An Exploration of Music Therapy as a Strength Based Treatment

In Adolescents with Chronic Medical Conditions and Depressive Symptoms

A Thesis

Submitted to the Faculty

of

Drexel University

by

Molly Ann Boes

in partial fulfillment of the

requirements for the degree

of

Master of Arts in Creative Arts Therapy

May 2010

  ii

© Copyright 2010 Molly Ann Boes. All Rights Reserved.

  iiiDEDICATION

I dedicate this thesis with love to my family and friends, who have been a source of love

and support throughout this process. Thank you for encouraging me to not only follow

my dreams, but to chase them.

This thesis is also dedicated to all of the young people who struggle daily with chronic

medical conditions. Never let the limitations of others dictate the path for your own life.

  ivACKNOWLEDGEMENTS

I would like to extend great thanks to my thesis committee: Paul Nolan, John Berns, and

Christine Tuden Neugebauer. Your assistance, encouragement, feedback, and time have

een invaluable in the completion of this paper. b

                                    

  vTABLE OF CONTENTS

ABSTRACT…………………………………………………………………………......vii

1. INTRODUCTION…………………………………………………………………….1

2. LITERATURE REVIEW……………………………………………………………..4

2.1 Specific Information on Adolescents…………………………………………………4

2.1.1 Characteristics of Development……………………………………………………..4

2.1.2 The Effects of a Chronic Condition…………………………………………………6

2.1.3 Coping with Chronic Disease……………………………………………...………10

2.1.4 Treatment Adherence……………………………..………………………………..11

2.1.5 Depression in Adolescents with Chronic Conditions…………………………..….12

2.2 Treatment Options…………………………………………………………………..16

2.2.1 Overview of Subject……………………………………………………………….16

2.2.2 Psychopharmacological Options…………………………………………………...17

2.2.3 Psychotherapeutic Options…………………………………………………………18

2.2.4 Creative Arts Therapies……………………………………………………………19

2.3 Music Therapy………………………………………………………………………21

2.3.1 Music Therapy Defined……………………………………………………………21

2.3.2 Music Therapy for Use with Depression…………………………………………..23

2.3.3 Music Therapy for Hospitalized Adolescents……………………………………...25

3. METHODOLOGY…………………………………………………………………..28

3.1 Design……………………………………………………………………………….28

3.2 Subjects……………………………………………………………………………...28

3.3 Procedures…………………………………………………………………………...28

  vi

3.4 Data Analysis…………………………………….……………....………...………..29

3.5 Operational Definitions of Terms…………………………………………………...29

4. RESULTS……………………………………………………………………………31

5. DISCUSSION………………………………………………………………………..42

5.1 Overview of Results…………………………………………………………………42

5.2 Implications and Clinical Application………………………………………………42

5.3 Limitations of the Study………………………………………………………….….45

5.4 Suggestions for Further Research….………………………………………………..45

6. SUMMARY AND CONCLUSIONS………………………………………………..47

LIST OF REFERENCES………………………………………………………………..49

APPENDIX A: Characteristics of Adolescent Development……………………………58

APPENDIX B: Effects of a Chronic Condition………………………………………….59

APPENDIX C: Coping with Chronic Disease…………………………………………...60

APPENDIX D: Treatment Adherence………………………………………………...…61

APPENDIX E: Depression in Adolescents with Chronic Conditions…………………...62

APPENDIX F: Overview of Treatment Options………………………………………...63

APPENDIX G: Psychopharmacological Options………………………………………..64

APPENDIX H: Psychotherapeutic Options……………………………………………..65

APPENDIX I: Creative Arts Therapies………………………………………………….66

APPENDIX J: Music Therapy Defined………………………………………………….67

APPENDIX K: Music Therapy for Use with Depression……………………………….68

APPENDIX L: Music Therapy for Hospitalized Adolescents…………………..………69

  viiABSTRACT

An Exploration of Music Therapy as a Strength Based Treatment In Adolescents with Chronic Medical Conditions and Depressive Symptoms

Molly Ann Boes Paul Nolan, MCAT, MT-BC, LPC

This study explores music therapy with adolescents who have a chronic medical

condition and also show depressive or dysphoric symptoms. There are many options,

both pharmacological and psychotherapeutic, for treating these symptoms, but there is

little research in the field of music therapy for addressing the specific needs of these

adolescents.

Using database searches, literature was complied and reviewed on topics

including adolescent development, the effects of chronic medical conditions on

adolescents, and current treatment options for this population, including

psychopharmacology and various theories of psychotherapy including the creative arts

therapies. Music therapy was defined and applicable literature was addressed.

  Using clinical vignettes, results showed improvement in mental, emotional, 

and interpersonal processes that occurred during the music therapy process for 

adolescents within an inpatient hospital setting.  Such phenomena include the 

experience of pleasure and mastery, opportunities for healthy dissociation, 

restoration of self‐esteem through healthy narcissism, retreating resistance, identity 

development, opportunities for peak experiences and independence, and an 

investment in the music therapy process. 

   From these results, it can be implied that music therapy can be a 

beneficial option for the treatment of depressive symptoms in adolescence with 

chronic medical conditions.  The vignettes point to the effects of music therapy that

seemed to restore, strengthen, or revitalize healthy psychological functions that may have

become damaged or weakened due to the effects of the disease. Further research is

uggested to continue the development of music therapy for this population. 

viii

s

 

      

  1CHAPTER I: INTRODUCTION

The purpose of this literature based study is to explore published methods of

music therapy as possible treatment options for depressive and dysphoric symptoms in

adolescents with chronic medical conditions. This thesis reviewed literature about

current treatments such as verbal therapy and pharmacological options for this

population, as well as literature addressing the difficulties that can arise when treating

these adolescents. It also attended to varying music therapy treatment options.

Recommendations were then made from the results.

Adolescents with chronic medical conditions have a higher risk for depressive

symptoms than their healthy peers (Siegel, Golden, Gough, Lashley, & Sacker, 1990).

These symptoms affect the quality of life of these adolescents (Bhatia, 2007) and

negatively impact the medical condition (Bennett, 1994). This thesis addressed this

problem by researching music therapy treatment options for these adolescents. This

research has the potential to help this population by showing how music therapy can

address the unique needs of the adolescents both in inpatient and outpatient settings. The

results of this research can be recommended to both music therapists and other medical

professionals as an effective approach for treating adolescents with chronic conditions

and co-morbid depressive symptoms.

Pharmacological treatments have been shown to increase suicidal symptoms and

attempts in 4% of the child and adolescent aged population (United States Food and Drug

Administration, 2009). Data also exists showing that there is no statistical difference in

suicide rate among patients in studies assigned to antidepressants or placebos (Khan,

Khan, Kolts, & Brown, 2003).

  2The most commonly reported form of treatment, cognitive-behavior therapy

(CBT), has shown some promise among this population, but it has been researched and

used primarily with adult populations (Koplewicz, 2002). This treatment is also used

mainly for moderate to severe forms of depression (Paxton & Leventhal, 2006).

Interpersonal psychotherapy (IPT) has been deemed equivalent to CBT, but challenges

have arisen with difficulty forming the therapeutic alliance and adolescent egocentrism

(Chan, 2005). Existing treatment options are limited and under-researched, thus creating

the need for a treatment approach that is both effective and meets the adolescent where

they are. There also arises the issue of compliance of treatment in adolescents with

chronic conditions (Kyngas, Kroll, & Duffy, 2000).

Through music therapy, a supportive environment is created from the natural

structure of the music. Music offers the adolescent a form of expression that can affect

their emotions deeper than words alone (Tervo, 2001). Adolescents can use music to

relieve and dispel negative emotions, as well as for identity formation (Arnett, 1995).

The question then that this thesis will attempt to address is “In what ways can

music therapy by used to treat adolescents who have chronic medical conditions and

related depressive symptoms?” The research objective is that types of music therapy can

be used as an effective treatment option to help alleviate depressive symptoms in

adolescents who also have chronic medical conditions.

One delimitation that was imposed on this study was limiting the age of the

population being studied to adolescence, which in this study was defined as ages 12

through 21. Another delimitation was that while many adolescents suffer from

depression, this study was limited to adolescents who also have a coexisting chronic

  3medical condition. The current limitations of the study are that the results will not be

generalizable to every adolescent with a chronic medical condition. Another limitation is

that because no human subjects are being studied, actual results could differ from what is

inferred from the research.

It is expected that the findings of this thesis can be applied in the clinical setting,

in both inpatient and outpatient situations. By utilizing the creativity that can be

facilitated through music therapy (Robertson, 1992), depressive symptoms in adolescents

could be alleviated.

                          

  4CHAPTER II: LITERATURE REVIEW

Overview In the first section of this chapter, the author will provide basic information on

adolescent development that may relate to the effects that a chronic condition can have on

that development. Coping and treatment adherence during adolescence are also covered.

Comorbid depression in adolescents with chronic conditions is looked at, followed in the

second section by current treatment options for adolescent depression including

psychopharmacologic, psychotherapeutic, and creative arts therapy options. Although

music therapy does fall into the creative arts therapy category, for this literature review it

will be defined and examined within its own section.

2.1. Specific Information on Adolescents 2.1.1.Characteristics of Development Adolescence is a time of great change physically, psychosocially, and cognitively.

For the purposes of this literature review, psychosocial and cognitive changes in

adolescence will be the primary focus. Rice, a family psychologist, and Dolgin, a child

development psychologist, state that Freud described adolescence as a time of “sexual

excitement, anxiety, and sometimes personality disturbance” (Rice & Dolgin, 2005, p.

