiatric music therapy, Silverman (2012) conducted a descriptive study with
board-certified psychiatric music therapists in the United States. The researcher e-mailed
a brief survey to all members of the American Music Therapy Association listed in the
“mental health” section of the 2009 Member Sourcebook. Fifty-three respondents partici-
pated for a response rate of 18.4%. Different areas of concern were noted, which differed
with theoretical orientation. Outpatient care was the highest concern, followed by health-
care reform, brief treatment, and evidence-based practice. Participants rated job security
as the lowest area of concern. Participants who identified themselves as having cognitive
behavioral, eclectic, and humanistic orientations rated the importance of qualitative re-
search and quantitative research equally. Research, training, employment, and licensure/
credentials/reimbursement were the main areas of concern. These areas could potentially
be topics for continuing music therapy education and research.
Importance of MT-BC and licensure

For psychiatric music therapy to thrive in the United States, it is vital to support the Ameri-
can Music Therapy Association (AMTA; <www.musictherapy.org>) and the Certification
Board for Music Therapists (CBMT; <www.cbmt.org>). Membership in the AMTA, which
includes numerous benefits, is imperative to maintain a strong and thriving professional
association. State regulatory issues, jointly coordinated by AMTA and CBMT with grass-
roots state task forces, are also of utmost importance. Licensure will only help increase
access to services for psychiatric patients and protect patients from other people who may
use music but lack the formal academic and clinical training a board-certified music thera-
pist has attained. Although non-music therapists using music to help people are without
doubt well intentioned, their services may be contraindicated for psychiatric patients due
to lack of knowledge, training, competencies, and ability to document patient progress.
Thus, the AMTA and the CBMT are continually working to advocate for the profession
and attempting to make music therapy licensure in all 50 states a reality, thus protecting
consumers and facilitating access to resources. To help advocate for the field, psychiatric
music therapists might consider serving on various committees within their facilities to
increase recognition of the profession and their clinical work with the ultimate goal of
increasing services within the facility. By regularly providing in-services in high-turnover
settings, psychiatric music therapists can continue to advocate for the profession and make
it clear that they are integral contributing members of the treatment milieu.
Compassion fatigue, burnout, and self-care

Psychiatric music therapists may be at heightened risk for therapist fatigue and burnout.
Working with psychiatric patients can be highly rewarding but also challenging, especially
for music therapists with less clinical experience. In order to be effective, genuine, authen-
tic, and competent therapists, it is vital that psychiatric music therapists are physically,
emotionally, socially, psychologically, intellectually, and spiritually healthy. As psychiatric
music therapists may serve as models of health for their patients, it is crucial for them to
“practice what they preach.” Although psychiatric music therapists might not be coping
with depression in the same manner that a person with major depressive disorder might,
they will likely have to cope with negative feelings, sadness, and stressors on a daily basis.
Compassion fatigue, burnout, and self-care 299
Psychiatric music therapists can use these coping, preventive, and holistic wellness experi-
ences to self-disclose to patients that they too encounter daily problems in living and need
to use coping skills, social supports, and resources to help solve, manage, and prioritize
personal problems and conflicts. Although psychiatric music therapists may not be tak-
ing prescribed psychotropic medications, they can share their adherence with nonpsy-
chotropic prescribed medications with patients to model therapeutic compliance. Finally,
psychiatric music therapists may have enhanced positive (or negative) associations with
certain music due to helping effects related to their clinical work. A music therapist might
experience a “helping high” whenever she or he hears a certain song due to a positive pa-
tient experience. Thus, psychiatric music therapists should be aware of their own biases
and associations—both positive and negative—with music and how these associations
may affect therapeutic work with future clients.
In a descriptive study of factors related to occupational stress and burnout among music
therapists, Oppenheim (1987) found many music therapists attributed negative occupa-
tional aspects of their job to insufficient pay, lack of respect and support from administra-
tors, and performing duties outside the music therapy field. At the conclusion of the paper,
Oppenheim suggested methods for preventing occupational burnout: creating a peer sup-
port system, termination of unhealthy relationships, professional counseling, daily exer-
cise, hobbies, continued learning, and plenty of sleep. In an innovative study concerning
personality, burnout, and longevity, Vega (2010) found the highest degree earned was sig-
nificantly related to career longevity as a music therapist. Youngshin (2012) noted that
various factors in work settings can increase stress levels in music therapists, which may
lead to burnout. Clements-Cortes (2013) defined burnout and identified social, work, and
individual factors that may lead to burnout and manifestations of burnout. In her inform-
ative paper, she also suggested potential interventions to reduce burnout in music therap-
ists. These types of studies and papers are valuable; future research is warranted in order to
increase the size of the music therapy workforce.
The list in Box 14.1 includes recommendations for self-care to decrease compassion
fatigue and burnout.
Box 14.1 Self-Care Recommendations

◆ Use vacation time for vacations—do not integrate music therapy clinical, adminis-
trative, or academic work with time for rest and relaxation.
◆ Do not work from home; work only from the clinical site.
◆ Seek and use supervision.
◆ Remember that developing into an effective clinician requires time and can be
enhanced through professional development, supervision, and extensive reading
(Mansell, Carey, & Tai, 2013).
◆ Supervise and mentor students, interns, and music therapists with less clinical
experience.
Box 14.1 Self-Care Recommendations (continued)
◆ Attend and participate in music therapy conferences.

◆ Use coping skills and implement them into a regular schedule (e.g., exercise, pleas-
ure reading, music making, ensemble participation).
◆ Join and participate in a performing arts group.
◆ Enroll in music lessons on a principal or secondary instrument.
◆ Prioritize work responsibilities and be highly organized at work to proactively pre-
vent stress over what items and issues one can control.
◆ Meditate and practice deep breathing techniques in work environments.
◆ Emphasize positive experiences and mentally reiterate these experiences when ar-
riving to and leaving work settings each day.
◆ Keep an e-mail file folder with positive e-mails and feedback from colleagues, fam-
ily, and friends. Read through the e-mails in this file when overwhelmed.
Predicting the future of psychiatric music therapy

Predicting the future of psychiatric music therapy is a daunting task. Although Cassity’s
(2007) Delphi poll was innovative and informative, future Delphi polls are warranted to
better position music therapists at the forefront of psychiatric treatment. Psychiatric music
therapists have adapted to changes in treatment models in the past and will likely continue
to adapt as advances are made in neuroscience, psychopharmacology, and psychosocial
interventions for people with mental disorders. However, while medications may suppress
mental illness symptoms, they do not enhance functional recovery. As it seems unlikely

◆ Although not without controversy, manuals are flexible ways to standardize and
control a therapeutic intervention.
◆ Researchers are developing innovative techniques to tailor and create unique phar-
macological interventions to people’s specific genetic information.
◆ Innovative models of music therapy, including community, resource, wellness, and
neurological models, are evolving and shaping new directors for contemporary
treatment.
◆ Psychiatric music therapists may be at heighted risk for burnout and should proac-
tively manage stressors to maintain their holistic health.
◆ In order to thrive as a profession, it is vital that music therapists support their profes-
sional organizations.
that mental illnesses will disappear altogether via a “magic bullet-type cure,” music thera-
pists will remain a vital component of psychosocial treatment for this often marginalized,
disadvantaged, and disenfranchised population.
Our fear of psychosis or disruptive behavior may keep us from seeing the heroic struggle that people
with this disorder face just to survive amidst the internal chaos and panic that is part of this chronic
illness. Our expectations of these citizens are low: they should stay out of jail, on their medication
and not distress their families, friends and fellow citizens. They deserve better. (Insel, 2010, p. 192)
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1 If medications become completely effective and without any negative side effects, what might the role of
psychiatric music therapy be in both in- and outpatient care?
2 What are advantages and disadvantages of manualized music therapy treatments?
3 How might working with psychiatric consumers—as opposed to other clinical populations—be difficult
from cognitive and affective perspectives?
4 What self-care strategies do you find effective? Are these strategies used in social or individual contexts?
How might you adapt and use them in various environments (e.g., vocational, social, individual)?
5 How might technology play a role to increase access to music therapy services for mental health
consumers?
6 Of the six established evidence-based treatments for adult psychiatric consumers (see Chapter 13), what
two evidence-based treatments might be most realistically applied to music therapy in future clinical
practice? Why?
Glossary
A
Acceptance (mechanism of change): When the client feels unconditional positive re-
gard, specifically from the therapist, she or he is more likely to change.
Access hypothesis: Thoughts are not unconscious or unavailable and thinking is know-
able. Clients receiving the proper training can become aware of their cognitions and if
these thoughts are useful or maladaptive.
Acculturation: The process of adjustment between a person’s own culture and a host
culture.
Action (stage of change): A person is behaving in a different manner that is congruent
with change.
Action theory: Describing how the intervention affects selected mediators.
Active control: Sometimes referred to as a psychological placebo, a treatment (such
as supportive befriending) provided to the control group instead of providing the
control group with no additional psychosocial treatment (or treatment as usual/
standard care).
Acute psychiatric care: Often referred to as crisis stabilization, typically brief inpatient
care where the hospitalization is from three to seven days. These inpatient units are
typically locked for safety concerns.
Additive treatment: A treatment that does not exist alone but is used in conjunction
with other treatments.
Adherence/compliance: Taking medication as prescribed (from a pharmacological
perspective) and implementing and using psychotherapeutic techniques learned in
therapy (from a psychotherapeutic perspective). Can also refer to attending and par-
ticipating in psychotherapeutic and psychoeducational programming.
Altruism (mechanism of change): Change may result when the client is aware that she
or he is the recipient of the therapist’s (or another group member’s) care. Change can
also result from the sense of providing the care to others and feeling that one is helping
others.
American Music Therapy Association: The professional organization of music therap-
ists in the United States. <http://www.musictherapy.org>
Anti-psychiatry movement: Psychiatric treatments in the form of medications are over-
used and cause more damage than benefit to the patients.
306 GLOSSARY
Attentional control theory: Anxiety hinders the well-documented limited capacity of

