Regular Article

Psychother Psychosom 2013;82:319– Received: August 16, 2012

331 DOI: 10.1159/000348452 Accepted after revision: January 21, 2013
Published online: August 9, 2013

Individual Music Therapy for Mental

Health Care Clients with Low Therapy
Motivation: Multicentre Randomised
Controlled Trial
Christian Golda Karin Mösslera Denise Grockeh Tor Olav Heldala
Lars Tjemslande Trond Aarref Leif Edvard Aarøb, d Hans Rittmannsbergerg
Brynjulf Stigec Jörg Assmusa Randi Rolvsjordc
a
GAMUT, Uni Health, Uni Research and b Department of Health Promotion and Development, c GAMUT, University of
Bergen, Bergen, and d Division of Mental Health, Norwegian Institute of Public Health, Oslo, e Stavanger University
Hospital, Stavanger, and f Nordfjord Psychiatric Centre, Nordfjordeid, Norway; g State Psychiatric Clinic Wagner-Jauregg,
Linz, Austria; h University of Melbourne, Melbourne, Vic., Australia

Key Words tion-to-treat basis using generalised estimating

Motivation · Effectiveness · Pragmatic trial ·
Resource-oriented music therapy · Serious mental
disorders
Abstract
Background: Music therapy (MT) has been shown to be
ef- ficacious for mental health care clients with
various disor- ders such as schizophrenia, depression
and substance abuse. Referral to MT in clinical
practice is often based on other factors than diagnosis.
We aimed to examine the ef- fectiveness of resource-
oriented MT for mental health care clients with low
motivation for other therapies. Method: This was a
pragmatic parallel trial. In specialised centres in Norway,
Austria and Australia, 144 adults with non-organic mental
disorders and low therapy motivation were ran-
domised to 3 months of biweekly individual, resource-
ori- ented MT plus treatment as usual (TAU) or TAU
alone. TAU was typically intensive (71% were
inpatients) and included the best combination of
therapies available for each par- ticipant, excluding MT.
Blinded assessments of the Scale for the Assessment of
Negative Symptoms (SANS) and 15 sec- ondary
outcomes were collected before randomisation and after
1, 3 and 9 months. Changes were analysed on an inten-
equations in longitudinal linear models, controlling for
diagnosis, site and time point. Results: MT was superior
to TAU for total negative symptoms (SANS, d = 0.54, p
< 0.001) as well as functioning, clinical global
impressions, social avoidance through music, and
vitality (all p < 0.01). Conclusion: Indi- vidual MT as
conducted in routine practice is an effective addition
to usual care for mental health care clients with low
motivation. Copyright © 2013 S. Karger AG,
Basel
Introduction
Despite significant progress in the development of
both psychosocial and pharmacological treatments for
people with serious mental disorders, there are still
many who do not benefit sufficiently from the usually
available therapies. Low motivation, sometimes but not
necessar- ily related to lack of insight, and usually
leading to poor therapy outcome, has been described in
people with seri- ous mental disorders such as
schizophrenia [1–4], de- pression and bipolar disorder
[2, 5], and psychosomatic disorders [6, 7]. Motivation
plays a central role in numer-
 © 2013 S. Karger AG, Basel
0033–3190/13/0825–0319$38.00/0
E-Mail karger@karger.com
www.karger.com/pps
ous mental disorders, but its potential for treatment and
for understanding mental disorders has not been fully
utilised [8, 9]. It is also related to dropout from therapy,
which can be a significant problem [10, 11].
Music therapy (MT) is an intervention where clients
are encouraged to express themselves and to relate to
others through musical means. There is an emerging ev-
idence base that this form of therapy can improve symp-
toms and functioning of people with serious mental dis-
orders such as schizophrenia, depression and substance-
related disorders [12–16]. However, music therapists do
not normally focus primarily on the client’s diagnosis.
Other criteria may be more important in defining the
population for whom MT is most indicated. From a re-
source-oriented perspective, the client’s resources,
strengths and potentials, more than problems and symp-
toms, should be emphasised, as well as collaboration
and equal relationships [17, 18]. Such a perspective to
MT builds on a contextual understanding of therapeutic
pro- cesses [19–21], the philosophy of empowerment
[22, 23] and positive psychology [24].
Several clinical and research reports have described
clients who were not able to improve through other ther-
apies but benefited from MT [14, 25–30]. Low
motivation for other therapies appears to be a common
reason for referral to MT [26]. After previous trials have
demon- strated the efficacy of MT for serious mental
disorders, broad, practice-based trials are now needed to
confirm its effectiveness with the populations and
