615 people participated in the survey and were asked to complete the Depression and Anxiety Stress Scale (DASS; Henry and Crawford, 2005) and the Rumination-Reflection Questionnaire (RRQ; Trapnell, 1997). Purposive sampling was used, and potential participants with DASS scores above 15 and rumination scores above four were approached, as these are indicative of severe symptoms of depression and ongoing ruminative coping styles. This generated a list of 27 potential participants, 4 of whom were not approached because they had indicated being negatively affected by participating in the survey. The participants on the inclusion list were contacted by email, with 7 young people aged from 19 to 28 years (mostly female) responding and being interviewed. Participant demographics are included in **Table 1**. As the previous study had been conducted online the participants lived in a number of different countries.

# Materials and Procedure

Ethics approval was granted by the Human Research Committee (#1443393.1) at the University of Melbourne. Potential participants were contacted via email and if they responded with interest were sent a Plain Language Statement and Consent form. Written informed consent was obtained from all participants prior to conduct of the interviews. Due to the diverse locations of participants, all but one interview was conducted via the video call function on Skype using Version <IP_ADDRESS>. Audio of the interviews was recorded using MP3 Skype Recorder 4.32 Free Edition. Since all participants were fluent English speakers interviews were conducted in English and took approximately 45 min to 1 h. Participants were offered a \$15 iTunes voucher for participating in the study.

Interviews were conducted by the first two authors and memos were created after each interview to record the impressions of the interviewers about participants' demeanor, body language, tone of voice and time taken to respond as well as the interviewers' reflections on how their own personal biases may have influenced their conduct of the interview (Finlay, 2002). Discussions between the first two authors took place after each interview to determine the direction of the subsequent interview. An interview guide was used, however, interviews proceeded freely based on participant responses (see **Appendix**). In general, the interviewer sought to prompt participants to discuss their use of music to regulate their moods, and in particular negative moods. In order to determine the level of awareness and responsiveness to the idea that music does not always have positive effects on mood, and to avoid the positive bias that has limited some previous studies, the interviewers deliberately introduced the topic of negative effects toward the end of the interview if participants had not raised the issue themselves.

# Analysis

Interviews were transcribed verbatim. A preliminary analysis of each interview was conducted using open coding in accordance with Strauss and Corbin (2008). The initial in vivo codes related primarily to the ways the young people described using music to regulate mood and included codes such as "for comfort," "music is used as a distraction" and "to keep fighting." This initial coding allowed the first author to immerse herself in the data and revealed new questions for consideration in subsequent interviews to enable deeper exploration of new issues. For example, themes of anxiety began to emerge as common around the fourth interview, and so additional questions in relation to this were added to the interview guide for subsequent interviews.

Once open coding of the interviews had been completed a second wave of analysis was conducted independently by two pairs of researchers (the first two and last two authors) who each identified themes and central categories that connected the various ideas that were emerging from the data. Axial coding as described by Charmaz (2006) was then used to discern possible relationships between the various categories and codes, with constant return to the data to better understand whether similar coding was representative of shared ideas. The codes were examined to assess the motivations participants gave for adopting particular mood regulation strategies with music and the factors influencing the relative success of these strategies. This informed the generation of sub-categories within the larger concepts that had been identified across participants. The properties and dimensions of the categories and sub-categories were then delineated with a focus on the central code of awareness and, where present, how this awareness was described as developing. Memos were used as a way of noting impressions from the data, with statements such as "It seems like. . ." The analysts would then return to the raw data to see whether these impressions could be sustained by what had actually been said. This process allowed for a constant attention to the possibility of the researchers' pre-assumptions influencing interpretation of the data, rather than allowing details about the phenomenon to emerge from the participants' experiences, which was the focus of this study. The two research teams then compared their analyses and used selective coding to integrate and further refine the central category, it's properties and dimensions and to develop a theoretical proposition.

# Reflexivity

Since researchers who have worked in a particular field for some time may already be familiar with previous findings in this area and be somewhat influenced by their knowledge, reflexivity was considered an important part of the research process (Finlay, 2002). Qualitative analysis is an inherently subjective process and two of the authors (SG and KM) have undertaken a number of studies of this topic previously. It was therefore critical to ensure that analysis was not used

to simply confirm our existing beliefs (confirmation bias). Undertaking two separate analyses was our primary strategy for testing our ability to focus on what was being said by the seven participants and we frequently returned to the data to scrutinize our emerging ideas and test how closely it matched the raw data. This allowed us to rigorously debate and refine our presentation of the findings. Throughout the interviews and analysis process, the researchers also engaged in personal and shared reflections and debate about potential meanings inherent in the data.

# FINDINGS

# Strategies for Music Choice

Our analysis suggested that the strategies participants described for using music to manage negative moods fell into two broad categories: (i) selecting music that differed from the negative mood in an effort to shift a negative mood, and (ii) selecting music that mirrored the negative mood in an effort to cope with negative feelings. These strategies are depicted in **Figure 1** following the model of Biasutti (2013, 2018). Both strategies appeared to have negative outcomes at times and positive outcomes at other times.

# Music That Differed From Current Mood

Many (5 of 7) of the participants described listening to music that differed from the mood they were experiencing in order to try to alter a negative mood. For example, Participant 3 described listening to classical music when angry to help her calm down: "If I'm listening to classical music because I'm trying to calm myself down, it's soothing. It helps me relax. It's more like trying to relax, that I'm feeling the music and trying to absorb every note." Similarly, several participants identified using calming music to reduce feelings of anxiety. Participant 5 stated "I have anxiety issues so I find it quite a nice way to settle myself," while Participant 7 described using music to "get out of my head" when feeling anxious. Participant 2 also reported sometimes using music to "block out things that are bothering me." Participant 5 also described successfully listening to upbeat music when feeling down. She stated: "If I'm feeling depressed I tend to put on happy music like cheesy pop and things to try and cheer myself up almost. Something with a fast tempo to kind of boost my mood." These strategies were considered to represent conscious processes adopted by participants to change their mood. In contrast, Participant 4 reported that listening to music that didn't match her negative mood gave her "the impression that everyone else is having fun except for me."

# Music That Mirrored Current Mood

The other prevalent theme we perceived across most (6 of 7) participants was the use of music to mirror mood in an attempt to cope with feelings of sadness and depression. While the term 'cope' can cover a wide range of strategies for dealing with undesirable situations and affective states including problemsolving and attempting to change one's mood, in the context of this data the term is used to describe strategies designed to mitigate or lessen the intensity or unpleasantness of an undesirable mood without actually shifting it's valence. Different participants described selecting music that mirrored their current mood in relation to a diverse range of intentions or aims, and outcomes. However, our interpretation was that these strategies often appeared to be designed to help participants cope with affective states, rather than to change them.

Some participants expressed the desire to be "comforted" when listening to music, gaining understanding that "I'm not the only one going through problems" (Participant 3). This strategy provided a feeling of "validation" of the experience for Participant 4, and Participant 6 described something similar saying, "I'm tired and I'm still sad but it's less heavy and it's like someone understands." Participant 3 also reported that sometimes it was just a matter of changing the degree of sadness being felt, describing how in the past she found it useful to listen to music that was "at a level that is just a little bit above what I'm feeling, to maybe bring me up a little bit but not so much that it would bother me." In this case, even a small improvement in mood was perceived as a positive change.

Others listened to mood-matching music with the express aim of intensifying their negative emotions. Several participants reported listening to slow, acoustic, classical pieces to reflect and emphasize a sad or low mood state. For example, Participant 1 described deliberately choosing songs that conveyed "extreme manifestations" of the sad mood she was in. Two participants described their motivation as being to "drown in" (Participant 3) or "wallow in" the negative emotions (Participant 4). Participant 3 described how this had a positive effect, and how it "gets me to the highest point and then I come down," suggesting that she experienced some relief once the more intense emotions diminished. For Participant 1, the effect was less clear and she reported listening to music with suicidal lyrics when depressed, stating that this "probably just intensified the emotion, which [may] or [may not] be beneficial." Participant 4 similarly reported that this could leave her not even feeling "motivated enough to change the music."

In contrast to the others, Participant 2 reported that she preferred to avoid music that could make her feel more depressed. This did not necessarily entail listening to music that was upbeat and happy, which she tended to listen to when having a "better day," but she said: "If I'm not feeling so good I'll listen to a classical piece, something slow." She also made the following statement.

"I try not to listen to depressing music if I'm already feeling down because it's not going to do anything to help really. Sometimes I kind of need it to know that other people feel the same way, but a lot of time its just going to make me feel worse and so then I don't want to do that. . . Usually I listen to more positive things."

# Factors Influencing the Outcomes

Our analysis of the properties and dimensions of the strategies presenting in the data revealed that both positive and negative effects were experienced from both strategies for managing moods with music. This was determined during axial coding, where we examined the circumstances surrounding these strategies in order to determine some of the factors that contributed to a positive or negative outcome. We identified three properties: (i) the messages conveyed by the lyrics, (ii) the frequency and duration of listening to certain music, (iii) the nature and intensity of the prior affective state of the listener.

# The Messages Conveyed by the Lyrics

Some participants described particularly being attracted to music with lyrics that have special meaning for them when feeling down. When Participant 1 described the kind of music she was drawn to in a depressed mood, she said "It's both the music and the lyrics as well, and I think that what the singer's expressing is a sort of frustration and I'll think, 'Oh yes, that's exactly what we feel here'." Participant 6 described how music with lyrics was especially important to her when she was feeling sad: "When I'm really, really sad that's the only time I'll listen to music where I care more about the lyrics."

However, the outcomes weren't necessarily positive for participants when they listened to music with lyrics that closely related to how they felt. Participant 1 stated: "I started thinking about the lyrics and stuff and it's not pleasant stuff and I began to think, well maybe it's listening to this stuff which is really contributing to my being in a very low mood." Participant 6 similarly said: "I was just getting really perturbed because I was listening to the lyrics too much and I could relate and then I could go and watch TV or something but I kept thinking about the song."

More positive effects were noted when listening to songs that were considered "emotional but" also inspired "some optimism," or had an "uplifting message" (Participant 6). Participant 2 stated that "If the music has a positive outlook on life, I'm likely to kind of adopt that somewhat." Thus, several participants demonstrated how the differing messages in music, even music that mirrored their mood, could have differing effects on their mood.

## Frequency and Duration of Music Listening

Participant 1 explained how she had experienced a phase in her life when she was listening intensely to music with very negative, suicidal lyrics. She made the following statement.

"I was listening for hours a day. . .to be hearing people talking about drug problems, how much they don't like themselves, that they were locked up in the mental hospital etc. On a daily basis that probably isn't the world's best for mental health."

Participant 2 similarly described that the amount of time she spent listening to sad music needed to be limited. "Sometimes I kind of need it to know that other people feel the same way. . . But there does come a point when you are feeling bad enough and then that would make you feel worse and it's something you have to stay away from." Participant 6 also mentioned a time when she had been listening to songs about suicide "quite a few times. . .too much" with negative results. Thus, there was a recognition that intense or frequent listening to music that reflected negative thinking was likely to have a more negative impact on wellbeing.

# Nature and Intensity of the Prior Affective State

Being in a low negative mood state was frequently mentioned as a factor that would result in music listening having a negative or neutral effect on mood. For example, Participant 4 said: "If I am having a really bad day then nothing I do will really change that." She also stated that, "When I'm in a more neutral mood I can change my emotions according to what I'm listening to but when I'm really sad nothing helps." Similarly, Participant 7 commented that it's the strength of his mood that influences how easy it is to modify with music: "Some moods are harder to shake."