25). His psychoanalytic theory describes adolescence as a time when individuation

occurs, a period when a child separates from his or her parents to create their own feeling

and thoughts. They also state that Anna Freud viewed adolescence in a similar manner as

her father, describing it as a “period of internal conflict, psychic disequilibrium, and

erratic behavior” (p.27). In addition to this perspective, the authors cite Erikson’s view

of adolescence as a time of identity vs. diffusion. It is during this stage of personality

that the adolescent must develop a sense of one’s current and future self or a lack of

  5commitment and instability will ensue. Rice and Dolgin add that cognitively,

adolescents are moving through Piaget’s Formal Operational Stage. It is in this stage that

adolescents start to think in “more logical, abstract terms” (p.31). It is in this stage that

adolescents develop the ability to think into the future. However, this stage is takes time

to complete, and can last into the mid twenties because the frontal cortex of the brain is

not completely developed (p.152). Havighurst (1953) presented his own theory of

personality development, outlining nine tasks that adolescents must accomplish before

moving forward into adulthood. These tasks include: achieving new and mature relations

with age mates of both sexes, achieving masculine or feminine social role, accepting

one’s physique and using the body effectively, achieving emotional independence from

parents and other adults, achieving assurance of economic independence and selecting

and preparing for occupation, preparing for marriage and family life, developing

intellectual skills and concepts necessary for civic competence, desiring and achieving

socially responsible behavior, and acquiring a set of values and an ethical system as a

guide to behavior.

Working with adolescents presents different challenges than working with

children. British and Australian pediatricians Payne, Martin, Viner, and Skinner (2005)

provide suggestions for adolescent treatment within the pediatric medical practice. The

two main points of their approach include communicating with the adolescents by

developing a rapport and establishing confidentiality.

Pamela Burnard, a British professor with research on musical creativity and

development, lists the main four musical developmental milestones of creativity theories

(Burnard, 2006). Gardner’s theory only follows creative development through age 7.

  6Ross has two categories that address adolescents. At ages 8-13, there is concern with

conventions for musical production, whereas adolescents aged 14+ are more concerned

with personal style, personal taste, and embodied meaning. Swanwick and Tillman also

have two categories where adolescent development is addressed. Children aged 10-15

are in the Form Stage of Imaginative Play. It is in the Speculative mode where

experimentation and musical surprises are present, and in the Idiomatic mode where

musical styles and authenticity come into play. At the age of 15+, the Value Stage of

Metacognition, the Symbolic mode presents a wider range of musical styles, and the

Systematic mode increases the personal style and identification with certain music.

Hargreaves and Galton believe that ages 8-15 is a Rule Systems phase, where there is

increased mastery of cultural codes, and ages 16+ is the Professional phase, where there

is a more mature understanding of artistic conventions. Originality and divergence are

valued as part of the maturing process. Burnard believes that musical creativity becomes

associated with identity differentiation during adolescence. It is related to establishing

and maintaining relationships and social standings within the peer group.

2.1.2. The Effects of a Chronic Condition

Many common chronic illnesses are increasing in prevalence among adolescents

(Payne, Martin, Viner, & Skinner, 2005). Asthma, diabetes, cystic fibrosis, inflammatory

bowel disease, chronic arthritis, metabolic diseases, and neuromuscular diseases are listed

as common to the adolescent population, as well as some forms of cancer (Suris,

Michaud, & Viner, 2004).

The varying effects of having a chronic condition during adolescence are outlined

in many pieces of literature. Suris, Michaud, and Viner (2004) analyzed the effects of a

  7chronic disease on adolescent development by examining growth and puberty,

psychosocial development, and the effects on the course and management of the disease.

Psychologically, a chronic condition during adolescence could lead to the sick role

becoming a part of the person’s self-identity, a longer period of egocentricity, and

impaired development of cognitive functions and information processing, although this is

not always the case. Socially, reduced independence occurs and there is social isolation.

These issues affect the chronic illness by causing the possibility of poor treatment

adherence.

In reviewing twenty pieces of the literature, Taylor, Gibson, and Franck (2008)

found seven overarching themes in adolescents’ perceptions of living with a chronic

illness: developing and maintaining friendships, being normal/getting on with life, the

importance of family, attitude towards treatment, experiences of school, relationship with

the healthcare professional, and the future. They recommend these themes be taken into

account and implemented into practice when working with the adolescent population.

Berntsson, Berg, and Brydolf (2007) performed their own qualitative interview with

chronically ill adolescents to define the experience of well-being. They found three

themes: the feeling of acceptance of the illness as a natural part of life, a feeling of

support from family, friends, professionals, and society, and a continual feeling of

personal growth.

Using a 1-year longitudinal study surveying 54 adolescents with type I diabetes,

Skinner and Hampson (2001) hypothesized that an individual’s personal model of

diabetes is a “proximal determinant of both the emotional and behavioral response to the

illness” (p. 828). They found that the “greater impact a young person perceives diabetes

  8to have on his or her life, the more anxiety he or she subsequently experiences” (p. 831).

Illness centrality, or the extent to which a person defines himself or herself in terms of his

or her illness, can be another determinate of psychological and physical health in

adolescents with chronic conditions. Helgeson and Novak (2006) examined the

implications of illness centrality among 132 adolescents with type I diabetes. The

outcomes of these interviews showed that especially for females, diabetes was a central

part of their self-concept. For those females who viewed their diabetes negatively in their

self-concept, there was a higher incidence of depressive symptoms. Self-concept and

depressive symptoms were unrelated in the males who were interviewed, although they

did have poorer metabolic control than the females.

Grey, Boland, Yu, Sullivan-Bolyai, and Tamborlane (1998) obtained self-reports

to examine the quality of life in 52 adolescents with insulin dependent diabetes mellitus

(IDDM). They found that while the majority of adolescents included were not clinically

depressed (as seen by 6 of the 52 scoring over 13 on the Children’s Depression

Inventory), those adolescents who reported their diabetes having a larger impact on their

quality of life and those adolescents who worried about their diabetes had more

symptoms of depression. By examining psychosocial correlates of type I diabetes, Cote

et al. (2003) found that while there was a correlation between depressive symptoms and

utilization of healthcare services in children aged 8 to 12, the same correlation did not

exist in adolescents aged 13 to 18. The authors attribute this to adolescents becoming

better skilled “in accurately identifying depressive symptoms and seeking appropriate

mental health services” (p. 12) over time.

  9Forero, Bauman, Young, Booth, and Nutbeam (1996) examined evidence from a

regional study among Australian schools using behavioral and psychological questions to

compare adolescents with asthma and without asthma. The results show that adolescents

with asthma were more likely to engage in risk taking behaviors and perceive their school

performance as below average. It also showed that adolescents with asthma had a

statistically significant higher proportion of psychosomatic symptoms including feeling

low/depressed, feeling irritable, headaches, backaches, feeling nervous, sleeping

difficulties, and feeling dizzy than adolescents without asthma. Also comparing

adolescents with asthma to their non-asthmatic peers, Gillaspy, Hoff, Mullins, Van Pelt,

and Chaney (2002) had 50 adolescents fill out the Brief Symptom Inventory, the Beck

Depression Inventory, and the Beck Anxiety Inventory. Adolescents with asthma had

higher scores on multiple measures, specifically on measures of depressive

symptomology, anxiety, and global distress.

Engaging in high-risk behaviors is not limited to adolescents with asthma,

however. Suris, Michaud, Akre, and Sawyer (2008) examined the data of 7548 Swiss

adolescents, of which 760 reported a chronic illness or disability. After controlling for

variables, it was found that adolescents with a chronic condition were more likely to be

depressed. They were also more likely to smoke daily, use cannabis, and have performed

violent or antisocial acts. Adolescents with a chronic condition were also more likely to

report either three, or greater than or equal to four at risk behaviors than their peers

without a chronic condition.

  102.1.3. Coping with Chronic Disease

The conceptual framework for studying coping in adolescents consists of four

axes (Schmidt, Peterson, & Bullinger, 2003). The interpersonal axis includes family,

peers, healthcare providers, and other people surrounding the adolescent. The

development axis includes any factors associated with cognitive, emotional, and

intellectual development. The situational context axis examines the specific chronic

condition, and the adolescent’s setting. The final axis is participation, which involves the

adolescent’s health care needs, healthcare utilization, self-management, and the

involvement in medical decision-making. Throughout their article, Schmidt et al. focus

on these concepts to guide their research and to make theoretical assumptions. They

conclude that the axes are intertwined, and must be addressed in treating children and

adolescents with chronic conditions.

One perspective that incorporates one’s health within psychologically based

treatment is strength-based treatment. This approach emphasizes patients assets in

relation to their deficits, and maintains that people are resilient and able to overcome

life’s adversities. Strength-based treatment also focuses on what strengths a person has

that will help them cope with an adverse event (Smith, 2006). This perspective not only

allows the counselor or therapist to recognize strengths, but works to help patients

acknowledge the strengths within themselves as well.

In his article introducing strength-based treatment for practice within the

educational and treatment settings, Laursen (2003) explains how this type of treatment

can help “youth increase achievements and live more fulfilled lives (p.12). Four pillars

of effective positive treatment are also outlined: “1. cultivating strengths, supports, and

  11successful coping with random events, 2. forming and maintaining a positive

therapeutic alliance, 3. Cultivating a spirit of hope and positive expectations, and 4.

Employing methods respectful of the client’s values and needs (p.13).