settings where it is commonly applied.
The present study aimed to examine the effectiveness
of MT compared to treatment as usual (TAU) to
improve the ability of clients to express themselves
emotionally, to build satisfying social relationships and
to improve their general motivation. To answer the
question of effective- ness, we aimed to emphasise
strongly those features that characterise clinical practice
in MT in all study dimen- sions, ranging from
participants through interventions and comparisons to
outcomes [31].
Methods
Trial Design
This was a pragmatic [31], single-blind, multicentre ran-
domised trial with two parallel groups of equal size. Treatment
duration was 3 months and duration of follow-up 9 months (fig.
1). The study was originally planned to be conducted in Norway
but was later extended to an international multicentre trial
with four sites: Nordfjord (Norway), Rogaland (Norway), Linz
(Austria) and Melbourne (Australia). The central randomisation
office was first located at Sogn og Fjordane University College,
320 Psychother Psychosom 2013;82:319–331
DOI: 10.1159/000348452
Christian Gold
GAMUT, Uni Health, Uni Research
Lars Hilles gt. 3
NO–5015 Bergen (Norway)
E-Mail christian.gold @ uni.no
Sandane, Norway, and moved to Uni Research, Bergen, Norway
in 2006. The trial was registered before recruitment began (trial
registration No. NCT00137189) and the full study protocol pub-
lished [25]. The first author had full access to all the data in the
study and had final responsibility for the decision to submit for
publication.
Participants
The study included adults in mental health care who had a
low motivation for therapy. In addition to this main eligibility
criterion, we aimed to formulate as few restrictions (exclusion
criteria) as reasonably possible. In a pragmatic trial, eligibility
criteria should be as wide as in clinical practice, ideally including
all participants with the condition of interest ‘regardless of their
anticipated risk, responsiveness, co-morbidities or past compli-
ance’ [31]. Participants were recruited between September 2005
and December 2009 in specialised mental health care centres
(Nordfjord Psychiatric Centre, Sogn og Fjordane, Norway;
Stavanger University Hospital and Jæren District Psychiatric
Centre, herein combined as Rogaland, Norway; State Psychiatric
Clinic Wagner-Jauregg, Linz, Austria, and Sunshine Hospital,
Melbourne, Australia). Ethical approval for the study was grant-
ed by all relevant committees (Regional Committee for Medical
and Health Research Ethics Western Norway – REK Vest, Ethics
Committee of Upper Austria and Melbourne Health Ethics). All
participants provided written informed consent to participate in
the study. Criteria for inclusion and exclusion were assessed by
the clinician who had the primary responsibility for the patient
at the hospital unit, based on information collected by the clinical
team. Eligible participants were informed about the study by a
team member, using both oral and written information, and in-
vited to participate. The information provided included the title
and aim of the study, why they were eligible, what participation
would comprise for them, that they would be randomised, what
information would be collected, and that they would be free to
withdraw at any time without having to specify reasons.
Inclusion Criteria
In line with the goal of pragmatic trials of effectiveness [31]
as well as the focus of the resource-oriented MT approach [17,
18], we selected a broad range of diagnoses. Participants were
inpa- tients, outpatients or day patients in mental health care,
with a primary diagnosis of a non-organic mental disorder (F1–
F6 ac- cording to ICD-10 criteria), as assessed by a psychiatrist
at the study site. In addition, participants had to meet at least one
of the following criteria: (1) low motivation due to lacking or
insufficient insight; (2) difficulties talking about feelings or
problems; (3) wants a ‘medication cure’ or ‘does not believe in
talking’; (4) has not achieved sufficient improvement in previous
psychotherapy, or (5) other type of low motivation (specified).
These criteria were chosen because they reflect common reasons
for referral to MT [26]. Participants could still receive other
therapies, regardless of their motivation for or perceived benefit
from them.
Exclusion Criteria
As the assessments for the study included several self-report
measures [25], people who were unable to complete these could
not be included. Furthermore, people with a severe life-threaten-
ing somatic illness were not included because that would alter
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the goals and process of therapy significantly.
UniversityDownloaded
McMaster University
Gold et al.
 271 assessed for eligibility

