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Psychomusicology: Music, Mind & Brain

2011, Vol. 21, No. 1 & No. 2

2012 by Psychomusicology
DOI: 10.1037/h0094011

Singing, health and well-being:


A health psychologists review

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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

M ary L . Gick
Carleton University
a b s t r ac tResearch is reviewed on singing, health
and well-being from the perspective of health psychology.
In accordance with a multidimensional, biopsychosocial
conceptual framework commonly used by health
psychologists, the review is organized by biological,
psychological and social factors that collectively contribute
to health. Studies using quantitative and qualitative
methods are reviewed that include singing prescribed
as intervention, and research with professional and
amateur singers. Although research findings are often
inconclusive, preliminary evidence suggests possible
benefits of breathing and short-term immune response.
Mood, stress, and social responses may vary with amateur
or professional status and nature of the singing activity
(group or solo, rehearsal or performance). Potential
mechanisms and variables for future study are proposed.
Recommendations for further research include studies
that are interdisciplinary, address basic descriptive
phenomena as well as explanatory mechanisms, utilize
appropriate methods and controls while maintaining
validity, measure long-term health, examine potential
drawbacks of singing, and explore linkages among
biological, psychological and social processes.
k e y wo r d s singing, health, well-being, singing and
health, singing and well-being

The idea that singing may be conducive to wellbeing is an old one. In Cervantes (1605/1885) 17th
century novel, Don Quixote states that he who
sings scares away his woes (p. 171). Longfellows
(1881) poem The Day is Done similarly suggests
the power of singing to drive away sorrow (e.g.,
Such songs have power to quiet The restless pulse
of care; p. 134). In addition, Hunter (1999) reports
on references to physical health benefits of singing
in his review of articles published between 1891 and
1949 in a popular music magazine, The Etude.
176

Why might singing be beneficial? Everyday experience suggests that singing favorite, upbeat songs
may energize us or even provide a physical workout. Indeed, singing was discussed by several Etude
authors as an appropriate means of exercising the
lungs in women, because they were often prohibited
from participating in exercise, and, moreover, had
to wear restricting corsets (Hunter, 1999). Hunter
(1999) also reports that Etude authors described singing as a pleasant diversion for hospitalized patients.
Given that positive mood and exercise are generally
related to good health (Pressman & Cohen, 2005),
it is not unreasonable to expect potential benefits to
health from singing.
Is there research evidence to support the
common-sense and anecdotal claims of benefits
of singing to health and well-being? In contrast to
research on benefits of music to health or well-being,
singing is under-researched. A search of a common
psychology database (PsychInfo) yielded 550 journal articles on music (and not singing), health or
well-being, in contrast to 48 articles on singing,
health or well-being. Research on singing varies
widely in purpose, methodological approach, and
measures. Examples include a quasi-experimental
study of successful aging in choral members vs. nonchoral members of a retirement community (Wise,
Hartmann, & Fischer, 1992); an experimental study
of singing as an inexpensive and non-pharmacological treatment for distress following knee surgery
(Giaquinto, Cacciato, Minasi, Sostero, & Amanda,
2006), and associations between performance
satisfaction and immune response in professional
choral singers (Beck, Cesario, Yousefi, & Enamoto,
Mary L. Gick, Ph.D., Department of Psychology, Carleton
University.
Correspondence concerning this article should be addressed
to Mary L. Gick, Department of Psychology, Carleton University,
Ottawa, ON K1S 5B6, Canada. E-mail: Mary_Gick@carleton.ca

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Singing, health & well being

2000). Given the varying populations and methodological approaches, perhaps it is not surprising
that the research lacks an overarching theoretical
framework, including what is meant by health and
well-being.
One objective of the present review is to consolidate research on singing, health and well-being
into a common conceptual framework in order to
facilitate its evaluation, consideration of possible
mechanisms by which singing may have its effects,
and suggestions for further research. In addition
to an examination of whether research supports
claims for benefits, I explore whether there is any
evidence for harm to health and well-being associated with singing.
In the next section of the paper, I summarize the primary conceptual frameworks of health
psychology and well-being research that are used
to organize the review. A review of the research
is presented in the following section, which first
describes search strategies used to locate studies,
inclusion and exclusion criteria, and overall organization of the review into subsections according
to the health and well-being frameworks. In the
final section of the paper, I provide a summary of
the main findings, present potential mechanisms
and variables for further study, and provide suggestions for future research, including methodological
considerations.

h e a lt h , i l l n e s s a n d w e l l - b e i n g

as a reaction to the biomedical model that considered health as the absence of disease that is caused
by biological factors alone. Engel described how
biological factors are insufficient to understanding of health and illness because people can feel
well but have a disease, and, conversely, feel unwell
and yet have no diagnosed illness. Engel called
for a consideration of not only biological variables
but also the patients psychological and emotional
states, and social context. Health psychologists
endorse a similar view proposed by the World
Health Organization that health does not merely
involve the absence of disease but includes physical, psychological and social well-being (World
Health Organization, 1948).
In addition to including more than biological
factors in consideration of health and illness, Engel
(1977) adopted systems theory into the biopsychosocial model and the suggestion that perturbations
in biological components affect psychological and
social factors. Conversely, psychological and social
factors affect biological variables. The biopsychosocial model is considered useful for understanding
multiple contributions to health and illness, and
is the dominant conceptual framework in health
psychology research (see Engel, 1977; Schwartz,
1982; and Suls & Rothman, 2004, for further
discussion and critiques). Below I give an overview
of some key biological, psychological and social
factors, together with research examples in order
to facilitate understanding of the singing research
that follows, especially for readers who may be
unfamiliar with health psychology.

Health Psychology and


the Biopsychosocial Model

Biological factors

The field of health psychology is concerned with


the role of psychological variables in physical
health and illness, and involves basic and clinical research on topics that range from promotion
of health to prevention and treatment of illness.
Health psychologists typically adopt a multidimensional model that considers biological,
psychological, and social factors, together with
their interactions, in their effects on health and
illness. The term biopsychosocial model was first
proposed by the psychiatrist George Engel (1977)

Important biological factors associated with


health and illness include the immune system that
defends the body against attack by disease or injury
through natural, fast-acting immune responses as
well as more slow-acting, specific immune responses
(Segerstrom & Miller, 2004). Another important
component is the autonomic nervous system, which
is broadly categorized into the sympathetic nervous
system that is stimulated during stress or action, and
the parasympathetic nervous system that is active
during resting states such as digestion and relaxation
177

Mary L. Gick

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(Taylor & Sirois, 2009). Biological responses to stress


include the release of neurotransmitters that stimulate the sympathetic nervous system and allow the
person to fight or flee the stressful event (Cannon,
1932). Stress hormones such as cortisol can reduce
inflammation in the short-term and allow the body
to respond to stress, but may negatively affect health
by hindering the immune systems response over
time (Segerstrom & Miller, 2004).

Psychological factors
Psychological factors include variables such
as negative (e.g., anxiety, depression, negative affect) and positive (e.g., positive affect,
joy) moods and emotions. Appraisal of a potentially stressful event as negative or challenging
(Lazarus & Folkman, 1984), and ways of coping
with it are also important factors. Ways of coping
include problem solving coping that deals directly
with the event (e.g., information seeking) and
emotionally-based coping such as relaxation or
distraction that may regulate emotions associated with stress (Folkman, Lazarus, Gruen, &
DeLongis, 1986). Psychological factors of negative and positive emotions can be important risk
(e.g., Frasure-Smith, Lesperance, Juneau, Talajic,
& Bourassa, 1999) and protective (e.g., Scheier et
al., 1989) factors, respectively, which can affect
the course of physical illness, such as recovery
from heart disease. Psychological variables also
include behaviors (Suls & Rothman, 2004) such
as positive (e.g., exercise) and negative (e.g.,
smoking) health behaviors that have corresponding effects on health (Taylor & Sirois, 2009).

Social factors
Social factors include variables such as social
support, measured by variables such as number
of people in ones network, and kinds of support
(e.g., emotional, informational) received (Taylor
& Sirois, 2009). The number of social connections
among people is associated with lower mortality
over time (Berkman & Syme, 1979). Social support
can also reduce occurrence or intensity of respiratory viruses (e.g., Cohen, Doyle, Skoner, Rabin,
178

& Gwaltney, 1997). Social factors also consist of


variables at a higher level than individual, interpersonal interactions, and include factors such as
socioeconomic status (SES), ethnicity and culture
(sometimes considered macro variables; Suls
& Rothman, 2004). SES is generally positively
related to health (Adler et al., 1993) through
possible mechanisms such as chronic exposure
to stress (in lower SES) and altered psychological
and biological responses to it (Adler & Rehkopf,
2008).

Linkages among factors


Examples of linkages among biological, psychological and social levels are the following. Social
threat of performing tasks in front of others can
lead to increased shame and cortisol responses in
standard laboratory tasks, and cortisol responses
that are absent when performed alone in activities such as competitive ballroom dancing (Miller,
Chen, & Cole, 2009). Because of increased exposure to stressful life events, children growing up
in low SES (as opposed to high SES) environments
may develop a vigilant coping style of monitoring
ambiguous situations for potential threat; increased
threat perceptions mediate relationships between
low SES and biological variables such as inflammatory responses in children who have asthma (Miller
et al., 2009).

Well-being
Well-being can be defined as optimal psychological functioning and experience (Ryan & Deci,
2001, p. 142). Research includes the study of both
hedonic and eudaimonic (Ryan & Deci, 2001; Ryff,
Singer, & Love, 2004) well-being. Hedonic wellbeing is concerned with pleasure, and includes
measures such as subjective well-being that is
defined by positive mood, absence of negative
mood, and satisfaction with life (Ryan & Deci,
2001). Eudaimonic well-being focuses on maximizing human potential; measures include Ryff et
al.s (2004) measures of autonomy, environmental
mastery (e.g., feeling in charge), personal growth,
self-acceptance, purpose in life, and positive

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Singing, health & well being

relations with others, and positive emotions such


as vitality, or a feeling of having energy for the self
(Ryan & Deci, 2001).

relevant work. In rare cases where the full text of the


article could not be obtained, authors were emailed
to request it.

Well-being and health

Inclusion and Exclusion Criteria

The hedonic measure of subjective well-being


has a modest association with self reports of physical health (Ryan & Deci, 2001). In the case of
eudaimonic well-being, positive relationships
with others is associated with biological markers
of health such as lower daily levels of salivary cortisol (Ryff et al., 2004), and vitality is associated
with fewer reports of physical symptoms (Ryan
& Deci, 2001). However, well-being is not necessarily synonymous with good physical health. For
example, in their review of well-being research,
Ryan and Deci (2001) report that people with
objective markers of poor physical health, such
as chronic illness, may nonetheless report high
levels of subjective well-being, similar to Engels
(1977) observations. In addition, although educational status is positively associated with hedonic
and especially eudaimonic well-being, variability in eudaimonic well-being has been found to
increase at lower levels of education such that
many people with low SES (generally associated
with poorer health) nonetheless report high
levels of purpose in life (see Ryan & Deci, 2001,
and Ryff et al., 2004, for further discussion of
well-being and its association to health).

