Modelling of Intensive Group Music Therapy for Acute Adult Psychiatric Inpatients

431 Pages·2017·12.22 MB·English

Modelling of Intensive Group Music Therapy for Acute
Adult Psychiatric Inpatients

Catherine Carr

Barts and the London School of Medicine and Dentistry,
Queen Mary University of London

Submitted in partial fulfilment of the requirements of
the Degree of Doctor of Philosophy

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Modelling of intensive group music therapy for acute adult psychiatric inpatients
ABSTRACT
Background:
Acute inpatient stays are decreasing. Evidence for music therapy in mental healthcare exists
but practice varies. Short admissions and therapy frequency (usually weekly), limit access, yet
acceptability of increased frequency to patients is unknown. Research to model processes and
outcomes of intensive provision may identify how best to provide for acute contexts informing
clinical practice and future research.
Methods:
114 patients admitted to hospital with acute mental health problems were recruited. Patients
attended group music therapy 1-3 times per week during admission. Repeated measures
assessing patient experiences, session appraisal, motivation and commitment were completed.
Questionnaire thematic analysis identified important processes which were coded from
session recordings. Multilevel modelling was used to examine associations between music
therapy components, session appraisal, motivation, commitment and subsequent attendance.
End of therapy interviews with 16 patients explored changes experienced and views on
therapy frequency.
Results: Attendance was 3 times greater for patients with 3 sessions per week. The majority
found increased frequency acceptable and beneficial. Processes of engagement, emotional
expression and social connection suggested active music-making, synchrony and singing to be
important for group cohesion. Singing was significantly associated with appraisal and
motivation. Musical initiation by group members was associated with motivation and
commitment. All three outcomes were associated with each other, with session appraisal and
increased frequency independently associated with subsequent attendance. Patient
attributions for change included creativity, experiential learning and therapist directed
reflective discussions.
Conclusion: Intensive group music therapy is acceptable to the majority of patients, perceived
as beneficial and increases access. Intensive provision is associated with greater engagement
and positive experiences, which in turn, are associated with group commitment. Patient
experiences can inform practice. Further research should examine effectiveness of intensive
provision. Therapists should continue to prioritise engagement through active music-making
and singing, and services consider implementation of intensive provision.

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Table of Contents
Declaration p.2
Abstract p.3
Table of contents p.4-6
List of tables p.7-8
List of figures p.9
List of appendices p.10
Abbreviations p.11
Acknowledgements p.12
Thesis outline p.13-18
Chapter one: Introduction p.19-39
Summary p.19
Provision of inpatient services for adults with acute mental health p.19-27
problems
Music therapy approaches in mental health p.28-31
Evidence base for music therapy in mental health p.31-37
Methods of research in music therapy p.37-39
Conclusion p.39
Chapter two: Research questions p.40-43
Summary of research background p.40
Intensity of group music therapy for acute inpatients- rationale p.40-41
Delivery of music therapy for acute inpatients- rationale p.41
Thesis aim, objectives and research questions p.42-43
Chapter three: An updated systematic review of music therapy practice
and outcomes with acute adult psychiatric inpatients p.44-74
Introduction and background p.44-45

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Methods p.45-49
Results p.49-70
Discussion p.70-72
Implications, strengths and limitations p.72-73
Conclusion p.74
Chapter four: Methods for studying change processes in music therapy
and psychotherapy p.75-85
Introduction p.75
Complex interventions p.75-77
Music therapy process research methods p.77-81
Psychotherapy change process research methods p.81-83
Conclusion p.83-85
Chapter five: Development and piloting of the ‘Experiences of Music
Therapy’ questionnaire p.86-116
Summary p.86
Existing measures of patient subjective experiences p.86-90
Aim and objectives p.90
Method p.90-97
Focus group and interview results p.97-110
Piloting- method p.111
Piloting- results p.112-116
Final questionnaire p.116
Chapter six: Building a model: Identification of group music therapy
methods and processes in acute inpatient settings p.117-171
Introduction p.117-118
Philosophical approach p.118-119

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Aims and objectives p.120
Methods p.121-132
Research aim 1: Analysis p.132-133
Research aim 1: Results p.133-149
Research aim 2: Development of video coding framework p.149-152
Research aim 2: Results p.153-156
Patient reported changes and attributions for change p.156-160
Discussion p.161-170
Conclusion p.171
Chapter seven: Multilevel modelling of processes and outcomes
of intensive group music therapy for acute adult psychiatric inpatients p.172-226
Introduction p.172-175
Aims and objectives p.176-177
Methods p.177-183
Study 1: Results p.183-207
Study 2: Results p.207-220
Discussion p.221-226
Chapter eight: Discussion and conclusions p.227-251
Introduction p.227
Answers to the research questions p.227-237
Methodological challenges p.237-238
Strengths and limitations of the research p.239-243
Comparison with the literature p.243-248
Implications for clinicians, policy and research p.248-251
References p.252-285
Appendices p.286-430