A number of participants described using music to distract from, or mask unpleasant emotional states. For example, Participant 6 described herself as having "an anxiety disorder" and being able to use music to "distract" herself or "calm" herself down. Although this strategy was sometimes described as helpful in alleviating the intensity of emotional experiences, some participants also acknowledged the temporary nature of this solution. For example, Participant 7 stated that music could not remove anxious feelings altogether, but that it would just "temporarily mask the depression" and then he would "be back to square one" when the music finished. Similarly, Participant 6 stated that "on the spot it's useful because I'm just thinking about the music, I'm forcing myself not to think about what's making me anxious but when I stop everything comes back." Thus, some participants identified that 'covering up' emotions were a short-term and somewhat limited solution.

Strategies also appeared to differ depending on the individual's mood. Participant 3 said that when she was feeling sad she usually chose music that matched her mood because she found it "comforting" and "reassuring." However, when angry she would listen to music that she hoped would change her mood.

# Awareness

In examining some of the factors that influenced the outcome of music listening for people with symptoms of depression, it seemed possible that a key factor was the level of awareness and consciousness with which individuals selected music. Selective coding allowed us to explore the data in order to further test this theory. In order to overcome previous study limitations which have demonstrated that individuals do not always directly report negative effects of listening to music, coding strategies here looked not only at clear statements relating to awareness, but at other indications such as inconsistent responses or signs of ambiguity or confusion. Upon direct request, most participants were able to list a song or a type of music that had previously caused a deterioration in mood for them. For example, Participant 4 reported that listening to "emo" music had previously had a negative effect on her mood. Participant 1 similarly described listening to Elliott Smith and realizing that her mood was "continually low."

It was evident that for several participants their insight into the potential for music to have negative effects was something they had gained over time, usually after some negative experiences. For example, Participant 5 stated:

"It's something I've developed over time. It's like a mechanism I've developed as I got more used to having mental health problems. . .I used to listen to a lot of punk rock stuff and all that kind of emo stuff nonsense and it just used to make me much more worked up because it's so intense that it does not help. But it took me quite a long time to realize what was happening."

Awareness was obtained in several ways. Some participants were made more aware by the comments of friends and family. Participant 5 made the following statement.

"My family members were like, 'This is too intense. Why are you listening to this?  There is a history of mental illness in my family so they are quite good at knowing how to deal with it. And I was like, 'No it is helping'. . . until I heard a few people my own age say that it's not working.

She similarly said: "Some of my friends had some of the same issues and they said how they listened to some music that made them feel worse and I was like "oh maybe they have figured out what's wrong with me too" and I sort of realized that."

Of note in Participant 5's comments is the fact that she had at first believed that the music was helping her, but she ultimately identified with the experience of friends who noted that it was not always as helpful as it could be.

For Participant 6 it was therapy that had helped her to become more aware of her listening habits. She made the following statement:

"When I was younger I did have a tendency to just listen to songs more, especially if they made me sad and they emphasized my mood. Now, I would take a break from them and listen to something different because I'm trying, well not trying to control my mood but it was one of the things I discussed with my therapist. I was not trying not to hurt myself more, but trying to not feel worse about things."

For Participant 1, the realization appears to have come to her personally without prompting from other people. "I began to think, 'Well maybe it's listening to this stuff which is really contributing to my being in a very low mood, so I had to stop then." She reported realizing that listening to particular music with suicidal lyrics had "brought [her] into a more negative mood."

However, there was some evidence that despite a recognition of the negative effects of past experiences, this did not always translate into an awareness of the potential impact of current listening behaviors. Several participants seemed to lack clarity in their own mind about whether particular listening was useful or not. This was evidenced by some inconsistent statements within the interviews. For example, when Participant 4 was asked what she listens to when she is in a low mood she said: "emo music." However, when asked to describe a situation where music had made her feel worse she described how in high school emo music had made her "feel worse." When asked again whether she would do the same thing now, she said: "Probably not." In this case, the participant recognized some negative effects in the past but still reported the same listening choices. However, asking the participant to reflect on the past negative experience caused her to change her answer about current listening choices. Whether or not this reflected an actual change in opinion is unclear.

Participant 6 was similarly somewhat ambiguous about whether her listening choices made her feel worse. As cited above, this participant reported discussing with her therapist about avoiding music that made her feel "worse about things." She seemed to have some useful strategies for regulating her mood such as listening to music that is "sad" but that gives her "some optimism," or music that gave her some relief in that after listening she was "still sad but less heavy." However, when speaking about a previous experience she made the following statement.

"I don't know if it made me feel worse. . .but there was this one song about suicide that I remember listening to. . .the song itself kind of hit close to home at that moment. . . I was just getting really perturbed because I was listening to the lyrics too much."

When asked if she would listen to the same song again she said "sometimes I do," but preferred not to listen to it when in a good mood because it "brings back memories." Thus, while this participant appeared to have some awareness of her complex responses to certain music in the past, she sometimes seemed to revert to unhealthy patterns in periods of depression. Of note with this participant was a recognition that the message in the lyrics – whether suicidal or optimistic – was an important factor even when the music was "sad" overall, with the former tending to make her feel worse, while the latter helped her to feel "like someone understands."

Similarly, Participant 1 gave some conflicting statements in reference to her preference for listening to Elliott Smith and his music with suicidal themes when feeling depressed. At first when describing her response to this music she stated, "I just kind of think, 'Oh God, this is just so sad and so depressing.' I kind of sit there and think 'oh woe is me'." She also reported having had to stop listening to this music at one stage because she had been getting too depressed, and stated that the music "probably just intensified the emotion." However, when the interviewer introduced the question of whether some other listening choices might be more helpful, the participant was quick to justify her preferences stating, "If I listen to depressing music when I'm depressed it does have some benefits." Music was intensely important to this participant. She reported listening to music much of each day and spending a lot of time reading about musicians and their lives. The type of music she listened to appeared to be closely connected to her sense of identity, and her attraction to music that was meaningful and musically "masterful," something which she associated with singer-songwriters such as Elliott Smith. Thus, for this participant there appeared to be some resistance to the idea that such music choices could have a negative influence on mental health despite a recognition of past negative experiences.

Participant 2's approach contrasted with the other participants. She described herself as having been better in recent years, but even when going through a period of depression, her music listening choices did not necessarily have a negative outcome. She described using music as a temporary thing to escape from her difficulties. "I remember there were times when I would find a 12 min piece and just put my headphones on, turn it up, probably too loud, and then sit there and enjoy it for 12 min and that was 12 min that I didn't have to deal with everything else." This demonstrated some intentionality of music use, but not necessarily an ability to sustain the wellbeing benefits with music. Participant 4 similarly described her approach to music listening when depressed as "a way of soothing my emotions rather than solving them."

Thus the participants in general described unconscious listening that worsened their mood as a past way of using music when they had little to no insight about their emerging mental health problems. This suggests that when participants were not aware of how poor their mental health was becoming, they used music in ways that contributed to their deterioration and stopped once something challenged them – the realization of depression, comments by family or friends, or therapy. However, the same listening behaviors sometimes seemed to continue or re-occur in current circumstances especially when there was a deterioration in wellbeing.

# Pathways to More Conscious Music Use

The emphasis placed by grounded theory analysts on actions and interactions encourages modeling of diverse pathways through a phenomenon (Strauss, 1987; Morse et al., 2016). For this study, the findings suggested a model of the pathways young people with symptoms of depression take through music use that reflect differing strategies for dealing with undesirable moods (see **Figure 2**). The model demonstrates how listeners may have the intention to either cope with or to change an undesirable mood, but outcomes vary depending on the strategy used, which in turn is influenced by the individuals' fluctuating level of awareness. In this model, individuals have the antecedent condition of depression and are influenced in their music listening selections by the central condition, which is the state of being in an undesirable mood. They then exercise their intention to either cope with their mood or change their mood through strategies that involve selecting either mood matching music or music that is different to their mood. These selections are influenced by their own changing levels of awareness which in turn, are influenced by intervening conditions such as negative experiences or discussions with family, friends, or a therapist. These differing strategies can have varying outcomes, with mood matching music generally leading to either maintenance of mood or feeling worse, and listening to music that is different to the initial undesirable mood generally resulting in mood repair or a temporary change to mood.

# DISCUSSION

This study focused on exploring the degree to which young people with symptoms of depression are aware of the effect their music listening choices have on mood and wellbeing, and how they reach that state of awareness. Our findings demonstrated that most young people in our study reported past behaviors reflecting limited awareness and unconscious motivations, often with undesirable outcomes. However, intervening conditions including insights gained from friends, family, a therapist or through self-reflection, resulted in some increased awareness. Previous research has demonstrated that increased awareness of the effect of music listening choices can be deliberately influenced, such as through use of the Healthy-Unhealthy Music Scale as an awareness raising tool (Saarikallio et al., 2015; McFerran et al., 2018).

However, in the current study, some young people demonstrated an initial resistance to increased awareness, or a reversion to previous unhelpful patterns of music listening even after reaching a level of awareness, particularly during depressive

episodes. Thus, the pathways young people took through music listening and awareness of the effects of their music listening choices were not always linear. Skill building appeared to be a gradual process of discovery by continual cycling through varying intentions, strategies and outcomes, with new levels of consciousness being reached as new events and experiences challenged old behaviors.

Of note in the current study was that some participants described being more able to use music to change states such as anxiety or anger even when these were quite severe, but were less inclined to use this strategy when feeling depressed. When seeking to change an anxious mood, for example, participants reported listening to calming music – music that did not match their current mood. In contrast, when dealing with depression, many of the participants reported using music that maintained their current mood in order to feel validated and to have their feelings acknowledged.

While the intention of participants was to use music to help them cope with their depressed mood, this sometimes resulted in intensifying the state. It may be that the different interactional strategies used in each case contributed to the differing outcomes since research suggests that listening to mood shifting music is often more effective than listening to sad music when feeling depressed (Garrido and Schubert, 2015b). Alternately, it may be that anxiety is more amenable to influence by music listening. In a systematic review of studies relating to music and people with dementia, for example, it was found that music can reliably reduce agitation in patients, while the effects of music on symptoms of depression are less consistent (Garrido et al., 2018). Anxiety is often exacerbated by a fear of the symptoms of anxiety themselves (Dugas et al., 2012), but calming music can reduce physiological symptoms of anxiety thereby inducing a relaxation response (Hamel, 2001). On the other hand, depression is often closely related to thought patterns which may be less likely to be altered when listening to music, particularly if the music echoes the existing negative thoughts.

It may be this relationship between thought patterns and depression that can help explain why the benefits of listening to distracting music was sometimes time-limited, ceasing as soon as the song was over. This has further been noted in Cheong-Clinch's study of adolescents with mental illness (Cheong-Clinch and McFerran, 2016), where music was found to mediate mood momentarily, but it was more difficult for young people to achieve sustained benefits. As reflected in our findings, the content of the lyrics often had an influence on whether positive benefits were achieved. When participants listened to music that mirrored their current circumstances this appeared to have less desirable mood outcomes, possibly because listening to such music is akin to ruminating. In contrast, outcomes were more positive for participants in the current study when they listened to music with optimistic messages. Previous research has similarly demonstrated that the thoughts triggered by music have a greater impact on mood outcomes than features of the music itself (Garrido et al., 2016). Thus, listening to music that is distracting

as opposed to music that alters mood via shifting thought patterns, may be only of temporary benefit.