2.1.4. Treatment Adherence

“The failure of the adolescent medical patient to adhere to prescribed medical

treatment is one of the major reasons for psychiatric consultation in pediatric medical

settings” (Shaw, 2001, p. 137). In his article, Shaw addresses both developmental and

psychopathological issues affecting treatment adherence. The developmental concept of

separation-individuation affects treatment adherence by challenging the issue of how well

adolescents are able to medically take care of themselves without supervision.

Adolescents normally fluctuate in their separation-individuation ability as they attempt to

distance themselves from previous caretakers such as their parents to establish their own

unique identity. Cause and effect thinking is not fully developed either, which creates

higher risk taking behavior regarding medical decisions. Difficulties with risk

assessment arise due to cognitive immaturity and adolescent omnipotence. Chronic

illnesses can create separation between adolescents and their peer groups, which can then

affect treatment adherence. Risk taking comes into play when adolescents with chronic

conditions do not fully comply with treatment, but neither do they disregard treatment

altogether. Psychiatric co-morbidity can exist in adolescents with chronic conditions, and

can manifest in the form of attention deficit hyperactivity disorder, post-traumatic stress

disorder, personality pathology, and depression. Specifically for depression, low self-

esteem can be correlated with poor treatment adherence. When an adolescent with a

chronic condition is depressed, they might make “deliberate decisions to refuse treatment

  12believing that the costs of treatment outweigh the potential benefits” (Shaw, 2001, p.

143).

Kyngas, Kroll, and Duffy (2000) reviewed the literature on adolescents with

chronic diseases to establish factors that can influence compliance. From the findings,

they categorized the factors into groups: developmental issues, medical and demographic

factors, cognitive-emotional and motivational factors, family support, peer support, and

interaction with healthcare providers. From their findings, they also gave a summary of

compliance-promoting interventions: patient education programs, family support, and

goal setting. Grey, Davidson, Boland, and Tamborlane (2001) address goal setting by

looking at the clinical and psychosocial factors associated with the achievement of

treatment goals. Eighty-one adolescents with type I diabetes were interviewed at baseline

and a one year follow up. It was found that adolescents who participated in coping skills

training and those who were less depressed at baseline were the most likely to have an

improved quality of life compared to baseline results at the one year follow up.

2.1.5. Depression in Adolescents with Chronic Conditions

Kaplan & Sadock’s Comprehensive Textbook of Psychiatry (2009) outlines

depressive disorders for children and adolescents. To qualify as major depressive

disorder, there must have been at least one major depressive episode where there was a 2-

week period of either depressed or irritable mood or a loss of interest or pleasure. There

also must be four of the following symptoms:

weight loss, weight gain, failure to make expected weight gain, or an increase or

decrease in appetite; insomnia or hypersomnia; psychomotor agitation or

retardation; fatigue or loss of energy; feelings of worthlessness or excessive or

  13inappropriate guilt; diminished ability to think or concentrate or indecisiveness;

and recurrent thoughts of death, recurrent suicidal ideation, or suicide attempt or

suicide plan. The symptoms must cause impairment in functioning or cause

clinically significant distress. (Wagner & Brent, 2009, p. 3652)

Depressive disorder not otherwise specified lasts a minimum of two weeks with

depressed or irritable mood and does not require all five symptoms of Major Depressive

Disorder. The article also notes that medical conditions such as neurological disorders,

endocrinological abnormalities, infections, autoimmune diseases and cancer can be a

differential diagnosis for depressive disorders, and that some medications such as anti-

inflammatory agents, antibiotics, steroids, stimulants, and oral contraceptives may lead to

depressive symptoms.

The National Institute of Mental Health [NIMH] produced a pamphlet in 2008 for

the general population that defines depression, lists the symptoms, examines the co-

morbidities, addresses the different causes, and explains treatment. According to the

NIMH (2008), “depression often coexists with other serious medical illnesses” (p.5).

There is also research that treating the depression can improve the treatment of the

coexisting illness. Bhatia and Bhatia (2007) focus their informative article specifically

on childhood and adolescent depression. They cover information in a similar format as

NIMH, but gear it towards family physicians. The article also lists chronic illness as a

risk factor for child and adolescent depressive disorders, along with other biomedical and

psychosocial factors.

In 1994, Bennett completed a meta-analysis of research studies examining

depression among children and adolescents with chronic medical problems. His findings

  14show that children and adolescents with chronic conditions have been proven to have a

higher risk of depression than their healthy peers. Within the chronic diseases studied, it

was also found that certain conditions pose a higher risk for depression in children and

adolescents: asthma, sickle cell anemia, and recurrent abdominal pain.

Seigel, Golden, Gough, Lashley, and Sacker (1990) completed their own study

compiling a questionnaire from the Beck Depression Inventory (BDI), the Rosenberg

Scale of Self-Esteem, and the McCutcheon Life Events Checklist. The authors compared

80 adolescents with sickle cell disease, asthma, or diabetes with 100 healthy adolescents.

The results found showed statistical significance in the difference between the mean

depression score of the groups, with 65% of adolescents with a chronic disease showing

signs of moderate to severe depression, and just 13% of healthy adolescents showing

signs of moderate to severe depression.

In a critical examination of the literature, Dantzer, Swendsen, Maurice-Tison, and

Salamon (2003) attempted

(1) to determine the general association of psychological factors, especially

anxiety and depression, with diabetes, (2) to examine the specific association of

anxiety and depression with metabolic control, and (3) to propose methodological

changes that are needed to advance future research in the field (p. 797).

They summarize by concluding that there is an association between diabetes and

psychological disorders in adolescents. Kanner, Hamrin, and Grey (2003) explore the

clinical implications of this depression in adolescents with diabetes in their article. By

examining the relevant literature in the field, this article provides background information

and treatment options to inform healthcare practice.

  15In a study of 2672 youth ages 10 to 21 with diabetes, Lawrence et al. (2006)

researched the prevalence and correlates of depressed mood. Looking at demographic

characteristics, glycosylated hemoglobin (HbA1c) level, hospitalizations, emergency

department visits, diabetic ketoacidosis (DKA) and hypoglycemic episodes. The HbA1c

is a test that the amount of glucose in the blood over a 2 or 3 month period (American

Diabetes Association, 2010). DKA occurs when a chemical that is produced when there

is a shortage of insulin builds up in the body. Symptoms include nausea, vomiting,

stomach pain, confusion, or coma (American Diabetes Association). After calculating

the data, Lawrence et al. found that depression is more likely to occur in adolescents who

are male with type 2 diabetes, female with other comorbidities, adolescents with poor

glycemic control, and a history of frequent emergency department visits. It is

recommended this information be taken into consideration when treating adolescents with

diabetes.

Hood et al. (2006) investigated similar characteristics, but broke the data down

into three categories: demographics, diabetes-specific, and family-functioning variables.

Questionnaires were administered to both the patients and their parents. The results show

that the youth were likely to be in agreement with their parents about their depressive

symptoms. In a two-year longitudinal study, Stewart, Rao, Emslie, Klein, and White

(2005) surveyed and followed adolescents with type 1 diabetes to determine the

relationship between depressive symptoms and hospitalizations. After controlling for

variables, it was found that depressive symptoms “significantly predicted the likelihood

of subsequent hospitalization” (p. 1317).

  162.2. Treatment Options This section will cover a variety of current treatments for adolescent depression.

Included in this literature review will be psychopharmacological options, cognitive

behavior therapy, interpersonal psychotherapy, psychodynamic therapy family therapy,

and creative arts therapies.

2.2.1. Overview of Subject

In his book on recognizing and treating adolescent depression, Koplewicz (2002)

uses his experience in the field to increase public knowledge about this subject. He

outlines the positives and negatives of the specific antidepressants Prozac, Zoloft, Paxil,

Luvox, and Celexa. Psychotherapeutic methods are also described, specifically cognitive

behavior therapy (CBT) and interpersonal therapy (IPT). Koplewicz also references the

Treatment for Adolescents with Depression Study that examined the combined effects of

CBT and Fluoxetine, a selective serotonin reuptake inhibitor (SSRI).

The Treatment for Adolescents with Depression Study (TADS) used a

randomized controlled trial with 439 adolescent patients to monitor the effect of four

treatments for major depressive disorder (March et al., 2004). Over twelve weeks the

subjects received fluoxetine alone, CBT alone, a combined treatment of fluoxetine and

CBT, or a placebo. The results show that the combined treatment of fluoxetine and CBT

is a superior treatment for adolescents with major depressive disorder based on the results

of the Revised Children’s Depression Rating Scale and Clinical Global impressions

improvement scores.

  172.2.2. Psychopharmacological Options By studying a national sample of data from a drug company manufacturing

paroxetine, Olfson, Marcus, and Druss (2008) examined the effects that the warning from

the Food and Drug Administration about antidepressant use had on the overall

prescription rate. In 2004, the FDA required that all antidepressants have a black box

warning describing the potential side effects and increased risk of suicide for young

people. The researchers studied three age categories: youth ages 6 to 17, adults ages 18

to 64, and older adults ages 65 and older. They also examined paroxetine use by gender

and by specialty of prescribing physician. Youth experienced the greatest change in

prescription rate based on the results of the analysis. Before the national warning, there

was a year-to-year increase of +30.0%. After the warning, that number changed to a -

44.2% prescription rate per year.