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List of Tables
Table 3.1 Delivery of music therapy across included papers p.53
Table 3.2 Session structure and content across papers p.55
Table 3.3 Comparison of outcomes (standardised mean difference) p.61-64
across studies and vote count
Table 5.1 Initial questionnaire domains and items p.92
Table 5.2 Participant characteristics of focus groups and interviews p.97
Table 5.3 Final questionnaire domains p.110
Table 5.4 Description of sample, time to complete and mean ratings of items p.112
Table 5.5 Accuracy and comprehension of items p.113
Table 5.6 Frequency of endorsement for each item p.114
Table 5.7 Discrimination index scores for individual item responses p.115
Table 5.8 Inter-item correlation matrix p.115
Table 5.9 Item reliability and final statistics for the appraisal scale p.116
Table 6.1 Example ward group timetable p.123
Table 6.2 Socio-demographic and clinical characteristics of sample p.134
Table 6.3 Patient characteristics of end of therapy interviews p.135
Table 6.4 Frequency of coding for types of music therapy activity p.136
referred to by patients and therapists within their most important event
Table 6.5 Typology of helpful and unhelpful features of group music therapy p.151
Table 6.6 Content of music therapy sessions from video coding with p.154
mean durations/counts and range
Table 6.7 Patient reported changes and attributions for change p.159
Table 6.8 Frequency of participant ratings of changes by attribution of change p.160
Table 7.1 Baseline clinical and sociodemographic data and participant p.187
endpoint data

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Table 7.2 Number of participants with data at baseline, endpoint and number p.189-190
of participants at each repeated follow up
Table 7.3 Number of observations for each session p.191
Table 7.4 Pattern of missingness for outcome variables p.192
Table 7.5 Multilevel 3 level univariate associations between predictors and p.193-194
patient appraisal of sessions
Table 7.6 Multivariate associations with outcome of patient appraisal p.196
Table 7.7 Multilevel 3 level univariate associations between predictors and p.198-199
patient motivation for change
Table 7.8 Multivariate associations of variables with motivation for change p.201
Table 7.9 Multilevel 3 level univariate associations between predictors and p.203-204
patient commitment to the group
Table 7.10 Multivariate associations between variables and outcome of patient p.205
commitment to the group
Table 7.11 Average attendance of music therapy groups and patient availability p.208
Table 7.12 Reasons for non-attendance of sessions p.209
Table 7.13 Patterns of attendance grouped by frequency and length of stay p.210-212
Table 7.14 Typology of responses to the frequency of music therapy, by group p.213
Table 7.15 Univariate associations of significant p<.1 between predictors and p.218-219
attendance of the following session
Table 7.16 Multivariate associations between variables and attendance of the p.220
following session

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List of Figures
Figure 3.1 PRISMA Diagram of systematic review searches p.50
Figure 4.1 Phases of complex intervention development p.77
Figure 4.2 Preliminary model of factors involved in music therapy processes p.85
and outcomes
Figure 5.1 Experiences of music therapy- analytic themes from focus groups p.99
Figure 5.2 Frequency distributions of item responses p.114
Figure 6.1 Flow diagram of participants recruited into the study p.126
Figure 6.2 Processes and hypothesised model of engagement within group p.163
music therapy for acute adult psychiatric inpatients
Figure 6.3 Excerpt from group improvisation moving from unpulsed to p.165-169
synchronised playing
Figure 7.1 Hypothesised model of music therapy engagement and variables p.175
measured
Figure 7.2(a) Mean appraisal by session number p.184
Figure 7.2(b) Mean appraisal by site p.184
Figure 7.2(c) Mean motivation by session number p.185
Figure 7.2(d) Mean motivation by site p.185
Figure 7.2(e) Mean commitment to group by session p.186
Figure 7.2(f) Mean commitment by site p.186
Figure 7.3 Variables with significant associations with patient outcomes p.223
of appraisal, motivation, commitment and attendance of the following session

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List of Appendices
Appendix A: Publication of original systematic review p.286
Appendix B: Ethical approval, patient information sheet, p.374
consent form and topic guide for patient scale development focus groups
Appendix C: Final ‘Experiences of music therapy’ questionnaire p.386
Appendix D: Sample size calculation p.391
Appendix E: Ethical approval, patient information sheet, consent form p.395
and capacity checklist for prospective study
Appendix F: Measures used in the prospective study p.403
Appendix G: Sensitivity analysis of multiple imputed data p.418

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