Running head: THE EFFECT OF MELODY ON SYMPTOMS OF ANXIETY IN

BEREAVED PATIENTS

The Effect of Grounding Melodic Interventions on Symptoms of Anxiety in Bereavard

Patients: a Proposed Study

JUAN PEDRO ZAMBONINI

Temple University
Music Therapy Research MUED 8611

THE EFFECT OF MELODY ON SYMPTOMS OF ANXIETY IN BEREAVED

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Background
Anxiety has a prevalence of 18.1% among the U.S. adult population (National
Institute of Mental Health, 2013). It can be caused by various factors including vital
crises such as those that occur after the loss of loved one. In this sense, anxiety and
bereavement have a close relationship.
In a prospective study conducted Boelen and Prigerson, it was discovered that
anxiety is an important determinant of functioning after loss for patients with a Prolonged
Grief Disorder (PGD) (Boelen & Prigerson, 2007). In this study, Boelen and Prigerson
asked 346 mourners who were bereaved between 6 months and 2 years to rate an anxiety
scale showing how often they experienced anxiety symptoms in the last week. They
included standardized measures such as the Inventory of Complicated Grief-revised
(ICG-r) (Prigerson & Jacobs, 2001 as cited in Boelen & Prigerson, 2007), the SCL-90
(Derogatis, 1983 as cited in Boelen & Prigerson, 2007) and the Rand 36-item Health
Survey (RAND 36, Ware, Sherbourne, 1992 as cited in Boelen & Prigerson, 2007). As a
result, they found a significant correlation between the onset of a mood, anxiety, or
alcohol use disorder and the unexpected death of a loved one.
Keyes et al. (2014) mention that the sudden passing of a loved one might have
consequences specific to attachment loss as well as to stress mechanisms (Keyes et al.,
2014). This attachment could also be considered in the lines of the lack grounding and
how that is a great cause for anxiety, even at the early stages of life (Bowlby, 1969). The
national study with a sample of 27,534 adult Americans, Keyes et al found that
unexpected death of a loved one was associated consistently with elevated odds of new

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onsets of PTSD, panic disorder, and depressive episodes at all stages of the life course
(Keyes et al, 2014).
Various studies across the globe have demonstrated the ability of music to lower
anxiety levels of bereaved patients (Nakamura, Sakai & Takeichi, 1990; Raglio et al.,
2016). More precisely, music therapy has been proven to be an effective treatment to
reduce anxiety and depression. Chen, Hannibal and Gold conducted a randomized control
trial to illustrate that music therapy can alleviate anxiety and depression of Chinese
prisoners as well as improve their self-esteem (Chen, Hannibal & Gold, 2015).
Throughout the study, the researchers included many indicators of their efforts to
minimize bias. For example, all eligible participants were individually randomized to two
groups of equal size. Also, one of the researchers who had no direct contact with the
participants conducted a computer-generated randomization and kept this list concealed
until a decision was made about inclusion. The data collection was conducted by a
psychological counselor and not by the music therapist in order to prevent a social
desirability bias. All these actions show an effective way of randomization, allocation
concealment and blinding to minimize bias in the study. At the end of the study, the
results showed that anxiety and depression in the music therapy condition decreased
significantly at mid-test and post-test; self-esteem improved significantly at mid-test on
one measure and significantly on two measures at post-test. Improvements were greater
in younger participants and/or in those with a lower level of education. Group music
therapy seems to be effective in improving anxiety, depression, and self-esteem and was
shown to be most beneficial for prisoners of younger age or with lower education level.

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Silverman (2010) conducted a study to isolate and quantitatively evaluate the

effects of pitch and rhythm of unfamiliar and familiar melodies on working memory and
anxiety as measured by sequential digit recall performance. The study included a sample
of 60 college students (N = 60). 30 participants were music majors (13 female and 17
male) and 30 were non-music majors (22 female and 8 male). During the study, the
researcher recorded six nine-digit sequences from the monosyllabic digits 1 through 10.
The digit sequences were randomly paired with six different types of treatment stimuli.
The digits were paired with (a) a familiar melody and pitch only, (b) a familiar melody
and rhythm only, (c) a familiar melody with both pitch and rhythm, (d) an unfamiliar
melody with pitch only, (e) an unfamiliar melody with rhythm only, and (f) an unfamiliar
melody with both pitch and rhythm. Once the sequences were recorded, they were played
to the participants for them to write down the digits, which they remembered from the
recorded stimulus. Participants also completed a 5-point Likert scale representing the
level of anxiety before, during and after the digit test. Allocation concealment and
blinding were not reported, however, the order in which the serial position was selected
was randomized using a Latin Square design to control learning, order and carry-over
effects. To determine if the differences in the analysis were statistically significant, a
factorial repeated measures analysis of variance (ANOVA) was conducted. The
researcher also devised clear operational definitions and used measures that were
validated in a recent research within a relevant population. Also, the limitations of the
study were recognized to avoid generalizations concerning the effectiveness of the paired
musical elements of pitch, rhythm, and familiarity on recall performance. The results of
this study are congruent with existing working memory and music literature suggesting