working memory, thus creating an imbalance between the two attentional systems that
the central executive controls.
Atypical medications: Newer classes of medications that are chemically different than
older medications. These medications ideally have the same (or enhanced) therapeutic
benefits with fewer and less severe side effects.
B
Booster sessions: Periodically conducted additional psychotherapeutic or psychoedu-
cational sessions to refresh and enhance knowledge and application of skills learned
during treatment.
Brief treatment/therapy: Treatment in which a person receives a relatively brief dose,
often between two and ten sessions.
C
Catastrophize: A cognitive distortion in which a person perceives a situation as worse
than it actually is.
Certification Board for Music Therapists: The organization responsible for the MT-BC
(music therapist, board certified) credential in the United States. <http: //www.cbmt.org>
Change hypothesis: With an understanding of cognitive strategies and resulting emo-
tional and behavioral reactions, people can learn to change the way they respond to
events.
Cochrane collaboration and reviews: Often systematic reviews and meta-analyses pro-
viding the highest levels of evidence concerning the efficacy of preventive, therapeutic,
and rehabilitative regimens. Studies used in Cochrane reviews are typically random-
ized controlled trials. The Cochrane collaboration: <http: //www.cochrane.org>
Cognitive behavioral therapy: A therapeutic philosophy based on altering patients’
thoughts, behaviors, and emotions as these three constructs are integrated and symbi-
otic in humans. A therapist using this treatment works to replace maladaptive cogni-
tions, behaviors, and emotions with ones that are adaptive and functional.
Cognitive disability: Impaired intellectual functioning.
Community music therapy: Consumers participate in a music-centered approach as
community members in wider social constructs.
Comorbidity: Having multiple diagnoses.
Complementary therapy: A therapy used in conjunction with other treatments but not
considered a stand-alone treatment.
Conceptual theory: Describing how the mediators are causally related to the outcome.
Contemplation (stage of change): A person perceives some benefits to change, but costs
associated with change outweigh the benefits.
GLOSSARY 307
Continuum model of music and therapy within music therapy: A model depicting
the fluid ratio between music and therapy both within and between music therapy
sessions.
Converging biomarker approach: Uses different biological indicators across multiple
psychiatric disorders as referents for neurobiological-based diagnostic phenotypes.
Coping: Cognitive and behavioral efforts to manage stressful events.
Coping style: A trait characteristic describing how a person might typically deal with a
variety of distressing circumstances.
Crisis stabilization unit: Sometimes referred to as acute psychiatric care, a short-term
unit in which the primary duty is to keep the patient safe from harming herself/himself
and prevent the patient from harming others. Typically, these units are locked for safety
concerns.
Cross addiction: One addiction is suspended in lieu of another addiction. Can include
non-substance addictions such as gambling, eating, sex, and relationships.
Current procedural terminology code (CPT Code): A five-digit code that is used to
describe healthcare services of various providers.
D
Dephi poll: A systematic and interactive research technique used to forecast fu-
ture events in which participants are experts and are allowed to view other experts’
predictions.
Detoxification unit: A short-term inpatient medical unit specifically for people who are
withdrawing from substance misuse. Typically more focused on the medical aspect of
withdrawal and thus provides minimal psychosocial treatments designed to treat the
addiction.
Direct therapy: A treatment in which a therapist gives advice and helps to provide the
patient with a clear action plan. Typically a briefer treatment in which the patient learns
to manage the illness.
Discovery-oriented research: A research process wherein an investigator may not have
a clear intervention or is uncertain about the psychotherapeutic phenomena and pro-
cesses. Uses all research methodologies and paradigms and does not test established
treatments or hypotheses but rather attempts to understand treatment process dynam-
ics in the hopes of identifying variables and treatment strategies to test.
Dodo Bird Verdict: A controversial verdict that diverse talk-based therapies have rela-
tively equivalent effects.
Dual-factor model of mental health: Clinicians evaluate not only pathology (i.e., an
objective measure of symptoms) but also subjective well-being.
Dysphoric symptoms: Symptoms including appetite and sleep difficulties, depressed
mood, and social withdrawal.
308 GLOSSARY
E
Educational music therapy for illness management and recovery: A music therapy
approach focused on improving the patient’s knowledge and illness management skills
to facilitate psychiatric recovery.
Effectiveness research: Research taking place in realistic settings, often clinically based.
Efficacy research: Research taking place in ideal laboratory situations, often not clinic-
ally based.
Electroconvulsive therapy: A specific treatment sending electrical currents through a
person’s brain in an attempt to relieve psychiatric symptoms.
Elegant therapy: Therapy that is brief rather than long-term.
Empirical: Based upon observation, experience, or data—not theoretical. Capable of
being verified or disproved via scientific investigation.
Epistemological: A way of understanding. Sometimes referred to as theory of knowledge.
Evidence-based practice: A philosophy of care integrating the current research litera-
ture, the values and preferences of the patient, and the clinician’s expertise.
Evidence-based treatment: A specific and established treatment that has consistently
positive research results.
External validity: The generalizability of the results from a research study.
F
Fill-in-the-blank songwriting: A highly structured intervention in which the music
therapist (or client) selects a song and removes certain key words or lyrics. Patients
then add words to complete the lines.
Free composition songwriting: An intervention with minimal structure. Clients make
all decisions regarding rhythms, melodies, harmonies, dynamics, instrumentation, and
lyrics.
H
Health maintenance organization (HMO): An organization that provides health cover-
age with providers under contract.
Helping alliance: The therapeutic relationship between the therapist and client. Often
described as the degree of engagement with each other; may affect beneficial change
and treatment outcomes in the client.
I
Illness management: Often referred to as psychoeducation, a mutual process between a
psychiatric consumer and some type of educator attempting to increase the knowledge
and illness management skills of the consumer. A psychosocial technique designed to
teach patients about their illnesses and how to manage them.
GLOSSARY 309
Inpatient psychiatric unit: Typically a locked unit for people who are considered a dan-
ger to themselves or others.
In-service: A formal or informal presentation or training program designed to heighten
the knowledge of attendees concerning a specific topic.
Insight: A deep understanding of the self, a person, or thing.
Insight (mechanism of change): Clients tend to feel better when they have heightened
awareness of themselves and others. This awareness may help them have enhanced per-
spectives concerning their thoughts, feelings, and behaviors.
Integrated dual disorder treatment: A specific evidence-based treatment concurrently
integrating both the treatment and care of the psychiatric disorder and substance mis-
use disorder.
Integrative therapy: A treatment that does not exist alone but is used in conjunction
with other therapies.
Interaction (mechanism of change): Clients can improve when they are able to admit to
the therapist or peers within the group that they do indeed have a problem.
Internal validity: The adequacy of the research design.
L
Likert-type scale: A quantitative scale designed to efficiently measure a single construct.
Example: “Please rate your anxiety on a 1–9 scale, with 1 representing minimal anxiety
and 9 representing the highest anxiety.”
Lyric analysis intervention: An intervention in which the therapist plays a song and asks
clients questions about the song, music, and lyrics and how they may be able to relate
to the lyrics, situation, or characters depicted in the song.
Lyric replacement songwriting: An intervention in which the music therapist (or client)
selects a song (foundation song) and helps clients to change all or most of the lyrics.
Thus, music therapy recipients use their own words to rewrite the song lyrics but do
not alter the music.
M
Maintenance (stage of change): A person has been in the action stage of change for six or
more months, actively behaving and thinking in ways congruent with change.
Manual: A specific and detailed set of strategies that can be used to treat a disorder.
Mechanism of change: A specific factor that results in psychotherapeutic change.
Mediation hypothesis: The way people perceive situations can influence their behaviors
and feelings.
Mediator: A construct that shows important statistical relations between an interven-
tion and outcome, but may not necessarily explain the precise process through which
changes occurs.
310 GLOSSARY
Medical model of disability: Identifies disability as a defect in a bodily function or sys-