127 excluded:
29 did not meet inclusion criteria 88 did not consent
10 did not attend first contact

144 randomised

72 allocated to MT, biweekly sessions over 3 months

72 allocated to TAU
48 received 18–25 sessions
16 received 10–17 sessions
8 received 2–9 sessions

67 completed 1-month follow-up 2 lost 59 completed 1-month follow-up 11 lost

3 missing but available later 2 missing but available later

Fig. 1. Flow chart of study participants. 65 completed 3-month follow-up 7 lost 54 completed 3-month follow-up 17 lost
‘Lost’ indicates participants with missing 0 missing but available later 1 missing but available later
data at the given time point and all later
time points (including those who were lost
at a previous time point). ‘Missing’ indi-
52 completed 9-month follow-up 20 lost 48 completed 9-month follow-up 24 lost
cates participants with missing data on the
given time point but with available data
on a later time point.

Interventions
ceptable but not necessary’ and ‘proscribed’ ones [17]. This
Participants were randomly assigned to MT or TAU over a
system allowed us to describe both the similarities with
pe- riod of 3 months.
(‘essential but not unique’) and the differences to (‘unique and
essential’) other MT approaches. For example, one ‘unique and
Music Therapy
essential’ principle is en- titled ‘collaborating with the client
Participants assigned to this group were offered individual
concerning goals of therapy and methods of working’. It is
MT sessions, 2 sessions per week of 45 min each, for a period of
described that this ‘implies a shared re- sponsibility of the
3 months from the date of randomisation. Previous research has
process of therapy in which both the therapist and the client are
suggested that about 20 sessions may be needed for MT to have
using their competences towards their common goal/ agreement
an effect on people with schizophrenia [12], and that a medium
to help the client’. The relationship between therapist and client
effect of MT will be reached after 10–24 sessions on symptoms
should be ‘based upon equality and mutuality’ [17]. Oth- er
and functioning of people with serious mental disorders [14].
approaches might use a more prescriptive strategy where the
The maximum number of sessions in this study was 26, and we
ther- apist tends to make such decisions for, rather than with, the
encouraged therapists to ensure that clients received at least 18
client. By contrast, essential but not unique principles include
sessions within the 3-month period when this was possible. Ten
items that are typical for MT in general, such as ‘engaging the
academically and clinically qual- ified music therapists with
client in music interplay (such as musical improvisation, creating
clinical experience in MT in psychiatry provided MT in
songs, playing pre-composed music or listening to music)’,
accordance with a flexible therapy manual devel- oped for this
‘tuning into the client’s musical expressions’, and also ‘reflecting
study [17]. Outlining 21 principles of resource-orient- ed MT,
verbally on music and mu- sical interplay’. It is, however,
this manual describes general therapeutic attitudes and be-
important to note that the differences between approaches might
haviours (e.g. focusing on the client’s strengths and potentials)
be relatively gradual – while approaches differ in the extent to
as well as specific attitudes within the musical interaction (e.g.
which they explicitly emphasise and focus on resources, it would
tuning into the client’s musical expression). In accordance with
not be appropriate to say that some approaches only focus on
recommen- dations for psychotherapy research [32], ‘unique and
resources while others do not do so at all [17].
essential’ and ‘essential but not unique’ principles were
In training sessions as well as regular supervision meetings
described as well as ‘ac-
with therapists it was emphasised that the goal was flexible
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appli-