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that pairing information with rhythm can facilitate recall, music majors outperform nonmusic majors, and recall accuracy is best in positions of primacy and recency. However
there were no significant changes in the anxiety measures taken before and after the digit
recalls.
The effects of music therapy in anxiety have also been documented in empirical
case studies where music has aided in the elaboration of grief to find personal identity.
Smeijsters and van den Hurk (1999) conducted a study with a 53-year-old woman that
was referred to music therapy to express and explore her feelings, work through her
loneliness, and experiment with making decisions after receiving psychotherapeutic
treatment for a depression caused by the loss of her husband 3 years ago. As a result of
the treatment, the patient was able to express her feelings, process her loss and build a
sense of identity that she reported she had lost many years ago (Smeijsters & van den
Hurk, 1999). The authors define the reserarch methodology of the study within
naturalistic inquiry and grounded theory. They also present guidelines to enhance the
effectiveness of the treatment and to suggest transferability to similar contexts. The
procedures for data collection and analysis were done using techniques such as
categorizing, developing themes, writing memos, member checking, peer debriefing, and
triangulation. Such data collection procedures gave place to thick descriptions from
multiple perspectives such as the ones of the therapist, the researcher, the psychotherapist
and the client. This assisted to ensure transferability.
In a different study, Martin et al. (2012) conducted 4 pilot trials of Voice
Movement Therapy (VMT) with 19 young women who self-injure to reduce the
frequency of non-suicidal self-injuries and to improve emotion regulation, alexithymia,

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general mental health, and self-esteem. The study was conducted with clear procedures
and standardized measures were used for data collection. Four standardized measures
were used that were relevant to the dependent variables. Given the small sample size and
the presence of some outliers on some variables, the data was compared using a
Wilcoxon signed ranks test. No randomization, blinding or allocation concealment was
reported. As part of the results, it was found that VMT participants experienced
significant improvements in overall mental health, anxiety, somatic symptoms, and social
dysfunction.
Within the vocal approaches of music therapy used to alleviate anxiety in a
bereavement process, Ilya & Harris (2015) set out to understand the therapists
experiences of singing an imaginal dialogue with a deceased loved one. The research
question was formulated to understand why singing the intervention of an imaginal
dialogue might be tolerable, helpful, or difficult (Iliya & Harris, 2015). For this study,
they purposively selected nine creative arts therapists that were identified as women that
belonged to a minority group with a minimum of three years clinical experience and an
experience of having lost a loved one over a year ago. Given that the data analysis was
continuous, the participants were recruited until data saturation was reached. The
purposive sampling supports the transferability of the study. The protocol was clearly
described. The music therapy intervention was a single-session which was divided into
three parts: a) verbally discussing the loss and singing grounding exercises to warm-up;
b) singing the imaginal dialog; c) singing more grounding exercises and verbally
processing the interventions to reach a sense of closure. The researchers explicited their
bias by stating to have a personal history of grief and loss, which, according to the

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authors, gave them greater sensitivity to the topic. They also situated themselves as
singers and music therapists with advanced training in Austins (2008) method of vocal
psychotherapy with. The use of bracketing and reflexivity in reflexive diaries was also
reported. The reserachers also included the participants voices by having them complete
an open-ended questionnaire regarding their experience and mailed it directly to the
researcher. Within three days after the researcher about their experience in interviewed
the session participants open-ended, semi-structured phone interviews. The researcher
also contacted the participants once every week by e-mail for four consecutive weeks to
check back in with the participants and potentially provide additional therapeutic support.
The previously stated actions ensure trustworthiness by proving credibility, transferability
dependability and confirmability. At the end of the study, they found that music and
singing helped participants exchange apologies, greetings, questions, and answers with
their decea sed loved ones. Music and singing allowed participants to experience a sense
of flow that bypassed intellectualization while creating feelings of safety and
containment. The intervention helped participants access, express, and tolerate their grief,
which they named to be helpful in establishing a bond to the deceased.
Zarate (2015) conducted a study in which individual responses to music
psychotherapy and vocal psychotherapy were examined to evaluate effects on anxiety
symptoms. The study sought to explore if co-created improvised music between therapist
and client was effective in the treatment of anxiety. It used multiple single-subject
designs (SSD). Repeated measures with a convenience sample of 16 participants were
conducted. The Beck Anxiety Inventory (BAI - Beck & Steer, 1993 as cited in Zarate,
2015) was administered weekly for 12 consecutive weeks in one-hour individual weekly