Nevertheless it is important not to ignore momentary benefits for people struggling with depression. Some theorists suggest that the cumulative benefits of positive moments can serve as protective factors that eventually lead to improved wellbeing (Rutter, 2012). More pragmatically, young people who are struggling with suicidal thoughts appreciate even small periods of escape (Cheong-Clinch and McFerran, 2016). Such brief distractions are helpful in that they reduce time spent ruminating and can reduce the incidence of self-harm and suicide attempts (Polanco-Roman et al., 2015). Furthermore, studies in music therapy have indicated that selecting music that matches one's mood as the beginning point of a process that gradually shifts toward more positive music – a strategy known as the iso-principle – can produce a more enduring repair of mood (Davis et al., 2008). The participants in the current study did report experiencing some lessening of the intensity of their negative moods after listening to moodmatching music. It is possible that for some, the reduced intensity of their negative moods was the beginning of a process of recovery. However, the data in this study did not reveal this clearly, and it is likely that the long-term outcomes of this process differ from individual to individual particularly in situations where the person has a high level of unawareness about the thinking patterns and emotions being triggered by the music.

# Clinical Implications

While some participants in this study described reaching awareness of their strategies for music use on their own, external input such as from friends, family or a therapist was also described and has been categorized as intervening conditions in **Figure 2**. Although this may suggest that telling young people to be more careful about their music listening could be beneficial, a broader cultural context is also at play. Young people report feeling resentful of the judgments made about their music choices, and one function of music is often described as being to assert an independent identity, beyond parental authority (Laiho, 2004). In a previous study, we were able to encourage young people seeking support for depression to contemplate their music listening habits, but this occurred within a respectful conversation that involved both validating music preferences as well as dialoguing about consequences (McFerran et al., 2018).

It is also common for caring adults to mistake the mechanism of action in this scenario and to blame the qualities of the music itself, rather than focusing on how music choices reflect mental health. This has historically been a point of contention between fans of heavier genres, such as Rock and Rap, and correlations are frequently found with antisocial behaviors (Lozon and Bensimon, 2014). Nevertheless, a causal relationship between particular music genres and mental illness or problem behaviors has never been established (North and Hargreaves, 2006). Rather, complex interactions between an array of personal and social mechanisms underlie our emotional reactions to music (Juslin et al., 2015). Interventions that focus on self-reflection and raising awareness of the interaction between thoughts and feelings triggered by our music listening choices are likely to be more successful than those targeting particular music genres or styles.

# CONCLUSION

There is ample evidence to demonstrate that people use music to improve their mood on a daily basis, both in everyday life (DeNora, 2000; Saarikallio, 2007; McFerran et al., 2015; Papinczak et al., 2015) and in music therapy (Maratos et al., 2009; Cheong-Clinch, 2013; Bibb and Skwews McFerran, 2018). There is also an emerging body of research which seeks to qualify these findings, since it is clear that music is not a magic pill that can immediately resolve a negative mood and nor is it always helpful. This research contributes to this second discourse, highlighting how individual's uses of music can result in various outcomes depending on a range of factors. Individuals can use music listening to improve, maintain or intensify a mood, and may do any of these things at various times. Although it appears that people with depression are most likely to use music to intensify a negative mood, they are also the least aware of this tendency. This is further complicated by the finding that an individual can become aware of unhelpful listening habits, but can lose that awareness when in a depressive state and revert to intensifying strategies.

The current study is limited by the fact that the sample was primarily female. This gender imbalance is not unusual in studies relating to mental health (see for e.g., Lindner et al., 2016), and is likely a reflection of the higher rates of depression among females (Freeman and Freeman, 2013). Nevertheless, future studies could benefit from recruitment of a more balanced sample so as to explore gender differences in strategy selection and outcomes of music use. Future research should also consider the influence of cultural context. The current study included at least one participant from a non-English speaking background. While music tastes among young people are becoming increasingly globalized (Cicchelli and Octobre, 2017), culture nevertheless has an impact not only on music selections, but on the way individuals value particular emotional experiences (Oishi et al., 2007).

Using music to influence mood is likely to continue to be a popular strategy for many people, both in their everyday life and through music therapy or other therapeutic contexts. Therefore, our ability to predict when this is likely to be more or less helpful and to develop strategies for supporting people during the most difficult moods is critical. However, the nuances of the pathways through music listening and toward an improved mood are complex and need to be individually identified and negotiated. The findings from this research indicate that promoting awareness of the power of music to enhance any mood is helpful, but that we should be prepared for circuitous pathways and open to change in all directions when people engage with their preferred music.

# ETHICS STATEMENT

fpsyg-10-01199 May 22, 2019 Time: 18:45 # 10

The study was approved by the Human Ethics Committee of the University of Melbourne. Written consent was provided by all participants.

# REFERENCES

# AUTHOR CONTRIBUTIONS

SG and KM developed the initial project design. JS and SG undertook the data collection. All authors contributed substantially to data analysis, write up, and development of the conceptual model.

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2019 Stewart, Garrido, Hense and McFerran. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

# APPENDIX: INTERVIEW GUIDE

fpsyg-10-01199 May 22, 2019 Time: 18:45 # 12

# Bridging the Clinic to Community: Music Performance as Social Transformation for Military Service Members

#### Rebecca Vaudreuil1,2 \*, Hannah Bronson<sup>1</sup> and Joke Bradt<sup>3</sup>

<sup>1</sup> National Endowment for the Arts, Washington, DC, United States, <sup>2</sup> National Intrepid Center of Excellence, Bethesda, MD, United States, <sup>3</sup> Department of Creative Arts Therapies, Drexel University, Philadelphia, PA, United States

The use of music performance in music therapy with military service members is discussed as a vehicle for social transformation and reintegration. The use of performance in music therapy is not without controversy primarily because therapy is considered a process, not a product, and confidentiality and privacy are essential components of therapy. However, others have argued that public performances can validate therapeutic changes in clients, give voice to their experiences, raise awareness of social issues within their communities, transform perceptions of injury, or illness in audience members, and may result in the clients gaining support and validation from their communities. We discuss the potential of music performances to contribute to individual development, reinforce rehabilitation, enhance function, and facilitate change at the community level to support reintegration of military service members. We illustrate this through two brief case reports of service members who received music therapy as part of their treatment for post-traumatic stress disorder, traumatic brain injury, and other psychological health concerns at the National Intrepid Center of Excellence, a Directorate of the Walter Reed National Military Medical Center, Bethesda, MD, United States. The service members wrote, learned, and refined songs over multiple music therapy sessions and created song introductions to share with audiences the meanings and benefits gained from integrating performance in music therapy. The case reports also include excerpts of interviews conducted with these service members several months after treatment about their experiences of performing and the perceived impact of their performances on the audience and greater community.

Keywords: performance, music, music therapy, social transformation, military service members, traumatic barin injury, post traumatic stress disorder

# INTRODUCTION

Music performance is an integral part of the creative process. Whereas the general public may associate the concept of performance with entertainment, performances are increasingly used to stimulate discourse related to socio-political and psychological issues (e.g., Yotis et al., 2017). In music therapy, performance is utilized to give voice to clients' experiences and facilitate greater understanding of their struggles Baker, 2013; O'Grady et al., 2015). Recently, media outlets

#### Edited by:

Graham Frederick Welch, UCL Institute of Education, United Kingdom

#### Reviewed by:

Kimberly Sena Moore, University of Miami, United States Lori Gooding, Florida State University, United States

\*Correspondence: Rebecca Vaudreuil<EMAIL_ADDRESS>
#### Specialty section:

This article was submitted to Performance Science, a section of the journal Frontiers in Psychology

Received: 07 September 2018 Accepted: 14 January 2019 Published: 05 February 2019

#### Citation:

Vaudreuil R, Bronson H and Bradt J (2019) Bridging the Clinic to Community: Music Performance as Social Transformation for Military Service Members. Front. Psychol. 10:119. doi: 10.3389/fpsyg.2019.00119

have reported on music performances by military personnel who have sustained physical and/or psychological injuries (Public Broadcasting Service, 2017; KXTV, 2018). Little attention has been paid in the literature, however, to the unique benefits and challenges of the use of performance with military populations. The purpose of this perspective article is to discuss the potential for growth and social transformation for service members when integrating performance into music therapy. In addition, we present considerations to ensure that performance is an enriching experience for service members and audiences. We illustrate this through two brief case reports of service members who chose to integrate performance into music therapy treatment.

# THE USE OF PERFORMANCE IN MUSIC THERAPY

Board-certified music therapists use a variety of music experiences within a therapeutic relationship to address individualized goal areas (e.g., emotional, cognitive, physical, social, spiritual) (American Music Therapy Association [AMTA], 1998–2018), which may include music-guided relaxation, expressive/(e.g., singing, instrument playing) and receptive/(e.g., listening to live/recorded music) music engagement, and songwriting. The focus of music therapy is on the therapeutic process, not the musical product (Ansdell, 2010); therefore, many music therapists are opposed to public performances by clients as this may blur boundaries of privacy and confidentiality (Ansdell, 2010). Additionally, music therapists have cautioned against incorporating performance because performance-related stress and potential adverse audience responses may put clients at risk (Turry, 2005). However, music therapists who practice within a community music therapy model (Ansdell, 2005; Soshensky, 2011; Stige and Aarø, 2012) have proposed that performance has significant potential for enhancing clients' health and psychosocial well-being. Ruud (2004) argued that performances in music therapy facilitate negotiation of "space between the private and the public, the client and the institution, or the client and the community." O'Grady et al. (2015) encourage music therapists to "shift the focus to when, not if, performance might be considered an appropriate method in music therapy" (p.124).

Performance integrated in music therapy offers opportunities for personal transformation and social change. First, performance provides a context for clients to creatively connect with audiences and share their experiences through artistic expression (Day et al., 2009). Through performance, clients can bring their experiences into a public space, which can raise awareness about personal struggles and societal (mis)perceptions, including mental health stigma (O'Grady, 2009). Second, it provides opportunities for clients to step outside of their comfort zones through structured risk-taking (Baker, 2013). Third, performance allows clients to demonstrate their skills and take pride in creativity (Baker, 2013). Fourth, positive feedback and public acknowledgment may enhance a client's self-confidence and motivation (O'Grady, 2009; Baker, 2013). Finally, performing can reciprocally impact the client-audience relationship: audiences can witness healthy parts of clients rather than deficits, and clients can feel supported by audiences, potentially resulting in transformative experiences (Soshensky, 2011; Baker, 2013).

# MUSIC PERFORMANCE BY MILITARY SERVICE MEMBERS

# Music Therapy in Military Settings

Music therapy is "a reflexive process wherein the therapist helps the client to optimize the client's health, using various facets of music experience and the relationships formed through them as the impetus for change" (Bruscia, 2014, Chapter 4, para. 5). Music therapy is utilized in the United States to treat service members recovering from service-related injuries, specifically traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD). The National Endowment for the Arts (NEA) Creative Forces: NEA Military Healing Arts Network is a partnership with the United States. Departments of Defense and Veterans Affairs and the state and local arts agencies with administrative support provided by Americans for the Arts. Creative Forces programming places creative arts therapies at the core of treatment models in military healthcare (National Endowments for the Arts, n.d.), and is established at 11 military facilities throughout the United States (Bronson et al., 2018). Before considering performance in clinical work, music therapists address functional rehabilitation (e.g., cognition, speech/language, sensorimotor) and behavioral health needs (Bronson et al., 2018). For example, a United States Army Captain co-authored a case report citing music therapy cotreatment as integral to his interdisciplinary rehabilitation. It motivated him to surpass his functional and psychological goals, ultimately leading to performances on local, national, and international platforms (Vaudreuil et al., 2018).