Studies were limited to articles published in


English with human participants (e.g., excluding songbirds). Given that research on singing
and health is still somewhat in its infancy, a
broad net was cast in order to produce a comprehensive review. Although health psychologists
use primarily quantitative methods (Murray
& Chamberlain, 1998), both quantitative and
qualitative research were included, because
each paradigm may provide valuable input.
Qualitative studies were evaluated using different
criteria than quantitative studies, such as providing sample details, efforts to reduce reporting
bias, especially when the researcher was also the
singing instructor, and analysis methods (Elliott,
Fischer, & Rennie, 1999). Studies were included
if there was some health or well-being outcome
(Melodic Intonation Therapy (MIT) for aphasia
was excluded; see Schlaug, Marchina, & Norton,
2008 for information about MIT), and active singing could be evaluated. Most articles included
adults; research with children was included if it
satisfied the inclusion criteria.
Studies on singing and health or well-being
were excluded if they evaluated a multi-component treatment that included singing together
with other musical inter ventions, such as playing instruments in people with Parkinsons
Disease (Pachetti et al., 2000), and results were
not broken down for the singing component,
or could not other wise be determined. Articles
were also excluded if there were no data
reported. For example, an interesting project on a hurricane choir formed after K atrina
reported only baseline data, but no postchoir or follow-up measures (Har vey, Smith,
Abraham, Hood, & Tannenbaum, 2007). In
addition, because active singing was the focus
of the review, listening to singing was excluded
unless it was used as a control for active singing
or it was clear that at least some participants

r e v i e w o f t h e l i t e r at u r e
o n s i n g i n g , h e a lt h a n d w e l l - b e i n g

Search Strategies
PsychInfo, PubMed, PsiTri, and the Cochrane
Database of Systematic Reviews were searched using
the following keywords: singing and (health or
well-being). In cases where this search yielded few
articles, it was repeated using the keyword singing alone, and articles were scanned for evidence
of health or well-being relevance. A Google Internet
search was similarly conducted. Reference lists and
citations of obtained articles were also examined for

179

Mary L. Gick

sang. Finally, studies were excluded if all


attempts to obtain the article failed, including
emailing the author.

responses, and other physical health (e.g., pain).


Studies of self-reported physical health or other
physical health variables (e.g., medications, doctor
visits) are also included under other physical health.

Organization of the Review

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Breathing
Studies are presented according to biological,
psychological, and social factors that are reported
in the singing study. In addition, I integrated the
well-being framework within the biopsychosocial
model as follows. Research on hedonic well-being
(e.g., positive mood) and non-social measures
of eudaimonic well-being (e.g., mastery and
personal growth) are included under psychological factors. The eudaimonic well-being measure
of positive relations with others is included under
social factors. Within each of the biological,
psychological and social subsections, studies are
divided further according to particular topics
(e.g., breathing in biological factors) that are
grouped idiosyncratically according to type (e.g.,
interventions, studies of community choirs) and
described at the start of each subsection, and
given subheadings. Figure 1 depicts the overall
organization of the review.
Within each grouping (e.g., inter ventions), studies are presented chronologically.
Details of each individual study are brief ly
described and include, where known, rationale
or purpose for the study, number and nature
of participants, nature and duration of singing activities, results, purported mechanisms
(if mentioned), and strengths and weaknesses,
where appropriate. Space limitations preclude
a complete description; interested readers are
referred to the original paper. In cases where
a studys results span more than one subsection (e.g., biological and psychological), study
details are presented only the first time.
Additional subheadings of authors names and
dates are included to facilitate retrieval of
initial study details at later points.

Biological Factors
Research on singing and biological factors includes
studies involving breathing, stress or immune
180

Research on singing and breathing involves


interventions for participants with health problems
characterized by breathing difficulties, and studies of group or choral singing in the community.
Intervention studies are presented first, followed by
research on community singing.

Interventions
The general rationale for intervention studies
was that controlled breathing involved in singing
may facilitate breathing in respiratory health conditions. Any other purpose is included with each
study.
Wade (2002). Wade (2002) explored whether
group singing would be helpful for breath control
in a quantitative study of children with asthma,
which is a disease characterized by obstruction of
the airways caused by inflammation, secretion of
mucous, or muscle spasms in the bronchial airways.
The purpose was as follows. Although playing wind
instruments had sometimes been used as treatment
for asthma, no studies had specifically examined
singing, which may share training of steady expiration with wind instrument playing. Singing was
compared to group music listening activity that also
incorporated progressive muscle relaxation (PMR),
as an additional exploration of music in asthma
treatment. Nine children (average age nine years,
four boys) with asthma participated in both singing
and relaxation 15-minute sessions twice weekly over
four weeks. The order of sessions was alternated to
control for any order effects. Listening music had
slow tempo and soft dynamics, in order to induce
relaxation. A variety of traditional (Scotlands
Burning) and other (Johnny Be Good) songs were
chosen by participants to sing.
Results indicated that lung functioning (as
measured by a peak flow meter) increased or
was maintained after group singing, and effects

Community
choirs, group
singing

Singing
vs. other
activities

Professional
and amateur
singers

Stress,
immune

Interventions
(pain,
Parkinsons
disease)
Self-reported
health

Other
physical
health

Figure 1. Overall organization of the review of singing, health and well-being.

Interventions
(breathing
problems)

Breathing

Biological

Interventions
(health, other)

Professional
and amateur
singers

Hedonic
well-being

Professional
and amateur
singers

Eudaimonic
well-being
(non-social)

Interventions
(health, other)

Psychological

Research on
Singing, Health and Well-being

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Interventions
(health, other)

Community
choirs

Interactions,
support

Social

Singing, health & well being

181

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Mary L. Gick

appeared larger when singing followed PMR.


In contrast, lung functioning increased in the
PMR condition only when it was completed first,
and with the exception of one session, decreased
when it followed singing. Wade (2002) suggested
that a ceiling effect in the singing condition may
have prevented PMR from producing additional
increases in lung functioning, and singing effects
may be enhanced when following relaxation.
A strength of this study is that participants
completed both conditions, which were conducted
in alternating order, and thus served as their own
controls. A weakness is that results were presented
individually for each participant, and no overall
statistical analysis was conducted to confirm the individual, promising trends. In addition, participants
had a choice of songs to sing, but did not choose the
listening music. Moreover, while listening music was
used according to tempo and dynamics to induce
relaxation, songs sung appeared to include a variety
of tempos that were not reported.
Engen (2005). Engen (2005) explored the
effects of group singing and breathing training
in a quantitative study of people diagnosed with
either emphysema (a type of Chronic Obstructive
Pulmonary Disease (COPD)), or COPD, probable
emphysema. COPD is a chronic disease characterized by shortness of breath and breathing limitations,
including expiration, or moving air out of the lungs,
due to deterioration of the air sacs and airways in
the lungs. One purpose of the study was to examine
the effects of diaphragmatic breathing (exhaling,
then inhaling, from the diaphragm), which is sometimes taught in singing and is commonly used to
treat COPD, but has not been systematically studied.
Three men and four women (average age of
72 years) were recruited from outpatient gerontology clinics and pulmonary rehabilitation
clinics. Participants had no prior musical experience. Participants met for twice weekly 45-minute
treatment sessions consisting of breathing training and choral singing over a total of six weeks; the
participants chose songs in conjunction with the
music therapist, who was Engen. Breathing training included both breathing support - the use of
abdominal muscles to support the breath and voice
during singing and breathing control - slowly
182

releasing air while maintaining a good volume of


air - that is necessary for good vocal tone (Engen,
2005). Objects such as a floating ball were used in
training and homework sessions in order to help
provide feedback for breathing exercises (e.g., pressure is required to keep the ball floating). In order
to prevent any possible inhibition about singing,
and to connect breathing exercises with the voice,
speaking followed by vocal warm-up exercises were
completed before singing. Breathing control was
measured by counting for as long as possible without taking a new breath, and breathing support was
measured by intensity of speech in decibels; both
measures were taken at baseline (one week prior to
treatment), weeks two, four and six, and two weeks
after the program.
Results indicated that all participants switched
from predominantly clavicular (chest) breathing to
predominantly diaphragmatic breathing after four
weeks, as measured by observation of abdominal
rising and falling during breathing. Both breathing control and support improved significantly,
although other physical health measures such as
distance walked and forced expiratory volume did
not change significantly.
Strengths of the study are the detailed description
of methods and breathing training. Three weaknesses of the study are as follows. No control group
was included as a comparison to breathing and singing training. In addition, the exact comparison of
times (e.g., baseline versus follow-up) is unclear in
reporting of the control and support results. Finally,
Engen was the researcher and instructor of breathing and singing, which is not recommended in order
to avoid possible bias (Elliott et al., 1999; Gold,
Sollie, Kruger, & Lie, 2009). However, because most
of the measures were objective variables such as
decibels, number counted to, and observable chest
versus abdominal displacement, researcher bias is
probably minimized.
Pai, Lo, Wolf, and Kajieker (2008). Pai, Lo, Wolf,
and Kajieker (2008) compared sleep-disordered
breathing of snoring in singers and non-singers in
a quasi-experimental, quantitative study, in order to
determine whether singing could be used eventually as a prescribed alternative to invasive surgical
treatment for snoring. Fifty-two semi-professional

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Singing, health & well being

existing singers from community choirs (average


age of 46 years; 20 men) who had received some
vocal training, and 55 non-singers from the same
community (average age of 43 years; 23 men) were
recruited into the study. Snoring was measured in
participants and their sleeping partners. Results
indicated that singers had lower snoring scores,
even after adjusting for age and weight indicators.
Pai et al. proposed that breathing control involved
in singing may strengthen muscles in the soft palate
that may be involved in snoring. Although promising, it is unclear whether results would generalize to
people who snore who dont already sing.
Bonilha, Onofre, Vieira, Prado, and Martinez
(2009). Bonilha, Onofre, Vieira, Prado, and Martinez
(2009) conducted a quantitative, randomized
controlled trial of non-hospitalized patients with
COPD. Fifteen patients (average age of 70 years, 12
men) were randomly assigned to a 30-week group
singing intervention that included singing familiar Brazilian folk songs, and preparatory warm-up
and breathing exercises consisting of a sharp inhale
followed by a controlled exhale. Fifteen other COPD
non-hospitalized patients (average age of 74 years,
12 men) were randomly assigned to a 30-week handicraft control group that did paper folding tasks.
Results indicated that both singing and handicraft
control groups showed improved quality of life, as
measured by a respiratory questionnaire inquiring
about symptoms and their impact (e.g., exercise
limitations). However, cardiorespiratory function
(maximal expiratory pressure, in which the participant takes a deep breath and blows as forcibly as
possible) increased only in singing participants and
decreased in handicraft controls when measured
one week after the program ended. Bonilha et
al. also observed that participants coughed and
eliminated sputum following singing, which is beneficial for COPD patients. Mechanisms suggested
for results were that training in controlled exhalation required to breathe during extended singing
may improve respiratory muscles, such as abdominal muscles that aid expiration in COPD patients.
In response to potential criticism that singing also
included breathing exercises, Bonilha et al. further
suggested that such breathing training is necessary
for singing.

Strengths of Bonilha et al.s (2009) study include


random assignment of participants to singing
and control groups. In addition, the same physiotherapist facilitated both groups, and singing
and handicraft teachers facilitated their respective groups. The study would have benefited from
extending the evaluation period to a follow-up to
indicate whether the positive effects lasted beyond
program completion.
Eley and Gorman (2010). Asthma is reported to be
a common health problem in aboriginal Australians,
whom Eley and Gorman (2010) also suggest have
a poor record of compliance with western-based
medical treatments. While the purpose of this quantitative study was to investigate didgeridoo playing
as a culturally relevant treatment for asthma, part of
the study is reviewed here because women and girls
sang rather than played the didgeridoo, because it is
considered a taboo for females to touch it. Singing
and breathing exercises were conducted with aboriginal girls, adolescents and women with asthma. Five
girls (age five to eight years), 18 adolescent (age 13 to
18 years) boys and girls, and five adult (age 50 to 77
years) men and women were recruited from schools
and the aboriginal medical system. Group singing
and breathing exercises were conducted by a professional singer and assisted by an aboriginal singer in
one-hour weekly sessions for six months. Breathing
was assessed at baseline, three months, and six
months. Results for singers indicated that one measure of breathing (peak expiratory flow that assesses
peak expiratory volume) increased significantly in
the total group of female singers between baseline
and immediately after the program.
Strengths of this study are the inclusion of
aboriginal teachers. Unfortunately, a weakness is
that all primary school girls dropped out of singing. In addition, the authors did not provide the
gender breakdown for adolescents and adults, and
it is unclear whether singing results varied between
these age groups.