tem that resides in the individual.
Meta-analysis: A quantitative method for combining the results of multiple quantitative
studies to determine overall effect sizes.
Meta-synthesis: An integrative review of studies on a specific topic; can be qualitative.
Mixed-method designs: Allows researchers to use both quantitative and qualitative
methods to answer their research questions and triangulate data; each data set can be
used to further interpret and understand the other.
Modeling (mechanism of change): Purposeful observation of other people can help cli-
ents. Clients can model behaviors and affective states of both peers and therapists.
Moral model of disability: Identifies disability as a manifestation of flaws in character
and morality.
N
National Alliance on Mental Illness (NAMI): A grassroots mental health organization
based in the United States dedicated to building better lives for people with mental ill-
nesses. <http://www.nami.org>
National Institute of Mental Health: The largest scientific organization in the United
States dedicated to research focused on the understanding, treatment, and prevention
of mental disorders. <http://www.nimh.nih.gov>
Normalize: When a person recognizes that other people share her or his problem and
this person is not the sole person experiencing the biopsychosocial stressor.
Normalizing rationale: Emphasizes a lack of developed and effective coping strategies
can lead to social withdrawal and service disengagement.
O
Outpatient: A person in the community receiving treatment but who is not hospitalized
on an inpatient unit.
P
Parallel group study: A group-based study with two or more groups designed to assess
the effects of a specific independent variable on a dependent measure.
Pathogenic: Capable of producing or enhancing disease or illness.
Personalized medicine: The tailoring of medical treatment to the individual character-
istics of each patient.
Pharmacological treatments/interventions: Medications used to help alleviate pa-
tients’ symptoms.
Placebo: A harmless pill or procedure given to a research participant that is purposely
not designed to help the participant.
GLOSSARY 311
Polypharmacy: The simultaneous use of multiple medications by a single patient for one
or more conditions. Can also refer to additional medications used to treat side effects
that result from medication use.
Precision medicine: Based on the study of molecular structures, medical treatment is
tailored to the patient’s individual characteristics. May eventually reveal a new tax-
onomy for diseases.
Precontemplation (stage of change): A person does not perceive benefits to change and
therefore is unwilling to change and unwilling to consider change.
Preparation/determination (stage of change): A person perceives more benefits
to change than costs associated with the change, but has not actively changed any
behaviors.
Problem solving: Sometimes considered a stand-alone or independent treatment, a cog-
nitive process in which people attempt to find suitable solutions for problems.
Process oriented: Emphasizing the process (e.g., the nonmusical processes of problem
solving and decision making within therapeutic songwriting) of treatment rather than
the product of treatment.
Prodromal: The early detection and treatment of mental illness symptoms.
Product oriented: Emphasizing the final product or end result of the treatment (e.g., the
music composed during a therapeutic songwriting intervention) rather than the pro-
cess of the treatment.
Psychoeducation: Often referred to as illness management, the mutual process between
a psychiatric consumer and some type of educator attempting to increase the know-
ledge and illness management skills of the consumer. A psychosocial technique de-
signed to teach patients about their illnesses and how to manage them.
Psychological placebo: Sometimes referred to as an active control, a treatment (such as
supportive befriending) that is provided to the control group instead of providing the
control group with nothing.
Psychosocial clubhouse model: Designed to empower “members” as consumers and
staff work collaboratively to run daily operations such as preparing meals, staffing the
reception desk, and developing and distributing a newsletter.
Psychosocial treatment: A nonmedication-based treatment.
Q
Quantitative research methods: Research involving numbers and emphasizing ob-
jective measurements and analysis of data collected through polls, questionnaires, or
surveys.
Qualitative research methods: Research involving in-depth analysis of human behavior
and experiences typically focused on investigating how and why to better understand
a phenomenon.
312 GLOSSARY
R
Randomized controlled trials (RCTs): Empirical investigations in which research par-
ticipants are randomly assigned to either a treatment group or a no-treatment/control
group.
Rapport: The therapeutic relationship between the therapist and client. Often described
as the degree of engagement with each other; can affect therapeutic outcome.
Rational drug design: Medications are constructed based from knowledge of a biologi-
cal target.
Reality testing (mechanism of change): Change can be a result of clients experimenting
with new behaviors in the security of a therapy session, especially while receiving sup-
port and feedback from the therapist and peers.
Research Domain Criteria (RDoC) initiative: The use of neurobiological underpin-
nings to characterize psychiatric disorders and identify sources of homogeneity and
heterogeneity within and across individual disorders and interrelated disorders.
Recidivism: A psychiatric relapse typically involving worsening of symptoms that often
requires inpatient hospitalization.
Recovery: An attitude and philosophy that was founded upon the consumer movement
and the belief that psychiatric consumers have the potential to recover and have pro-
ductive and satisfying lives.
Referentialist theory: Meanings derived from music refer to the extramusical world of
concepts, actions, emotional states, and character.
Resource-oriented music therapy: Based on patients’ strengths and resources; supports
patients’ potential for psychiatric recovery.
S
Scripts: A detailed plan outlining the components of a music therapy session often used
to control independent variables.
Self-efficacy: A person’s belief in her or his ability to succeed in a specific situation.
Semantic differential scale: A quantitative scale designed to measure a single construct
using bipolar adjectives. Example: “Please rate your mood on a 1–9 scale, with 1 repre-
senting sad and 9 representing happy.”
Serious (or severe) mental illness (SMI): A major and enduring psychiatric disorder
such as schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive
disorder.
Side effects: Negative and undesirable effects resultant of medications. Can include con-
stipation, dry mouth, muscle rigidity, tremors, and blurred vision.
Social model of disability: Disability is socially constructed and reflects problems in
society, not in the person.
GLOSSARY 313
Stages of change: Often referred to as transtheoretical, explains professionally facilitated

and self-initiated change and typically focuses on a progression through five stages:
precontemplation, contemplation, preparation, action, and maintenance. Relapse is
sometimes referred to as a sixth stage of change.
Stigma: A set of negative and often unfair beliefs that a society or group of people have
about something. Can result in diminished help-seeking behaviors in psychiatric
consumers.
Experienced stigma: When a person has experienced stigma against herself or himself.
Perceived stigma: When a person perceives she or he is being stigmatized.
Self-stigma: A prejudice that people with mental illness turn against themselves.
Stress-vulnerability model: A popular model within illness management and recov-
ery literature highlighting that each person has unique psychological, physiological,
genetic, and social predispositions that affect her or his vulnerability to a psychotic
breakdown. Thus, the psychiatric disorder is conjectured to be affected by psychosocial
stressors as well as biological vulnerabilities.
Surreptitious prescribing: Knowingly concealing medications in food or drink.
Systematic review: A tool that facilitates the appraisal, summarization, and synthesis of
large quantities of research in a rigorous and unbiased manner. Does not necessarily
include a meta-analysis as a statistical component.
T
Tardive dyskinesia: A side effect causing uncontrollable grimacing and lip smacking.
Theoretical frameworks: Considered essential ingredients of research studies, sets of
related constructs that illustrate the phenomenon under empirical investigation.
Third-person to first-person dialogue: When a music therapist asks patients a question
about a character in a song, but a patient spontaneously responds with a self-statement
without prompting from the therapist.
Time-limited therapy: Conceptualizes problems as temporary and changeable and
provides focused treatment for a specific client-identified problem when only a small
number of sessions are possible or necessary.
Transdiagnostic theory: De-emphasizing a person’s specific psychiatric diagnosis and
instead focusing on the person’s psychosocial stressors and solutions to her or his
problems.
Transference (mechanism of change): From a nonpsychoanalytic or nonpsychodynamic
perspective, the emotional bond that forms between the client and therapist. Bonds can
also form between clients in group therapy sessions.
Transtheoretical: A theory than is not guided by a particular philosophical orientation
or theory.
314 GLOSSARY
Trephotaxis: The provision of the necessary conditions for the promotion of growth,
learning, and development.
Trigger: A person, place, thing, or idea that negatively impacts stress and precipitates a
negative response.
Twelve-step program: A popular set of guiding principles outlining a course of action
for recovery from various types of addiction and substance misuse.
U
Universalization/universality (mechanism of change): A client’s problems and issues
are not idiosyncratic or unique. Clients can improve when they become aware and ac-
knowledge that other people have similar or related problems and situations.
V
Ventilation (mechanism of change): Change can be a result of catharsis; self-expression
or displaying emotions in a context where a client can feel accepted.
Vicarious learning: A type of learning that occurs as a function of observing, retaining,
and replicating novel behavior executed by others within a social context.
Visual analog scale: A scale designed to measure a construct by indicating the measure
on a continuum.
W
Wellness: A state or condition of being in good health.
Working alliance: The therapeutic relationship between the therapist and client. Often
described as the degree of engagement with each other; can affect therapeutic outcome.
Name Index
A C
Abrams, B. 268 Calford, M.B. 242
Addis, M.E. 289 Caneva, P. 239
Ahern, L. 124 Caputi, P. 40
Ahluwalia, J.S. 224 Cardemil, E.V. 289
Albornoz, Y. 247 Carey, T.A. viii, 106, 122
Alford, B.A. 33 Carpenter, J.S. 256–7
Alshuler, I.M. 57 Carr, C. 85, 142, 239
Andresen, R. 40 Carroll, L. 26
Angst, J. 2 Cassity, J.E. 65, 144
Ansdell, G. 60, 195, 275–6 Cassity, M.D. 11, 33, 65, 144, 239, 300
Aranson, C.L.R. 63 Castillo-Perez, S. 239
Assmus, J. 242 Castle, D. 241
Castonguay, L.G. 105
B Ceccato, E. 239
Baker, F.A. 227, 247 Cevasco, A.M. 247, 274
Baranowski, T. 224 Chambless, D.L. 27
Barbour, R.S. 274 Chang, E.D. 93
Barbui, C. 20–1 Chapman, J.E. 29
Barker, P. 83 Chaput, J. 136
Bartrop, R. 242 Chase, K.M. 226–7
Bechdolf, A. 88–9 Chen, X.J. 60, 242, 277
Beck, A.T. 29 Choi, A. 239
Bednarz, L.F. 73 Chu, B. 290
Bellack, A.S. 40 Claridge, G. 20
Bergin, A.E. 25 Clark, D.L. 78, 248
Bero, L.A. 271 Clarkin, J.F. 126
Bertrams, A. 86 Cleary, M. 207
Beutler, L.E. 105 Clements-Cortes, A. 299
Bieschke, K.J. 225 Cline, C.A. 205
Binder, R.L. 241 Cochrane, A. 267
Bio, M. 246 Cohen, Y. 121
Birchwood, M. 90 Colom, F. 32, 37, 82, 91–2
Blader, J.C. 9, 129–30, 202 Comas-Diaz, L. 219
Blatt, S.J. 238 Cook, M. 239
Bloch, S. 241 Cooper, Z. 121
Bloom, B.L. 8, 9 Corrigan, P.W. 143, 204, 205, 236
Bloom, D.E. 61 Corsini, R.J. 25, 107
Bogaerts, S. 241 Craske, M.G. 28, 29, 86–7, 158, 253, 289
Bolay, H.V. 290 Crawford, M. 240, 242, 273
Bordin, E.S. 151–2 Crepaz, N. 256
Borg, M. 40–1 Crits-Christoph, P. 26–7, 271
Boyle, P. 205 Cummings, N.A. 79
Bradley, R.J. 241 Cutcliffe, J. 20
Bradt, J. 226
Braithwaite, R.L. 224 D
Brown, L.S. 225 Dahle, T. 240, 272, 273
Bruscia, K.E. 71, 73 Darrow, A.A. 226
Bryant, D.R. 33 Darsie, E. 136
Bunt, L. 239 Davison, G.C. 27
Burns, D.S. 254, 256–7 De Leon, G. 152
Butler, A.C. 29 de l’Etoile, S.K. 240
316 NAME INDEX
DeBord, K.A. 225 Gaudiano, B.A. 103