# Performance as a Vehicle for Rehabilitation and Social Transformation

Performance contributes to service members' agency in recovery processes and has the potential to facilitate change and enhance overall perception of self and others by mastering challenges of TBI and PTSD. We find it helpful to conceptualize the levels of transformation per Bronfenbrenner's Ecological Systems theory (Bronfenbrenner, 1977), specifically how people interact, adapt, and develop within their environments. Social transformation is a fluid process for the individual and occurs within the microsystem (e.g., installation, clinic) and in the macrosystem (e.g., culture, community). **Figure 1** shows a model adapted from Bronfenbrenner to reflect the levels of environment that impact military personnel.

Performance provides opportunities for service members to be viewed in ways that enhance interactions within different environments (e.g., family, occupational, and community). It allows service members to increase awareness of selfperceptions, challenge belief systems, and view treatment as an evolving mechanism for change. Historically, the image of the warrior across many cultures has represented strength, power, and indestructibility, while demonstrating emotions and

vulnerability has been interpreted as weakness (Peace et al., 2016). Performance allows reframing of the service members' and audiences' perspectives, transforming vulnerability to be recognized as resilience. A major transformation that service members ascribe to performance is a shift in perception from primarily internal to one that supports simultaneous awareness of internal and external processes. They describe public performances as validating and report that it allows expression of their inner-selves while feeling connected to audiences.

Through observing service members' performances, audiences, commonly comprised of family, peers, clinicians, and community members can: (1) increase awareness of service members' unique strengths by observing their products of music therapy, (2) comprehend service members' experiences in an innovative way, (3) shift perspective of service members as healthy and resilient, rather than viewing deficits, and (4) develop an understanding of how to construct supportive communities that better accommodate service member (re)integration.

# Clinical Considerations of Performance in Music Therapy

Performance is not a requirement of music therapy, rather an optional component that can serve to cultivate tactical creativity and culminate therapeutic experiences. If service members decide to perform, they have complete autonomy over their experience including: (1) target audience, (2) arrangement/dynamics, (3) accompaniment/instrumentation, and (4) co-performance participation. Co-performances can occur between service member and peer(s), music therapists, providers from other disciplines, visiting musicians, or any combination of these. In some cases, performances are recorded and used as auditory feedback for service members to gain insight, further process experiences, and have as a tangible item to take with them.

It is important to consider how music therapists utilize the therapeutic relationship to support performance. Transparency regarding potential benefits and risks of performance must be addressed prior to client engagement in performance. Service members may be hesitant about performing personal content and therapists must remain acutely aware of this by placing emphasis on preparation, continuous evaluation of the experience, and offering emotional support throughout (Baker, 2013). There are many reasons why service members may feel uncomfortable sharing their experiences through performance, including stigma of injury and the perceived lack of understanding from the civilian sector. If the service member does not possess the internal resources to withstand increased vulnerability, performance can be counter-therapeutic or re-traumatizing; thus, the clinician must recognize the client's unique capacity for risk-taking (Baker, 2013). In addition, it is essential that informed consent is established prior to the client engaging in performance. This provides consistency of client autonomy and optimization of choice and control when introducing integration of performance in music therapy. Ethical safeguards were employed with the service members highlighted in the case report section of this article to mitigate risk of performance. Clear and continuous communication on a spectrum from intervention to performance was incorporated throughout preperformance preparation, support during the performance, and post-performance processing.

# PERFORMANCE INITIATIVES AND CASE EXAMPLES

We present here two examples of performance initiatives integrated into military music therapy programs followed by two brief case reports of service members who received music therapy in intensive outpatient and longitudinal care at the NICoE and performed at the Creative Arts Café as part of their treatment. Case examples are based on clinical observations, service member interviews, and focus on how performance shaped social transformation. Both service members were interviewed about their experiences several months after treatment. A content analysis of the interviews focused on three areas: (1) music therapy treatment, (2) transformation through performance, and (3) post-music therapy transition. Please note that pseudonyms are used to maintain client confidentiality.

# Resounding Joy's Semper Sound Band

The Semper Sound Band (est. 2011) is a component of Resounding Joy's Military Music Therapy program (Resounding Joy, n.d.). Performance was a natural progression for service members who first received individual music therapy and progressed to group sessions. Mutual interest amongst group members led to a 'jam group,' which resulted in the formation of the band. Performance allows band members to showcase talents to family members, peers, clinicians, and communities through events, on and off base.

# Creative Forces Creative Arts Café

Based on the concept of the Semper Sound Band, the Creative Arts Café is an initiative developed at the National Intrepid Center of Excellence (NICoE) in 2016 and replicated across Creative Forces sites (Bronson et al., 2018). The Creative Arts Café is a performance space where service members can highlight

certain aspects of their treatment processes in creative arts therapies. It serves as a platform for service members, family members, and staff to share creativity through the arts. It supports the clinic to community continuum, as service members often first perform in music therapy and then may decide to perform on base and in the greater community. It is important to note that the Creative Arts Café initiative is open to all forms of artistry (music, art, dance, writing/spoken word, theatre, etc. . .), however, the case reports presented below focus exclusively on music performance.

# Case Report 1

#### Background

"Greg" is a male in his twenties and was a Sergeant (SGT) in the United States Army. He was an unrestrained passenger in a Humvee rollover in 2014. He suffered intracranial hemorrhages, presented unresponsive, and was intubated. Greg was medevacked, stabilized, and returned to the United States for ongoing treatment. He was referred to music therapy by a nurse case manager for cognitive deficits due to severe TBI. Greg received a music therapy assessment in January 2016 and received weekly individual and small group sessions for 15-months as part of outpatient treatment.

### Music Therapy Treatment

Upon initial music therapy assessment, it was determined that Greg was experiencing expressive speech issues in addition to memory and coordination deficits. The music therapist consulted with speech therapy to create integrative treatment approaches. Music therapy sessions were designed to assist his breathing, speech fluency, and rhythmic phrasing. A few months into music therapy, Greg and a fellow service member were working on a song that supported shared speech and cognition goals. The music therapist determined that it was appropriate to offer performance as an opportunity to: (1) encourage active participation in treatment, (2) enhance self-practice, and (3) engage with an audience while applying skills learned in music therapy. Greg and his peer were working on the song, "We Didn't Start the Fire" by Billy Joel and opted to perform it as a duet. In his interview "Greg" stated, "I chose that song, because I knew for a fact that it would help with my speech...and it helped with my memory."

Therapeutic singing, rhythmic cueing, and vocal prosody exercises were used to address hypernasality, slurred speech, fluidity, intonation, and articulation. Greg stated, "[Music therapy] helped my pronunciation of words, [performance] pushed me harder in music therapy, which in turn pushed my brain harder to focus on my words and my motor functions." He furthermore acknowledged how performance had helped him address vocal and cognitive changes experienced since his accident: "My voice changed since I got hurt...I didn't really want to talk to people... With music therapy, I learned not to be ashamed of my voice, and that it won't get better if I don't talk. It helped me with my memory because I had to remember lyrics, chord changes, and everything else...it made a great impact overall." Through performance in music therapy, Greg gained insight into personal struggles and was motivated to continue engaging in independent practice and performance. He shared, "Watching expressions of people I don't even know...seeing and feeling that someone you've never met before [is] showing happiness and joy from your performance. . .that is what is really empowering."

#### Performance as Motivation for Therapeutic Work

Greg participated in monthly performances as a therapeutic tool to provide awareness of his successes in rehabilitation goals. Eventually, he was able to simultaneously sing and play, which is a high-level cognitive process and an ongoing goal. He recounts, "Between music therapy sessions, I was rehearsing. Every time I got stuck on a word, I went back to my room and [would] say it, and my speech got clearer. It made me feel amazing after [performing] because, honestly I noticed every time I did something, people would be amazed." Performance supported Greg in changing from an internal focus to being able to communicate with others using music. This was observed by a shift in song selections from those that solely challenged his speaking/singing ability to songs that he connected with on a deeper level. Intentional song selection eventually led to Greg writing original compositions that reflected his belief systems and included messages to inspire himself and others. He spoke about the emotional benefits and comfort that he experienced from performance in music therapy, "With music, that's your friend, your therapist, and everything beyond, and it doesn't have anything bad to say about you ever."

### Generalization of Music Therapy in Transition

When Greg started music therapy, it was difficult and uncomfortable for him to speak on command or initiate conversations. Through the process of preparing for performances, which also included verbal song introductions, he continued to make clinical gains post-music therapy treatment, including speaking at his retirement ceremony and national public performances. Greg medically retired in May 2017 and is currently attending college with aspirations to become a motivational speaker. He reflected about his experiences performing in music therapy, "[Performance] worked my body harder. If I did not have music therapy, I would not be doing as well as I am today. I [still] incorporate what music expresses in my life."

# Case Report 2

# Background

"Chad" is a male in his thirties and was a Staff Sergeant (SSgt) in the United States Marine Corps. He served multiple combat deployments over his 13 years of service, during which he experienced blast exposure. Upon homecoming, Chad was diagnosed with mild TBI, chronic PTSD, and other combatrelated psychological health concerns. He initially engaged in individual and group music therapy through the intensive outpatient program. Chad continued music therapy for 1 year post-IOP, in weekly individual sessions.

#### "Tuning in" to Treatment

Chad's music therapy goals addressed pervasive symptoms of chronic PTSD, as well as mild TBI issues of cognition, emotional

regulation, and expression. Music therapy sessions incorporated various interactive experiences (e.g., active music making, lyric analysis, songwriting) to assist him in processing his military service and positively reframing self-perception and identity. Chad often selected songs by preferred artists to express things that were difficult to communicate prior to music therapy. He recounts, "Something about music made it easier to talk about issues that were bothering me. We spoke about issues that I hadn't even discussed with my [psycho]therapist at that point." After 8 months of individual sessions, Chad opted to perform a song at a Creative Arts Café that he had been preparing for his wedding. The integration of personally meaningful music into music therapy motivated his engagement in performance. Lyric analysis and songwriting facilitated emotional expression, as Chad modified songs to reflect his values. He shared, "I was able to add a spin on the song from my perspective, with help from the music therapist, which involved changing lyrics at the end, "Mercy," look what's become of us/One by one we turned it around/Maybe carry on just a little bit longer/God's gonna give us what we need" (adapted from "Mercy" Dave Matthews Band, 2012).

### Transforming Trauma

A song of particular significance that Chad subsequently performed was an arrangement of "Walls" by Kings of Leon. He reflected on the song's symbolism," 'When the walls come down,' that's how I felt music therapy was helping me...my walls coming down." Chad's musical engagement often inspired feelings of hope and reduction of personal guilt as reflected in his comment, "I feel like singing or even whistling means that there is some kind of happiness inside me, and it's not all dark...Music therapy is like God answering my prayers. A light in the darkness, and a reassurance that while I have experienced horror, I am not the cause of it all." He shared how performing helped him reduce isolation, "Performances can help to reconnect with people and even give others a chance to understand me more." The reciprocal experience of self-understanding while feeling "heard" by the audience allowed for continuous progression in treatment.