Community choirs, group singing


In addition to intervention research for breathing problems, other research on community singing
reported on breathing outcomes. These studies
183

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Mary L. Gick

included university choirs and singing clubs for the


elderly, all in the United Kingdom.
Clift and Hancox (2001). Two seminal studies were
conducted by Clift and Hancox (2001), in which
university choral singers were asked to describe
possible benefits of singing, as part of an overall
research goal to assess the therapeutic value of the
arts. In the first, qualitative study, 84 members (85%)
of a university choral society answered open-ended
questions at the end of fall term about perceived
health benefits of singing. Age and gender of participants were not reported in this initial, exploratory
study. Forty-one percent of participants reported
increased control over breathing in their answers.
In the second, quantitative study, a questionnaire
was constructed from participants responses in the
first study and administered to 91 members (90%;
74 females; 50% were 18 to 19 years) of the choir at
the start of winter term. Results of the statistically
analysed questionnaire indicated that most participants endorsed the notion that singing improves
breathing.
Strengths of the studies include the examples
provided and acknowledgement of the exploratory
nature of the studies and their limitations, including the use of only one choir. A related limitation
that appears not to be acknowledged is that, because
the same university choir is used for both studies,
it is unclear whether choir membership changed
over semesters, and, thus, whether many of the
same participants are included in both studies. If
the membership did not change, participants in the
second study are answering questions derived from
their own responses in the first study, rather than
cross-validating the results in a separate sample.
Skingley and Bungay (2010). Skingley and Bungay
(2010) conducted a qualitative study of participants belonging to six Silver Song Clubs, which
are community singing groups for the elderly in the
United Kingdom. Seventeen people over the age
of 60 (12 women) participated in interviews that
were recorded and analysed into themes. The most
common physical benefit reported was improved
breathing. Skingley and Bungay mention that
breathing benefits were reported most frequently by
participants with singing experience, and suggest
that this effect may be due to the breathing control
184

required by some of the difficult song pieces.


Strengths of this study are the data analysis methods, and acknowledgement of limitations, such as
the possibility that past musical experience may
have influenced the results.

Stress and immune responses


Several studies examined the effects of singing
on biological variables including stress and immune
responses. Studies of singing as compared to other
activities are presented first, followed by research
with professional and amateur singers.

Singing vs. other activities


Research reported in this section includes
experimental or quasi-experimental studies that
compared singing to other activities, such as swimming or talking. One study is an intervention for a
physical health problem.
Valentine and Evans (2001). The purpose of
this quasi-experimental, quantitative study was
to explore the mechanisms underlying possible
improvements in mental health as a function of
leisure activities, which included choral singing,
solo singing and swimming. Swimming was chosen
because it was expected to have a more vigorous
physical aspect than singing. Choral was compared
to solo singing to examine contributions of the
social factor of group singing. Swimmers and singers
(primarily students, men and women, average age
of 21 years) were recruited at their usual location:
weekly lesson for soloists (n = 10), choral practice for
group singers (n = 13), and the pool for swimmers (n
= 13). Heart rate was measured before and after 30
minutes of activities. No significant differences were
found between singing groups. A significant interaction was obtained in heart rate, and showed greater
changes in swimming than singing; heart rate
increased greatly in swimming, increased slightly
in solo singing, and decreased slightly in choral
singing.
One limitation of the study is that participants
were not randomly assigned to their activities, and
thus effects may be due to pre-existing individual
differences leading to selection of those activities,

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Singing, health & well being

as noted by the authors. Indeed, baseline heart


rate appears to be lower in swimmers than in singers, as revealed by inspection of tables and graphs
in the results. However, the authors further noted
that they chose this quasi-experimental design in
order to have an ecologically valid study in which
participants would be motivated and skilled in
their activity. Nonetheless, the potential differences in baseline values appear not to be measured
or controlled statistically (e.g., by analysis of covariance). An additional drawback is that the vocal
music used was not described.
Fechir et al. (2008). In a quantitative study, Fechir
et al. (2008) examined the effect of various tasks
used to induce emotional stress in laboratory studies in order to develop a better understanding of
activation of different parts of the sympathetic
nervous system (e.g., heart rate, sweating). Singing
a German childrens song out loud to the experimenters was included as one of the stress tasks
(others included tasks such as mental arithmetic
and giving a short talk). A control task of viewing
neutral pictures was also used. Each task lasted two
minutes and was preceded by a 30-second baseline
and followed by a stress rating. Tasks appeared in
randomized order only once, and were separated
by five minutes; a return to baseline was confirmed
after each task. Eleven healthy volunteers (average
age of 24 years, 5 men) performed all tasks.
Results indicated that, relative to individual baselines, singing increased emotional sweating, heart
rate, blood pressure, and electromyographic activity
in the trapezius muscle. Relative to viewing neutral
pictures, singing produced higher stress ratings
and emotional sweating. Strengths of this study are
the completion of all tasks by all participants, the
randomized order of tasks, and the separation of
tasks by return to baseline.
Grape, Wikstrom, Ekman, Hasson, and Theorell
(2010). Grape, Wikstrom, Elkman, Hasson, and
Theorell (2010) explored the effects of choral singing on stress responses in patients with Irritable
Bowel Syndrome (IBS), a common disorder of the
large intestine. Grape et al. chose singing in part
because low levels of the hormone oxytocin (a
hormone with complex links to stress, including
sometimes increased relaxation; Taylor, 2006) have

been reported in people with IBS, and oxytocin


increased after a singing lesson (described later in
Professional and amateur singers; Grape, Sandgren,
Hansson, Ericson, & Theorell, 2003).
People with IBS who indicated interest in being
in a randomized controlled study were recruited into
the quantitative study from newspapers and a patient
union journal. Twenty-seven people were randomly
assigned to the choir condition, and 28 participants
were randomly assigned to a control condition that
discussed music. Participants engaged in one-andone-half hour singing or discussion sessions over
the course of a year. Singing sessions were led by a
professional music therapist, and involved exercises
of breathing, relaxation, and pitch, as well as singing. Testosterone in saliva indicating a regenerative
process counteracting stress was measured at baseline, six, nine, and 12 months. Results indicated
increased testosterone in the singing group, even
when men were excluded, but only for the first six
months of the program.
Strengths of the study are its length, allowing long-term effects to be examined. Limitations
include 50% attrition in each group, and the fact
that the vocal music used was not described. An
additional methodological limitation is that the
singing session included an extra component of
relaxation that was not present in discussions.

Professional and amateur singers


Some research with professional and amateur
singers studied not only biological stress and
immune responses, but also their associations with
psychological well-being. For ease of following these
associations between biological and psychological
outcomes, they are presented here in addition to the
biological variables. Where appropriate to facilitate
understanding, psychological well-being outcomes
are also presented.
Beck et al. (2000). Beck et al. (2000) hypothesized that professional singing is an inherently
anxiety provoking situation before and during
performances; coping successfully with this anxiety
may result in well-being factors such as satisfaction
with performance, feelings of positive emotional
arousal, relaxation, and group fellowship (p. 90).
185

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The purpose of Beck et al.s quantitative study of


professional singers was to determine if increases in
Secretory Immunoglobulin A (SIgA) would follow
singing provided it was associated with well-being.
This rationale was based on research that indicates
associations between positive mood and increases in
SIgA (Pressman & Cohen, 2005). SIgA is found in
mucosal surfaces such as saliva and is the bodys first
line of defense against respiratory infections.
Members were randomly selected from a subset
of a professional choir that did not have medical or
other conditions that might affect their immune
system. Thirty-two men and women participated
(average age of 46 years), and had been singing in choirs for about 36 years. Saliva samples
were collected immediately before and after
two evening rehearsals and one performance of
Beethovens Missa Solemnis. Results indicated that
SIgA increased after rehearsals and especially after
performance. Specific performances were rated on
a self-report questionnaire as more exciting and less
frustrating, but more anxious than specific rehearsals. While long-term performance perceptions,
including hedonic (feeling high) and eudaimonic
(spiritual, deep feeling) aspects, did not differ
between performance and rehearsal, they only
predicted changes in SIgA for performance, and not
rehearsals. Reports of satisfaction with a particular
performance were also associated with increases
in SIgA. Although the stress hormone cortisol was
measured before and after singing, and decreased
only after rehearsal, baseline levels were too low for
changes to be considered valid (Beck et al., 2000).
Taken together, results suggest support for Beck
et al.s (2000) hypothesis that short-term boosts to
the immune system occur when associated with
positive emotions or satisfaction following singing
that is anxiety provoking. Strengths of the study are
the testing of a hypothesis and the random sample.
Although Beck et al. acknowledged that there was
no control group that did not sing (e.g., to rule out
natural changes in SIgA), rehearsals served somewhat as a comparison to performances.
Grape, Sandgren, Hansson, Ericson, and Theorell
(2003). The effects of singing were explored in this
mixed-method study in order to determine whether
purported positive effects of culture on well-being
186

would hold specifically for singing, and whether


results would vary between professionals and
amateurs. Eight amateur (earning no income from
singing, two men) and eight professional (earning
at least 24% of income from singing, four men) singers responses were compared directly before and
after a solo singing lesson. Heart-rate variability
(HRV), which measures how much the heart varies
its rate (e.g., in breathing, faster during inhaling
and slower during exhaling) and is considered an
indicator of cardiac health (Ellis & Thayer, 2010),
was measured and predicted to change more in
professionals, due to higher engagement of the
sympathetic nervous system as a result of increased
performance expectations. Arousal and psychological stress were measured by cortisol and Tumor
Necrosis Factor (TNF) alpha (a pro-inflammatory
immune system marker), respectively, both of which
were also expected to increase more in professionals. Oxytocin was predicted to increase especially in
amateurs.
Results indicated a significant interaction for
HRV, with professional singers exhibiting greater
HRV than amateurs. Cortisol was higher overall in
professionals, and there was a marginally significant
interaction such that cortisol increased in professionals and decreased in amateurs; the TNF-alpha
interaction was significant. Oxytocin increased
overall from before to after singing, and there were
no group differences or interactions.
Grape et al. (2003) interpreted the findings as
indicative that professionals were better able than
amateurs to control breathing and other functions
affecting HRV, and thus exhibited better cardiophysiological fitness. Strengths of the study include
the variety of biological measures. A weakness is that
singing teachers recruited participants, and almost
one quarter of professionals contacted refused
participation. Moreover, differences between nonparticipants and recruited participants were not
reported.
Kreutz, Bongard, Rohrmann, Hodapp, and Grebe
(2004). The purpose of this quantitative study
was to determine the importance of active singing on immune and stress responses such as those
reported by Beck et al. (2000). A one-hour session of
active singing of sections of Mozarts Requiem was