There is great concern in the literature that antidepressants can cause more harm

than good for depressed children. Antonuccio (2008) examines this concern in his

article, where he addresses the effectiveness, side effects, and the risk/benefit profile of

using antidepressants. Side effects from the medication include “agitation, sleep

disruption, gastrointestinal problems, and sexual problems” (p. 93). These risks increase

when a child or adolescent is on another medication in addition to an antidepressant.

This is not just a national issue, however, as Shearer and Bermingham (2008) also

examined this concern in the United Kingdom. They advise to err on the side of caution

due to two unresolved ethical concerns: “1. Its effectiveness over placebo 2. Short- and

long-term safety with regards the developing brain and body” (p. 710). They conclude

  18with the acknowledgement that prescribing physicians must be informed of all risks

and that antidepressants are not a quick fix for depression in children and adolescents.

2.2.3 Psychotherapeutic Options Cognitive behavioral therapy is currently one of the most researched

psychotherapeutic treatment options for depression. Reinecke, Ryan, and DuBois (1998)

conducted a literature review and meta-analysis on CBT studies involving depression and

depressive symptoms during adolescence. They find reasons for “optimism about the

effectiveness of psychotherapy with adolescents” (p. 31). Altering maladaptive beliefs

and changing behavior are important in the treatment of depression, and they are the

foundations of CBT treatment. In a literature review examining CBT interventions,

Lewinsohn and Clarke (1999) look at specific forms of treatment for adolescent

depression. Cognitive techniques include constructive thinking, positive self- talk, being

your own coach, coping skills, and self-change skills. In the family therapy context, an

emphasis is placed on conflict resolution, communication skills, and parenting skills.

Behavioral treatment includes the teaching of problem-solving skills, increasing pleasant

activities, and social skill building. Affective education and management involves

relaxation and anger management.

Interpersonal Psychotherapy (IPT) is another common approach for adolescents

with depression. It is a time-limited form of individual psychotherapy originally

developed for adults that explores a patient’s interpersonal problems such as grief, role

transitions, deficits, and disputes. Chan (2005) looks specifically at IPT as a treatment

model for adolescents with depression and chronic medical problems. The therapy

focuses on four main problem areas: grief, interpersonal role disputes, interpersonal role

  19transitions, and interpersonal deficits. Clinical studies show IPT as a successful

treatment for adolescents with depression, and so it is deduced it would also be an

appropriate intervention for adolescents with co-morbid depression and chronic disease.

Individual psychodynamic psychotherapy and family therapy can be effective

treatments for child and adolescent depression but are under researched within hospital

environments. Trowell et al. (2007) conducted a randomized control trial with 72

patients aged 9-15. After dividing the patients into two groups, sessions were conducted

over 9 months. Patients received either eight to fourteen 90 minute sessions of family

therapy, or sixteen to thirty 50 minute sessions of individual therapy. Assessments were

conducted before and after the treatment, as well as at a six month follow-up. Results

indicate that 74.3% of individuals receiving individual psychodynamic therapy and

75.7% of individuals receiving family therapy were no longer clinically depressed at the

conclusion of treatment. These numbers increased to 100% of individuals receiving

psychodynamic therapy and 81% of cases in the family therapy group at the six-month

follow-up, keeping in mind that what may appear as depressive symptoms can fade with

time.

2.2.4 Creative Arts Therapies In this section, art therapy, dance-movement therapy, and drama therapy are

examined, with music therapy being defined, researched, and expanded upon in the next

section. Art therapy can be an appropriate intervention for adolescents because it fits the

developmental need for adolescents to make their mark (Riley, 1999). It provides an

outlet for the pleasure that art making can bring; also it is an outlet for expression.

Through imagery, metaphorical language can be used for communication between the

  20adolescent and the art therapist. Riley (2003) explains that art therapy can be a

successful treatment for depression because it does the following for adolescents: the

adolescent can control communication through verbal and nonverbal interactions, the

adolescent feels respected when the art therapist honors the adolescent’s art, the

adolescent has an opportunity to feel omnipotent through the safe environment of the

artwork, and the adolescent can externalize his or her problems by creating art and then

manipulating the art in a safe environment.

Dance-Movement therapy (DMT) has also been researched as a treatment

approach for adolescents with mild depression. In a study involving 40 adolescents,

Jeong et al. (2005) randomly assigned the adolescents into two groups; one group

received 12 weeks of dance movement therapy 3 times a week for 45 minutes each

session, the control group received no therapeutic intervention. Physiological distress

was measured through self-report at baseline and after the 12 weeks. Neurohormones

cortisol, serotonin, and dopamine were also measured. After the 12 weeks, physiological

distress decreased in all members of the DMT group, whereas there was no significant

group change in the control group. With the neurohormones, the control group’s levels

of cortisol and dopamine increased and the serotonin level stayed the same. The DMT

group’s cortisol and dopamine levels decreased, while the serotonin level increased. The

results of the DMT group are preferred when trying to alleviate mild depression.

Drama therapy integrates techniques taken from theater such as role-play, stories,

and improvisation into a form of therapy that can help children and adolescents tell their

own story, set goals, express feelings, and explore their inner experience (National

Association for Drama Therapy, 2010). This is important as it can reduce feelings of

  21isolation, help in the development of coping skills, and improve self-esteem and self

worth. The benefit of using this type of therapy is that the therapist is able to meet the

patient where they are at, be it depressed, angry, or frustrated, and then create a safe

space in which play is used to express those emotions without words.

2.3. Music Therapy 2.3.1. Music Therapy Defined While there are many definitions for music therapy, according to the American

Music Therapy Association website (2009),

Music therapy is an established healthcare profession that uses music to address

physical, emotional, cognitive, and social needs of individuals of all ages. Music

therapy improves the quality of life for persons who are well and meets the needs

of children and adults with disabilities or illnesses.

They also confirm the effectiveness of music therapy as supported by research.

Boxill (1985) defined music therapy: “When music, as an agent of change, is used

to establish a therapeutic relationship, to nurture a person’s growth and development, to

assist in self-actualization, the process is music therapy” (p. 5). It is through music and

the relationship that ensues that the music therapist can help the patient. The following

are examples of a variety of approaches in music therapy.

“Music therapy is the prescribed use of music by a qualified person to effect

positive changes in the psychological, physical, cognitive, or social functioning of

individuals with health or educational problems,” according to Tervo in his article Music

Therapy for Adolescents (Tervo, 2001, p. 79). In this article, he explains how music can

help adolescents in expressing difficult feelings, especially rock music. Rock music

  22allows the adolescent an opportunity to connect with difficult feelings because of the

beat and firm pulse, which are “both safe and exciting” (p.81) even when the style and

lyrics change over generations.

Tervo (2001) has experienced three stages in his clinical work: the stage of

interest, in which the adolescent learns about music therapy through the support of the

music therapist and the support of self-expression. In this stage, the adolescent’s

unconscious hopes and fantasies are present. The second stage is the stage of learning, in

which an adolescent becomes familiar with different instruments. Because instruments

cannot be easily mastered, this can lead to developmental frustration for the adolescent.

The therapist provides support during this time of difficulty. Coping with the frustration

and powerful emotions also comes from learning the music, as the musical structure

provides safety. The third stage is the stage of improvisation, in which the adolescent is

freely able to express intense and personal feelings. It is not the musical skills or ability

of the adolescent that allows music therapy to be effective with this population, but the

transference and self-expression involved in the process.

Adolescents use the media around them as a tool for self-socialization. According

to Arnett (1995), there are five ways that this occurs. First, adolescents use media around

them simply as entertainment. Identity formation occurs as media provides the material

needed for the construction of the identity. Because adolescents tend to require a higher

amount of stimulation than adults, media can provide this high sensation. Media also

provides an outlet for which adolescents can cope through the relief and dispelling of

negative emotions. Finally, it is through the media that youth culture is maintained and

adolescents are able to identify with it.

  23

2.3.2. Music Therapy for Use with Depression Utilizing adolescent’s natural draw to music, Sheri Goldstein developed a tool

using songwriting as an assessment for hopelessness in depressed adolescents (1990). A

fill-in-the-blank song was created using the true/false statements from the Beck

Hopelessness Scale, and space was also left for patients to further explain themselves.

All of this was accomplished within the 12-bar-blues musical form.

In a literature review examining five randomized music therapy studies, Maratos,

Gold, Wang, and Crawford (2008) compare the effects of music therapy on adult patients

with depression with the effects of standard care. Four out of the five studies showed a

statistically significant reduction in depressive symptoms, while the fifth study showed

no differences. It is important to note in all studies that the dropout rate of patients in all

reported music therapy treatment was relatively low.

A meta-analysis was conducted by Gold, Voracek, and Wigram (2004) to

examine the overall efficacy of music therapy for psychopathology in adolescents and

children. After reviewing the studies, it was determined that music therapy has a

clinically relevant positive effect as an intervention. Music therapy was the most helpful

when a variety of music therapy approaches were used including behavioral,

psychodynamic, and humanistic. While the positive effects were higher when music

therapy was used in the treatment of behavioral and developmental diagnosis, there were

also positive outcomes in children and adolescents with emotional and mixed

psychopathologic diagnoses.

Self-esteem can be an issue for adolescents with an emotional instability such as

depression. Haines (1989) completed a six-week study of 19 such adolescents, 10 of

  24whom were in a music therapy group and 9 adolescents were placed in a control group

receiving group verbal therapy. Although no statistical significant difference was found

in self-esteem, there were differences in the process of the six-week treatment. The

patients who were members of the music therapy group had no complaints and were

excited about the group, while all but one of the patients were disappointed about their

placement in the verbal therapy group.