Music Therapy for Clients with Low Motivation Psych

other Psychosom 2013;82:319–331 DOI: 10.1159/000348452 321
cation, and that deviations may be appropriate and desirable
using one-way mirrors or video recordings as appropriate. Test
de- pending on the individual client and his/her therapeutic
ratings were continued until familiarity and agreement was
process. Therapists self-rated their own adherence and
achieved. Rating was based on a 1-hour interview with the par-
competence at the end of each session. In addition, in a
ticipant. Internal consistency in this sample was high
randomly selected 50% sub- sample of all clients in this
(Cronbach’s alpha 0.95), confirming the reliability values
condition, a randomly selected session was videotaped and
reported in earlier studies.
the therapist’s adherence and competence was assessed by
three independent observers (qualified music therapists with
Secondary Outcomes
training in resource-oriented MT principles). Each item was
As secondary outcomes we chose further measures that were
rated on a 5-point Likert scale from 0 (not at all) to 4 (very
either of general relevance or that were assumed to be linked to
much), and means were calculated across the items of each
how MT works. As the goals of resource-oriented MT are gener-
category.
ally broad, following the client’s individual goals and wishes
rath- er than targeting a selected outcome, we aimed to collect a
Treatment as Usual
broad variety of outcome domains.
In line with pragmatic trials of effectiveness [31], all partici-
General symptoms were assessed using the BSI-18 self-report
pants were allowed to continue or begin any other treatment
scale, with 18 items addressing anxiety, depression and somatic
during their participation in the study. The best combination of
complaints [45]. It has demonstrated concurrent and predictive
known and available medical and non-medical therapies, as de-
validity as well as internal consistency in clinical and community
cided by the multidisciplinary team at the institution where the
samples. Functioning was measured using a blind rating with the
participant received mental health care, was offered and provid-
GAF [46]. The GAF is a widely used single-item scale which has
ed to all participants. Such concomitant treatment was moni-
demonstrated good predictive validity and interrater reliability.
tored. This excluded any MT outside the study during the first
Clinical global impressions were evaluated by a blinded assessor
3 months after randomisation. After that, participants were al-
us- ing the CGI Scale [47]. It consists of two 1-item scales –
lowed to receive some MT. The number of MT sessions during
severity (CGI-S) and change (CGI-C) – and has been widely
that period (i.e. from the 4th to the 9th month) was also moni-
used to assess treatment outcomes in mental health because of its
tored.
simplicity and intuitiveness.
Secondary outcomes specifically linked to the assumed
Outcomes
mecha- nisms of MT were as follows: the Interest in Music (IiM)
Primary Outcome
Scale, developed and validated for the present study [48], is a
Selecting an appropriate primary end point is a challenge in a
self-report measure consisting of 12 Likert-scaled items. Its two
study that is broad in terms of diagnoses. We chose a measure of
subscales, ac- tivity and engagement in music (IiM A&E) and
negative symptoms as this concept encompasses areas that are
social avoidance through music (IiM SA), have demonstrated
highly relevant for MT: the ability (or its absence) to express
reliability and valid- ity in the study sample [48].
one- self emotionally (affective flattening), the ability to form
Motivation for change was measured using a modified
and sus- tain satisfactory relationships (anhedonia/asociality) and
version of the two URICA subscales, precontemplation and
general motivation (avolition/apathy). Although negative
contemplation [49, 50]. Predictive validity, reliability and
symptoms are usually associated with schizophrenia, there is
sensitivity for change of this scale have been shown for a variety
evidence that they are relevant for other disorders as well,
of mental disorders [51, 52]. We added 2 items, ‘I hope that I
notably for affective dis- orders [33–37]. Negative symptoms in
could learn how to better in- teract with other people’ and ‘I need
themselves are strongly predictive of a need for care, irrespective
to find something meaningful to do’ to the existing 16 items. We
of the primary diagnosis or whether the negative symptoms are
used the sum score (with pre- contemplation items reversed) as a
considered primary or sec- ondary [38]. For the present study, it
simple continuous measure be- cause the categorical concept of
was important to note that people with negative symptoms often
stages of change has been criticised [53]. Internal consistency of
have little ability to lead a creative, active, self-determined and
our 18-item version of the URICA in this sample was good
social life, and that MT has previously been found to improve
(Cronbach’s alpha 0.88).
these aspects of mental health [12, 14]. Music therapists do not
Motivation was assessed by a blinded rater using the SANS
merely attempt to remove symp- toms, but try to help clients to
Avolition/Apathy Scale [41]. Self-efficacy was assessed using the
get in touch with abilities that may be lost, inaccessible or not yet
General Perceived Self-Efficacy Scale (GES) [54]. This is a self-
fully developed [39]. The concept of negative symptoms actually
re- port measure with 10 Likert-scaled items that has
describes abilities, even though it is their absence that is assessed
demonstrated test-retest reliability and internal consistency in
[40]. The primary outcome was the composite score of the Scale
both clinical and non-clinical samples. Self-esteem was measured
for the Assessment of Negative Symp- toms (SANS) [41], as
using the Rosen- berg Self-Esteem Scale (RSE) [55], a self-
completed by a trained assessor blinded to randomisation status.
report measure with 10 items. The scale has been used in many
This is a sum score of 24 items with a total possible range from 0
studies. Discriminant va- lidity, test-retest reliability and internal
to 120. Validity has been demonstrated for a variety of mental
consistency have been shown for patients with mental disorders.
disorders [33, 35]. Several studies have con- firmed interrater
Vitality was assessed using the vitality subscale of the SF-36
reliability, with intraclass correlation coeffi- cients ranging from
[56]. This is a self-report scale with 4 items. It has demonstrated
0.60 to 0.92 [41]. Test-retest reliability and internal consistency
discriminant validity and sensitivity to change in schizophrenic
have been demonstrated in people with schizophrenia [41], and
patients, and internal con- sistency and test-retest reliability have
the scale has also shown sensitivity to change in previous MT
also been confirmed. Affect regulation was measured by a
trials [12, 14, 42–44]. Reliability within and across sites was
blinded rater using the SANS sub- scale, affecting flattening and
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ensured through test ratings and discussions