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Singing, health & well being

compared to a one-hour session of passive listening


of the same material one week later. Participants were
31 members (23 women, average age of 57 years) of
an amateur choir. Singing was also preceded by 10
minutes of breathing and vocal warm-up exercises.
Results indicated that SIgA increased after singing
rehearsal but not after listening. Positive affect was
not associated with SIgA increases in rehearsal in
Kreutz et al. (2004), similar to Beck et al. This similarity was found despite differences in participants
and methodology; positive affect was measured
immediately after singing in Kreutz et al.s amateurs,
while typical responses were assessed in Beck et
al.s professionals. Additional results in Kreutz et
al. were that the stress hormone cortisol decreased
after listening but not rehearsal. One weakness of
the study is that listening always followed singing.
Order of singing and listening should be alternated
so that any effects attributed to listening are not
contaminated by the fact that it always occurred
after singing.
Beck, Gottfried, Hall, Cisler, and Bozeman (2006).
The purpose of this quantitative study was to
determine whether effects on immune and stress
responses obtained with choral singers (Beck et al.,
2000) would also occur in solo singers. Eight college
music students (average age of 21 years) who had
been singing for 10 years performed in front of an
audience, and rehearsed alone; performances and
rehearsals were completed over 10 weeks. Results
indicated increases in SIgA after solo singing but not
after rehearsal. Cortisol increased in performance
and decreased in rehearsal, although not significantly. Increases in SIgA after performance were
associated with long-term positive emotions, similar to professional choral singers (Beck et al., 2000),
and also less professional identity and lower feelings
of stress from singing. A high satisfaction with the
performance was associated with a decrease in cortisol in solo student singers, not an increase in SIgA as
with professional choral singers (Beck et al., 2000).
Two weaknesses of Beck et al. (2006) are that gender
of participants was not reported, and vocal music
sung was not described.
Harmat and Theorell (2010). This quantitative
study examined the effect of an audience and the
difficulty of pieces on autonomic nervous system

activity in singers. Heart rate and HRV were measured during solo rehearsals and solo concerts in
five professional singers and four flute players
(mean age of 35 years, five women). Participants
performed both easy and difficult pieces (categorized by familiarity as well as tempo, with difficult
being faster); the order was alternated across
participants, who were also asked, retrospectively, for perceptions of nervousness before and
during rehearsals and concerts. Results were not
separately reported for singers; however, because
no differences between singers and flute players
were obtained (Harmat & Theorell, 2010), overall
results are presented here.
Results indicated that heart rate increased, and
heart rate variability decreased, during concerts
that contained an audience as compared to rehearsals that had no audience. Difficulty of pieces showed
non-significant trends in heart rate increase and
HRV decrease. High nervousness before the concert
was associated with a measure of HRV, and not heart
rate, during the concert.
Strengths of this study are the inclusion of both
heart rate and HRV, the methodological control
over the variables (e.g., same locations with the
same temperature for rehearsals and concerts), and
the within-participant design for song difficulty. A
weakness is the small sample size, as noted by the
authors. A minor weakness is that the exact timing
of the retrospective measure of nervousness is
unclear.

Other physical health


Several studies investigated the benefits of singing on other aspects of physical health, including
pain. The first three are intervention studies. Two
additional studies involved self-reported health in
retired people and the elderly.

Interventions
Three studies explored the use of singing as
an intervention for physical health problems. One
study included patients with Parkinsons disease,
and is presented first. The other two studies are
interventions for pain.
187

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Satoh and Kuzuhara (2008). This quantitative


study examined the use of singing to improve the
regularity of walking of people with Parkinsons
disease. Parkinsons Disease leads to disruption of
the regular rhythm of walking via hypothesized
mechanisms that keep time in the basal ganglia
and cerebellum regions of the brain (Satoh &
Kuzuhara, 2008). People with Parkinsons disease
may experience difficulty in taking an initial
step. Satoh and Kuzuhara (2008) observed that
although listening to music has been used to regulate the pace of walking, listening and adjusting
walking to the music appeared to be difficult for
patients. Singing was chosen in this study because
participants need not divide their attention
between the input task of listening and the output
task of walking, and, moreover, can choose their
own tempo.
Five men and three women (average age of 54
years) with Parkinsons disease were trained in
stages leading up to the final step of mentally singing a familiar Japanese nursery song while walking.
The penultimate step was singing while walking,
and prior steps included listening, and clapping.
Results included a reduction in both length of step
and time to walk; walking included both turning
and walking in straight lines. Importantly, participants also reported using mental singing while
walking outside of the intervention. One advantage of mental singing suggested by Satoh and
Kuzuhara (2008) is that it is extremely flexible, and
there is no need for external cueing (e.g., metronomes). Satoh and Kuzuhara further suggest the
mechanism that singing may improve regulation of
the basal ganglia involved in walking, although no
direct evidence is reported. Limitations acknowledged by the authors include a need for inclusion
of more severely impaired persons. An additional
limitation is that exact recruitment criteria were
unclear; because persons with mild or moderate
impairment were included suggests that they lived
in the community.
Kenny and Faunce (2004). Kenny and Faunce
(2004) explored the use of vocal music to reduce
pain. Kenny and Faunce noted that previous
research on music and pain had been restricted
to instrumental music. In this study, active group
188

singing was compared to listening to group singing in a total of 77 chronic pain patients. Patients
were randomly assigned to active singing (average age of 42 years) or listening (average age of 38
years), which were both added to a three-week standard treatment of chronic pain. Standard treatment
consisted of nine sessions of cognitive behavioral
therapy, exercise, and supervised reduction or withdrawal of pain medication. Group singing sessions
were conducted by a singing teacher and consisted
of vocal warm-up exercises and singing of simple,
lively songs. Listening included listening to singing while exercising. Participants who failed to
attend singing sessions were analyzed as a separate
group (average age of 42 years), which served as a
quasi-control group that received only standard
treatment, and allowed for a comparison of singing
to standard treatment alone. Measures of pain and
coping were collected at baseline, post-treatment,
and six months.
Results indicated no significant differences
between singing and listening when comparing
baseline and post-intervention pain scores, which
improved in all groups. A marginally significant
increase in active coping (a measure of pain selfstatements that also included catastrophizing)
was found from baseline to post-intervention in
the active singing group compared to those who
dropped out, but was not maintained at follow-up.
Kenny & Faunce (2004) suggest that, because the
standard pain treatment is effective, additional
benefits of singing for pain outcomes might be difficult to obtain.
Strengths of the study include random assignment to groups, and, especially, the 6-month
follow-up. A weakness is that the exercising in
the listening group was not specified, and it is
not clear whether it was the same exercising that
was included in the standard program. However,
this lack of clarity may be less important for the
obtained difference in active coping in the singing
group compared to those who dropped out. Kenny
and Faunce (2004) suggest that singing may possibly provide distraction from pain, and arousal of
emotional experiences that may provide catharsis, although no evidence was provided for these
potential mechanisms.

Singing, health & well being

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Grape, Theorell, Wikstrom, and Ekman (2009).


Grape, Theorell, Wikstrom, and Ekman (2009)
included participants from Grape et al.s (2010)
study (described previously in the section on Stress
and immune responses) to explore choral singing
as a means of reducing pain in people with IBS.
Results indicated a strong but non-significant trend
in decreased self-reported pain after one year in the
singing group, but not the discussion group.

Self-reported health
Two studies of singing and physical health in
elderly or retired people used participants recruited
from the community. A third, case study involved
self-reports of headache pain in a singer. This case
study is in contrast to most studies reviewed in this
paper that suggest benefits of singing to health and
well-being.
Wise et al. (1992). Wise et al. (1992) compared
49 members of a community choir to 49 non-singing members randomly selected from the same
retirement community to explore whether singing
was associated with successful aging. The average
age of all participants was 64 years. Singers and
non-singers did not differ in demographic variables or level of non-musical activities (e.g., visiting
friends). However, singers had significantly greater
musical backgrounds (e.g., took musical instrument lessons; fathers sang at home and outside
the home) than non-singers. Results indicated no
difference in self-reported health between groups.
A strength of this study is that a comparison
group of non-singers was included, although not
randomly assigned.
Cohen et al. (2006). Cohen et al. (2006) recruited
participants to a quasi-experimental study that
compared a choral singing intervention to regular
community activities on the physical health of the
elderly. Participants who were primarily women of
retirement age (average age of 79 years) voluntarily signed up for the singing (n = 90) or community
activity (n = 77) condition, based on recruitment
notices. As compared to non-singers, recruited
choral singers self-reported higher overall physical
health, fewer doctor visits, fewer medications and
falls, and no decline in activities from before to

after the one-year program. Strengths of the


study are the one-year length, and inclusion of a
comparison group, although it was not randomly
assigned.
Kim, Lee, Lee, Park, and Kim (2008). Kim, Lee,
Lee, Park, and Kim (2008) report a case study of
a singer with recurrent thunderclap headaches;
these are severe headaches with sudden onset that
are usually associated with activities such as coughing or exertion, such as during exercise or sexual
activity. The headache appeared suddenly while the
41-year-old woman was singing. Kim et al. (2008)
suggest that the headache was caused by very high
pitched notes that lead to extra abdominal pressure
connected to cranial areas associated with pain.
A weakness of the study is that the singers background is not described. Because this is a single case
study, further research is needed in order to determine the frequency of this problem.

Psychological factors
Research on the psychological factors associated
with health and well-being as a function of singing
is divided into subsections of hedonic and eudaimonic well-being. Studies on hedonic well-being are
reported first. Research on singing and eudaimonic
well-being follows that excludes positive relations
with others (presented later in Social factors) and
includes measures such as personal growth, purpose
or mastery.

Hedonic well-being
Research on singing and hedonic well-being
includes interventions to improve mood or life satisfaction, or lower distress in people, as well as studies
of these effects in amateur or professional singers.
Intervention studies include people with physical
or mental health conditions, the elderly living in
nursing homes or the community, and homeless
and middle-class people living in the community.
Intervention studies are presented first, followed by
studies of amateur or professional singers; in both
cases, studies described in Biological factors are
presented first; additional studies are presented
subsequently.
189

Mary L. Gick

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Interventions
Kenny and Faunces (2004) previously described
study of singing vs. listening on pain also measured
mood. Similar to the results on pain reports, no
significant differences were found between singing
and listening when comparing baseline and postintervention mood scores, which improved in all
groups.
Korb (1997). Korb (1997) compared the effects
of singing to reminiscence on mood, within a
broad purpose of exploring music therapy with
patients with dementia. Nine male veterans (age
was not reported) served as their own controls, and
completed group singing, group rhythm, and group
reminiscence sessions in an alternating fashion,
randomly ordered. Sessions were 30 minutes each
and were held twice weekly for 12 weeks; thus a total
of eight sessions each of singing, rhythm and reminiscence were included. Singing included familiar
folk songs, such as You Are My Sunshine. Results
indicated that mood, as measured by an affective
balance scale completed by observers (e.g., smiles
appropriately, tearful), was more positive immediately after singing and rhythm, as compared to
reminiscence conditions. A strength of the study
is that participants served as their own controls for
conditions in alternating order. A weakness is that,
although participation is reported, it is unclear
whether all participants sang along.
Houston, McKee, Carroll, and Marsh (1998). This
quantitative study investigated the effect of humorous songs on the psychological well-being of elderly
residents of nursing homes, as part of an overall purpose of studying the benefits of humor on
well-being. Nursing homes were randomly selected
from the phone book. Three nursing homes were
randomly assigned to either the singing condition
or the control condition (31 participants each), in
which participants did not complete any special
activities. The average age of mostly women participants was 84 years. Although the exact group
composition of age and gender was not reported,
Houston et al. (1998) noted that there were no age
or gender differences between the two conditions.
Singing consisted of singing along to a pre-recorded
one-hour tape that researchers sang and danced
190

to in a humorous way over a period of four weeks.