### Moving to the Next "Stage"

As Chad began preparing for his transition from active duty, he transferred skills developed through performance to continue growing in his life and relationships. His evolving interpretations of songs he performed in music therapy reflected his progression in treatment. For example, when he first used "Mercy" in sessions, the meaning was focused on in-the-moment needs, specifically symptom management. It progressed to address broader areas, namely humanization and becoming a better partner. Ultimately, Chad sang and played bass and percussion in a multimedia project of "Mercy" that he presented this to his wife, family, and friends at his wedding. He speaks about how the spirituality of the song aligned with his transformation in recovery, "The first line in the song is, "Don't give up". Even though I felt like I had so many times, I didn't give up, and to this day I am alive and not giving up. It was a sad song for me when the demons were in control, but God transformed the song into healing when it took on a new meaning for my wife and I, when we listened to it together. It transformed again as we grew as a couple, and we both went through really hard times along the path to recovery. [My wife] stayed with me through everything...there was no way I could let this song not be a part of our wedding day and music therapy was the reason it became a part of it." Chad medically retired in July 2017.

# CONCLUSION

Performance is an impactful tool for music therapists to utilize in support of clients' transformative processes. When integrated with apt intention and appropriate oversight, performance can be clinically conducive, informative, and reciprocally beneficial for service members and audiences. Performance helps educate military leadership, clinical providers, and the general public about the power of incorporating creative expression into structured environments. Creative Arts Cafés are models replicated across multiple sites that serve to bridge the clinic to community, supporting the overall transformation of service members and their families by validating their experiences and allowing for expression of their inner-selves while feeling connected to audiences. Musical performance benefits our society as a whole, supporting personal, collective, and societal transformation. This shapes the performer as well the perception of audiences and builds stronger, healthier communities in which individuals thrive.

# DISCLOSURE STATEMENT

The views expressed in this article are those of the author and do not reflect the official policy of the Department of the Army/Navy/Air Force, Department of Defense, or United States Government. The identification of specific products, scientific instrumentation, organizations, individuals or compositions is considered an integral part of the research endeavor and does not constitute endorsement or implied endorsement on the part of the author, DoD, or any component agency.

# ETHICAL DISCLOSURE

The case studies presented in this article were determined exempt by the NICoE/WRNMMC institutional review committee. Written informed consent was obtained from the participants for the publication of the case reports.

# ETHICS STATEMENT

This study was carried out in accordance with the recommendations of the National Intrepid Center of Excellence/Walter Reed National Military Medical Center PAO and designated as exempt from ethics committee review. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the National Intrepid Center of Excellence/Walter Reed National Military Medical Center PAO.

# AUTHOR CONTRIBUTIONS

fpsyg-10-00119 February 1, 2019 Time: 17:51 # 6

RV is a board-certified music therapist and served as contract support to the NICoE through National Endowment for the Arts, Creative Forces: NEA Military Healing Arts Network. During her tenure at the NICoE, she was the primary music therapist of the service members who were highlighted in the case report section of this article. As lead author, she conceptualized this article and took the lead in writing the article. She was responsible for final edits of the manuscript. HB contributed to content analysis of the interviews and writing the manuscript. JB contributed to sections of the manuscript.

# FUNDING

This work was supported by the National Endowment for the Arts, Creative Forces: NEA Military Healing Arts Network.

# REFERENCES

# ACKNOWLEDGMENTS

The authors would like to express heartfelt thanks to the service members highlighted in this article for openly sharing their powerful music therapy and performance experiences. Special recognition to service members and veterans who share their creative artistry through performance and shed a light that cannot be replicated. Special gratitude is extended to all the men and women who bravely serve their country in the United States Armed Forces and the leadership, providers, and staff who assist in their rehabilitation processes. Special thanks to Kalli Pelaccio, MT-BC for her efforts in developing the Creative Arts Café model at NICoE. The authors of this paper would like to acknowledge the contributions of Creative ForcesTM: NEA Military Healing Arts Network, an initiative of the National Endowment for the Arts (NEA) in partnership with the United States Departments of Defense and Veterans Affairs and the state and local arts agencies for their extensive support of creative arts therapies clinical programming and research. Administrative support for the initiative is provided by Americans for the Arts.

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2019 Vaudreuil, Bronson and Bradt. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

# Exploring Wellbeing and Creativity Through Collaborative Composition as Part of Hull 2017 City of Culture

*Caroline Waddington-Jones1 , Andrew King1 \* and Pamela Burnard2*

*1 School of Music, University of Hull, Kingston upon Hull, United Kingdom, 2 Faculty of Education, University of Cambridge, Cambridge, United Kingdom*

Several studies have highlighted the positive effects of group music-making and have suggested that it may be the creative and social aspects of such activities, which have a positive effect on participants' wellbeing. Collaborative composition offers strong examples of both aspects as participants work together to create new material. However, although it seems likely that participants' influence over and ownership of the creative material contributes to these positive effects, studies have yet to examine these elements in detail. Through analysis of video observations, pre- and post-project interviews, video recall interviews, and questionnaires, this article aims to: (1) evaluate the impact of participation in collaborative composition workshops on the subjective and psychological wellbeing of older adults and (2) identify skills and approaches employed by the composer-facilitators in order to understand more fully the approach and skills employed to engage participants effectively in the creative process. This second aim is of particular interest given the current movement toward social prescribing and arts and health interventions in the UK. Analysis revealed that all dimensions of the PERMA framework for subjective and psychological wellbeing were present in this collaborative composition project. The specific nature of collaborative composition is considered in comparison with other forms of group musical engagement. For older adults, collaborative composition has much to offer as an activity encouraging social interaction with others with shared interests, increasing positive affect, and enhancing self-esteem. Analysis of workshop videos and interviews with composers identified various facilitation skills employed by the composers to establish safe creative space and to encourage participants to engage in the process of collaborative composition.

Keywords: wellbeing, collaborative composition, older adults, creativity, Hull 2017, PERMA

# INTRODUCTION

Since ancient times, humans have been fascinated with how to live a good life, with prominent thinkers such as Aristotle arguing that wellbeing is the overarching purpose of all human actions (Aristotle, 2004). In recent years, there has been increased research interest in wellbeing, as people seek to learn how they might lead healthier and happier lives. There has been much debate within the realm of positive psychology over how to define wellbeing, with researchers

#### *Edited by:*

*Evangelos Himonides, University College London, United Kingdom*

#### *Reviewed by:*

*Monica Esslin-Peard, University of Liverpool, United Kingdom Francisco Cuadrado, Universidad Loyola Andalucía, Spain*

> *\*Correspondence: Andrew King<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Performance Science, a section of the journal Frontiers in Psychology*

*Received: 22 December 2018 Accepted: 26 February 2019 Published: 22 March 2019*

#### *Citation:*

*Waddington-Jones C, King A and Burnard P (2019) Exploring Wellbeing and Creativity Through Collaborative Composition as Part of Hull 2017 City of Culture. Front. Psychol. 10:548. doi: 10.3389/fpsyg.2019.00548*

broadly conceptualizing two dimensions of wellbeing: subjective and psychological (e.g., Diener et al., 1999; Deci and Ryan, 2008; Proctor et al., 2009).

Our modern conceptualization of subjective wellbeing is rooted in the utilitarian hedonist philosophies of John Stuart Mill and Jeremy Bentham who both argued that pleasure is central to wellbeing. This dimension of wellbeing primarily concerns our subjective judgments of how satisfied we are with life (Diener, 1984) and emphasizes high positive affect and low negative affect (Bradburn, 1969; Kahneman et al., 1999). Subjective wellbeing involves the pursuit of happiness and is based on the principle that the more positive emotion we experience, the happier we will be (Seligman, 2002). By contrast, psychological wellbeing has emerged from Aristotle's concept of *eudaimonia* and accentuates positive psychological functioning and human development (e.g., Rogers, 1961; Waterman, 1993). Various dimensions of positive psychological functioning have been proposed, including how we relate to other people, how independent we are, how we engage in various experiences, and how we find meaning in our lives (e.g., Seligman et al., 2005; Ryan et al., 2008).

More recently, positive psychologists have suggested that in order for humans to flourish fully, a balance of the elements of both subjective and psychological dimensions of wellbeing is required (Peterson et al., 2005; Sirgy and Wu, 2009; Seligman, 2010). Seligman (2010) has proposed a framework that incorporates elements of both dimensions of wellbeing: PERMA (Positive emotions, Engagement, Relationships, Meaning, Accomplishment). Positive emotions are the subjective wellbeing element of the PERMA model. The more positive affect or pleasure we experience, the happier we will be. Engagement in this context is closely connected to flow theory (Csikszentmihalyi, 1975) and refers to the experience of total immersion in an activity. The relationships' dimension of the framework recognizes that humans are inherently social and that we thrive through our connections to and interactions with others. Having a clear sense of meaning or purpose in life seems to be a major component of human wellbeing and is the key to understanding motivation (De Muijnck, 2013). Finally, Seligman (2010) considers accomplishment to be a key motivation for many people. It is closely connected to goals and ambition, and it seems likely that gaining mastery or competence in a particular skill may increase self-esteem.

# Older Adults and Wellbeing

As people are now living longer lives, more research is being dedicated to understanding how we can flourish later in life. A review of the existing literature on older adults and wellbeing suggests that the Engagement and Relationships dimensions of PERMA may be particularly relevant. Cumming and Henry (1961) have proposed that as adults age, they disengage from society physically and socially, and that society also withdraws from older adults. Empirical research has suggested that older adults who are most connected report greater satisfaction with themselves and their lives—or greater subjective wellbeing (Bjorklund, 2011). Research has found that social engagement, in the form of social activities, productive activities, helping activities, formal and informal learning, and leisure, is positively correlated with older adults' physical and mental health (Herzog et al., 2002), and that joint participation in leisure activities with members of one's social network has been positively associated with life satisfaction (Holman and Jacquart, 1988).

Elsewhere, studies have found that participation in adult education has positive impacts on older adults' psychological wellbeing (Schuller et al., 2002; Feinstein and Hammond, 2004; Hammond and Feinstein, 2006). This tended to take the form of increased self-esteem and seems likely to be related to the Accomplishment as well as the Engagement and Relationships dimensions of PERMA. Through mastering a new skill or acquiring knowledge, as well as engaging in a new activity and socializing with others, participants' psychological wellbeing increases.

# Musical Engagement and Wellbeing

The field of Arts and Health in the UK is flourishing at present, particularly in light of the current emphasis on health promotion (see e.g., Coulter and Gordon-Nesbitt, 2016) and the formation of the *All-Party Parliamentary Group on Arts for Health and Wellbeing* in 2014. Most recently, in the UK, there has been a movement toward social prescribing, which advocates for engagement in arts-based activities to enhance wellbeing. Several studies have highlighted the positive relationship between musical engagement and both subjective and psychological dimensions of wellbeing (e.g., Hays and Minichiello, 2005; Ritchie and Williamon, 2011; Van Goethem and Sloboda, 2011; Croom, 2015). It has been argued that active rather than passive musical engagement tends to provide benefits for an individual's psychological as well as subjective wellbeing (e.g., Csikszentmihalyi, 2002; Hallam et al., 2012; Creech et al., 2013). It seems likely that this may be due to the higher levels of engagement, the opportunities for selfexpression, and the subsequent sense of accomplishment and clarity of identity inherent in active music-making.

Croom (2015) has proposed that the PERMA framework (Seligman, 2010) provides a useful lens through which to examine musical engagement and wellbeing. He cites evidence for musical engagement increasing positive affect (e.g., Laukka, 2007; Van Goethem and Sloboda, 2011; DeMarco et al., 2012), offering opportunities for deep engagement (e.g., Pates et al., 2003; Dietrich, 2004; Rogatko, 2009; de Manzano et al., 2010; Peifer, 2012), connecting with other people (e.g., Packer and Ballantyne, 2011; Procter, 2011; Schiepe-Tiska and Engeser, 2012; Koelsch, 2013; Rabinowitch et al., 2013; Ballantyne et al., 2014), bringing a sense of meaning or purpose to people's lives (Frith, 1996; DeNora, 2000; Hays and Minichiello, 2005), and accomplishment (e.g., Hylton, 1981; Edgerton, 1994; Lee and Nantais, 1996; Hiscock et al., 2013; Klaphajone et al., 2013). Musical engagement, therefore, has the potential to contribute positively to all dimensions of wellbeing.