Deleppo, J. 2–3 Gelenberg, A.J. 19
Delos Reyes, C.M. 205 Generally, N.R. 247, 274
DeMichele, J.T. 33 Gfeller, K.E. x, 254
DeRubeis, R.J. 271 Gibbs, L. 267
Des Jarlais, D. 256 Gifford, A. 290
Devereaux, P. 266 Gilliland, E.G. 57
Devitt, P. 23 Glass, G.V. 26, 272
Di Giulio, G. 27 Gleadhill, L.M. 247
Dickhauser, O. 86 Glicksohn, J. 121
Diener, E. 291 Glied, S.A. 31
Diesenhaus, I. 235 Gold, C. 60, 240, 242, 246, 250, 272, 273, 277, 290
Dingle, G.A. 247 Goldberg, F.S. 241
Dixon, L. 81 Gomez-Perez, V. 239
Dobson, D. 30, 103, 149, 160 Gordon, A.J. 78, 248
Dobson, K.S. 30, 103, 149, 160 Green, C.A. vii, 170, 201
Dorow, L.G. 246 Greener, J.M. 152
Double, D. 21 Grocke, D. 182, 241
Dowrick, C. 154 Guyatt, G. 266
Dozois, D.J.A. 30, 155
Drause, M.S. 26 H
Dumon, F. vi Hadsell, N. 72, 79, 296
Duncan, B.L. 151, 225, 288 Hakvoort, L. 241
Duncan, J. 242 Hammer, S.E. 247
Hansen, N.B. 250
E Hanser, S.B. 156–7
Ebmeier, K.P. 86 Harris, C.S. 241
Eddy, D.M. 267 Harvey, A. 122
Edwards, J. 268, 270–1 Hayashi, N. 241
Elkin, I. 32 Hayes, C. 290
Else, B. 268 Hayes, P.A. 224
Englert, C. 86 Haynes, R. 266
Erkkila, J. 240 Heaney, C.J. 242, 275
Euper, J.A. 58–9 Heath, I. 21, 22
Evans, K.L. 120 Heidal, T.O. 242, 272, 273, 277
Eyre, L. 240, 296 Heide, F.J. 226
Eysenck, H.H. 26 Heldal, T.O. 60, 240, 242
Henry, D. 21
F Henter, I. 5
Fairburn, C.G. 121 Hillecke, T. 290
Falloon, I.R.H. 154 Hollon, S.D. 27, 106
Fawcett, J. 274 Hong-Yi, Z. 246
Fineout-Overholt, E. 269–70, 276 Horsfall, J. 207
Fisher, D.B. 124 Horvath, A. 151
Floersch, J. 185 Houtmans, T. 246
Folkman, S. 92 Howard, K.I. 26
Fonagy, P. 28 Hubble, M.A. 151, 225
Forman, E.M. 29, 250 Hunsley, J. 27
Forsdyke, D. 58 Hunt, G.E. 207
Frank, R.G. 31
Freethy, M. 239 I
Frese, F.J. 268 Insel, T.R. 4, 20, 25, 131, 293, 301
Froman, R.J. 227 Iwamasa, G.Y. 224
Frusciante, J. 188
Fuchs, K. 242 J
Jacobson, N.S. 106
G Jadad, A.R. 271
Gallagher, P. 2–3 Jahoda, M. 291
Gang, M. 242 James, M.R. 247
Garfield, S.L. 25, 250 Jespersen, K.V. 227
NAME INDEX 317
Joe, G.W. 152 M

Jonas, D. 237, 252, 297 McCracken, S.G. 143, 204, 205
Jones, C. 227 McFarlane, W.R. 33–4
Jones, J. 72, 75 McGlashen, T.H. 89
Jones, J.D. 248 McGovern, D. 90
Jones, S. 32 McGuire, A.B. 59, 84, 85
Jung, X.T. 273 McNeilly, C. 143, 204, 205
McNiel, D.E. 241
K Mahoney, M. viii
Kahans, D. 242 Manos, E 38
Kalathara, M. 207 Mansell, W. viii, 106, 122
Kay, S.R. 207–8 Maratos, A. 242, 273
Kazdin, A.E. 103, 152, 236–7, 253 Marcionetti, M.J. 245
Kendall, P.C. 290 Marcus, M. 155
Kennedy, R. 247, 274 Martell, C.R. 225
Kern, P. 268 Mathews, S. 57
Kessler, R.C. 2 Mayoral, M. 239
Kiedis, A. 188 Mays, K.L. 78, 248
Kihlstrom, J.F. 294 Meehan, J. 60, 195, 275–6
Kim, S. 228 Meinzer, A.E. 207
Kirk, S. 120 Melnyk, B.M. 268, 269–70, 276
Kirkby, R.J. 6 Messer, S.B. 125–6
Kitagawa, N. 86 Michel, D.E. 58
Kleespies, P. 2–3 Miller, S.D. 151, 225, 288
Kogan, J. 149 Miller, W.R. 6, 206
Koo, M. 243 Millon, T. 235
Kopta, S.M. 26 Minkoff, K. 205
Koyama, T. 86 Molloy, D. 226
Kraeplin, E. 38 Moreno, J. 226
Krasnow, A.D. 289 Morgan, K. 242
Kress, K. 268 Morrison, N. 31
Kruger, V. 250 Mossler, K. 60, 242, 277
Kruszynski, R.A. 205 Moynihan, R. 21
Kuo, J.C. 243 Murray-Swank, A. 81
Kutchins, H. 120
Kwon, M. 242 N
Nauta, M. 290
L Newton, R. 273
Lakeman, R. 20 Nickel, A. 290
Lam, D. 90 Nickkel, B. 73
Lambert, M.J. 105–6, 250 Niles, B. 2–3
Lamonaca, D. 239 Norcross, J.C. 33
Lawrence, R. 31 Nordoff, P. 195
Lazarus, R.S. 92
Lee, M.S. 239 O
Leonard, J.M. 54, 245, 251 Oades, L. 40
Levant, R.F. 227 O’Callaghan, C. 182
Levy, K.N. 126 Odell-Miller, H. 85, 142
Liberman, R.P. 22 Oh, K. 242
Lie, S.A. 250 Oishi, S. 291
Lim, H. 239 Olkin, R. 226
Lipe, A.W. 296 Oppenheim, L. 299
Longhofer, J. 185 Otto, M. 149
Lopez, L. 278
Loveland, D. 236 P
Luborsky, L. 26, 27 Paniagua, F.A. 219
Lucas, R.E. 291 Parikh, S.V. 32
Lukens, E.P. 33–4 Pavlicevic, M. 242
Lyles, C. 256 Pearson, A. 274
Lyons, J.S. 28 Peng, S.M. 243
318 NAME INDEX
Perez, R.M. 225 Standley, J.M. 72, 75

Perez-Campos, E. 239 Stanley, J. 268
Persons, J.B. 160 Stevens, K. 269
Pike, D. 239 Stige, B. 290, 295
Pilkonis, PA. 238 Stirman, S.W. 271
Powers, B.A. 274 Sue, D. 219
Priebe, S. 85, 142 Sue, D.W. 219
Priestly, M. 226 Swamy, S. 228
Prince, S.E. 225 Swope, A.J. 226
Szasz, T. 21
R
Ralph, R.O. 121 T
Randall, K.W. 236 Tai, S.J. viii, 106, 122
Rathod, S. 31 Taliaferro, G. 226
Rawal, P.H. 28 Talmon, M. 7–9, 85, 224
Reed, G.M. 271 Talwar, N. 246
Reid, P.T. 224 Tang, W. 61, 246
Reilly-Harrington, N. 149 Tansella, M. 20–1
Resnicow, K. 224 Telfer, J. 242
Ridgway, P.A. 40 Tennant, C. 242
Rizvi, S. 32 Thaut, M.H. x, 246, 297
Robb, S.L. 253–4, 256–7 Titus, S.K. 241
Robbins, C. 195 Toppozada, M.R. 226
Rollnick, S. 206 Trevarthan, C. 242
Rolvsjord, R. 40–1, 290 Trimble, J.E. 218
Rose, E.J. 86 Tryon, G.S. 149
Rose, N. 20 Turkington, D. 31
Rose, S. 294
Rosen, C.S. 105 U
Rosen, G.M. 27 Ulrich, G. 246
Rosenberg, B. 107
Rosenhan, D.L. 120–1 V
Rosenow, S. 183, 246 Van de Wall, W. 58
Rosenzweig, S. 26 Vega, V.P. 299
Ross, S. 248 Velasco, M.C. 239
Roth, A. 28 Vieta, E. 3, 32, 37
Rothman, A. 271 Vogel-Scibilia, S. 268
Rowan-Szal, G.A. 152 Vuust, P. 227
Rubin, A. 266–7, 274
W
S Walker, M.T. 131
Safran, S.A. 225 Walter, G. 207
Sanislow, C.A. 238 Wampold, B.E. 26–7, 151
Saunders, S.M. 26 Wang, P.S. 2
Shafran, R. 121, 122 Wang, X. 242, 273
Sham, P. 90 Warner, R. 40
Shlonsky, A. 267 Watkins, E.R. 122
Simpson, D.D. 152 Watson, D.M. 185
Singer, B. 26 Wen-Ying, Y. 246
Skinner, E.A. 93 Werner, P.D. 226
Slotoroff, C. 185 Westen, D.I. 119, 257
Slovak, H. 188 Westra, H.A. 155
Smeijsters, H. 106 Wheeler, B. 268
Smith, D. 28 Wheeler, B.L. 72–3
Smith, M.L. 26, 272 Whitaker, R. 21
Smyrnios, K.X. 6 Whitehead-Pleaux, A. 225
Solli, H.P. 40–1, 250 Whittaker, J. 57
Soni, A. 4 Whitty, P. 23
Soshensky, R. 295 Wigram, T. 240, 272, 273
Spencer, E. 90 Williams, G. 246
Spreen, M. 241 Winett, C. 149
NAME INDEX 319
Winograd, G. 149 Yong-Zhen, W. 246