Measures of general distress that included anxiety and depression subscales, and other specific
measures of anxiety and depression, were taken one
week prior to, and one week following, the intervention. Results indicated that the anxiety subscale of
the general distress measure, and the separate anxiety and depression measures, were both lower in the
singing group.
A strength of this study is the random assignment of nursing homes (although not participants)
to conditions. Although Houston et al. (1998)
conducted both the assessments and led the singing sessions, they noted that significant results were
obtained only on one general distress subscale,
which argues against bias in reporting. However, a
weakness of the design is that it is unclear whether
the same results would have occurred if participant singing along had not been accompanied by
researchers dancing and singing in a humorous way.
Hillman (2002). This quantitative study examined
the effects of a community singing program (Call
That Singing) in people of retirement age, within
the broader purpose of evaluating the arts in the
elderly. Seventy-five people (60 women) completed a
survey on possible benefits of the singing program,
which consisted of weekly rehearsals and occasional
performances over a period of time ranging from
six months to 11 years. Results indicated significant increases in overall quality of life, including
emotional well-being.
Two limitations noted by Hillman (2002) are the
following. Most singers rated their physical health
as good or excellent before joining the community singing program, as compared to just over
one half of elderly people in a national comparative sample; this suggests a possible selection bias
that participants were healthier at the start. In addition, because Hillman was a well-known leader in
the Glasgow community singing program, her dual
status of researcher may have created efforts in
participants to please her. An additional limitation
is that participants were not surveyed at the start of
the program, but were asked to provide retrospective reports for the time of entry, which could have
been up to 11 years prior to testing; such a long time
gap might have influenced memory and reduced

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Singing, health & well being

accuracy of perceived ratings. However, the fact that


not all variables demonstrated significant improvements is evidence against both a social desirability
bias, as noted by Hillman, and a possible memory
bias. Finally, all participants reported having some
form of musical interest before joining the program,
which may limit the generalizability of the results to
those interested in music.
Unwin, Kenny and Davis (2002). Unwin, Kenny
and Davis (2002) compared singing to listening to
explore the hypothesis that mood changes might
be heightened in singing, due to the extra physical exercise involved. Eighty-one participants (age
55 to 65 years) were recruited from the community
and randomly assigned to singing and listening
conditions. Most participants were women who had
previous amateur singing experience. Group singers performed vocal exercises and sang unfamiliar
songs in non-native languages for 30 minutes, and
a control group listened to the singing group sing
these songs for 30 minutes. Results indicated that
benefits to mood appeared to occur in both groups,
with no significant advantage to singing.
A strength of the study is that participants were
randomly assigned to conditions. However, the singing intervention of unfamiliar songs in non-native
languages was chosen to remove any emotional associations to lyrics that might independently affect
mood. It is unclear whether results would generalize to singing familiar songs, and/or those in native
languages.
Bailey and Davidson (2003a). In a landmark, qualitative study, Bailey & Davidson (2003a) explored
the possible benefits of choral singing in amateur
choirs without extensive musical experience. Seven
homeless men (average age of 52 years) were invited
to form a homeless choir by a volunteer who himself
was a choral singer and also worked in a soup kitchen.
Participants were interviewed and the content of
interviews was subjected to an interpretive phenomenological analysis. Participants reported increased
emotional well-being as a result of singing (Bailey &
Davidson, 2003a).
Bailey and Davidson (2005). Bailey and Davidson
(2005) examined whether findings of increased
emotional health would be replicated in a second
study of eight men and women (average age of 51

years) who were members of a choir in which participants were marginalized by mental illness, substance
abuse, and/or poverty. Phenomenological analysis
of interviews revealed similar results as the homeless
choir. Participants reported improved emotional
well-being, such as feelings of joy, release from
tension, and heightened arousal. In a third study of
amateur choirs, Bailey and Davidson (2005) interviewed eight middle-class adults (average age of 48
years, one man) belonging to church or community
choirs, who had varying degrees of musical expertise. Choral members who participated in focus
groups reported increased hedonic well-being, such
as emotional release from tension, increased energy
and positive mood.
Overall, Bailey and Davidsons (2003a, 2005)
studies of amateur choirs suggest that emotional
well-being was an important self-reported benefit. Strengths of the studies include the detailed
examples and quotes. A weakness in all studies is
that not all members of the choirs participated,
and factors that distinguish participants from
non-participants were not reported. An additional
weakness is that the musical repertoire of the choirs
appears not to be described.
Giaquinto et al. (2006). This quantitative study
explored the effects of singing as an alternative to
medication for reducing anxiety and depression
that typically follow knee arthroplasty surgery. Four
men and eight women (average age of 69 years)
were recruited from patients referred to rehabilitation after knee surgery. Participants were randomly
assigned to either 45-minute group singing sessions
followed by 45-minute group conversations about
music, or the reverse order of conditions (conversation then singing). Sessions occurred six days per
week for two weeks. Results indicated that the total
anxiety and depression scores were significantly
lower after singing; depression, but not anxiety,
was significantly lower when measured on its own.
Answers to yes/no questions indicated that most
participants preferred singing to conversation; songs
that were slow tempo and sentimental were preferred
to lively songs, such as military marches. A strength
of this study is the random assignment to order of
conditions, and the fact that participants served as
their own controls for the two conditions.
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Bannan and Montgomery-Smith (2008). This


mixed-method study explored the effects of group
singing in a pilot study of people with dementia
(including Alzheimers), in order to determine if
people with dementia would be able to participate
and demonstrate enjoyment, and also to explore
singing as a way to possibly facilitate communication. Twenty-five participants included people
with dementia, their caregivers and health care
workers (all over 40 years of age). Participants
completed three weekly, one-hour sessions
consisting of vocal warm-ups, clapping, singing
of familiar folk songs, rounds, and learning of
one novel round. Activities were completed in a
circle, and sessions were videotaped and audiotaped. Lyrics to songs were provided and used if
desired. Teaching of songs was described by the
authors as varying according to the session, and
was not prescribed in advance. Health care workers and caregivers also completed questionnaires,
with participation of people with dementia as
appropriate.
Results indicated positive enjoyment of group
singing sessions. Increased alertness was also
observed in participants with dementia. Notably,
all participants were able to perform all material
and learn the new composition, except one person
with Alzheimers who nonetheless learned to whistle the novel song. A strength of this study was the
taping of sessions. In addition, the musical leader,
who was Bannan, was uninformed prior to the
study as to the category of participants. However, a
limitation is that recruitment criteria are unclear,
in addition to other participant characteristics.
An additional weakness noted by the authors was
the potential demand characteristic created by
informing health care workers and caregivers that
positive results would be used to facilitate continuing the program.
Magill, Levin, and Spodek (2008). This quantitative study explored the use of a 20-minute,
one-session singing therapy to improve emotional
well-being in cancer patients who were too weak
to participate in standard cognitive behavioral
therapy. Patients chose two songs from songbooks
or other sources, and were invited to sing along
with the music therapist; those too weak to sing
192

hummed or listened. Therapists asked questions


following the songs, such as the meaning to the
patients; discussion ensued, and included coping
statements. Thirty-nine cancer patients participated in the pilot study, and a measure of distress
in cancer patients was taken before and after the
session. A statistically significant drop in average
distress was found following the singing session.
Although a promising intervention for cancer
patients, it is unclear whether discussion of meaning and coping need to be included with singing
for effects to occur, because a comparison condition where participants only sang was not included
in the study. In addition, it is unclear how many
participants sang along.
Pavlakou (2009). This qualitative study
explored the effect of group singing in women,
as part of a general interest in art and music therapies with people with eating disorders; these
therapies do not dwell on food and eating but
may instead reveal underlying issues that might
lead to problems. Participants were eight women
who self-identified as having disordered eating
(diagnoses of bulimia or anorexia, or associated
symptoms such as bingeing and purging (e.g.,
using laxatives), or extreme restriction in eating
and problems with body image, respectively;
American Psychiatric Association, 1994). Women
participated in six sessions of warm-ups, stretching, and singing familiar songs; they also did
semi-structured interviews. Most women had no
formal music training but had previously participated in community choirs.
Results obtained using thematic analysis indicated that women reported reconnection with their
bodies, distraction from problems, and release from
emotional tension. Women reported that focussing
on lyrics and melody was a major factor in providing distraction. Participants reported that exercises
contributed to feelings of relaxation and positive
affect, as well as reconnecting with bodily sensations.
Pavlakou (2009) suggests that noticing sensations
may be particularly important for anorexic women
who may suppress feelings of hunger. Strengths of
the study include the multiple examples given and
attention to potential mechanisms, as well as the
thematic analysis.

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Professional and amateur singers


Turning to research with professional and
amateur singers, Wise et al.s (1992) study of
a retirement community (described in Other
physical health) indicated no differences in life
satisfaction between choral singers and non-singers. Valentine and Evans (2001) comparison of
solo and choral singers, and swimmers (described
in Stress and immune responses) indicated
significant increases in hedonic tone and energetic arousal, and reduction in tense arousal in
all three groups. Significant interactions were
obtained such that greater increases in hedonic
tone and energetic arousal occurred in swimming than singing. No significant differences were
found between singing groups. However, similar
to limitations noted earlier with respect to heart
rate, baseline hedonic tone and energetic arousal
appeared to be lower, and tense arousal, higher, in
swimmers than in singers.
Clift and Hancoxs (2001) university choral singers (described in Breathing) reported perceived
benefits of hedonic well-being, such as positive
mood. Grape et al. (2003) (described in Stress
and immune responses) measured visual analogue
scales of opposite emotions (sad/joyful, tense/
relaxed, listless/energetic) in professional and
amateur singers before and after a singing lesson.
Although both professionals and amateurs reported
feeling more energetic and relaxed, only amateurs
reported more joy after the lesson. Semi-structured
interviews conducted after the lesson indicated that
only amateurs reported positive mood.
In Kreutz et al.s (2004) study of amateur choral
singers (described in Stress and immune responses),
negative affect increased after listening; after
rehearsing, negative affect decreased, and positive
affect increased. Kreutz et al. suggested that the
negative affect results may indicate that it is aversive for singers who normally rehearse to listen to
singing. In addition to the previously mentioned
weakness of potential order effects of singing and
listening, it is unclear whether participants were
informed in advance that they would be listening
instead of singing. Listening might be less aversive if
participants expected it.

Professional solo singers indicated that participants were less nervous before rehearsal than
during the concert (Harmat & Theorell, 2010).
Skingley and Bungays (2010) study of elderly people
in singing programs (described in Breathing) indicates that the most frequently reported benefit was
feelings of enjoyment.
Kenny, Davis, and Oates (2004). This quantitative
study explored performance anxiety in professional
singers and its association to psychological wellbeing. Kenny et al. (2004) noted that performance
anxiety has been the subject of extensive research
in orchestral musicians, or college students, but less
so in professional singers. Kenny et al. recruited 32
(of 48, or 67%) members of a national opera group
(average age of 41 years, 21 women). Measures of
performance anxiety (including during solo and
group singing), and state and trait anxiety, were
taken following a rehearsal during a typical opera
season. Participants completed the more lengthy
measure of occupational stress inventory (e.g., occupational strain of physical environment) within one
week.
Results indicated that opera singers had higher
occupational role strain and personal strain than a
normative sample of working adults. Occupational
concerns included variables such as dust in the
environment, and heat and cold. Importantly, singers also were three times more likely to have high
trait, but not state, anxiety than a normative sample.
Singers who had high trait anxiety also reported
more personal resources than a normative sample,
such as practice of healthy behaviors of exercise,
adequate sleep, good diet, relaxation, and avoiding alcohol. Trait anxiety was highly associated with
performance anxiety. Singers who had high solo
and choral performance anxiety did not differ in
trait anxiety from those with high solo performance
anxiety only. Kenny et al. (2004) suggested that, in
a small group where singers are monitored closely
and mistakes more easily exposed, the differences
between solo and group performance may decrease,
resulting in similar levels of anxiety for some singers.
Although the cross-sectional nature of the study
precludes a causal explanation, Kenny et al. (2004)
hypothesized that one reason for the connection between trait and performance anxiety may
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be that the annual requirement to re-audition


may have increased baseline levels of trait anxiety. Furthermore, in addition to serving the goal
of maintaining a healthy voice, practising healthy
behaviors may have served as a coping mechanism
to deal with high anxiety (Kenny et al., 2004). A
strength of this study was the comparison to a
normative sample for measures such as trait anxiety
and personal resources, and attention to possible
mechanisms.
Clift et al. (2007). In this mixed method, national
study of British community choirs (Clift et al., 2007),
633 choral singers (primarily women, average age of
61 years) completed a quality of life questionnaire
that assessed psychological and other aspects of
well-being, and other open-ended or specific questions about the possible benefits of singing. Results
indicated that most choral singers endorsed the view
that singing was associated with hedonic well-being
measures such as positive mood, and in women more
than men. In addition, a subgroup of participants
who reported low psychological quality of life had
experienced significant challenges such as recent
bereavement, or chronic mental health problems.
Clift et al. (2007) reported that answers to openended questions in this group indicated that music
improved their mood, and suggested mechanisms
that included deep breathing that helped reduce
anxiety, and focussed concentration on the music
that helped distract them from problems. Strengths
of this study include the large sample, a number of
choirs, use of the well-validated quality of life questionnaire, and description of potential mechanisms.
A weakness of the study is that the qualitative methods used to generate the proposed categories of
suggested mechanisms from answers to open-ended
questions were not given (Elliott et al., 1999).