# Older Adults, Musical Engagement, and Wellbeing

Musicking in the lives of older people has begun to receive a lot of attention in recent years, with studies examining, for example, the benefits of everyday musical engagement for older adults (e.g., Hays and Minichiello, 2005), adults with dementia (e.g., Sixsmith and Gibson, 2007), and the impact learning a musical instrument can have on wellbeing for older adults (Perkins and Williamon, 2014).

### Group Musicking

Wellbeing in relation to engagement in group music activities has been a particular focus of studies, as researchers seek to understand more fully this long-acknowledged positive impact of musicking with others (Small, 1999). Creech et al. (2013) investigated the relationship between engagement in group music-making activities and wellbeing according to the Basic Psychological Needs Scale (Deci and Ryan, 2008) and the CASP-12 measure of quality of life in later life (Higgs et al., 2003), finding that, even compared to other group activities, group music-making had a significant positive impact on participants' self-reported wellbeing for the "purpose," "control and autonomy," and "social affirmation" components of these scales. Elsewhere, Hallam and Creech (2016) combined questionnaires with interviews and observations to examine the effects of participation in community music activities can have on older adults' wellbeing. Again, compared to a control, the older adults participating in group music-making scored higher on quality of life instruments. Analysis of the qualitative data revealed benefits for health, emotional, and cognitive dimensions of wellbeing. Similarly, in a study characterizing collaborative and communal creativities in instrumental group learning and performance, Burnard and Dragovic (2014a,b) found the physicality of performance and levels of performance development to be sites for enhancing pupil wellbeing.

# Collaborative Composition

Although such studies have considered that it may be the creative and social aspects of group music-making which particularly influence wellbeing, so far only one study (Habron et al., 2013) has explored the potential benefits of group music-making involving the collaborative creation of new musical material. The researchers found that the sense of control over musical materials, opportunities for creativity and identity formation, as well as social interaction with other participants and musicians were all beneficial for participants' wellbeing. This is supported by other studies on collaborative composition, which have highlighted its potential for inducing flow (Macdonald et al., 2006) and have considered the collaborative aspect of the activity both socially and musically (Miell and MacDonald, 2000; Burland and Davidson, 2001; Hopkins, 2015; Williams, 2018).

Collaborative composition has not been considered yet through the lens of PERMA. However, as a form of active group musical engagement, and based on the evidence from these existing studies of collaborative composition and group music-making, it seems reasonable to suggest that collaborative composition may influence all dimensions of PERMA. While the participants in Habron et al.'s (2013) investigation of the relationship between collaborative composition and wellbeing had creative control over the music realized by the professional musicians involved in the project, they did not create the music themselves. Furthermore, no study has yet examined the facilitative skills required by composers in order to engage participants in collaborative composition. The present research therefore sought to explore the perceived impact of collaborative composition and group performance on diverse groups of people and to identify skills and approaches employed by the composer-facilitators.

# Hull 2017: New Music Biennial

As part of the program for Hull City of Culture 2017, five composer residencies took place over 4 months within various communities in the city as part of the PRS Foundation's *New Music Biennial*. Designed to spark interest in collaborative composition and new music, the composers ran workshops with different groups of participants, including refugees and asylum seekers, travelers, older adults, primary school children, formerly homeless people, and vulnerable young people. The residencies culminated in two public performances at Hull City Hall, involving performances from each composer's groups and a "supergroup" performance delivered by all the groups together.

Here, we present an evaluation of two of the composer residencies that sought to engage older people and primary school children: the first, a song-writing project bringing together older people living in retirement communities and children from a primary school in East Hull; the second, the creation of an ambisonic sound installation facilitated by a beatboxer and sound artist of international acclaim with members of choral group based in Hull. Two research questions will be addressed:

# MATERIALS AND METHODS

# Participants

The participants were two male, non-Hull-based, professional composers (Composer A and Composer B). Neither composer had a teaching qualification, but both had extensive experience of facilitating composition workshops, and this was the main reason that these two residencies were chosen out of the five for data collection and evaluation. Composer A worked with 25 members of a local choral group, a community choir whose membership changes on a project-by-project basis. Some members of the chorus were new for this project. Composer B worked with nine residents of two Hull-based homes from an independent Housing Association for older people in Hull. These residents formed a new group for the project. Later in the residency, they were joined by 25 years four pupils from a primary school in East Hull to collaborate for a final performance.

# Procedure

The two composers were interviewed at the start and at the end of their four-month residencies. Interviews were semistructured and questions focused on the composers' intentions for their residencies, their perception of possible challenges, and what they hoped the impact of the residency might be on the participants. Post-residency interviews followed a similar question structure but sought to reveal what had actually happened during the residency, what the challenges had been, and what the composers perceived to have been the impact of their residencies.

Two-hour workshop sessions with each composer were observed, and three of these observed sessions were also videorecorded. In addition to this observational data, recall interviews were conducted with two participants in Composer A's residency using excerpts of the video data from one of the workshops. Finally, post-project questionnaires were administered to participants at one of the performance days at City Hall at the end of the project. These asked participants about their perception of the impact of the residency on them.

# Analysis

Interview, observational, and questionnaire data were reviewed, transcribed, and collated using *NVivo*. Thematic analysis was undertaken using an inductive approach modeled on grounded theory in which the aim of the analysis was to describe the data and theorize the findings. Themes were developed by collapsing, combining, or extending initial codes.

# RESULTS AND DISCUSSION

In terms of the perceived impact of participating in the collaborative composition workshops and group performances on wellbeing, an inductive thematic analysis of the video-recall interview and post-residency questionnaire data revealed various themes. These themes were then considered in relation to the dimensions of PERMA, and some close connections were identified. **Table 1** shows the theme and sub-themes, which emerged from the analysis.

# Enjoyment

Participants described or displayed "Enjoyment" of sessions. This theme seems to relate closely to the positive emotion dimension of PERMA. Examples of this theme from the postresidency questionnaires included comments such as "The project has been uplifting—I look forward to rehearsals" and "Uplifting—lifts the soul. Wonderful." Reflecting on the residency, one of the video-recall interview participants explained:

It was fun, and I wanted to do more of it. To be part of different things … I have really enjoyed it and it definitely gave me a lot of energy and inspired me for the time in between the workshops and then afterwards. (Videorecall interview participant 1)

The positive emotion dimension of PERMA is connected to subjective wellbeing: the more positive affect we experience, the happier we will be. Since the participants found the workshops uplifting and fun, it seems likely that their participation in the workshops will have increased their subjective wellbeing.

# Togetherness

The theme "Togetherness" variously described bonding between participants ("social cohesion") and coming together as a group musically ("musical cohesion") and seems to be closely related to the Relationships dimension of PERMA.

#### Social Cohesion

In reflecting on their experiences of the residency, many participants emphasized their pleasure at making new friends and being together on a regular basis as a group. Comments from the Big Elastic Band on the post-residency questionnaires included: "I have made some great friends"; "I have really enjoyed getting out and being together with others in the group"; "I have taken away a spirit of willingness: wanting to learn and participate with everybody—children and adults." Hull Freedom Chorus participants commented that they: "enjoyed being together"; "enjoyed meeting new people"; and "felt involved and happy with a changing group of singers."

Despite being a group formed especially for this residency, it was evident that the Big Elastic Band members grew to value the social dimension that the collaborative composition workshops provided. This seems to connect closely to the Relationships dimension of the PERMA framework. The collaborative composition workshops offered participants a means of bringing together people with a shared interest in creating music who would not otherwise meet. The Big Elastic Band had been formed especially for the collaborative composition residency, and the 25 members of Hull Freedom Chorus who came together for this residency included several individuals who had not been a part of the group previously.

#### Musical Cohesion

In the post-project questionnaires, participants commented on the impact of the residency in terms of being able to "working with and listening to others" and "feeling able to make a creative contribution to the group." While reviewing the video footage of a workshop, both video recall participants described their experiences of creating new sounds as a group:

I did have my eyes closed and I could hear everyone else. It amplified everything. Well that's what the sea does, there's all sorts of different sounds in the sea. It's not just one sound, it's all sorts of different sounds, and that's what it sounded like to me. It just sounded like the sea. If you think of ripples of the sea going over pebbles. Each pebble is a different shape and making a different sound as it rushes back. That's what it felt like to me. Everybody was doing it, like the sea ebbing away. It was a big sound and that's what the sea is, it's a big sound. (Video-recall interview participant 2)

Here, the participant describes a moment of group vocal improvisation in which the group are exploring the sounds of the sea. Research in group music-making has suggested that creating music together involves communication, cooperation, empathy, and ultimately may facilitate increased social cohesion (King, 2006; Seddon and Biasutti, 2009; Koelsch, 2013; Waddington, 2017). Since many participants in the present study reported that their participation in the residencies led to the formation of new friendships and a sense of group togetherness, the findings of this analysis seem to support the existing evidence in this area. Since collaborative composition involves co-creating new musical material rather than reproducing existing musical material, the various social and musical processes underlying this co-creation may be more pronounced.

In music educational contexts, Rusinek (2012) has suggested that when engaging in collaborative composition, participants operate in the "zone of proximal development" (Vygotsky, 1978) in which they co-construct musical understanding and new musical material. It is possible that these shared experiences of musicking and co-creation of musical material also contribute positively toward strengthening social relationships and an emerging sense of group identity.

## Empowerment

The theme of "Empowerment" broke down into sub-themes of "Engagement," "Meaning," and "Accomplishment": dimensions of PERMA.

#### Engagement

In the Engagement sub-theme, participants described moments of total absorption in the creative process. When reviewing some workshop footage, one of the video-recall participants explained: "I found the sounds provoke the images for me. That's what I liked about it. I was able not just to immerse myself in the sound which developed but the images came as well. I really appreciated that. I liked that" (video-recall interview participant 2). Such moments of absorption in these creative activities are characteristic of flow experiences (Csikszentmihalyi, 1975). Research has suggested that the more flow we experience, the happier we will be (Csikszentmihalyi, 2002). The finding of the present study that engaging in collaborative composition and group musicking may lead to flow experiences adds further weight to the existing evidence that group musical engagement in general and collaborative composition in particular can positively contribute to psychological wellbeing (e.g., Macdonald et al., 2006; Waddington, 2017).

#### Meaning

In their post-residency questionnaires, participants spoke about how the workshops had contributed to the structure of their weeks. One participant commented that the Big Elastic Band workshops were an important moment in their week to "get out and be together with others in the group." Many participants wrote that they were looking forward to continuing to sing and compose together as a group. It seems likely that they had gained a sense of group identity and purpose.

#### Accomplishment

The post-residency questionnaires recorded many examples of accomplishment. Participants described various musical achievements: "confidence in singing (especially in a smaller group, it has proved you can sing, even though you are in your 80s)"; "musically—I now know how to make a song from scratch"; "stepping out of my comfort zone"; and "opened my mind to a greater variety of options for experimenting with sound and my voice." One of the video-recall participants also noted that she "had a different feeling afterwards, like a sense of achievement because I did the drill and I got to hear myself being the drill." A few participants also noted that this sense of accomplishment had led to, e.g., "greater confidence on a personal level."