blunting [41]. The 7-item scale has

322 Psychother Psychosom 2013;82:319–331 DOI: 10.1159/000348452

Gol d et al.
good internal consistency; interrater reliability is moderate.
Statistical Analysis
Sensi- tivity to change following MT has been demonstrated in
Success of randomisation was verified by testing equality of
people with schizophrenia. Relational competence was assessed
means or proportions of baseline characteristics. In addition, we
using the IIP-32 [57]. This self-report scale contains 32 items
used the reverse propensity score [62] to examine any relation
describing a variety of interpersonal problems. It has
be- tween baseline SANS values and the probability of
demonstrated internal consistency in psychotherapy patients and
assignment to MT. The reverse propensity score can detect
test-retest reliability in a non-clinical sample.
baseline imbalances even if they are not associated with any
Social relationships were assessed using both a self-report
observed covariates and is therefore a powerful tool for detecting
and a blinded assessment. First, we used the social relationships
unblinding of the allocation sequence and selection bias [62].
sub- scale of the Q-LES-Q [58] to elicit the view of the
Analyses of effects were on an intention-to-treat (ITT) basis
participants themselves on the quality of their social
to provide a conservative estimate of effectiveness. This means
relationships. It has 11 face-valid items and has demonstrated
that participants who were randomised and had available
sensitivity to change, test- retest reliability and internal
outcome data were included in the analysis regardless of whether
consistency in major depression. Sec- ond, we used the SANS
or not they re- ceived the complete intervention. The ITT
anhedonia/asociality subscale [41] to ob- tain a blinded
analysis is an important feature which affects the population to
assessment of the same domain. The 5-item scale has
which results can be gener- alised. In psychotherapy studies, it is
demonstrated satisfactory interrater reliability, internal consisten-
typical that as many as 30– 60% do not complete therapy as
cy, and sensitivity to change following MT.
intended [10, 11]; in a recent study on art therapy, 40% did not
attend any session [63]. Because we intended to generalise our
Sample Size
effect estimates to all those who are of- fered MT, as opposed to
The required sample size was calculated for the primary out-
the smaller group of those who complete it, we chose an ITT
come. We assumed an effect size slightly smaller than medium (f
analysis.
= 0.20, equivalent to d = 0.40), based on the results of our
We excluded the first 10 participants from the analysis
Cochrane review [59]. For α = 0.05, 80% power, and an assumed
because recent research has indicated that these may not
36% vari- ance explained by the baseline value, the required
represent the true effects of therapy adequately due to the impact
usable sample size was calculated as 130. To allow for 10%
of implementing trial procedures [64]. We repeated all analyses
dropouts, we aimed to randomise 144 participants. The protocol
with these partici- pants included to examine the impact of trial
considered that the ac- tual power may be somewhat higher
procedures in this study. Further sensitivity analyses are
because of the multiple fol- low-up time points [25, 60].
described below.
Conversely, power was probably re- duced again through the
Distributions of data were examined graphically. For
extension to an international multicentre trial, as some clustering
normally distributed continuous variables, effects of MT versus
according to site was likely to occur [61].
TAU were analysed using generalised estimating equations
(GEE) [65] with gaussian distribution, identity link function, and
Randomisation and Masking
exchangeable correlation structure (function geeglm in R