Eudaimonic well-being: non-social aspects


A few studies of choral or group singing included
eudaimonic well-being outcomes that are not social
relations with others, such as purpose, personal
growth, or self-acceptance. Most studies are interventions that have already been described and are
presented first. Additional studies follow that involve
professional and amateur singers.
194

Interventions
There was a marginally significant effect of
self-confidence in Hillmans (2002) retired participants of a community singing program (described
in Hedonic well-being). Bailey and Davidsons
(2003a, 2005) study of choirs of homeless people
or those marginalized by poverty or mental illness
(described in Hedonic well-being) indicated that
participants reported that membership in the choir
that also included public performances resulted
in feelings of pride, self-confidence, mastery and
identity. Responses from members of Bailey and
Davidsons (2005) middle-class choir also indicated pride and mastery that appeared to be related
to musical accomplishment rather than personal
factors. Women in Pavlakous (2009) study of women
with self-reported eating disorders (described in
Hedonic well-being) also reported increased feelings of mastery and self-confidence following group
singing, as well as feelings of fulfilment and confidence that appeared to generalize beyond the
singing sessions.
Silber (2005). In a qualitative study, Silber (2005)
explored whether a multi-part choir similar to
Bailey and Davidsons (2005) homeless choirs would
produce positive benefits in a womens prison choir.
The choir consisted of seven women (age 17 to 35
years) who rehearsed popular Hebrew songs for 90
minutes on a weekly basis for eight months, and also
gave three concerts. Silber reported effects of eudaimonic well-being, such as personal growth, purpose
and meaning, especially when the womens prison
choir was joined by a university choir in a combined
concert. Empowerment was also indicated, and
Silber suggested that this may be in part due to
ownership and choice with which she provided
women (e.g., choice of tempo for a song).
Strengths of this study are that rehearsals were
videotaped in order to reduce potential bias, due
to the fact that Silber was not only the researcher
but also the choir leader; analysis that was done in
consultation with a clinical psychologist (Silber is a
music educator and professional choral director);
and attention to potential mechanisms. A weakness
is that it is unclear how participants were recruited
into the choir.

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Professional and amateur singers


Choral singers in a retirement community had
lower scores than non-singers on a measure of selfactualization (Wise et al., 1992; described in Other
physical health). Wise et al. (1992) suggested that
choral singing may involve giving lower priority to
individual concerns for the benefit of group goals.
Alternatively, because these choral singers had sung
for most of their lives, the structure of a choral
group may have attracted people with lower selfactualizing tendencies (Wise et al., 1992).
In Grape et al.s (2003) study of professional
and amateur singers following a singing lesson
(described in Stress and immune responses), analysis of semi-structured interviews indicated that
amateurs reported singing as a means of selfexpression, in contrast to professional singers
who reported a focus on technique. Participants
suffering from bereavement or mental health issues
in community choirs endorsed factors such as a
sense of purpose, learning and commitment (Clift
et al., 2007, reported in Hedonic well-being).

Social factors
Studies related to social factors, including eudaimonic well-being of positive relationships with
others, and social interactions and social support,
have been reported in some singing research.
Research includes interventions for health or
other conditions, and studies of community choirs.
Previously described studies are presented first,
followed by additional studies, in both subsections of interventions and studies of community
choirs.

Interventions
Bailey and Davidsons (2003a, 2005) studies of
choirs consisting of participants marginalized by
homelessness, poverty or mental illness (described
in Hedonic well-being) suggested that social support
and camaraderie from choir membership as well as
positive reactions from audiences through public
performances were very important for these groups.
In contrast, most middle-class choral singers in

Bailey and Davidsons (2005) study were grateful for


the safety in numbers provided by group singing, as
opposed to its social interaction.
Silbers (2005) study of a womens prison choir
(described in Eudaimonic well-being: non-social
aspects) also reported improved social relations.
Observations by prison officials additionally
suggested that prison choral members improved
in other interpersonal interactions, such as dealing with authority figures. Silber noted that social
factors such as cooperation and trust are lacking
in a prison population; in addition, non-verbal,
musical methods such as harmonic backup for
soloists encouraged support and trust. Indeed,
Silber further reported that looking at and listening to other choral members increased in the
process of rehearsals. Moreover, participants also
increased direct communication with each other
(instead of exclusively through Silber as choral
director), and physical signs of affection such as
hugging.
Other, previously described intervention research reporting social benefits includes Bannan
and Montgomery-Smiths (2009) study of people
with dementia (described in Hedonic well-being);
increased eye contact was observed following group
singing. In addition, Pavlakou (2009) suggested
that the choral group experience of women with
eating disorders (described in Hedonic well-being)
afforded opportunities for social interaction in a
supportive, non-judgmental environment, which
may be important for this population that may
include characteristics of low extraversion and
interpersonal difficulties (Tasca, Demidenko, et al.,
2009).
Olderog Millard and Smith (1989). This pioneering, quantitative study explored whether singing
would enhance social behaviors, such as walking
and talking with others, in people with Alzheimers
Disease. Specifically, Olderog Millard and Smith
(1989) noted that the frequent claim that music is
a helpful activity for people with dementia (because
it provides opportunities such as reminiscence,
for example) had not been systematically investigated. Seven women and three men with middle
stage Alzheimers served as their own controls and
engaged in 30-minute group sessions of singing
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Mary L. Gick

familiar songs, alternating with 30-minute group


discussions, twice weekly over a period of five
weeks. Participants demonstrated increased walking with others during and immediately after
singing sessions, as observed by trained observers.
Importantly, Olderog Millard and Smith reported
that all but two participants sang along.
A strength of this study is that participants served
as their own controls, and trained observers were
used. However, a weakness noted by the researchers was that singing sessions were better attended;
the authors also reported that discussion sessions
tended to be dominated by high verbal participants.
Thus, it is unclear if singing would produce better
effects than a discussion group that was better
attended.
Bygren et al. (2009). Bygren et al. (2009) explored
the effects of various cultural activities, including
singing, on office workers in Sweden. Participants
who were primarily women in their forties were
randomly assigned to singing, film, art or concert
attending, based on their interests, or to a waitinglist control group that began activities after the
treatment group completed their activities. Choral
singing was conducted in two-hour weekly sessions
for eight weeks. Results indicated that the social
functioning sub-scale of a multidimensional measure of health (that assesses whether health problems
interfere with social activities) increased more in the
treatment group than in the control group. Details
of the singing were not given, and singing results
were not reported separately. However, there were
no interactions obtained with type of activity, which
suggests that singing improves social functioning
in these healthy office workers, but no more than
other artistic endeavors such as attending films or
concerts.

Community choirs
Previously described studies of community
choirs report social benefits. Wise et al.s (1992)
retired choral singers (described in Other physical health) frequently reported that they enjoyed
the sense of community (p. 1179) that comes
with membership in a choir. Studies of existing
university (Clift & Hancox, 2001) and community
196

(Clift et al., 2007) choirs (described in Breathing


and Hedonic well-being, respectively) reported
interaction with others as a benefit of singing.
In addition, younger members were more likely
to endorse social aspects of the university choir
(Clift & Hancox, 2001). Community singing
groups in the elderly (Skingley & Bungay, 2010,
described in Breathing) also reported increased
social interaction.
Faulkner and Davidson (2006). This qualitative study explored perceptions of cooperation
and collaboration of 11 members of an all-mens
choir (age ranged from 20 to 70 years), as part of
an ongoing study of the role of singing in a rural,
isolated part of Iceland. The method of interpretative phenomenological analysis of interviews
was used. Results indicated that the process of
collaboration served purposes of learning and
rehearsing. For instance, the choirs sang in fourpart harmony, and because few men read music,
they may have learned the parts by listening to
other singers. In rehearsing, men collaborated by
choosing to stand beside those singing a different part in order to listen to the entire choir, as
would an audience, and find the balance between
parts. Collaboration was also observed in settings
outside of the choir, such as learning a vocal part
of an Icelandic folk song in singing that occurred
in everyday situations of birthday celebrations
and family gatherings. Indeed, Faulkner and
Davidson (2006) reported that exposure to such
informal singing often led to mens joining the
choir in the first place. Competition appeared to
occur only in the form of good-natured ribbing
between different vocal parts that served as a
motivation for learning.
Interestingly, Faulker and Davidson (2006)
report that singing in unison that was encouraged by the church was resisted by men in the
choir, who reported that they enjoyed singing
in harmony and finding their place in that overall sound. Faulkner and Davidson proposed that
singing in harmony is a way to serve a basic need
of connecting with others for men in Icelandic
society. Strengths of this study are the examples
provided, and attention to both potential mechanisms and cultural context.

Singing, health & well being

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discussion
In this final section, I provide an integrative
summary of main findings gleaned from the
review. I then propose potential mechanisms by
which singing may benefit health and well-being,
and variables for future study, based on my review
together with a consideration of health psychology
research. I conclude with general recommendations
for future research that include methodological
considerations.

Summary of Review
There were methodological weaknesses with
some quantitative studies, such as lack of control
groups, small sample sizes, and potential selection
bias. Some qualitative studies also had methodological drawbacks, such as unclear methods of
recruitment and analysis. Notwithstanding the
methodological shortcomings, taken together,
there is inconclusive but promising evidence for
some potential benefits of singing to health and
well-being.