# Collaborative Composition and Wellbeing

There are many similarities between collaborative composition and other forms of active group music-making, such as ensemble playing. Both activities involve musical interaction, potential for experiencing flow, and socioemotional bonding. However, unlike ensemble playing, collaborative composition also involves creating new musical material. Consequently, there is a sense of group and individual ownership over the creative process in collaborative composition that may not be so prominent in ensemble playing activities. This aspect of ownership in collaborative composition also differs somewhat from group improvization in which the musical material is recorded in some form to enable reproduction. Capturing group members' creative contributions in this way offers tangible evidence of accomplishment. This may enhance participants' sense of achievement and increase self-esteem.

Another facet of collaborative composition, which differs from other forms of group musical engagement, is the potential for facilitating interaction and strengthening relationships between group members. Collaborative composition in the residencies evaluated for the present paper involved participants drawing on their life experiences or their personal memories of Hull as inspiration for the creation of songs or vocal soundscapes. As such, there were many opportunities for sharing personal experiences in each of the groups as part of the workshops as part of group discussions at the start of the creative process or through sharing ideas on the shaping of the musical material once composition had begun. It is likely that the sharing of these personal experiences facilitated socioemotional bonding between the group members. Below are the lyrics to one of the songs composed by the Big Elastic Band.

#### **Whisper**

I whisper in the night to my lost love To dance with romance To dance with romance I took a chance Forever in my heart The love of my life

> I wasn't ready for you to go Oh, how I loved you so In the silence, you answer me You say you needed to be free Forever in my heart The love of my life

Memories you left so clear Will always keep you near Through the heartache and pain I know I will dance again I know we will dance again some day.

(Lyrics to a song written by the Big Elastic Band)

This was one example of several sets of lyrics that members shared with the rest of the group. The lyrics to this song were written by one of the group members about a personal life experience. She shared the lyrics with the rest of the group who then all worked together, facilitated by Composer B, to create a melody for the song. The lyrics to this song are deeply personal to this group member. That she felt able to share her words with the rest of the group may be taken as evidence of the trust and the relationship that developed between members over the relatively short span of the residency. This adds further weight to the findings of the analysis of the interview and questionnaire data above that revealed that participants felt that their participation in the residencies had resulted in the development and strengthening of relationships with other members of the group.

These two elements—the recorded evidence of group or individual contributions and the opportunities for sharing personal experiences or ideas—seem to be unique to collaborative composition and relate closely to the Accomplishment and Relationships dimensions of PERMA. As with other forms of group music-making and as demonstrated in the analysis of the interview and questionnaire data here, collaborative composition can also contribute positively to the other dimensions of PERMA and, hence, to subjective and psychological wellbeing. For older adults in particular who may be less socially engaged or have lower self-esteem than younger adults (Orth et al., 2010), collaborative composition activities may positively contribute to the Relationships and Accomplishment dimensions of wellbeing.

Since there is compelling evidence in the rich, qualitative data analyzed here that collaborative composition had numerous benefits for older adults' subjective and psychological wellbeing, it is important that we also seek to understand how these participants can be engaged successfully in collaborative composition. Encouraging participants to share ideas and engage in the creative process requires a lot of skill from the composers as facilitators move beyond their musical expertise. They must be able to build a rapport with the group members and establish a safe, non-judgmental space within the group that promotes this kind of engagement.

# Composers as Facilitators

These two composers were identified by the City of Culture managers in their post-project interviews as particularly good examples of composers working collaboratively to create material with participants. In their pre-project interviews, the composers identified two key challenges when considering how to approach engaging participants in collaborative composition during their residencies.

Composer A reflected on the challenge of coming in as an outsider and building trust with the participants in his residency in order to facilitate a creative process:

I think the first part of the challenge is building up a trust with people in Hull. I'm very conscious about being an artist that goes to a place where I'm not from …So, the whole thing for me is about really working with the people from Hull, to produce something that will not only go out, but will also hopefully remain in Hull. So I see myself more as a catalyst to facilitate a process that will come from the people that are already there. (Composer A, pre-residency interview)

The challenges of encouraging participants to engage in the creative process were also highlighted by Composer B, as he spoke about trying to bring people together:

And I suppose the challenge is always allowing people to be connected and easy with [the process of collaborative composition]…. It's a very fractured community, you have people with all sorts of different abilities and they're coming in, they're coming out, so everything has to grow very organically. I think the challenges are really just about finding different ways that people can kind of connect to it, you know. As soon as they connect to it, it starts being part of what they are and they have a sort of sense of belonging to it and then that helps them grow from there. It's just finding different ways of doing that …. The whole residency is about allowing all of those people to write their own stuff essentially. (Composer B, pre-residency interview)

This composer recognized the additional challenge that at least one of the groups of participants that he was facilitating was formed just to participate in his residency. As a newly formed group, there would be a period of "forming" (Tuckman, 1965) as members settled into the pattern of working together as well as working with the composer-facilitator. This presents a further challenge from the facilitator's perspective in terms of engaging participants in a group creative process such as collaborative composition.

#### TABLE 2 | Coding framework for facilitator skills.

Common to both of these accounts is a sense that facilitating group ownership rather than composer ownership over the creative process and material produced was a priority for both composers. Composer A described himself as "a catalyst to facilitate a process that will come from the people" and Composer B spoke about participants' sense of "belonging" and connection to the process. It was evident from these pre-residency interviews that these composers both set out to facilitate true collaborative composition rather than taking a more composer-directed approach to their residencies.

Analysis of the video data identified the facilitation skills and tools employed by the composers (see **Table 2**). The creation of safe space is critical for participants to feel comfortable engaging in a creative process (Rogers, 1993). Both composers used a range of skills to facilitate this engagement. Three themes were identified in the video data: "Confidence and Clarity," "Facilitator-Group Dynamic," and "Comfort." Each theme had various sub-themes.

### Confidence and Clarity

Both composers were coded as "Demonstrating Expertise" at regular intervals. These were moments were the composerfacilitators demonstrated their musical skills and served to remind workshop participants of the composers' expertise and, consequently, encouraged a higher level of confidence in both the composer and the creative process. Both composers modeled techniques frequently rather than explaining verbally. The theme of "Modeling" often overlapped with "Demonstrating Expertise," suggesting that Modeling was a way of explaining exactly what the composer wanted the group to do while also reminding them of the composer's expertise. Ensuring a good understanding of instructions also contributed to the establishment of safe space. When verbal instructions were used, both composers were very clear in outlining ideas (coded as "Precise Explanation"). This seemed to minimize confusion and uncertainty and so contributed to establishing safe space and facilitating creative expression. This supports Macdonald et al.'s (2006) finding that the clarity of instructions is crucial for engaging participants in collaborative composition.

#### Facilitator-Group Dynamic

There were examples in both composers' workshops of the composers taking on a more authoritative role, to guide the workshop, for example, and a more equal role with the participants, encouraging group members to contribute or take ownership. These moments were coded as "Intimacy vs. Authority." Within this sub-theme was two further sub-themes: "Group Ownership" and "Composer-Directed."

Group Ownership described moments when the composers placed control over the creative material into their group's hands. This was supported by the video-recall interviews in which one participant commented that the composer had "given us that freedom. He's given us that opening to say 'Yes, I want to know what your opinions are' not closed up and said, 'You'll do it my way.'" This sub-theme was balanced at times with "Composer Direction," where composers would direct the creative process toward the requisite end product: the performances at City Hall.

To encourage contributions from the group, create a positive atmosphere, and offer reassurance and clarity, both composers offered "Praise and Feedback" to participants at regular intervals throughout the workshops. This seems to be in line with flow theory (Csikszentmihalyi, 1975), which suggests that frequent feedback is a condition for flow. Both composers offered encouragement, acknowledged effort, and praised participants at regular intervals during workshops.

Another tool both composers employed to cultivate a more egalitarian relationship with the group members and to encourage engagement was "Humor." In his pre-residency interview, Composer B explained:

The thing about writing music on any level is that it's like being in this brilliant playground where you are surrounded by lots of stuff, you know. So it's just a question of putting things on top of each other and connecting things together. And it's a real sense of play you know.  And then that leads somewhere. (Composer B, pre-residency interview)

This concept of play for both composers was central to engaging participants.  It's all about playing.  Covered in dirt, wow. It's about playing, and what I am trying to say to you is just try to play with stuff and see what happens, you know. That's the most important thing is that we play. (Composer A, workshop 19 June 2017)

This finding supports existing research suggesting that overcoming participants' fear of failure is crucial to engaging them in the creative process and in flow (Macdonald et al., 2006). Taking a playful approach to composition seemed to be strategies employed by both composers in their workshops. Humor seemed to be a mechanism for encouraging play during both composers' workshops.

# Comfort

Both composers emphasized voluntary participation at individual group members' comfort levels: "Comfort Level." By emphasizing the voluntary nature of participation, the composers empower the participants, giving them control over their level of engagement in the creative process. The composers also considered group members' comfort on a more practical level. Examples included reminders to rehydrate, asking whether participants would prefer to sit, checking energy levels and the temperature of the room. This was coded as "Environment and Physical Needs." This seems to relate to Maslow's (1987) Hierarchy of Needs, since if participants' basic needs in terms of physical comfort are not met, they will not be able to engage.

# The Role of the Composer-Facilitator

For these residencies, there was a balance between working toward a final product, a public performance, and emphasizing engaging in the creative process. Reflecting this challenge, there was a balance between composer-directed moments, and moments where the composers encouraged the group members to take ownership over the creative process. This way of working draws upon the composers' expertise not only in composition but also in facilitating, and ultimately empowering, their participants.

# CONCLUSION

This study has added further evidence to the existing literature on the relationship between collaborative composition and wellbeing. Analysis revealed that participants in the 4-month collaborative composition residencies for Hull 2017 perceived a positive impact on their subjective and psychological wellbeing, with participants' experiences being closely associated with all five dimensions of the PERMA framework (Seligman, 2010). It is interesting to note that the PERMA framework here emerged from an inductive analysis of the observational, videorecall interview, and questionnaire data rather than from a direct application of the framework to the data. The PERMA framework is beginning to be applied to highlight the benefits of musical engagement in various music educational and performance contexts (e.g., Lee et al., 2017; Ascenso et al., 2018). However, our work here suggests that there is much potential for this framework to be used as an evaluative tool for community music and music therapy projects as well.

The specific nature of collaborative composition has been considered in comparison with other forms of group musical engagement, and the potential for participants to experience a sense of achievement in identifying their own contribution to the group's work as well as the potential for group discussion, particularly focusing on personal experiences, and the impact that may have on strengthening relationships between group members have been highlighted. For older adults, collaborative composition has much to offer as an activity encouraging social interaction with others with shared interests, increasing positive affect, and enhancing self-esteem.

While there is strong evidence here for the value of collaborative composition as an activity that may enhance wellbeing, the intersubjective process of collaborative composition is complex and requires a range of skills from the composer-facilitator in order to engage participants effectively. With the current interest in arts and health interventions and social prescribing, it is vital that consideration be given to the quality of provision of projects such as this. This article has begun to consider some of the skills required to facilitate effective collaborative composition workshops with older adults. The City of Culture managers and the authors had identified the two composer residencies reported here as being the most successful in engaging participants in collaborative composition. Analysis of interview and video data identified the various techniques employed by the composerfacilitators to establish a safe space for participants to feel able to engage in the creative process.