After informed consent and baseline assessment, participants
package geepack) in longitudinal linear models. Centred baseline
were allocated to conditions using a computerised randomisation
SANS scores, diagno- sis (psychotic, F2, or other), site
procedure, stratified by treatment centre and type of disorder
(Nordfjord, Rogaland, Austria or Australia) and time (1, 3 or 9
(primary diagnosis of a psychotic disorder, F2 in ICD-10, vs.
months) were included as confound- ing variables. The
oth- er). A block size of two was chosen to balance limited
interactions of these variables with treatment group were also
resources of music therapists. As block size and the stratification
included. Effects from GEE models were trans- formed into
by diagnosis were not known to clinicians, we anticipated that
effect sizes to facilitate clinical interpretation and were
guessing future allocations would be unlikely. To conceal
interpreted in accordance with existing guidelines (i.e. 0.2 –
allocation from the in- volved clinicians and the participants, a
small effect, 0.5 – medium effect, 0.8 – large effect [66, 67]).
person who had no con- tact with the participants kept the
The CGI-C scale was not normally distributed and was analysed
randomisation list and provid- ed individual allocations of
as a dichoto- mous outcome (improved vs. not improved), using
included participants, who were iden- tified by number, age, sex
a longitudinal linear model as above but with a binomial
and diagnosis, either by e-mail or by text message.
distribution and logit link function. We applied a two-sided 5%
This was a single-blind study. The person who assessed out- significance level for the primary outcome and a two-sided 1%
comes was not involved in the daily work at the participant’s for secondary outcomes to account for multiple testing.
hospi- tal unit and was therefore not aware of the assigned
Several sensitivity analyses were conducted for the primary
treatment. Suc- cess of blinding was verified by asking assessors
outcome. First, we added age and sex as additional confounders
whether or not they had inadvertently become aware of the
into the model. Second, we assessed the potential impact of
participant’s allocation.
miss- ing data in two sensitivity analyses. Where the outcome
was unob- served, we assumed either no change from the last
Data Management
observed value (last observation carried forward), or no change
A local site investigator was appointed at each clinical site to from the baseline value. Another sensitivity analysis was planned
help to administrate the data collection and to ensure data for any unusual outliers that might have been found in the
quality. This person supervised and facilitated the data collection bivariate distribution of baseline scores and follow-up scores, but
process, ensured that assessments were reliable and timely, and was not necessary since no such outliers were found. Third, we
was respon- sible for transferral of information between the analysed therapist effects (i.e. the effects that the individual
clinical site and the central office. An administrative person at person conducting the therapy might have, as opposed to the
the central office dou- ble-checked that data entry was correct therapy method) as they may be im- portant in psychotherapy
and returned to the site investigator with questions if necessary. [21]. For this purpose, we calculated a linear mixed-effects
model (function lmer in R package lme4) for
Music Therapy for Clients with Low Psychother Psychosom 2013;82:319–331 323
Motivation DOI: 10.1159/000348452
the MT group, with client and therapist entered as nested random worked well. Assessors
factors. The remaining variables were the same as in the longitu-
dinal model. The variance due to client or therapist was
calculated from that model. R version 2.11.1 was used for all
analyses.