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music therapy sessions. Data were analyzed and presented through visual representation
and in aggregate form to supplement the SSD analysis. The results showed that after
clinical instrumental and vocal improvisation, participants anxiety symptoms
significantly decreased by week six of treatment. All participants (N = 16) identified with
at least three symptoms of anxiety and met the criteria for generalized anxiety disorder
from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The
researchers used standarized and relevant measures. A repeated measures ANOVA was
conducted to examine change in anxiety categories. No allocation concealment and
randomization procedres were reported. The results revealed statistically significant
changes in the clinical anxiety category between baseline and week six, and baseline and
Week 12.
With the information provided above, we can understand the bereaved patients are
likely to experience high anxiety levels during their grieving process. Vocal
psychotherapy and melody in a music therapy treatment can assist them in the processing
of that grief and the alleviation of their anxiety symptoms. We also understand that this
anxiety could be caused by the lack of grounding or an attachment issue. It would be
beneficial to know the impact of melody in these anxiety symptoms cuased by said
attachment. More precisely, what are the effects of grounding melodic interactions
between the patient and the therapist. However, at the present time, there are no rigorous
randomized controlled trials that support with scientific rigor the effectiveness of
grounding melodic interventions for this population.

Purpose Statement and Research Question

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The purpose of this study is to compare the effect of grounding melodic, rhythmic
and receptive music therapy interventions on anxiety symptoms for bereaved patients.
The independent variables of this study would be the grounding melodic,
rhythmic and receptive music therapy intervention. The dependent variables of this study
would be the anxiety symptoms of the bereaved patients. At this point in research
grounding melodic interventions can be operationally defined as live melodic interactions
between the patient and the therapist that return consistently to the tonal center.
Grounding rhythmic interventions can be operationally defined as live rhythmic
interactions between the patient and the therapist that follow a strict pulse and present a
clear accent. Grounding receptive music therapy interventions can be operationally
defined as prerecorded interactions using grounding melodic and rhythmic interventions
that are played to the client.
According to the stated above, the research hypothesis is that grounding melodic
interventions will be more effective in the reduction of symptoms of anxiety in bereaved
patients than grounding rhythmic interventions or grounding receptive music therapy
interventions.

Methods
Design
The study will be implemented using a multiple single subjects design following an
AB format as suggested by Zarate (2016) in her recent study.

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Participants
For the study, and given that the studies presented in the literature review had all a
sample under 20 participants, the sample size there will be of 30 male and female
participants between the age of 25 and 40. They will be recruited through an internet
campaign advertised in bereavement organizations sucha as Grief Recovery After A
Substance Passing and Grief Share. They will be asked to participate in a research study
for music therapy to alleviate anxiety symptoms. The burden for the participants will be
low since music therapy is a non-invasive treatment and they will not have to cover the
cost of the treatment sessions.
Procedure
Patients will be asked to participate in an individual session to encourage
disclosure and provide a safe environment to expose their feelings. The session structure
and protocol will be similar to the one presented by Ilya and Harris (2015) as it will have
three parts: a) a corporal warm-up; b) the musical experience; c) verbalization of some
sort of elaboration process such as painting or writing a narrative text.
The musical experiences described in the middle section of the session will
consist of grounding melodic, rhythmic or receptive music therapy interventions. The
grounding melodic intervention will be done using the Vocal Holding Technique (Austin,
2001) as proposed by Ilya and Harris (2015) and Zarate (2015). The grounding rhythmic
interventions will consist of rhythmic dialogs with a clear sense of pulse and metre.
Lastly, the grounding receptive music therapy experiences will consist of listening to
prerecorded samples of the melodic and rhythmic interventions described above.

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Each session will have a different musical experience, and the treatment order
will be selected randomly using a table of the randomized number. Based on the
overservations made Martin et al. on the short amount of treatment had, this proposed
treatment will have a total of 24 weekly sessions, over a period of 6 months. The
interventions will be delivered by a trained and certified music therapist with knowdlege
on Austins (2001) vocal holding techniques.
Data collection
The data collection will be done using the General Health Questionnaire (GHQ,
Winefield, Goldney, Winefield, Tiggemann, 1989 as cited by Martin et al.), focusing on
the subscale score of anxiety and it will be administered before and after the session. The
data collector will be blinded regarding the type of musical experience offered in the
session to ensure the reliability of the data collected and minimize bias.
Analysis
The data will be analyzed using an ANOVA to compare the scores using
grounding melodic interventions, grounding rhythmic interventions and receptive music
therapy interventions accordingly.
Ethical considerations
All of the participants will sign and informed consent and the project will be
modified to receive ethical clearance from the IRB at Temple University.

This study is intended to add to the knowledge base that is emerging from the
practice in private music therapy treatments to alleviate anxiety in a bereavement process.

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The inclusion of a randomized controlled trial that can prove the effectiveness of
grounding melodic intervention to alleviate anxiety will allow for the continuation of a
tradition in healing through vocal expression and the scientific consolidation of an
ancient belief that vocal expression can serve as a means to reach health.
References
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