Future work should engage in practices of reconfiguring and re-reading what counts as generative forces of wellbeing and the physicality of collaborative composition and performance practice/engagement and to evaluate the legacy of collaborative composition and performance projects such as this in terms of participants' continued engagement with music-making and the perceived impact on their wellbeing over time. The intention to keep engaging in music activities beyond this project was declared by most participants in post-project questionnaires and recall interviews. Many members of the Hull Freedom Chorus were keen to be involved in future projects exploring beatboxing, rap, or other less conventional styles. Funding has been awarded based on the success of this residency to support further work with the Big Elastic Band and continue their song-writing workshops. We intend to work with some of these participants over the coming months to evaluate their continued engagement in music-making beyond this project.

Nearly 20 years ago, in one of the earliest studies of children's group music compositions, Morgan et al. (2000) argued that the principal element of task activity within groups is the dialog among members. It is surely high time we recognized the importance of continued engagement with such music-making in terms of impact on wellbeing because it allows for ways to think differently and produce, juxtapose, contrast, combine, and communicate ideas through collaborative composition.

# DATA AVAILABILITY

The datasets for this study will not be made publicly available because participants have not consented for their video and interview data to be made available.

# ETHICS STATEMENT

This study was carried out in accordance with the recommendations of "The University Code of Good Research Practice," University of Hull Ethics Committee, with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the University of Hull Faculty of Arts, Culture, and Education Ethics Committee.

# AUTHOR CONTRIBUTIONS

CW-J collected the data, analyzed, and drafted the manuscript. AK is a principal investigator and designed the study.

# REFERENCES

Aristotle (2004). *Nicomachean ethics*. London: Penguin.

AK and PB revised the manuscript. PB consulted at each stage of project.

# FUNDING

The funder for this research study was Paul Hamlyn, *via* the Performing Rights Society and Sound and Music. Grant account: YAE048.

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Copyright © 2019 Waddington-Jones, King and Burnard. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# The Social Impact of Musical Engagement for Young Adults With Learning Difficulties: A Qualitative Study

#### *Graeme B. Wilson\* and Raymond A. R. MacDonald*

*Reid School of Music, Edinburgh College of Art, University of Edinburgh, Edinburgh, United Kingdom*

#### *Edited by:*

*Michele Biasutti, University of Padova, Italy*

#### *Reviewed by:*

*Ailbhe Kenny, Mary Immaculate College, Ireland Karen Burland, University of Leeds, United Kingdom*

> *\*Correspondence: Graeme B. Wilson<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Performance Science, a section of the journal Frontiers in Psychology*

*Received: 11 February 2019 Accepted: 17 May 2019 Published: 28 June 2019*

#### *Citation:*

*Wilson GB and MacDonald RAR (2019) The Social Impact of Musical Engagement for Young Adults With Learning Difficulties: A Qualitative Study. Front. Psychol. 10:1300. doi: 10.3389/fpsyg.2019.01300*

There is evidence that music interventions can offer opportunities for creative, psychological, and social developments for individuals with mild to profound learning disabilities, addressing the disadvantages they face in respect of social outcomes. This paper reports on a qualitative study investigating a community music intervention for such a population. Thirty-seven adult service users (12 female, 25 male) took part in weekly music workshops for 10 weeks. Their learning difficulties ranged from mild to profound, and their levels of independence ranged from requiring constant one-to-one care to living alone in sheltered accommodation. Interviews were conducted at multiple time points with music and resource center staff as well as participants and members of their families and other center users; researchers also observed all workshops, taking field notes. Thematic analysis of the data informed understanding of the disadvantages facing participants, their experience of the workshop program and its immediate and wider social outcomes, as well as suggesting key mechanisms for effects. Disadvantages and barriers facing participants included: limited access to enjoying or learning music; boredom, isolation, and limited networks; lack of experience of new social contexts; and an associated lack of confidence, low mood or self-esteem. Participants were found to enjoy and sustain engagement with a program of dedicated group music workshops delivered by staff trained in an empathic and inclusive approach. Impacts included an ongoing enthusiasm to engage in music; wider recognition of musicality; increased self-confidence; being happier, more relaxed, and/or enthusiastic after the workshops; better ability to interact with unfamiliar situations and people; and participation in social activities for an unprecedented length of time. Key factors in achieving those impacts are that participants: had fun and interacted socially; felt secure, welcomed, and involved at all times; exercised choice; worked with others in nonverbal tasks; and encountered challenge while engaging and progressing at their own rate.

Keywords: music, learning difficulties, disability, inequality, interaction, psychology, social

# INTRODUCTION

Individuals with support needs in respect of physical or mental impairments are disproportionately affected by loneliness, isolation, and limited self-efficacy, with negative impacts upon them and their communities (de Jong Gierveld et al., 2006; Hawthorne, 2008; Cacioppo and Cacioppo, 2014). However, in Scotland, barriers to employment, activities, and supportive networks of meaningful relationships are such that adults with a long-term limiting condition are still less likely to experience good general health or be economically active at working age, and more likely to experience discrimination, than those without a disability (Scottish Government, 2016a,b,c).

Positive benefits can accrue from initiatives to increase opportunities accessible by people with impairments and change prevailing perceptions of their potential to lead full social lives (Shochet et al., 2016), particularly if participant-led (Milner and Kelly, 2009). Making music represents one such initiative. As a key creative field, music offers powerful scope for selfdefinition (Green, 2006) and therefore great potential to address disadvantages faced by individuals with impairments. Music is an important activity, sophisticatedly woven into all daily lives (DeNora, 2000). It can be considered a fundamental aspect of society, central to many social activities, while profoundly affecting our moods, emotions, and behavior (Becker, 1986). At the same time, music also helps in the construction, negotiation, and maintenance of identities (Frith, 1996; MacDonald et al., 2017). Music therefore has a unique sociological and psychological importance, both in terms of how it is embedded within societies around the world, and how it facilitates social interaction (Roy and Dowd, 2010). While everyday music listening can play an important role in health and well-being (DeNora, 2013), a substantial body of evidence now shows that the creative and expressive physical and mental processes of making music together offer a powerful and accessible means to maintain well-being and foster social relationships (MacDonald et al., 2012). Making music with others in community settings can moreover have value throughout adult life (Pitts, 2005; Kenny, 2016). Nevertheless, barriers to access affect music as much as other fields.

A growing literature on the unique potential of musical involvement to improve outcomes for children with autism is emerging (Simpson and Keen, 2011). However, there is scarce literature on the impacts of music in the community (nonclinical) setting. Although development for all individuals continues throughout life, albeit at a slower rate following childhood, there is also little research on the potential of music at different stages of adulthood for individuals with autism. Furthermore, studies tend to consider outcomes in terms of behaviors or symptoms associated with the condition, rather than considering music's potential to tackle the persistent exclusion and inequality of disabled people and build social capital for this sector (Bates and Davis, 2004).

One previous study considered the impacts of a community music program for adults with a range of disabilities, which provided participants with experiences of a wide range of musical genres and facilitated them in developing new rock music based on their own lives and ideas (MacDonald and Miell, 2002). Interviews with six longer-term participants indicated a broader range of impacts than those on musical proficiency and understanding alone. Forming a band and performing professionally had forged new social links and allowed interviewees to interact in ways they had not before. They described substantial positive effects on their confidence and the identities they perceived for themselves. Musical involvement was a powerful means of challenging negative identities around their conditions that others constructed for them; interviewees blamed a daily experience of stereotyping for negative impacts on their mental health. However this research produced a limited picture based on snapshot retrospective interviews with participants who had already been involved in the program for years in some cases, and for whom there was no baseline information.

This paper reports on a recent research project in Scotland to address these gaps in knowledge. The project involved development and delivery of a new program of innovative music workshops for a key population experiencing inequality: young adults with autism. Qualitative research around this initiative aimed to answer the following questions:

# MATERIALS AND METHODS

# Design

# Intervention

The workshops were designed and delivered by a registered charity (Limelight Music Ltd.) which, for over 25 years, has pioneered innovative access to high-quality musical education, qualifications, involvement, and careers for individuals of all ages and abilities. Their workforce constitutes Scotland's first generation of professional musicians with impairments, who work alongside established nondisabled artists to train the next generation in inclusive music-making, and support those with additional support needs toward full-time musical employment.

As well as facilitating participants' musical development and future musicality, the workshops were intended to encourage their social interaction, relationship skills, and empathy, enhancing opportunities for greater community integration and development of social capital. Sessions for example included group music exercises followed by instrumental training (e.g., guitars or singing) to build achievable musical skills. Coaching in composing original songs was seen as a means to develop participants' confidence in their own musicality and proficiency, while rehearsing and performing in smaller music ensembles built confidence in social interaction.

Participants were individually supported during workshops by Limelight and care staff.

# Participants

Thirty-seven adult service users (12 female, 25 male) were recruited *via* four separate centers located around Renfrewshire (a local authority in central Scotland) to take part in workshop groups on either Mondays or Fridays. Their learning difficulties ranged from mild to profound, and their levels of independence ranged from requiring constant one-to-one care to living alone in sheltered accommodation.

# Interviews and Observations

Regular interviews with music staff allowed them to describe and explain their decisions, and delineate key objectives. Researchers observed all workshops, taking field notes.

In an initial 6-week consultation, in-depth interviews were carried out with six service users and six staff at one resource center for young adults with a diagnosis of autism or related conditions, and with parents of three further service users whose views could not be accessed directly. The interviews explored disadvantages faced by individuals with learning difficulties and identified priorities that music workshops might best address. Learning was fed back to the music workshop team as they designed the music activities.

Interviews were also sought during and after the workshop program with carers and family members and (where appropriate) workshop participants themselves, to gather their views on the workshops and any objectives and impacts they perceived. Informed consent for research participation was gathered in advance from participants, or from an identified person with responsibility if they lacked capacity for this. To inform potential interviewees, accessible printed or recorded information sheets were prepared detailing the voluntary, confidential, and anonymous nature of participation and how data would be used.

# Procedure

The partners arranged a 10-week program of music workshops for two separate groups between October and December 2017. One group was subdivided to accommodate, in separate halves, a group with profound disabilities, and a group with relatively high independent living. The other group brought together participants from three different centers. Seventeen 2-hour workshops were delivered from October to December 2017 in an accessible community rehearsal facility located separately from the resource centers, and another at one of the centers; two further workshops had to be rescheduled beyond the research period due to a conflict of activities. A lay researcher was recruited to contribute to observations and analysis; GW and/or the lay researcher observed all 18 workshops that took place during the research, taking notes, and conducted interviews with 10 participants, 4 parents of participants, and 11 resource center staff.

# Analysis

Interviews and observation notes were analyzed using thematic analysis (Denzin and Lincoln, 2017). Transcripts and notes were repeatedly read as they were gathered and coded by one researcher for initial themes and discussed regularly by the research team to resolve divergent instances and arrive at a consistent coding of higher level themes. These were reviewed in two focus groups, one with stakeholders from the project and one with music staff, to ensure a consistent understanding between research team and the population being researched.

# Ethics Approval Statement

This research received ethical approval from the Edinburgh College of Art Research Ethics Sub-Committee, University of Edinburgh, which includes consideration of any risk of disadvantaging individuals through the research.

# RESULTS

# Disadvantages and Barriers Faced by Participants in Their Lives

The initial interviews with resource center staff and users sought to understand what challenges center users faced in their lives, and therefore what inequalities the music intervention might have an impact on. These included limited options for activities, including music activities, difficulties in encountering public spaces, and associated mental health impacts.

Staff and family members perceived the center users as frequently bored or lacking resources or opportunities to keep themselves occupied, and some interviews with center users confirmed this:

*I: what would your life be like if you didn't come here once a week?*

*R: I don't know, just sit in the house mainly. [aye] Just do nothing, sit in the house, lying in bed, watch TV, tidy up, you know? (Malcolm)*