Wolberg, L.R. 73 Young, L. 228
Wong, G. 90 Youngshin, K. 299
Wren, V. 239
Wyatt, R.J. 5 Z
Zaretsky, A.E. 32
Y Zheng, L. 246
Yalom, I.D. 107 Zheng, Z. 61, 246
Yao, X. 61, 246 Zuroff, D.C. 238
Subject Index
A B
acceptance 94, 106, 110–11 ‘back in the saddle’ approach 90–1
access hypothesis 30 behavioral approaches 206, 219, 239, 241, 245, 246,
accountability 114, 268, 271, 278 253–4
action theory 253 behavioral disorders x, 55
action (transtheoretical stage of change) 104–5, 206 behavioral factors 107, 112–14, 207
active music therapy 73, 168, 206, 239, 245, 251, 255, behavioral skills and supports 206
295 behaviors, positive and negative 242
see also live music best available research evidence 266–7, 276–7
acute care patients 2, 9, 63–4, 189, 241, 243–6 best-practice guidelines 225
addiction 78, 207, 248 billing procedures 61–2
see also cross-addiction; substance abuse and bingo or ‘singo’ (group-based) 184
dependence biomedical approach 21
addiction-only services 207 biopsychosocial information 145–6
adverse effects of drugs 21 biopsychosocial medical model 34
adverse reactions to music, potential 144 bipolar disorder 2, 3, 5, 130, 242
affective factors 107, 110–12, 206 cognitive behavioral therapy 32
alcohol abuse and dependence 58, 108, 128, 152 electroconvulsive therapy (ECT) 24
Alcoholics Anonymous 208, 209 illness management 35, 37
altruism (affective factor) 111–12 medication noncompliance 22, 23–4
American Music Therapy Association (AMTA) 53–5, neurocognitive functioning 86
62, 161, 189, 227, 297, 298 overlap of symptoms 120
American Psychological Association (APA) 33, 227 prodromal, residual and recurring
American Society of Addiction Medicine 207 symptoms 89–90
anti-medication movement 20–2 systematic reviews and meta-analyses 273
anti-psychiatry movement 21 transdiagnostic theory for group-based
antipsychotic medications 86 therapy 123, 126, 128
side effects 19 blindfolded communication game (group-based) 184
anxiety/anxiety disorders 65, 130, 225, 239, 240, 244, blues lyrics 171, 173, 174
247, 250 board games (group-based musical ) 184
assessment 144 Bonny Method of Guided Imagery 78
cognitive behavioral therapy 32–3 booster sessions 37, 79, 87, 296
co-occurring psychiatric and substance misuse boredom and boredom alleviation 58, 125, 203, 211
disorders 203 burnout 298–300
and depressive disorders co-occurrence 2, 201
electroconvulsive therapy (ECT) 24 C
generalized 105 caveats viii–x
illness management and recovery 79, 82 ‘CD about me’ (art and music) 189
neurocognitive functioning 86 Certification Board for Music Therapists
prodromal, residual and recurring (CBMT) 53–4, 227, 298
symptoms 88–9 change 107, 249
rational drug design 294 desire/readiness for 103, 106, 249
transdiagnostic theory for group-based facilitating 171
therapy 125 hypothesis 30
appraisal 40, 93 positive 152
art and music 189, 240 predictors 242
assertive community treatment (ACT) 205–6, 273, stage of 126
278, 279 charades (group-based musical) 184
assertiveness 37, 60, 80, 186–7, 224 chorale, therapeutic 240–1, 296
assessment 143–7, 224 chronic mental illnesses/disorders 9–11, 79, 240,
attendance 103–5, 239, 245, 247 276, 296
attentional control theory 86 classical and baroque recorded music listening 239, 272
awareness stage (recovery) 41 clinical context ix
322 SUBJECT INDEX
clinical expertise 266–7 consolidated standards of reporting trials

Cochrane reviews 272, 273 (CONSORT) statement 256–7
cognitive behavioral therapy vii–viii, ix, x, xii, 27, constant comparative method 40
28–31, 63, 89, 169, 253 contemplation (transtheoretical model) 104–5, 206
access hypothesis 30 contemporary music therapy 59–61
assessments 143 contextual differences xi
bipolar disorder 32 contextual underpinnings vii–viii
change hypothesis 30 contingent interrupted music 246
co-occurring psychiatric and substance misuse continuum model of music and therapy 71–7
disorders 204 activity therapy 72
depression, anxiety and panic disorders 32–3 dual diagnoses interventions 74
drumming and percussion (group) 185 explanation 74–6
evaluation and community reintegration 160 four levels of engagement 73
evidence-based practice (EBP) 279 guiding questions 71–2
future of 33 insight music therapy 72
illness management and recovery 79 psychotherapy 73
integrated dual-disorder treatment (IDDT) 209 related literature 72–4
lesbian, gay, bisexual, transgendered and verbal psychotherapy with music 73
questioning (LGBTQ) 225 converging biomarker approach 294
manualization 289 co-occurring psychiatric and substance misuse
mediation hypothesis 30 disorders 201–13
multiculturalism 224 aggressive behaviors 202
neurocognitive functioning 86–7 associations between music and substance
objectives 149 misuse 212–13
and people with disabilities 226 behavioral problems 202
problem solving 154 dependence rates 202
prodromal, residual and recurring symptoms 88–9 HIV 202
rapport and therapeutic (working) alliance homelessness 202
development 151 medication compliance 202
rational drug design 294 mortality 202
research reviews 31–3 patient characteristics 207–8
schizophrenia and psychosis 31–2 prevalence rates 202
songwriting 173 quadrant model 207
supervision 161 recidivism 202
therapeutic mechanisms 105, 107 self-medication 202
transdiagnostic theory for group-based separate care (compartmentalization) 203
therapy 122 social problems 202–3
verbalizations 158 suicide rates 202
cognitive factors 107, 108–10 symptoms, worsening 202
cognitive functioning 10, 23–4, 55, 82, 242 twelve steps 208, 209, 210
cognitive reframing 206 work history 202
cognitive restructuring 94 see also integrated dual-disorder treatment (IDDT)
cognitive skills and supports 206 coping skills ix–x, 92–6, 190, 191–5, 241, 244
collaborative care model 3–4 active coping 94
collaborative partnership 278 alloplastic coping 93, 94
communication facilitation 72, 185 autoplastic coping 94
community-based therapy 295–6 avoidant coping 94
see also assertive community treatment behavioral coping 94
community reintegration and resources 66, 160–1, cards 212–13
210 cognitive coping 93, 94
community, sense of 63–4 contemporary therapy/objectives 60, 65–6
comorbidities vii, 2, 65, 120, 297 control coping 94
see also co-occurring psychiatric and substance disengagement coping 94
misuse disorders dispositional (trait) coping 94
compassion fatigue 298–300 documentation 158
competencies xii, 144, 204, 224, 227, 251–2 early medical intervention strategies 94
complete the lyric games (group-based) 184 emotion-focused/emotion-oriented coping 93, 94
composing songs see songwriting engagement coping 94
conceptual models 253 escape coping 94, 95
conduct disorders 130, 208 group therapy 64
‘consequence cards’ 212–13 illness management 35, 37
SUBJECT INDEX 323
illness management and recovery 80, 82, 83 therapeutic mechanisms 106