Results

Flow of Participants through the Study

The flow of participants is shown in figure 1. Of 88
who did not consent, 44 would have had difficulties
attending regular therapy sessions as an outpatient (i.e.
these people were either outpatients or going to be
discharged soon). The target number of 144 included
participants was ex- actly reached; 72 were randomised
to MT and 72 to TAU (Nordfjord 17 + 16, Rogaland 25
+ 27, Australia 7 + 7, Austria 23 + 22). A small number
of participants missed intermediate assessments but
were available later; the number of dropouts was
reasonable overall (details in fig. 1). All those
randomised to MT received at least some sessions (fig.
1).

Baseline Characteristics
Table 1 shows the baseline characteristics of the sam-
ple. About half of the participants were female. Age
ranged from 18 to 76 years. The most frequent
diagnostic groups were psychotic disorders (42%) and
mood (affec- tive) disorders (31%; table 1). Other
primary diagnoses included neurotic, stress-related and
somatoform disor- ders (F4, n = 16), personality
disorders (F6, n = 14), sub- stance-related mental
disorders (F1, n = 6), and behav- ioural syndromes
associated with physiological distur- bances (F5, n = 3);
64 participants (44%) also had one or more secondary
diagnoses and these were almost always also non-
organic mental disorders (F1–F6). More than half of the
participants were referred due to ‘difficulties talking
about feelings or problems,’ and almost half of them
had experienced limited benefit in a previous psy-
chotherapy (table 1). At the time of referral, 3 of 4 par-
ticipants (76%; table 1) had an interest in music.
Negative symptoms at baseline were at mean 38 (SD =
22; table 1), somewhat lower compared to previous
trials of MT for schizophrenia [12, 43, 44].
None of the baseline variables showed a significant
im- balance between the two study groups (all p > 0.05;
ta- ble 1). Furthermore, the reverse propensity score also
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showed no association between probability of