In another study comparing therapies, the effects of music and massage with

depressed adolescents are compared using frontal EEG measures (Jones and Field, 1999).

Asymmetry between the left and right frontal hemispheres has been shown to affect the

mood state, with those persons who have greater activation in the right frontal

hemisphere showing greater symptoms of depression. The music portion of the study

consisted of the adolescents listening to 15 minutes of uplifting rock music. Three EEG

measures of asymmetry were taken: before, during, and after the massage or music.

Results show that both treatment options decreased frontal asymmetry in the depressed

adolescents.

A case study was conducted with a depressed adolescent by Hendricks and

Bradley (2005) utilizing family therapy, interpersonal theory, and music techniques. The

adolescent brought familiar music into the family therapy session for the therapist and

parents to listen to. It was through the music listening that the parents and adolescent

were able to begin an open discussion about emotions and the expression of emotions.

Musical collages of recorded music were made by the adolescent to help him process and

describe difficult events in his past that were still affecting his thoughts. After the family

therapy sessions of interpersonal theory techniques and music techniques had ended, the

  25patient retook the Beck Depression Inventory and showed no depression. If the patient

began to experience depressive symptoms again, however, he informed the therapist that

he would let his parents know by playing a certain song for them.

2.3.3. Music Therapy for Hospitalized Adolescents Music and medicine have been linked throughout the centuries. The specific

benefits, however, are recently becoming more closely examined. Gallagher, Lagman,

Walsh, Davis, and LeGrand (2006) conducted a clinical study to objectively assess the

effect of music therapy within the medical setting, specifically on 200 patients with

chronic or advanced medical conditions. Using a variety of measures before and after

each music therapy session, it was found that symptoms including anxiety, depression,

pain, and shortness of breath improved after each session. These results proved to be

statistically significant, though the correlation was weak.

The clinical benefits of music therapy with hospitalized children, specifically

children with cancer, are examined in a study by Barrera, Rykov, and Doyle (2002). In

the study, 65 children aged 6 months to 17 years were divided into three age categories

and pre- and post-tests were given to measure a reduction in anxiety and an increase in

comfort. Results suggest that the music therapy did cause improvement in the childrens’

and adolescents’ affect, as well as an increase in levels of play for young children and in

adolescents.

Although literature exists on music therapy with adolescents with developmental

and physical disabilities, search results indicated very little literature specifically on

music therapy with hospitalized adolescents. Most literature addresses pediatrics,

including both children and adolescents as one age category. As research is starting to

  26show, the needs of adolescents in a medical setting can vary greatly from the needs of

children (Payne et al., 2005).

Specific music therapy techniques have been used to treat adolescents within the

hospital setting. In a case study format, Robb describes varying song writing techniques

with adolescents who have been traumatically injured (1996). Song writing is described

as “a flexible, yet structured musical medium for the expression of thoughts and feelings

(p. 32). Through the case examples, four techniques of song writing are described: fill-

in-the-blank format, group song writing, improvisational song writing, and discharge

songs.

Another technique for hospitalized adolescents in the literature is that of a

therapeutic music video. Burns, Robb, & Haase (2009), in a study that shows the

difficulty of maintaining subject retention within a medical setting, randomized 12

adolescents and young adults into two groups. These included the therapeutic music

video group, in which sessions were conducted by a board-certified music therapist, or an

audio-book group, in which sessions were conducted by a child life specialist. The goals

of the sessions, which were held twice weekly for three weeks, were to diminish

symptom distress and improve coping, derived meaning, resilience, and quality of life.

Outcomes for this study showed that the adolescents were more invested in the music

video process then their peers, as seen by the completion rates, where all of the six

adolescents completed the music video project, and while two adolescents in the audio-

book became ill during the study and were unable to complete the study, three

adolescents in this group withdrew from the study and one chose not to complete any of

the sessions after learning of his randomization status. This left only one adolescent

  27completing the audio book sessions. Using pre-session and post-session measures as a

basis for comparison, results indicate that there were positive trends in both groups.

  28CHAPTER III: METHODOLOGY

3.1. Design The design of this research is a literature-based study, reviewing adolescents with

chronic diseases and music therapy as a treatment option for their depressive symptoms.

A comparative analysis was used to compile and categorize the data into matrices. The

matrices (Garrard, 2007) were used to analyze the data and conclusions were made from

this analysis.

3.2. Subjects

There were no human subjects used for this study.

3.3. Procedures Literature was acquired using Drexel University supported databases MEDLINE

(OVID) and PsychINFO, as well as Google Scholar. Included in the search were peer-

reviewed journal articles and edited and single-author books from the fields of

psychology, pediatric medicine, general medicine, nursing, psychopharmacology, family

therapy, art therapy, dance-movement therapy, drama therapy, and music therapy. A

variety of search terms were used including but not limited to adolescent, youth, children,

teenager, chronic condition, chronic disease, medical condition, diabetes, asthma,

juvenile rheumatoid arthritis, depression, depressive symptom, development, coping,

treatment, creativity, therapy, psychotherapy, cognitive-behavior therapy, interpersonal

therapy, family therapy, creative arts therapy, art therapy, dance-movement therapy,

drama therapy, and music therapy. Most sources were limited to a publication date range

of the last ten years. The final sources were chosen based on their relevance to this study.

The collected sources were then analyzed and organized into the matrix method.

  29 3.4. Data Analysis The matrix method, developed by Judith Garrard (2007), was utilized for the

organization of the resources collected. Primary trends were found in the literature by

compiling and categorizing the data within the matrices. These primary trends,

specifically literature on strength based treatments and music therapy applications with

adolescents, were then integrated with clinical vignettes. Recommendations for specific

perspectives with hospitalized adolescents with chronic medical conditions were made

based upon an integration of literature and clinical vignettes.

3.5. Operational Definitions of Terms Adolescent- For the purpose of limiting this thesis, an adolescent will be defined as a

human subject between the ages of 12 and 21.

Chronic disease- A health condition, not considered terminal but lasting longer than 6

months with continuous medical care, that causes major limitations in daily living.

Almost 1 out of 10 Americans live with chronic conditions (U.S. Department of Health

and Human Services, 2009).

Compliance-The behaviors, thought processes, or actions taken to follow medical advice

by a patient or client are the basic components of compliance. The patient’s

collaboration and commitment to care are now also considered to be a part of

compliance, but it still remains difficult to measure and report (Kyngas, 2000).

Depression- A common but serious illness, depression interferes with normal functioning

and daily life. Though there are several different diagnosable forms of depression such

as Major Depressive Disorder and Dysthymic Disorder, this thesis will broaden the scope

to include adolescents who have not been formally diagnosed with a depressive disorder

  30but do exhibit depressive symptoms. Such symptoms include feelings of sadness,

anxiety, hopelessness, guilt, and helplessness, fatigue and decreased energy, insomnia or

hypersomnia, loss of interest in pleasurable activities, and thoughts of suicide (National

Institute of Mental Health, 2008).

Music Therapy- Music Therapy is an established healthcare profession that uses music to

address physical, emotional, cognitive, and social needs of individuals of all ages. Music

therapy improves the quality of life for persons who are well and meets the needs of

children and adults with disabilities or illnesses (American Music Therapy Association,

009). 2

                           

  31CHAPTER IV: RESULTS

The objective of this thesis is that music therapy can be used as an effective

treatment option to help hospitalized adolescents who also have co-morbid chronic

medical conditions deal with dysphoric moods and depressive symptoms. Major findings

in this study were influenced by the practice of this researcher and her music therapy

practice in a hospital setting.

The included clinical vignettes present examples of how music therapy affects

adolescents. For this thesis, the vignettes are being used to provide support for the

benefits of music therapy with the adolescent aged population. Instead of treating the

typical symptoms of childhood depression which include “mood disturbances, capacity

for enjoyment, depressed self-evaluation, disturbances in behavior toward other people,

and vegetative symptoms, which include fatigue, oversleeping, having difficulty with

activities requiring effort, and other symptoms of passivity or inactivity” (Encyclopedia

of Mental Disorders, 2009), music therapy elicits healthy responses that are the antidote

to these symptoms. It is the wellness within the patient that allows him or her to respond

to and be enticed by the art (Pratt, 1992).

In the following Table 1, the outcomes of studies examined in chapter two are

listed. Various modalities are included, and the results indicate that all methods of

treatment tend to have a positive effect on depression in adolescents.

  32Table 1 Author(s) Modality Population Outcomes March (2004) Cognitive-Behavior

Therapy (CBT) Volunteer sample of 111 patients aged 12-17 with a diagnosis of Major Depressive Disorder

Children’s Depression Rating Scale-Revised (CDRS-R) decreased mean difference of 17.58, Reynolds Adolescent Depression Scale (RADS) decreased mean difference of 10.73, and Suicidal Ideation Questionnaire-Junior High School Version (SIQ-Jr) decreased mean difference of 10.51.

March (2004) Psychopharmacology (Fluoxetine)

Volunteer sample of 109 patients aged 12-17 with a diagnosis of Major Depressive Disorder

CDRS-R decreased mean difference of 22.64, RADS decreased mean difference of 16.38, and SIQ-Jr decreased mean difference of 7.37.

March (2004) Combined Treatment (CBT & Fluoxetine)

Volunteer sample of 107 patients aged 12-17 with a diagnosis of Major Depressive Disorder

CDRS-R decreased mean difference of 27.00, RADS decreased mean difference of 23.17, and SIQ-Jr decreased mean difference of 15.54.