integrated dual-disorder treatment (IDDT) 206, transdiagnostic theory for group-based
210, 211 therapy 125, 127
involuntary/automatic coping 94 see also bipolar disorder; major depressive disorder
long-term treatment 63 descriptive studies 239–43, 247–8, 269, 271
maladaptive coping 94 determination (transtheoretical model) 104, 206
meaning-focused coping 94 detoxification facility 61, 171, 189, 210, 248, 249
modification of excessive behavior coping 94 developmental group 130
negative coping 93, 94 diagnostic reliability 119–21
passive coping 94 Diagnostic and Statistical Manual (DSM) 119–20,
positive coping 93, 94 121, 122, 131–2, 289, 293
primary coping 94 disabilities, people with 226
proactive coping 94, 243 disability-adjusted life years 4
problem-focused coping 93, 94 discharge planning and questions to be asked 161
prodromal, residual and recurring symptoms 90, 92 discovery-oriented research 252
rational drug design 295 discrimination 1, 225
reactive coping 94 disease mongering 21–2
secondary coping 94 disease personification, avoidance of 125
situational coping 93, 94 distress 2, 5, 10, 92, 93, 127
social coping 96 diversity see multiculturalism and diverse client
solitary coping 96 populations
songwriting 171, 173, 244 documentation 158–60
stimulating coping strategies (specific to coping Dodo Bird Verdict 26–8, 55, 169
with mania) 96 dose-response effect of treatment 250, 255
transdiagnostic theory for group-based Double Trouble 128, 204
therapy 123, 125, 126, 128 dropout rates 207, 273
volitional or effortful coping 96 drug use 122
counseling 54, 161, 205–6 see also addiction; substance abuse and dependence
countertransference 161 drumming and percussion 55, 185, 244, 245, 248, 251
crisis intervention 73, 273 dual disorders 9, 74, 248
critical thinking 267–8 see also co-occurring psychiatric and substance
cross-addiction 124, 211 misuse disorders; integrated dual-disorder
curative factors 107, 240, 241 treatment (IDDT)
current procedural terminology (CPT) codes 61–2 dual factor model 291–2
Dual Recovery Anonymous 204
D
data collection to systematically measure E
progress 156–8, 159 early detection and treatment of symptoms see
decision making 66 prodromal symptoms
see also evidence-based practice and decision early initial prodromal states (EIPS) 88
making easy listening/country music 241
definition of music therapy 139 economic implications 4–5
demographic characteristics 145, 207–8 educational music therapy for illness management
depression/depressive disorders 27, 130, 190–5, 239, and recovery 78–97, 244–5
240, 242, 244–7, 249–50 approaches 78–85
and anxiety comorbidity 201 cognitive behavioral strategies 89
assessment 144 coping skills 92–6
cognitive behavioral therapy 32–3 engagement and education 91
comorbidity 2 function 78, 81
electroconvulsive therapy (ECT) 24 interventions 81
group therapy 64 neurocognitive functioning 86–7
illness management and recovery 79, 82 objectives for treatment 81
lesbian, gay, bisexual, transgendered and patient problem 81
questioning (LGBTQ) 225 prodromal, residual and recurring
manuals 289 symptoms 87–92
neurocognitive functioning 86 relapse signature and relapse drill 91
prodromal, residual and recurring role of music therapist 81
symptoms 89–90 single-session therapy components 85
rapport and therapeutic (working) alliance symptom reduction 78–80
development 151 topic areas 85
systematic reviews and meta-analyses 273 see also psychoeducational approach
324 SUBJECT INDEX
effectiveness, reasons for 106–14, 248, 271 randomized controlled trials (RCTs) 267, 269–70,
acceptance (affective factor) 110–11 272, 273, 274, 276, 277
affective factors 110–12 rapport and therapeutic (working) alliance
altruism (affective factor) 111–12 development 278
behavioral factors 112–14 rating system for hierarchy of evidence 269
cognitive factors 108–10 six established treatments 278, 279–80
insight (cognitive factor) 109–10 supported employment (SE) 279
interaction (behavioral factor) 113–14 systematic reviews 269–77
modeling (cognitive factor) 110 terminology differentiation 276
reality testing (behavioral factor) 112–13 expert opinion and expertise 106, 276
transference (affective factor) 112 expressive music 74
universalization (cognitive factor) 108–9 external validity xi
ventilation (behavioral factor) 113
electroconvulsive therapy (ECT) 24 F
electronic records 158 family-based psychoeducation 127, 128, 154,
emotional disorders/problems x, 2, 55 280
emotions 42, 185, 246–8 family-focused therapy 26, 32, 206
empathy 106, 151, 182 family history and psychiatric disorders 208
empowerment model of recovery 38–9, 79, 185 family support 212
engagement (stages of treatment program) 73, 91, felt better and feel better (narrative
107, 144, 151–2, 172–3, 206, 207, 250 intervention) 191–5
enjoyment of therapy 247, 248 fidelity tests 288
ethical issues 23, 161, 226, 268 fiduciary responsibilities 267–8
etiology 5–9 fill-in-the-blank songwriting 175–6, 177
evaluation of treatment and community financial constraints of treatment see funding
reintegration 160 flexibility of music therapy 59
evidence-based medicine (EBM) 267 forensic music therapy viii–ix, 241
evidence-based practice (EBP) and decision four-quadrant model 206
making 256, 266–81, 288 free composition of music 175, 176, 179
accountability 278 free-response questions 146–7
ask clinical question (step 1) 277 friends, support of 251–2
assertive community treatment (ACT) 278, 279 functional cognitive behavioral therapy (fCBT) 36
case studies 269 functional skills 63
clinical expertise 266–7 functioning 126, 240, 248, 250
Cochrane reviews 272, 273 function of psychiatric music therapy 78, 81
collaborative partnership 278 funding music therapy services 61–2, 129, 267–8
collect most relevant and best evidence (step future treatments 287–301
2) 266–7, 277 community-based therapy 295–6
critically appraise evidence (step 3) 277 compassion fatigue, burnout and self-care
decision-making processes 276 298–300
descriptive studies 269, 271 concern, areas of 297–8
evaluate practice decision or change (step 5) 277 dual-factor model 291–2
family-based psychoeducation 280 manuals 287–91
five steps 276, 277 molecular biology: precision and personalized
future prospects 278, 281 medicine 292–3
illness management and recovery model 278, Music Therapist-Board Certified (MT-BC) and
280 licensure 298
integrate all evidence with clinical expertise, patient neurological model 297
preferences and values in making a practice quartered classification system 291–2
decision or change (step 4) 277 rational drug design 293–5
integrated dual-disorder treatment (IDDT) 279 wellness model 296–7
levels of evidence 269–70
manuals 290 G
medications 280 games and plays using music 241, 245, 247, 248,
meta-analyses 269, 272–4, 276, 277 251
non-randomized controlled trials (RCTs) 274, generalization 148, 237
275–6 see also ‘homework’ assignments to facilitate
patient characteristics, culture, values, expectations generalization
and preferences 266–7, 274–5 genetic analyses 293–4
qualitative research 269, 274–5 global state 79, 250, 272
quantitative research 272, 274–5 goals of treatment 63, 150–1
SUBJECT INDEX 325
group-based therapy ix, 55, 57, 64–5, 239, 241, 246, songwriting 140
250, 255 suggestions 137–8
active and receptive 239 training 140
cognitive behavioral 31 insight 54, 72, 84, 109–10, 246
cognitive factors 108 instrumental group improvisation 246
cohesiveness 124–5, 239 insurance companies 5–6, 61, 129
drumming percussion, facilitated 185 integrated dual-disorder treatment (IDDT) vii,
guitar lessons and recital 239 203–7, 208–12, 279
illness management and recovery 84, 85 assertive outreach 205–6
improvisation 240, 247 counseling 205–6
manualization 290 eight treatment principles 204
non-randomized controlled trials (RCT) 275 five practices 206
recreational 184 motivational interventions 205–6
singing 246 practising 205–7
songwriting 244, 249 rockumentaries 188
see also transdiagnostic theory for group-based social support 205–6
therapy staged interventions 205–6
growth stage (recovery) 41 treatment areas 211–12
guitar 54 integrative therapy 61, 78
interaction 72, 113–14, 242, 245
H internal validity xi, 288
hard rock/rap 241 International Classification of Diseases (ICD)
Health Care Financing Administration 143 119–20, 289, 293
health maintenance organizations (HMOs) 5–6 interpersonal relationships 79, 151, 239
helpfulness, perception of 243 interpersonal skills and supports 54, 206
helplessness, feelings of 38 interventions 81, 168–96
help-seeking behaviors 92, 121, 125, 131 active music therapy 168
historical background of music therapy 55–9 art and music 189
homelessness 10, 208 blues lyrics 171, 173, 174, 177
‘homework’ assignments to facilitate drumming percussion (group) 185
generalization 155–6 in-the-blank songwriting 175–6, 177
hopefulness 40, 205 free composition 175, 176, 179
hopelessness 40, 127 group-based 184–5
hot potato (group-based) 184 improvisation 190, 195–6
hymn playing, contingent 239 live music (receptive) 168
lyric analysis 168, 170, 179, 181–2
I lyric replacement 175, 176–9
illness management and recovery 33–42, 63, 65, 107, ‘my song’ 189–90
278, 280, 292 Orff-based and narrative based 190, 191–5
concept 37–42 pass/bound, 2, 3, 4.... 185
impact 35–6 ‘play your way out of trouble’ 175
overview 33–5 recreational 183–5
research 36–7 rhythm-based 183–5
songwriting 173 rock opera for assertiveness training 186–7
transdiagnostic theory for group-based therapy 127 rockumentaries 188
imagery 247–8 role-playing scenarios 186
improvisation 40, 55, 190, 195–6, 239–42, 246–8, songwriting approaches 168, 170–5, 177–8, 179,
250, 276 180, 182
incarceration 10, 208, 246 structuring songwriting interventions 175–9
individualized treatment 55, 65, 240–3, 246, 255, 276 take one, pass one 184
information collection about client 143 therapeutic dialogue within songwriting 172
information sharing (therapist/client) see rapport and ‘writer’s block’ 175
therapeutic (working) alliance development isolation 121, 125, 211
inpatients 239–46, 250–1 ‘iso’ principle 57
in-services 103–4, 136–42, 255
approaches 140 J
definition of music therapy 139 jargon and definitions vii, 149
from the patients... 139 Joanna Briggs Institute grades of
lyric analysis 141 recommendation 273
purpose of 139 Joint Commission on Accreditation of Health
research 141 Organizations 143
326 SUBJECT INDEX
L motivation 63, 107, 205–6, 247, 248, 249