Biological and physical factors


There was some support for improved breathing functioning in group singing in adults with
health problems related to breathing (e.g., COPD;
Bonilha et al., 2009; asthma; Eley & Gorman,
2010), possibly through mechanisms of improved
control over breathing found in breathing training that accompanied interventions (Engen,
2005). Improved breathing was also self-reported
as a benefit in qualitative studies of healthy
adult choral singers (Clift & Hancox, 2001) and
the elderly (Skingley & Bungay, 2010). Benefits
to asthmatic children were inconclusive (Eley &
Gorman, 2010; Wade, 2002).
There was some evidence that immune system
increases in SIgA occurred immediately following singing. SIgA increases occurred in amateur
(Kreutz et al., 2004) and professional (Beck et
al., 2000) choral singers in rehearsal and performance, and student solo (Beck et al., 2006)
performance. The fact that SIgA increases were

found in both choral and solo singers suggests


that results are not due to idiosyncratic features
of choral singing. SIgA changes were associated
with positive mood increases following performance in professional choral and solo student
singers, but not rehearsal in professional and
amateur choirs. Satisfaction with performance
was also associated with SIgA increases in professional choral singers.
Only two studies were reviewed on effects of
singing on pain, and results were inconclusive with
respect to chronic (Kenny & Faunce, 2004) or IBS
(Grape et al., 2009) pain. Severe headaches were
reported in one case study of a singer (Kim et al.,
2008). One study without a control group indicated
that singing is beneficial for walking in Parkinsons
disease (Satoh & Kuzuhara, 2008). Results were
mixed on whether singing may facilitate physical
health in the elderly or retired people, with positive
associations to self-reported physical health found
in a community intervention (Cohen et al., 2006),
but not in choral singers as compared to non-singers
who were equally active in a retirement community
(Wise et al., 1992).
Biological stress responses occurring during or
immediately after singing may depend in part on
the singer, situation, and whether singing is viewed
as stressful. Singing solo in front of experimenters
showed increases in many variables indicative of
sympathetic nervous system activity (e.g., sweating,
blood pressure) in volunteers (Fechir et al., 2008),
who rated the task as stressful. However, heart
rate increased only slightly after solo singing, and
decreased slightly after choral singing in students
(Valentine & Evans, 2001) who reported decreased
tense arousal, and increased energetic arousal and
hedonic tone after singing. Professional singers HRV
decreased following a solo concert, as compared to
a rehearsal (Harmat & Theorell, 2010), and singers
rated the concert as more stressful. After a solo singing lesson, some biological responses indicative of
increased stress (cortisol and TNF-alpha) increased
in professionals and decreased in amateurs (Grape
et al., 2003). In general, biological stress responses
appeared to occur more in solo singing and performance, as opposed to rehearsal, and in professional
singers.
197

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Psychological factors

Social factors

Overall, support for increased hedonic well-being


(e.g., positive mood, life satisfaction) associated with
singing also varied between studies of amateur and
professional singers. There was promising evidence
in qualitative studies of adult amateur choral singers, including community and middle-class choirs
(Clift & Hancox, 2001; Bailey & Davidson, 2005),
choirs with homeless people and those marginalized
by mental illness (Bailey & Davidson, 2003a, 2005),
and in mixed-method (Bannan & MontgomerySmith, 2008) and quantitative studies of people
with dementia (Korb, 1998). Reduced distress was
also reported in a singing intervention of people
recovering from knee surgery (Giaquinto et al.,
2006). Findings were mixed in elderly or retired
people, with two studies of group or choral singing
reporting positive effects (Hillman, 2002; Skingley
& Bungay, 2010) and one study indicating no effect
in choral singers as compared to equally active nonsingers (Wise et al., 1992).
Compared to studies of amateurs, there was less
support for associations of singing with hedonic
well-being in professionals. Although singing was
associated with long-term positive emotions in
professional choral singers (Beck et al., 2000), they
also rated performances as more anxiety provoking
than rehearsals; professional soloists were also more
nervous before concerts than rehearsals (Harmat &
Theorell, 2010). Moreover, one study of professional
opera singers indicated much higher trait anxiety than a normative sample (Kenny et al., 2004).
Amateurs, but not professionals, reported more
positive emotion after a singing lesson (Grape et al.,
2003). In addition to hedonic well-being, increased
eudaimonic well-being such as mastery, purpose or
personal growth was reported in amateur choral
singers (Clift et al., 2007), including studies of
homeless people and persons with mental illness
(Bailey & Davidson, 2003a, 2005), and women
with eating disorders (Pavlakou, 2009) or in prison
(Silber, 2005), but less so in middle-class (Bailey &
Davidson, 2005) or long-term choral singers in a
retirement community (Wise et al., 1992), or professional, as compared to amateur, solo singers after a
lesson (Grape et al., 2003).

There was some promising evidence suggesting


social benefits of singing, such as social interactions or social functioning in people living in the
community (Clift & Hancox, 2001; Clift et al., 2007;
Faulkner & Davidson, 2006); elderly or retired
people (Skingley & Bungay, 2010; Wise et al., 1992);
homeless people and people marginalized by mental
illness or poverty (Bailey & Davidson, 2003a, 2005);
people with dementia (Bannan & Montgomery,
2009; Olderog Millard & Smith, 1989); and women
with eating disorders (Pavlakou, 2009) and in
prison (Silber, 2005). However, most of the research
has been conducted with group or choral singing,
in which there is opportunity for social interaction. Notably, not one study of solo singing reported
social benefits. In addition, one study (Bygren et
al., 2009) indicated that, although effective for one
measure of social functioning, singing was no better
than other cultural activities (e.g., attending films
or concerts).

198

Future research
As indicated in my review, some researchers have
proposed mechanisms by which singing may be
associated with health and well-being, although
few studies provided evidence. Based on both
my review and research in health psychology, I
propose potential mechanisms and variables for
further study, followed by general methodological
recommendations.

Mechanisms and variables


Examples of potential biological, psychological and social mechanisms, and variables that may
be useful in exploring them, are listed in Table 1.
Variables are categorized according to factors associated with a person, song or situation that may
influence results. Variables listed are not exhaustive, nor are they necessarily linked to any, or one,
mechanism. For example, group vs. solo singing
may moderate effects of not only social support
but also stress responses associated with health and
well-being.

Singing, health & well being

Table 1
Singing, health and well-being: potential mechanisms and variables for future study

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Category

Examples

Mechanisms
Biological

Breathing control, autonomic nervous system, immune system

Psychological

Emotions, concentration, distraction, health behaviors

Social

Non-verbal communication, social interactions, social support

Variables
Person

Personality, age, gender, culture, socioeconomic status, musical background, amateur vs.
professional status, coping

Song

Tempo, mode, duration of notes, dynamics, genre, difficulty, familiarity, melody, lyrics,
harmony vs. unison (choral)

Situation

Breathing training, performance vs. rehearsal, group or choral vs. solo

Considering potential biological mechanisms,


studies that reported improvements in breathing after singing suggest that breathing control
that was included explicitly as part of the treatment (e.g., COPD patients; Bonilha et al., 2009),
or that may have occurred as a result of difficult
pieces (community elderly choral singers; Skingley
& Bungay, 2010) may have facilitated the obtained
improvements. One question is whether breathing
improvements can be obtained by singing alone, or
whether explicit breathing training is also necessary. Although further research is necessary on this
point, support for the mechanism of control over the
diaphragm and abdominal muscles during singing
is found in physiological (Leanderson, Sundberg,
& von Euler, 1987) and neuroimaging (Gunji, Ishii,
Chau, Kakigi, & Pantev, 2007) studies in untrained,
healthy singers without explicit breathing instruction, which suggests that singing alone possibly may
have positive effects on breathing without the inclusion of separate, formal breathing training (see also
Wan, Ruber, Hohmann, & Schlaug, 2010).
A related question is whether breathing exercises alone without including singing - might
produce positive effects on breathing in both
patients with respiratory problems and healthy
participants. Practice of slow breathing for three
months increased parasympathetic activity and
heart rate variability following standing up from a

sitting position in a study of male medical students


(Pal, Velkumary, & Madanmohan, 2004). However,
only heart rate responses to forced expiration, and
not breathing changes, were measured in Pal et al.
(2004). In her study of people with COPD, Engen
(2005) suggests that breathing exercises on their
own may have restricted benefits in part because
participants may not enjoy them, and also because
participants do not have the opportunity to see how
breathing connects with the voice.
Qualitative studies indicating self-reports of
improved breathing (e.g., Clift & Hancox, 2001;
Skingley & Bungay, 2010) did not include physical measures used in studies of people with COPD
or asthma. While the use of clinical measures and
instruments such as peak flow meters may be unnecessary in healthy participants, future research that
uses other measures such as ability to sustain a
note or hold ones breath, or measures diaphragmatic breathing before and after a singing program
(e.g., Engen, 2005) could provide some preliminary
evidence of breathing changes that may accompany
singing in healthy adults.
Turning to potential autonomic nervous system
mechanisms, only a few studies of professional or
amateur choral singers used measures of sympathetic nervous system activity such as heart rate
(Fechir et al., 2008; Valentine & Evans, 2001), or
HRV (Grape et al., 2003; Harmat & Theorell, 2010),
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Mary L. Gick

which is affected by sympathetic and parasympathetic activity in the autonomic nervous system.
HRV also connects to various structures in the
brain, including cortical and emotion circuits, and
is normally dominated by parasympathetic activity under resting conditions (Ellis & Thayer, 2010).
HRV changes following an activity may reflect a
change to more sympathetic dominance (Ellis &
Thayer, 2010; Grape et al., 2003). Reduced HRV is
found in cardiac related illnesses such as stroke or
heart disease, diabetes, Parkinsons and Alzheimers
disease, psychological problems such as post-traumatic stress, and higher all-cause mortality (Ellis
& Thayer, 2010). Given the connection of HRV to
health and illness, exploring the change in HRV in
response to singing may provide a biological way to
connect singing to health (Ellis & Thayer, 2010).
Indeed, HRV was reduced in response to increasing tempo of music in one music listening study,
due to the withdrawal of the parasympathetic
nervous system in response to the music (Ellis &
Thayer, 2010). Tempo of songs did not affect the
few professional singers HRV studied by Harmat
& Theorell (2010). Engen (2005) did report using
tempo, and also duration and dynamics, as part of
COPD breathing training, but no indication was
given of their systematic variation. People recovering from knee surgery reported higher enjoyment
of songs with slower tempos (Giaquinto et al., 2006);
however, it is unclear if this preference was because
of the recovery situation, or if tempo affected the
results of lower distress.
Future research is needed to determine whether
variables such as tempo, dynamics, and duration
of notes that need to be held (which might affect
breathing; Wan et al., 2010) might moderate effects
of sympathetic nervous system arousal or breathing. For example, singing fast-paced songs loudly
may engage the sympathetic nervous system and
increase arousal, while quiet songs with slow tempos
may activate the parasympathetic nervous system
and increase relaxation (Azoulay & Loewy, 2009).
Research could also benefit from a more systematic investigation of tempo and, additionally, mode,
in order to determine their impact on potential
psychological mechanisms of mood and emotions.
For example, songs in a major mode may induce
200

positive mood, while songs in a minor key may be


more likely to induce sadness, similar to instrumental music (Hunter, Schellenberg, & Schimmack,
2010).
In addition, although concentration (e.g., Bailey
& Davidson, 2005; Clift et al., 2007; Pavlakou,
2009) and distraction (e.g., Kenny & Faunce,
2004; Pavlakou, 2009) were suggested as possible
psychological mechanisms associated with benefits of singing, they have received little direct study.
Distraction in the form of listening to music with
or without the suggestion that it may be helpful is a successful treatment for dental pain relief (e.g.,
Anderson, Baron, & Logan, 1991); active singing
may afford a similar benefit of distraction from pain
(Kenny & Faunce, 2004) or stress. Variables such as
lyrics and melody (Pavlakou, 2009) or song familiarity may affect distraction and concentration, and
could be measured by ability to divide attention
between singing and a second task.
More generally, while stress and coping are often
studied together in health psychology, there appears
to be little singing research that includes coping.
Active coping with pain may have increased following singing as compared to standard pain treatment
(Kenny & Faunce, 2004). Healthy practices may have
been used for coping with anxiety in professional
singers (Kenny et al., 2004). Further research on
singing and coping is needed; one particular question for future research might be whether people
use singing itself as a means of coping with stress.
Considering social mechanisms, these may
include non-verbal communication (e.g., eye
contact; Bannan & Montgomery, 2008) that may
occur between caregivers and people with dementia
(whose musical memory may possibly be preserved;
Cuddy & Duffin, 2005; Vanstone & Cuddy, 2010)
while singing together, or during caregiver singing, which might facilitate caregiving activities (e.g.,
Brown, Gotell, & Ekman, 2001) that affect health
and well-being. Non-verbal communication may also
be important in choral (e.g., listening to and looking at others, hugging; Silber, 2005) and harmony
(e.g., standing next to one another; Faulkner &
Davidson, 2006) singing that may require more
collaboration and cooperation than unison singing
(Brown, Martinez, Hodges, Fox, & Parsons, 2004;