Trowell, et al. (2007)

Family Therapy 37 European patients aged 9-15 referred to trial

Children’s Depression Inventory (CDI) decreased mean difference of 14.76, Moods & Feeling Questionaire (MFQ) decreased mean difference of 11.14, and Children’s Global Assessment Scale (C-GAS) increased mean difference of 19.08

Trowell, et al. (2007)

Individual Psychodynamic Therapy

35 European patients aged 9-15 referred to trial

CDI decreased mean difference of 13.26, MFQ decreased mean difference of 8.55, and C-GAS increased mean difference of 19.97.

Jeong, et al. (2005) Dance Movement Therapy

40 Korean middle school volunteers with high depression scores

Improvements in negative psychological symptoms: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, & psychoticism. Decreased levels of cortisol and dopamine, increased levels of serotonin.

Gold, Voracek & Wigram (2004)

Music Therapy 11 music therapy studies involving children and adolescents were compared

Changes in development, self-confidence, communicative responses, social behavior, self-concept, self-esteem, behavior, and cognitive ability.

  33 Art can bring out well-being in adolescents within the hospital setting.

Thwaite, Bennett, Pynor, and Zigmond (2003) describe this experience in their article on

art within adolescent healthcare.

The process of creation can allow a catharsis of suppressed emotion, the safe

expression of fears of the forbidden, an exploration of possibilities, the experience

of variety and challenge, and the creation of metaphor for interpreting the world

(p. 72).

Through the creation of art, the adolescent is able to experience true expression and

communicate in a way that words are not necessary.

In her thesis on popular music facilitating the achievement of developmental

milestones, Margret Hofmann Patterson outlines four effects that music has on

adolescents (2001). She proposes music as a safe structure for ego regression, music as a

facilitator of autonomy from parental figures, music as a vehicle for the process of

identification, and music as a facilitator of identity development.

William Sears presents three classifications in under which all constructs of music

therapy can fall under (1968). Unlike Patterson, who focuses on adolescents, Sears

developed a general conceptual framework applicable to processes within the music

therapy process. He named these client processes: experience within structure,

experience in self-organization, and experience in relating to others.

Within the pediatric medical setting, this researcher has also seen other effects

among adolescents who receive music therapy. Some of these effects include better

coping with the hospital experience, pain, or medical conditions, increased expression of

emotion, improved self-esteem, decreased anxiety, awareness of one’s own creativity, the

  34formation of relationships and interaction with other patients, and better

communication with staff members.

After each of the following three clinical vignettes, the phenomena will be

addressed by the researcher. These findings are representative samples of phenomena

that could occur within the music therapy field.

Daniel

Daniel, a 14-year old on the adolescent unit, was admitted to the hospital for

excruciating abdominal pain. After running a battery of tests and scans, no

specific cause was determined for the pain. His mother was present throughout

his hospital stay. Daniel was referred to music therapy for help in coping with

the isolation within the hospital and his uncontrollable pain, leading to a feeling

of helplessness.

When asked about his musical background, Daniel described himself as a

drummer, but willing to play a variety of instruments. He explained how his older

sister was also very musical, and they would play together; he also played in a

band with some of his friends. The two music therapy sessions with Daniel

consisted mostly of improvisatory music making, with Daniel playing hand drums

and the therapist playing either another hand drum or guitar.

Daniel had never played hand drums before, playing only a drum kit at school

and at home. Throughout the sessions, he commented on how different it was to

play with his hands, how he could feel the drum resonate through his body, and

how he really liked that feeling. As the therapist and Daniel played together,

  35Daniel used different techniques to express different timbres. Rhythmically, he

created and maintained complexity in subdivisions while maintaining a musical

role with the therapist during the drumming duet. Between improvisations, he

commented on how good he thought the music sounded and many sounds could be

created out of a single drum.

Throughout the sessions there were also moments when Daniel’s pain would

affect him and he would start to double over and clutch his abdomen. If this

occurred in between improvisations, the music therapist simply encouraged him

to start playing again, which successfully helped Daniel dissociate the pain.

When the pain occurred during an improvisation, the music therapist continued

playing, while Daniel stopped for only a few seconds and then joined back in with

the music. The patient’s mother commented later on how the pain episodes

Daniel had during music therapy sessions seemed to not last as long, and Daniel

agreed with this observation.

The first important musical phenomenon that occurred during this music therapy

session with Daniel was his response, “This is the most fun I’ve ever had in the hospital.”

While this might seem like a comment that could be easily discarded, it is important to

note as a musical phenomenon. In exploring a new instrument by applying techniques he

was already familiar with, Daniel enjoyed the music therapy experience enough to

proclaim the fun that he had through a complex sequence of psychological processes. He

chose to problem solve in converting his drum kit experiences into the use of a hand

drum, during which he created a variety of musical timbres and rhythmic subdivisions

  36that contributed interest to the musical duet. The resulting affective experiences are

understood as experiences in mastery where a playful threat is encountered, challenging

the individuals resources in a creative experience that when successful, as in the case of

Daniel, result in a release of tension and the experience of pleasure.

Daniel’s response to pain was not something that he could master. As an

adolescent, this can present extra anxiety because during this period of development, the

adolescent is trying to establish more independence in his or her life. For Daniel, music

therapy provided the opportunity to gain mastery over instruments. This musical

phenomenon made available the experience of mastery, which could then be applied to

mastery of feelings and thoughts.

Another perspective of this phenomenon is that of healthy dissociation. When

Daniel played the drum during his music therapy session, he was not simply distracted

from his experience of pain. Instead the healthy dissociation he was experiencing uses a

longer amount of time and can be a part of an avoidant coping mechanism. This healthy

dissociation is not a symptom that needs to be pathologized, but can be a positive,

adaptive experience that is separated from one’s conscious awareness, in a “capacity

similar to imagination and absorption” (Krippner & Powers, 1997, p. 33).

Jasmine

Jasmine, a 15-year old on the oncology unit, was hospitalized for a bone marrow

transplant. Many female family members were present during daytime hours, but

in the early evening she was left alone. Jasmine was referred to music therapy by

  37the child life specialist as an outlet for emotional expression while processing

the hospitalization experience.

During initial sessions, family was present and the patient played both the

keyboard and the electronic drum pad. Her mother encouraged her to “learn

something,” especially on the keyboard. The more the mother prompted, the

more regressed and resistant Jasmine became in her playing, as seen by hand

smashing on the keyboard or very little effort with the drum pad despite choosing

to play it. She was also reserved in talking with the therapist, choosing to nod her

head or give brief one-word answers to questions.

Witnessing this behavior, the music therapist decided to try a song writing

exercise when the patient’s family was not present. The therapist found Jasmine

receptive to this idea, but unsure of where to start when coming up with lyrics.

After the suggestion of an ABAB rhyme scheme and the two initial words of

“place” and “space” to end two lines from the therapist, Jasmine was able to

create a full song describing what she feeling in the hospital. Other than the

words “place” and “space” the therapist gave no prompting of themes for the

song. The song that Jasmine came up with follows.

“Sittin’ around this place

Don’t have no place to go.

So I’m sittin’ here needin’ some space

Don’t have no place to go.

I just wanna go home

Don’t have no place to go

  38Lookin’ for someone to come

Don’t have no place to go.”

In the following session, the idea was proposed to Jasmine to record the song.

She wanted to make it into a rap, with a loop underneath it, which was created

using Garage Band recording software and a preset drum loop. After choosing

the background loop, Jasmine became very resistant to the whole idea, insisting

she did not want to record her own voice, and asking the music therapist to

record it instead. They came to a compromise where the music therapist said the

verses and Jasmine rapped the chorus, but only once the voice effect “Mouse”

was used, distorting the voices on the recording. Jasmine was pleased with the

final product, however, and asked for an extra copy.

Jasmine experienced a common phenomenon that occurs when adolescents are

experiencing something new or unfamiliar: her attention turned inward. This intentional

attention shift as a part of her creative process in this case can be understood as a

restorative process in the form of healthy narcissism, which is related in adolescence to

the development of the sense of self. The mother’s absence during the session also

allowed space for Jasmine to exhibit autonomy. Although this phenomenon occurred

during her music therapy sessions, through support and encouragement Jasmine was able

to overcome this reaction to interact with the music therapist and further restore her self-

esteem.

Once Jasmine had invested in the song writing process, another phenomenon

occurred. In this researcher’s clinical opinion, there is the possibility she showed

  39resistance due to a fear of failure when it came time to record her singing. Another

possibility is that the patient did like hearing her voice on a recording. This phenomenon

was overcome as well, but it became a part of the music therapy process that had to be

worked through, leading to what seemed to be a clear expression of pride and pleasure.

Josh

Josh, a 13-year old on the pulmonary unit, was hospitalized due to complications

with his cystic fibrosis. He also described himself as a drummer, and was

referred to music therapy as a creative outlet.

During the single session Josh had while in the hospital, he asked to play the

drums, and he had pulled out his own drumsticks ready to play anything

available. The therapist offered a variety of hand drums to him, and together they

set up a pattern on his bed that sounded quite similar to an actual drumset.

Tambourines were set on the bed table as cymbals, and various drums were taped

to the bed rails and placed in such a position so Josh was able to achieve his

desired affect. The music therapist played the keyboard, alternating chord

progressions and musical styles for each improvisation.

Josh commented on how good the music sounded, and how the music changed

sometimes without any planning. He alternated with the therapist in starting the

improvisation, but showed great flexibility and musicality in his playing as he

created phrases and took solos.