late initial prodromal states (LIPS) 88 co-occurring psychiatric and substance misuse
leisure skills 63, 66, 125, 169, 173 disorders 207
lesbian, gay, bisexual, transgendered, and questioning enhancement therapy 204, 279
(lesbian, gay, bisexual, transgendered and low 240
questioning (LGBTQ)) 225, 227 rapport and therapeutic (working) alliance
licensing issues 203 development 151, 152
listening to music 74, 239, 240, 242, 243, 245, 247 songwriting 172
lithium treatment 23, 35 therapeutic mechanisms 106
live music xi–xii, 54, 179, 181, 182, 251–2, 255 motivational interviewing 173, 209
meta-analysis 272 motivational pictures 213
quality and aesthetic qualities 85 movement to music 247
receptive 168 multiculturalism and diverse client
locus of control 244, 248 populations 218–30
longitudinal process (transtheoretical model) 206 acculturation 219, 224
lyrical ambiguity 109–10, 182 African Americans 220
lyric analysis 55, 141, 168, 170, 179, 181–2 Alaskan Natives 222
co-occurring psychiatric and substance misuse American Indians 222
disorders 210 Asian Americans 221
educational 245 characteristics and issues 220–3
future research 240, 243–4, 247–9, 251 clinical training 228–9
lyric bank 173, 177 cultural tendencies 219
lyric replacement 175, 176–9 demographics 218
lyric sheets 155 disabilities, people with 226
diverse populations other than ethnic 224
M ethnicity 224
maintenance (transtheoretical model) 104–5, 206 ethnocentrism 226
major depressive disorder 2, 4, 24, 86–8, 105 faith and belief systems 224
overlap of symptoms 120 family 220–3
Managed Care Initiative 204 first session 220–3
manic depression see bipolar disorder generation issues 224
manuals 287–91 Hispanic Americans 223
mediation hypothesis 30 Jewish people 227
Medicaid 5, 61 Latino Americans 223
medical model 36, 38, 226 lesbian, gay, bisexual, transgendered and
Medicare 5, 61 questioning (LGBTQ) 225, 227
medication 280 literature 226–8
adherence/compliance 22–4, 35, 63, 83, 91, 108, minority groups 218
123 ongoing treatment 220–3
management 66 overgeneralization, hazards of 219
as primary treatment 18–20 Pacific Islanders 221
side effects 61, 125, 294 refugee populations 227–8
see also pharmacological and psychosocial religion 220–3
treatments; psychotropic medications spirituality 224
mental state 79, 272 subcultures 218
meta-analyses 240, 242, 243, 269, 272–4, 276, 277 therapeutic recommendations 220–3
mild mental illness 2 translators and interpreters, avoidance of use
military hospitals viii, 54, 57–8 of 228
mixed methods design 239, 241, 243, 250, 254, 255 multiple diagnoses 122, 255, 271
modeling 64, 110, 125 see also co-occurring psychiatric and substance
moderate mental illness 2 misuse disorders; integrated dual-disorder
molecular biology: precision and personalized treatment (IDDT)
medicine 128–9, 292–3 musical chairs (group-based) 184
mood 246 music performances 295
disorders 2, 23 Music Therapist-Board Certified (MT-BC)
improvement 57, 183 credential xi, 53, 298
states, undesired 206 ‘my song’ 189–90
moral models and people with disabilities 226
moratorium stage (recovery) 41 N
morbidity 5, 10 name that tune (group-based) 184
see also comorbidities Narcotics Anonymous 128
mortality 3, 5 narrative based interventions 190, 191–5
SUBJECT INDEX 327
National Alliance on Mental Illness 18 personality disorders ix, 65, 129, 151
National Association for Music Therapy 58 personalized medicine 292–3
National Association of Psychiatric Health Systems 5 persuasion (stages of treatment program) 206
National Association of State Mental Health Program pharmaco-centrism 20
Directors pharmacological and psychosocial treatments 18–42,
Medical Directors Council 202 125
National Commission for Certifying Agencies cognitive behavioral therapy 31–3
(NCCA) 54 illness management as psychosocial
National Institute of Mental Health 18 treatment 33–42
Research Domain Criteria (RDoC) initiative 294 psychotropic medications 18–31
National Research Council of the National Academies philosophical underpinnings vii–viii
(NRCNA) 292 PICO format (questions) 277
neurocognitive functioning in mental illnesses 86–7 pictures with music (group-based) 184
neurological model 297 see also art and music
neurophysiological indicators 294 planning treatment 147–8
non-randomized controlled trials (RCTs) 239, 241, ‘play your way out of trouble’ 175
242, 243, 247, 274, 275–6 polypharmacy 21
normalization 30, 124, 128 polysymptomatic patients see multiple diagnoses
‘not otherwise specified’ diagnosis 120 post-traumatic stress disorder 58, 239
precision medicine 129, 292–3
O precontemplation (transtheoretical model) 104–5,
objectives for treatment 65–6, 81, 148–51 206
objectivity 158, 160 predictor variables or moderators 105–6
‘one-size-fits-all’ approach 288 preparation stage 41, 104, 206
on-task behaviors 107, 125 President’s Commission on Mental Health 218
‘open ward groups’ 142 President’s Council of Advisors on Science and
Orff-based interventions 190, 191–5 Technology (PCAST) 292
outcomes 20, 23, 125, 240, 253 President’s New Freedom Commission on Mental
outpatients 128, 239, 240, 241, 250–1, 295, 296 Health 41–2, 266, 287
overview of music therapy 53–66 prevalence of mental illness 2–3
acute care treatment 63–4 problem solving 63, 66, 83, 154, 172, 173
American Music Therapy Association (AMTA) process of music therapy 136–63
reimbursement methods 62 assessment 143–7
contemporary objectives 59–61, 65–6 clinical objectives 149–50
diagnoses 65 data collection to systematically measure
funding 61–2 progress 156–8, 159
group therapy 64–5 discharge planning and questions to be
historical background 55–9 asked 161
long-term treatment 63 documentation 158–60
psychoeducational modules 59 ‘homework’ assignments to facilitate
generalization 155–6
P in-services 136–42
panic disorders 32–3, 105 problem solving as collaborative approach 154
participation 74, 103, 107, 183 rapport development and therapeutic (working)
pass/bound, 2, 3, 4. . . . 185 alliance 150–3
passive music listening 246, 251, 255 referral 142–3
see also recorded music scheduling 162–3
pathology 144, 291–2 supervision 161–2
patient characteristics, culture, values, expectations treatment evaluation and community
and reintegration 160–1
preferences 105–6, 266–7, 274–5 treatment planning 147–8
peer acceptance 239 prodromal, residual and recurring symptoms 87–92,
peer accountability and involvement 155 94
peer-based model 297 progress notes 156–9
peer interactions 64–5 psychodynamic therapy 26, 253
peer support 160 psychoeducational approach ix, x, 32, 59, 80, 244,
perceptions: 273
and continuum model 76 family-based 127, 128, 154, 280
of staff 255 see also illness management
of therapist competence 252 psychoeducational knowledge 37, 60
of treatment 244, 245, 248, 249 psychoeducational model viii, xii
percussion see drumming and percussion psychoeducational objectives 65–6
328 SUBJECT INDEX
psychoses/psychotic disorders 63, 65, 130, 241, 242, recitals 242

243, 246 recorded music xi, 54, 179, 182, 245, 251–2, 255
cognitive behavioral therapy 31–2 classical and baroque 239
continuum model 72 meta-analysis 272
illness management and recovery 82 via iPod 251
lyric analysis 182 recording music 241, 295
manic-depressive 58 recovery concept 37–42, 63, 271
medication noncompliance 23–4 areas of experience and subdomains 42
meta-analysis 272 awareness stage 41
molecular biology 293 components 39
prodromal, residual and recurring continuum model 73
symptoms 89 growth stage 41
systematic reviews and meta-analyses 273 moratorium stage 41
transdiagnostic theory for group-based preparation stage 41
therapy 122 rebuilding stage 41
psychosocial clubhouse model 296 themes 40
psychosocial interventions, importance of 24–5 see also illness management and recovery
psychosocial means 63 recreational music therapy 55, 183, 246
psychosocial orientation 246 re-educative therapy 73
psychosocial treatments 294 referral 142–3
see also pharmacological and psychosocial refugee populations 227–8
treatments rehabilitative model of recovery 38–9, 63
psychotherapy 54, 73, 239 rehospitalization 23, 83
psychotic disorders see psychoses/psychotic reimbursement issues 129, 203, 268
disorders relapse 23, 63, 91, 108, 206
psychotropic medications 3, 18–31, 294 see also recidivism
anti-medication movement 20–2 relaxation and music 55, 185, 240, 246, 247, 248
cognitive behavioral therapy 28–31 relay races (group-based musical) 184
Dodo Bird Verdict 26–8 reporting guidelines (research) 256–7
electroconvulsive therapy (ECT) 24 research 54, 141, 235–58
illness management and recovery 83 application to music therapy 257
noncompliance/nonadherence 22–4 challenges and complications 235
primary treatment, medications as 18–20 and clinical practice, differences between xi
psychosocial interventions, importance of 24–5 financial resources 237
future research 238, 250–3
Q lack of 238
quadrant model for co-occurring disorders 207 priorities 253
qualitative methods/research 236–7, 250, 254–5, 257, qualitative research 236–7
269, 274–5, 292 quantitative research 236, 238
quality of life 3, 5, 39, 79, 82, 131, 241, 244, 246 reimbursement 237
quantitative methods/research 74–5, 144, 157–8, reporting guidelines 256–7
250, 252, 254, 257, 272, 274–5 studies 239–49
quartered classification system 291–2 suggestions 254–6
theory 253–4
R resource-oriented music therapy 240, 295–6
randomized controlled trials (RCTs) 27, 239–40, response to music therapy 243, 255
242–9, 267, 269–70, 272–4, 276–7 rhythm-based therapy 183–5, 247
rapport and therapeutic (working) alliance rock opera 186–7, 244
development 150–3, 244, 248, 255, 278 rock and roll bingo 251
assessment 143, 144 rockumentaries 188, 249
continuum model 72 role-play 75, 113, 172, 186, 244
illness management and recovery 84–5
multiculturalism 219, 227 S
recreational music 183 scheduling 162–3
rhythm-based interventions 183 schizoaffective disorder 36, 242
therapeutic mechanisms 104 schizophrenia 2, 19, 58, 60, 63, 239, 240, 242, 243,
rational drug design 293–5 246
reading music 245 cognitive behavioral therapy 31–2
reality testing (behavioral factor) 112–13 family-based psychoeducation 154
rebuilding stage (recovery) 41 illness management 36, 37
recidivism 10–11, 297 medication noncompliance 22, 23
SUBJECT INDEX 329
molecular biology 293 social marginalization 20, 131