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Singing, health & well being

Faulkner & Davidson, 2006). Comparisons of unison


to harmony singing and group to solo singing would
be useful in determining their associations with
variables such as social interaction, social support,
and positive relationships.
In addition to comparing different kinds of singing, singing needs to be compared to other activities
in its effects on social benefits, especially given that
some studies (Bygren et al., 2009; Wise et al., 1992)
indicated no benefits of singing as compared to
other activities. Future research should also determine whether any social benefits from singing
transfer to situations outside of the choir (Silber,
2005) and whether differences in personal (e.g.,
age; Clift & Hancox, 2001) or other factors affect
results, including type of perceived social support
(e.g., emotional vs. instrumental). Differences in
musical background may also be useful to explore,
given that some studies suggestive of positive effects
of singing (e.g., Pavlakou, 2009; Skingley & Bungay,
2010) indicated that most participants had musical
experience.
Culture may also be an important variable when it
comes to social benefits of group singing. For example, Bailey and Davidson (2005) commented about
similarities of marginalized vs. middle-class groups
to issues of collectivist (focus on group) vs. individualist (focus on individual) cultures, respectively;
only marginalized groups reported the importance
of social variables such as camaraderie. Faulkner
& Davidson (2006) also discussed the importance
of harmonic singing in Icelandic culture. Overall,
however, the importance of culture remains relatively unexplored in singing research.
In addition, further research is needed on potential linkages among biological, psychological and
social processes associated with singing, similar to
recommendations for research in health psychology (Miller et al., 2009; Suls & Rothman, 2004). For
example, diaphragmatic breathing that is taught in
formal singing or used as treatment for some respiratory illnesses (e.g., COPD; Bonilha et al., 2009)
is also used for stress reduction and relaxation
(Azoulay & Loewy, 2009; Wolpe, 1958). However,
effects of breathing training in singing for benefits other than breathing (e.g., relaxation), remain
unexamined (see Clift et al., 2007 for an exception).

Similarly, singing was associated with lower distress


following knee surgery (Giaquinto et al., 2006), but
effects of singing on physical rehabilitation of the
knee (e.g., shortening the length of time required
for simultaneously conducted physiotherapy) were
not examined, nor whether distress reduction might
mediate rehabilitation effects.
Positive mood may also have multiple influences
on health, such as social connections, health practices, and recovery from stress (Pressman & Cohen,
2005), and singing may activate reward areas in
the brain (at least more than speaking; Callan et
al., 2006). The hormone oxytocin also has links
to both social factors and stress responses (Taylor,
2006). In particular, oxytocin may reduce biological stress responses in supportive social situations,
but exacerbate them in unsupportive interactions,
especially in women (Taylor, 2006). Recall that the
hormone oxytocin increased in both professional
and amateur singers following a solo lesson (Grape
et al., 2003). Although both professionals and
amateurs both self-reported relaxation following the
lesson, cortisol and TNF-alpha (biological markers
of stress) increased in professionals but decreased
in amateurs, and only amateurs increased in positive mood and reported joy following the lesson
(Grape et al., 2003). Future research might determine whether oxytocin mediates stress reduction,
and increased stress, in amateur and professional
singers, respectively.
Interestingly, singing research thus far has not
examined the role of factors such as individual
differences in personality, which also could affect
multiple pathways of influence on health. For example, extraverts may be less stressed than introverts
in front of an audience, gain more social benefits from group or choral singing, and possibly be
more attracted to it in the first place. Furthermore,
with the exception of Kenny et al., (2004), research
reviewed here is silent on the relationship between
singing and health behaviors. Research that explores
potential reciprocal relationships between singing
and health behaviors might further understanding
of the associations between them, and their effects
on health. For example, given the possible attention and concern professional singers have about
their voice, adoption of positive health behaviors
201

Mary L. Gick

may help not only in coping with anxiety related to


the voice (Kenny et al., 2004), but also contribute to
long-term health. Conversely, beginning a singing
program may initiate a decrease in negative health
behaviors, such as smoking, which might positively
affect health.

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General methodological considerations


It is important to note that research conducted in
some areas reported in this review, such as health of
the elderly, has primarily used self reports of health.
Determining immune system responses associated
with singing might also be important in considering
singing as an intervention to the elderly or people
with compromised immune systems, such as those
with cancer, as long as there is adequate focus on
increasing quality of life (Young, 2009) in these
vulnerable groups.
However, with a few exceptions (Grape et al.,
2009, 2010; Kenny & Faunce, 2004), immune system
changes in reviewed studies were measured only
immediately after singing. Moreover, effects of
obtained immune system changes on health have
not been examined. Finding a short-term immune
or stress response provides no indication of whether
this result would have clinical significance for
short- or long-term health (Miller et al., 2009).
In addition, while some singing interventions for
physical health (e.g., breathing and COPD; Engen,
2005) did demonstrate increased improvement over
the duration of the program, the effect of duration
of singing has not been studied in general. Gold et
al. (2009) reported that duration of music therapy
sessions was positively related to treatment effects.
Further research is needed to determine if similar
results hold for singing.
Considering studies of choirs, much of the
choral research has been done in quasi-experimental studies of participants who are already
singing in a choir. Although random assignment of
participants to conditions is considered the gold
standard in medical clinical trials, and studies
were sometimes critiqued in this review on this
basis, control needs to be balanced with ecological validity for the research question. Recall that
a comparison of singers to swimmers did not
202

randomly assign participants to swimming or singing for the purpose of increasing ecological validity
(Valentine & Evans, 2001). Indeed, social support
research in health psychology indicates that benefits often accrue to naturally existing networks;
peer support groups with strangers do not always
work (Cohen, 2004). Creative use of existing singers serving as their own controls, especially in small
samples (e.g., Harmat & Theorell, 2010; Korb, 1997;
Wade, 2002); comparison to a normative sample
(Kenny et al., 2004); and, where possible, longitudinal research that compares singers to non-singers
who are active in other pursuits may be useful
methods for control while preserving the ecological validity of singing. Multilevel linear modeling
(MLM) for longitudinal data analysis that can evaluate effects within individuals and between groups
over time, control for pre-existing differences, and
predict group differences in change over time may
be particularly useful in future quantitative, longitudinal studies (Tasca & Gallop, 2009). MLM may
be especially useful in naturalistic settings (Tasca
& Gallop, 2009), where, for example, choral attendance varies among members.
Additional recommendations on control are to
keep not only singing but also comparison, control
activities meaningful and valid. Indeed, some
research reviewed here that compared singing to
listening has used somewhat unusual singing (e.g.,
unfamiliar, foreign languages to reduce emotional
connection; Unwin et al., 2002) or listening (e.g.,
replacing usual rehearsal; Kreutz et al., 2004) conditions that may lack validity. Furthermore, when
conducted as a control activity to active singing,
listening to singing was always conducted in a group
(Kreutz et al., 2004, Unwin et al., 2005). However,
amateur choral singers rated listening to music
alone as more positive than listening to music in
a group (Bailey & Davidson, 2003b). Listening to
singing also may be more pleasant when done alone,
and future studies that incorporate listening to singing as a control may wish to conduct it alone as an
additional condition.
Furthermore, a recent study indicated that
some people prefer to sing alone (8.2%; Chong,
2010) or indeed may not enjoy singing at all (3.5%
of 90 university students; Chong, 2010). Although

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Singing, health & well being

I have emphasized the importance of control


and explanation, and suggested potential mechanisms to explore for future research, there has
to be a balance between descriptive and explanatory research on singing, a point made in recent
critiques of health psychology (Suls & Rothman,
2004). Testing rigorous, mechanistic hypotheses
about singing and health should not be in lieu
of equally important descriptive research (e.g.,
Bailey & Davidson, 2003b; Chong, 2010) or assessment of what is essential to singing (e.g., emotional
connection, breathing). Moreover, Rozin (2009)
suggests that studies describing basic phenomena
associated with a research topic are especially
important in early research into it. Indeed, two
studies reviewed here reported negative associations of singing to health and well-being, which
were performance anxiety in professional singers
(Kenny et al., 2004) and severe headaches in one
singer (Kim et al., 2008). Future research should
encompass both descriptive studies, including
positive and negative associations of singing
with health and well-being, and investigations of
explanatory mechanisms.
Research on singing and health may benefit
from interdisciplinary studies that combine musical
expertise of singers and music therapists, together
with research expertise of health psychologists and
music therapists in designing meaningful basic
and intervention research. The AIRS international
research collaboration (http://www.airsplace.ca)
that consists of singers, music educators and therapists, and psychologists is ideally suited to this
purpose.

c o n c lu s i o n
Although the health benefits of singing have sometimes been promoted (e.g., Singing for health may
be an idea whose time has come; Stacy, Britain, &
Kerr, 2002, p. 156), research on singing reviewed
here often indicates anecdotal support and promising but inconclusive evidence. Perhaps research
on singing for health is an idea whose time has
come. Systematic interdisciplinary research that
includes qualitative and quantitative studies is

recommended to confirm preliminary findings of


health and well-being benefits of singing, determine their underlying mechanisms, and compare
singing to other activities that may benefit health
and well-being. Future research should also explore
conditions under which singing may detract from
health and well-being. Applying Schwartzs (1982)
approach to testing the biopsychosocial model in
treatment of illness, research is needed to determine conditions under which singing is beneficial
or harmful, and for whom.

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Singing, health & well being

au t h o r n o t e s

This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

The author would like to thank Nicholas Bannan,


Rebecca Engen, and Laszlo Harmat for sending
their articles, and Laurel Young and one anonymous reviewer for helpful comments on an earlier
version of this paper.
This paper is based in part on a paper presented

at the Advancing Interdisciplinary Research in


Singing (AIRS) symposium entitled Singing and
Psychology: Interdisciplinary Perspectives and
Implications, which was conducted at the Canadian
Psychological Associations 70th Annual Convention,
Montreal, Quebec, June 2009.

biogr aphy
Mary Gick received
a B.Sc. in psychology
(1975, McGill) and a
Ph.D. in experimental psychology (1981,
Michigan). She joined
Carleton University in
Ottawa
Ontario
in
1985 and conducted
cognitive research (publications include articles
Mary Gick
in Cognitive Psychology,
Journal of Experimental Psychology) until her sabbatical
in 1992, when she began studying health psychology
with the late David McClelland (Boston University),
and at the Cambridge Hospital Behavioral Medicine
Program (affiliated with Harvard Medical School).
She currently teaches health psychology and the
community practicum at Carleton. Her long-standing health interests in individual differences (e.g.,

attachment style) associated with health, coping


with medical problems, and seeking treatment for
them have led to articles published in such journals
as Rehabilitation Psychology and Journal of Psychosomatic
Research. Her more recent interests are using a
health framework to study environmental behavior; and singing, health and well-being. She has had
an active folk music avocation since her teenage
years. She taught clawhammer banjo at the Ottawa
Folklore Centre from 2003-2007, plays regularly at
sessions, and occasionally performs and appears
on professional recordings, including the Junonominated Michael Jerome Browne and the Twin Rivers
String Band. Mary is a Co-Investigator of AIRS and
was the Health and Well-being Steering Committee
Theme Leader during 2009-10, returning to that
role in 2011.

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