At one point during the music therapy session, a phlebotomist came into the room,

insisting she needed to take blood. Josh tried explaining that his port currently

  40had an IV in it, to which the phlebotomist responded that she would take blood

from his arm. Starting to become frustrated, Josh explained that she would not be

able to draw from his arm. The phlebotomist did not receive this information

well, insisting that the blood must be drawn. After a short back and forth

discussion between the phlebotomist and Josh, the therapist stepped in,

suggesting that the phlebotomist come back after Josh’s mother returned from a

short errand. This was a satisfactory solution for all parties involved, and Josh

was able to continue improvising on the makeshift drumset. Immediately

following this encounter with the phlebotomist however, Josh asked to start and

lead the final improvisation. While he was somewhat withdrawn immediately

following the interaction with the phlebotomist, his music remained expressive.

For Josh, the phenomenon that occurred in this music therapy session was the

opportunity for identity development and the emergence of personal style. He knew

before the session that he identified himself as a musician, and the music therapy process

helped him further maintain this identity even while in the hospital. The relationship

between Josh and this researcher fostered that identity, as a container was created by the

music therapist on the keyboard in which Josh could feel successful and express his own

personal style.

The music therapy session provided Josh the opportunity for a peak experience

through creativity. In the process of making music, Josh was able to realize self-

sufficiency, playfulness, effortlessness, richness, order, completion, uniqueness,

aliveness, and beauty. These values are listed by Maslow (1981) as characteristics

  41commonly perceived in peak experiences; these values contribute to the ideal for

which one strives.

When the phlebotomist entered, the control that Josh had over his own body and

in the decision making process were greatly reduced. In the music following that

interaction however, Josh could express that control that was taken away from him. This

phenomenon of music therapy as a place for control to be exhibited is supported by his

asking to lead the music following the interaction with the phlebotomist.

Although not shown in this research through a clinical vignette, musical

phenomena also occur in adolescent music therapy groups. When adolescents interact in

the group, there is a forced working together to create something larger than the self; the

music is a sum of all of the individual parts. The music therapist emphasizes the process

within the group, so that while there may be a final product, the process of creating that

music is where the actual therapy occurs.

The most common phenomenon that this researcher has witnessed within the

group music therapy context is the silence after a musical creation, and then the response

“that was cool” by the participating adolescents. This experience of creating “cool”

music within sessions is important, as it shows the adolescents are invested in the process

of group music therapy.

  42CHAPTER V: DISCUSSION

5.1 Overview This study examined music therapy treatment with adolescents who have co-

morbid depressive or dysphoric symptoms and chronic medical conditions. The

described case vignettes indicated different phenomena that occurred within the music

therapy sessions that can be attributed to the alleviation of some depressive symptoms.

Not only does music therapy work on alleviating symptoms, but it also increases

opportunities for healthy expression and that can lead to better adaptation within the

hospital setting. Such phenomena include experience of pleasure and mastery, 

opportunities for healthy dissociation, restoration of self‐esteem through healthy 

narcissism, retreating resistance, identity development, opportunities for peak 

experiences and independence, and an investment in the music therapy process. 

These phenomena occurred because of the music therapy process.  Within 

the music therapy process, a therapeutic relationship is formed between the patient 

and the music therapist.  The relationship provides the space for creativity, which 

arises due to adversity.  Through verbal and motor engagement, music therapy can 

influence affect and provide the opportunity for creative and emotional expression.  

Music therapy in some cases can educate about music, but it can also enhance the 

interpersonal abilities through the music.   

5.2 Implications and Clinical Application

The literature and results of this study indicate that music therapy could be an

applicable and well-received treatment option for adolescents with chronic medical

conditions and depressive symptoms. Through music therapy, adolescents are given the

  43opportunity to explore healthy areas of functioning, which can restore psychological

processes that have been influenced by the presence of depressive symptoms. As seen in

the literature, a strength-based treatment approach can empower an adolescent towards

better coping and acknowledgment of their own strengths (Smith, 2006). Within the

clinical vignettes, the effects of this strength-based approach can be seen, especially in

the case of Daniel. Instead of dwelling on his pain, the music therapist encouraged his

musical expression and the use of his musical talent, which was a source of strength

within the patient. For Daniel, the music therapy became a restorative experience where

health emerged and many of the negative aspects of the hospital experience faded into the

background.

Multiple qualities of music therapy can pique the interest of adolescent patients,

and this interest is linked with important inner workings of the adolescent, which helps

the adolescents stay invested in the music therapy process. This leads to a healthier

perspective of the hospital experience in which aspects of wellness are restored. Thwaite,

Bennett, Pynor, and Zigmond (2003) explain this process through the creation of art.

This phenomenon was seen in the case of Jasmine, who through the creation of a song

was allowed a catharsis of suppressed emotion and the safe expression of fears. Josh,

through the creation of music was allowed the experience of variety in the instruments

available, and the challenge of making what was available work to create the music.

The clinical vignettes also show the four effects Patterson outlines (2001). Daniel

was able to experience ego controlled regression through the music therapy that helped

the dissociation of his pain. Music therapy also served as a vehicle for the process of

identification for Daniel, as he was able to identify the musician within himself. For

  44Jasmine, the music served as a facilitator of autonomy from her parental figures, as

through the music therapy sessions, she was able to establish the autonomy she for which

she was longing. In Josh’s case, music therapy facilitated identity development, as he

was able to reestablish his identity as a musician.

Sears’ constructs also apply to the clinical vignettes (1968). Daniel had the

opportunity to experience relating to others as he made music with the music therapist.

Through the music making process, he became more aware of the therapeutic

relationship. Jasmine experienced structure through the process of writing and recording

her song which helped to transform her state from dysphoria to a more positive mood

state. Josh was able to experience self-organization with the support of the music

therapist by initiating the final musical piece.

Within the literature, there are many examples of how music therapy can tap into

the psyche of the adolescent. Problem solving is an example of everyday creative

thinking, and this can be seen in the case of Josh, who used creativity to solve the

problem of not having an actual drumset to play. Coping skills can seen in many forms

such as in a defense, by accessing intelligence, in developmentally appropriate ways, by

accessing resources, and in creative endowment. A supportive environment is also

created from the natural structure of the music (Tervo, 2001). This supportive

environment was critical in the case of Daniel, who needed that support to cope with his

pain. Positive transference and self-expression are involved in the music therapy process

as seen in the case of Jasmine, as she seemed to have experienced the music therapist as a

safe person within the hospital. This relationship created trust so that self-expression was

possible.

  455.3 Limitations of the Study This study examines music therapy with adolescents with depressive symptoms

who also have chronic medical conditions. While the study begins to explore and

describe music therapy with these adolescents, the results are not necessarily

generalizable to every adolescent with these conditions. The vignettes described in this

study consist of three music therapy sessions. Although the adolescents did not have a

diagnosis of depression, they showed some depressive symptoms related to their medical

status. Different or more extensive results may have been obtained if the sessions were

conducted with patients with the medical conditions specified for this thesis.

Incidentally, both males and females were represented in the vignettes. While

differences in gender were not considered as part of this study, there may be a difference

in the effects of music therapy between males and females. Additionally, two different

racial groups were also represented in the study. Racial and cultural groups were not

considered in this study either, but may have had an effect on the outcomes.

5.4 Suggestions for Further Research

Music therapy research involving chronically ill adolescents is very limited, and

this researcher found no literature relating to using music therapy when treating

adolescents with co-morbid depression and a chronic medical condition. A more

standardized protocol for working with these adolescents or the inclusion of more case

material may yield more definitive results about the use of music therapy with this

population. It may be useful to learn more about the experience of the adolescents

themselves in music therapy, and the perceived effects of the music therapy on their

depression. Another path for further research could involve comparing the differences in

  46group and individual music therapy sessions, and examining ways to reach adolescents

who are not in inpatient hospitals. Also, since the vignettes point to the effects of music

therapy that seemed to restore, strengthen, or revitalize healthy psychological functions

that may have become damaged or weakened due to the effects of the disease and

hospitalizations, researching differences between restorative and symptom reduction

music therapy may be beneficial.

  47CHAPTER VI: SUMMARY AND CONCLUSIONS

This thesis has begun to explore how music therapy can be used as an effective

strength based treatment option to help alleviate depressive symptoms in adolescents who

have chronic medical conditions. The needs of these adolescents were addressed as

literature in this study gave an overview of the characteristics of adolescent development

and discussed the effects of a chronic condition on the adolescent as well as coping and

treatment adherence. Treatment options in both the psychopharmacologic and

psychotherapeutic realms, including the creative arts therapies were presented. Current

music therapy trends in the literature were also included.

In presenting the results of this study, clinical vignettes showed examples of

musical phenomena that can occur when working with adolescents in a medical setting.

All subjects were developmentally appropriate within the age range defined as

adolescence with varying medical diagnoses. Each patient participated in music therapy,

using the music therapy experience in varying ways to create a space for self-expression.

In this research, music therapy seems to be able to fill a gap in the current practice

of treating the depressive symptoms in adolescents with chronic medical conditions. The

music therapy provides an outlet for emotional expression and creates a therapeutic space

for creativity. Improved affect and interpersonal relating abilities also occur through the

music making process, using music therapy methods to elicit healthy responses as an

antidote to depressive symptoms.

This literature-based study also suggests areas for future research. These areas

include: the creation of a more standardized protocol for working with these adolescents,

the collection of the adolescent’s experience in music therapy and their perceptions on its

  48effectiveness, and the comparison of group and individual music therapy sessions.