neurocognitive functioning 87 social problems 2, 79, 202–3
overlap of symptoms 120–1 social security disability income (SSDI) 4–5
prodromal, residual and recurring symptoms 88, social skills 169, 206
89 social supports 60, 205–6, 244, 245, 251–2
psychosocial interventions 25 enhancement 37
recovery model 40 illness management and recovery 80
substance abuse and dependence comorbidity 31, rhythm-based interventions 183
201 therapeutic mechanisms 106
systematic reviews and meta-analyses 272, 273 transdiagnostic theory for group-based
transdiagnostic theory for group-based therapy 123
therapy 123, 126–7 sociological theory and approach 72
scribble art 189 songwriting 55, 140, 168, 170–5, 179–80, 182, 240–2,
sedative effects of music 54, 58 245, 247–9
self-assessments 157 about coping skills 244
self-awareness 29, 54, 92, 157, 185 community-based therapy 295
self-care 161, 212, 298–300 contingency 243
self-concept 125 educational 244
self-confidence 205 in-the-blank 175–6, 177
self-destructive behavior 5 group-based 244, 249
self-determination 185 psychoeducational group 244
self-disclosure 181 structuring 175–9
self-efficacy 79, 83, 205 and therapeutic dialogue 172
self-esteem 63, 241 Sound Training for attention and memory
self-expression 54, 182 protocol 239
self-identification 92 sports games (group-based musical) 184
self-monitoring 123, 155, 157, 212, 247 stabilization (continuum model) 73
self-rating 242, 245, 246, 247, 248 staged interventions 205–6
self-regulatory behaviors 29 standardized testing 144
self-reports 144 standardized treatments 288
self-statements and beliefs 158 stigma 2, 3, 37, 38, 40, 60, 121, 244
self-talk 94 blues songwriting 177–8
severe mental illnesses/disorders 2, 3, 5, 241, 243, and educational songwriting 244
245 group therapy 64
contemporary treatment 9–11 illness management and recovery 80
evidence-based practice (EBP) 268, 275 lesbian, gay, bisexual, transgendered and
non-randomized controlled trials (RCT) 275 questioning (LGBTQ) 225
and personality disorder comorbidity 201 public, social, experienced and self- 24, 244
systematic reviews and meta-analyses 273 songwriting 171
Simon says (group-based) 184 transdiagnostic theory for group-based
singing 240–3, 246, 247, 251 therapy 125, 127, 128, 131, 132
single-session treatment 7–9, 85 stress and stress management 63, 83, 86–7, 123, 124,
skills, musical 161–2 247
social functioning 2, 10, 39, 79, 82, 241, 272 stress-vulnerability model 30, 84, 92
social impact, prevalence and contemporary substance abuse and dependence 6, 61, 65, 66, 129,
short-term treatment 1–12 247
acute care patients 9 cognitive factors 108
discrimination and misconceptions regarding continuum model 73
mental illness 1 and depressive disorders co-occurrence 2
economic implications 4–5 evidence-based practice (EBP) 279
etiology 5–9 ‘my song’ 189
hospitalizations, brief 5–6 rapport and therapeutic (working) alliance
implications for music therapists 11 development 151, 152
prevalence 2–3 rockumentaries 188
related problems for psychiatric systematic reviews and meta-analyses 273–4
consumers 3–4 transdiagnostic theory for group-based
severe and chronic mental illnesses 9–11 therapy 124
single-session treatment 7–9 see also co-occurring psychiatric and substance
social impact of mental illness 1–2 misuse disorders
treatments, brief and time-limited 6 suicide and suicidal ideation 2–3, 5, 10, 35, 122
social interactions 63, 65, 185 supervision 160–2
330 SUBJECT INDEX
supplemental security income (SSI) 4–5 clinical example 126–8

supported employment (SE) 279 diagnostic reliability 119–21
support groups 73, 127, 212, 279 implications 131–2
surreptitious prescribing 23 limitations 128–9
symptoms 240, 241, 246, 248 transference 112, 161
general 250 transparent reporting of evaluations with
management 66, 82 non-randomized
negative 240, 242, 246, 250 designs (TREND) statement 256
overlapping diagnoses 120, 121, 122 transtheoretical stages of change model 104–5,
positive 242 113–14, 206, 210
prodromal, residual and recurring 87–92, 94 trivia (group-based musical) 184
reduction 39, 78–80, 84, 107 trust 72, 84, 245, 251
systematic reviews 248, 269–70, 271–4, 276, 277 see also rapport and therapeutic (working) alliance
development
T TV music games (group-based) 184
take one, pass one 184 twelve steps 206, 208, 209, 210
talk-based therapies ix, 28
team game 243 U
tempo changes 57 unipolar depression see major depressive disorder
therapeutic mechanisms 103–15 United States Surgeon General 24, 218
attendance, participation and desire for universality/universalization 64, 108–9, 112, 124–5,
change 103–5 128, 172
characteristics facilitating change 106
client characteristics 105–6 V
effectiveness, reasons for 106–14 values, beliefs and perspectives 40, 276
in-services 103–4 ventilation (behavioral factor) 113
music therapy applications 114 verbalizations 72–3, 104, 158, 169–70, 183, 255
transtheoretical stages of change 104–5 vicarious learning 64, 124–5
time-limited treatments 6 videos (music) 295
topics for therapy 84–5 visual components and songwriting 175, 179
training of music therapists 53, 106, 140, 228–9,
288 W
transdiagnostic theory for group-based therapy 65, well-being 55, 144, 291–2
119–32, 209 wellness model 83, 211, 296–7
alternatives 129–31 World Economic Forum 61
application to music therapy 122–6 World Health Organization 4
background 121–2 ‘worried well’ 78

Music Therapy in Mental Health For Illness Management and Recovery

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Music Therapy in Mental Health For Illness Management and Recovery

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Music therapy in mental health

for illness management and

Michael J. Silverman, PhD, MT-BC

conceptualizing, developing, and continually refining theory-based and clinically derived

Jargon and defining psychiatric music therapy

Philosophical and contextual underpinnings

and psychoeducational model of music therapy in which I emphasize illness management

treatment and outcome. Readers interested in applications of music therapy in forensic

Differences between research and clinical practice

Music in psychiatric music therapy

Use of this text

1 The social impact, prevalence, and contemporary short-term treatment

Name Index 315

Subject Index 321

1 The social impact, prevalence, and contemporary short-term treatment

Neurocognitive functioning in mental illness 86

Developing rapport and therapeutic alliance 150

Reporting guidelines 256

Areas of concern in psychiatric music therapy 297

Name Index 315

Subject Index 321

The social impact, prevalence,

Social impact of mental illness

Box 1.1 Discrimination and Misconceptions Concerning

Other health problems for psychiatric consumers

Brief and time-limited treatments

Table 1.1 Components of Talmon’s (1990) Single-Session Therapy

Component Brief description

Box 1.2 Talmon’s (1990) Helpful Attitudes for Single-Session

Contemporary psychiatric treatment for acute care patients

Contemporary psychiatric treatment for patients with severe

Implications for music therapists

Box 1.3 Chapter 1 Main Ideas

Questions for review and discussion

Pharmacological and psychosocial

In an article concerning experimental medicine, Insel (2012) noted that physicians

compliance concerning psychosocial interventions such as missing appointments, not fol-

Importance of psychosocial interventions

Comparing psychotherapies and the Dodo Bird Verdict

Music therapy ramifications of the Dodo Bird Verdict

Cognitive behavioral therapy

therapy—separate yet interrelated psychotherapies—the term cognitive behavioral ther-

Box 2.1 Three Basic Cognitive Behavioral Treatment Principles

disengagement. Cognitive behavioral therapy emphasizes collaborative approaches to adap-

Reviews of cognitive behavioral therapy research

Depression, anxiety, and panic disorders

The future of cognitive behavioral therapy

Illness management as a psychosocial treatment

The impact of illness management

Illness management research

The recovery concept

Box 2.2 Recovery Components

Box 2.3 Recovery Themes

Box 2.4 Recovery Stages

Area of Having a good time Being together Feeling Being

Box 2.5 Chapter 2 Main Ideas

Dinkmeyer, D. (1991). Mental health counseling: A psychoeducational approach. Journal of Mental

National Alliance on Mental Illness. (2012). Commonly prescribed psychotropic medications.

Questions for review and discussion

An overview of music therapy

History of psychiatric music therapy

Contemporary psychiatric music therapy

Box 3.1 Psychoeducational Modules