Methods for reaching adolescents outside of inpatient hospital settings, and the

differences between restorative and symptom reduction music therapy are also suggested

ch areas. as future resear

   

                               

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  58Appendix A: Characteristics of Adolescent Development

Author(s) Topic

Rice & Dolgin (2005)

This textbook is a complete overview of the adolescent years, including development, culture, and relationships.

Payne, Martin, Viner, & Skinner (2005)

This article examines the benefits of addressing the needs of adolescents in healthcare practice.

Burnard (2006) In this textbook musical and creative development is examined through multiple theories.

Havighurst (1953) This author presents nine tasks for adolescent personality development.

                              

  59Appendix B: Effects of a Chronic Condition

Author(s) Topic

Suris, Michaud & Viner (2004)

This article looks at the biological, psychological, and social effects of a chronic illness on adolescent development, as well as developmental issues that affect a chronic illness.

Taylor, Gibson & Franck (2008)

This literature review looks at the personal lived experience of adolescents with a chronic illness. Seven main themes were found: developing and maintaining friendships, being normal/getting on with life, the importance of family, attitude to treatment, experiences of school, relationship with healthcare professional, and the future.

Berntsson, Berg & Brydolf (2007)

This study interviewed adolescents with chronic illness about their experiences of well-being. Three themes emerged: feeling of acceptance of illness as a natural part of life, feeling of support, and a feeling of personal growth.

Skinner & Hampson (2001)

This study followed adolescents with Type 1 diabetes for one year, using self-reports at baseline and at follow-up for perceived diabetes self-care, well-being, and personal models of diabetes. Glycemic control was also monitored through normal measures.

Helgeson & Novak (2006)

By interviewing adolescents with diabetes, this study examined the implications of illness centrality for psychological and physical health.

Grey, Boland, Yu, Sullivan-Bolyai & Tamborlane (1998)

Self-reports in this study were used to look at quality of life for adolescents with diabetes. Measures included quality of life, depression, coping, family behavior, and self-efficacy.

Cote, et al. (2003) This study examined the correlation of depressive symptomolgy and healthcare utilization in children and adolescents with Type 1 diabetes using self-surveys.

Forero, Bauman, Young, Booth & Nutbeam (1996)

Adolescents with asthma were surveyed in this study to examine health behaviors and social adjustment.

Gillaspy, Hoff, Mullins, Van Pelt & Cheney (2002)

This study examines adolescents with asthma and the relationship between asthma and psychological distress using several different inventory measures.

Suris, Michaud, Akre & Sawyer 2008) (

This large study surveyed Swiss adolescents to determine the co-occurrence of a chronic health condition and health risk behaviors.

     

  60Appendix C: Coping with Chronic Disease 

 Author(s) Topic

Schmidt, Peterson & Bullinger (2003)

This article provides a framework for understanding the factors that affect children and adolescents when coping with chronic disease.

Smith (2006) In this extended article, a strength-based treatment model is proposed for high-risk youth.

Laursen (2003) This article outlines strength-based treatment as an alternative to problem orientation and pathology in both therapeutic and educational settings.

                                 

  61Appendix D: Treatment Adherence

Author(s) Topic

Shaw (2001) Treatment adherence in adolescents is examined and defined in this article.

Kyngas, Kroll & Duffy (2000)

This article reviews factors that can influence compliance in adolescents with chronic conditions.

Grey, Davidson, Boland & Tamborlane (2001)

The design of this study was to determine if coping skills training affected the achievement of treatment goals (metabolic control and quality of life) when compared to standardized care in adolescents with Type 1 diabetes.

                                

  62Appendix E: Depression in Adolescents with Chronic Conditions

Author(s) Topic

Wagner & Brent (2009)

This chapter from the Kaplan & Sadock’s Comprehensive Textbook of Psychiatry (2009) presents an overview of depressive disorders in children and adolescents.

National Institute of Mental Health (2008)

This pamphlet defines depression, lists the symptoms, examines co-morbidities, addresses the different causes, and explains treatment for the general population.

Bhatia & Bhatia (2006)

This article gives an overview of depression as it is found specifically in children and adolescents.

Bennett (1994) This meta-analysis analyzed 46 studies addressing children with chronic medical conditions and depression. Specific medical conditions include asthma, cancer cystic fibrosis, Type 1 diabetes, inflammatory bowel disease, recurrent abdominal pain, and sickle cell anemia.

Seigel, Golden, Gough, Lashley & Sacker (1990)

In this study, adolescents with and without chronic diseases were given questionnaires addressing depression, self-esteem, and life events, and the results were then analyzed and compared.

Dantzer, Swendsen, Maurice-Tison & Salamon (2003)

In this critical review, literature addressing anxiety and depression in juvenile diabetes is examined and recommendations are then made based on the results.

Kanner, Hamrin & Grey (2003)

This article addresses the clinical implications of depression in adolescents with diabetes, as well as general background information and treatment options.

Lawrence, et al. (2006)

This large study looked at 2672 youth with both types of diabetes to determine associations that could attribute to depressed mood.

American Diabetes Association (2010)

This website provides definitions for common terms that are used in diabetes treatment and literature.

Hood, et al. (2006) This study used self-report measures with 145 youth with Type 1 diabetes, finding that the prevalence of clinical depression in 1 out of 7 of the youth surveyed.

Stewart, Rao, Emslie, Klein &

hite (2005) W

In this study, adolescents with Type 1 diabetes were surveyed and followed for two years to determine the relationship between depressive symptoms and hospitalizations.

        

  63Appendix F: Overview of Treatment Options

Author(s) Topic

Koplewicz (2002) This book addresses multiple aspects of adolescent depression, and examines multiple forms of treatment with case examples.

March, et al. (2004) This largely cited study involved 439 depressed adolescents randomized into different treatment groups: Flouxetine, CBT, and their combined effect.

                                   

  64Appendix G: Psychopharmacological Options

Author(s) Topic Olfson, Marcus & Druss (2008)

This study examines the effect the FDA issued black box warning on all antidepressants had on the prescribing of the involved drugs.

Antonuccio (2008) This article gives general information about antidepressants and their use with children.

Shearer & Bermingham 2008) (

In this article, side effects and medical complications from pediatric antidepressant use in the United Kingdom are acknowledged and cautioned against.

                                  

  65Appendix H: Psychotherapeutic Options

Author(s) Topic

Reinecke, Ryan & DuBois (1998)

This review examined literature about CBT for the treatment of depression and depressive symptoms during adolescence.

Lewinsohn & Clarke (1999)

In this literature review, different forms of psychotherapy are analyzed for use with adolescent depression.

Chan (2005) This article outlines the use of Interpersonal Psychotherapy for depressed adolescents with a chronic medical problems.

Trowell et al. (2007)

This randomized control trial compares psychodynamic therapy with family therapy in the treatment of child and adolescent depression.

                              

  66Appendix I: Creative Arts Therapies

Author(s) Topic

Riley (1999) This article provides a background for the use of art therapy with adolescents.

Riley (2003) This chapter of an art therapy handbook provides specific information on how art therapy can be used for depression treatment in adolescents.

Jeong et al. (2005) In this study involving 40 adolescents with mild depression, scores of psychological distress decreased after 12 weeks of dance movement therapy

National Association for Drama Therapy 2010) (

This fact sheet describes common techniques used in drama therapy when working with children and adolescents.

                            

  67Appendix J: Music Therapy Defined

Author(s) Topic

American Music Therapy Association (2009)

This website serves as a primary resource for music therapy and provides a basic definition of the profession.

Boxill (1985) In her book on music therapy for the developmentally disabled, music therapy and the therapeutic relationship are defined.

Tervo (2001) This article addresses different techniques in music therapy and the benefit they have with adolescents. Case examples are included for support.

Arnett (1995) This article looks at five uses of media by adolescents: entertainment, identity formation, high sensation, coping, and youth culture identification.

                             

  68Appendix K: Music Therapy for Use Depression

Author(s) Topic

Goldstein (1990) This article describes the creation of an assessment tool using songwriting in music therapy for depressed adolescents.

Maratos, Gold, Wang & Crawford (2008)

This is a review of literature addressing five studies with music therapy and depression.

Gold, Voracek & Wigram (2004)

This meta-analysis examines music therapy research involving children and adolescents with psychopathology.

Haines (1989) In this study, music therapy is compared to verbal therapy as treatment for the self-esteem of emotionally disturbed adolescents.

Jones & Field (1999)

This study evaluates the use of massage therapy and music therapy for depressed adolescents using EEG readings for data.

Hendricks & radley (2005) B

In this case study, music techniques are embedded within interpersonal therapy for a depressed adolescent and his family.

                          

  69Appendix L: Music Therapy for Hospitalized Adolescents

Author(s) Topic

Gallagher, Lagman, Walsh, Davis, & LeGrand (2006)

This study aimed to objectively assess the specific effects of music therapy on 200 patients with chronic and advanced illnesses.

Barrera, Rykov, & Doyle (2002)

In this study, the effectiveness of music therapy with 65 children in health settings is documented using pre- and post-test meauses.

Payne et al. (2005) This article discusses how the needs of adolescents vary from the needs of children in medical settings.

Robb (1996) In this article, the hospitalized adolescent who has been traumatically injured is examined and four techniques in song writing are provided through case examples.

Burns, Robb, & aase (2009) H

In this study, 12 adolescents and young adults undergoing stem-cell transplantation were randomized into either a therapeutic music therapy group or an audio-book group.