assignment to MT and SANS score and therefore no
indication of any otherwise unobserved selection bias. It
can be confident- ly concluded that randomisation
became aware of the participant’s correct allocation in
8% of all cases; in another 2% assessors reported that
they had become aware of the allocated treatment but
guessed in- correctly. In no case was blinding broken
intentionally.
Treatments Received and Treatment Fidelity
At baseline, standard treatments as provided by the
mental health care institution included for most par-
ticipants some medication (antipsychotic, n = 88, 61%;
antidepressive, n = 78, 54%; mood stabilisers, n = 49,
34%; other psychotropic drugs, n = 54, 38%; other
med- ication, n = 53, 37%). In addition, 63 (44%)
received psychotherapy or other psychological
treatment, 6 (4%) electroconvulsive therapy, and 59
(41%) other non- pharmacological interventions. These
latter interven- tions included supportive talks and
counselling not oth- erwise specified, occupational
therapy, physiotherapy, sport therapy, art therapy, body
therapy, gardening, mi- lieu therapy, social work or
educational programs. At later time points, we found
similar rates with psycho- therapy/psychological
treatment, but rates of psycho- tropic drugs and other
non-pharmacological interven- tions were reduced. The
number of inpatients decreased from 102 (71%) at
baseline (table 1) to 66 (46%), 48
(33%) and 35 (24%) at 1, 3 and 9 months, respectively.
324 Psychother Psychosom 2013;82:319–331
DOI: 10.1159/000348452
Ten music therapists (Nordfjord 2, Rogaland 5,
Australia 1, Austria 2) provided MT. Eight of them were
female; all had completed specialised MT training as
was common in their country (5 bachelor, 4 master, 1
PhD or equivalent), and all had experience with
mental health care clients. Caseload within the study
varied
from 1 to 16.
Participants randomised to MT received a mean
number of 17.5 (SD = 5.5) sessions during the 3
months following randomisation (means by site:
Nordfjord 16, Rogaland 15, Australia 24, Austria 19;
thereof mean = 6.4, SD = 3.8 and median = 6 during
the first month). The mean number of sessions
received per week dropped slightly from 1.5 during
the first 30 days after randomi- sation to 1.1 during
the next 60 days. Two thirds of all participants
received at least the minimum target of 18 sessions
(fig. 1). None of those randomised to TAU re- ceived
any MT during that period. Between 3 and 9
months after randomisation, a small number of MT
sessions were provided to participants of both groups
(MT group: mean = 1.3, SD 2.8, n = 66; TAU group:
mean = 5.0, SD 5.8, n = 61).
Treatment fidelity was assessed as adherence and
competence in the use of therapeutic principles. Means
were calculated across all 1,229 MT sessions for self-
Gold et al.
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 Table 1. Baseline characteristics of 144 participants randomised to MT or TAU

Characteristic Total (n = 144) MT (n = 72) TAU (n = 72)

Age 33.99±11.33 33.81±11.03 34.17±11.70
Male 75 (52) 43 (60) 32 (44)
Setting
Inpatient 102 (71) 55 (76) 47 (65)
Day patient 6 (4) 2 (3) 4 (6)
Outpatient 36 (25) 15 (21) 21 (29)
Diagnosis
F2 Psychotic 61 (42) 31 (43) 30 (42)
F3 Affective 44 (31) 26 (36) 18 (25)
Other1 39 (27) 15 (21) 24 (33)
Type of low motivation2
Insufficient insight 35 (24) 16 (22) 19 (26)
Difficulty talking about feelings/problems 85 (59) 40 (56) 45 (63)
Does not believe in talking 10 (7) 3 (4) 7 (10)
Insufficient improvement in psychotherapy 71 (49) 40 (56) 31 (43)
Other 15 (10) 4 (6) 11 (15)
Prior interest in music 119 (83) 64 (89) 55 (76)
Scores
Negative symptoms (SANS, n = 141)3 37.67±22.28 39.71±23.98 35.54±20.32
General symptoms (BSI-18, n = 140)3 42.3±15.68 42.97±14.96 41.63±16.45
Functioning (GAF, n = 143)4 48.15±10.99 47.1±10.85 49.23±11.1
Clinical global impressions (CGI-S, n = 142)3 4.2±1.16 4.18±1.18 4.21±1.14
Activity and engagement in music (IiM A&E, n = 141)4 36.72±8.68 36.25±8.55 37.19±8.85
Social avoidance through music (IiM SA, n = 141)3 5.04±2.29 5.08±2.03 4.99±2.55
Motivation for change (URICA, n = 141)4 73.23±12.02 73.15±11.17 73.3±12.91
Motivation (SANS, n = 142)3 7.71±4.18 7.78±4.41 7.64±3.95
Self-efficacy (GSE, n = 141)4 30.59±9.42 29.89±9.47 31.3±9.39
Self-esteem (RSE, n = 140)4 30.49±10.13 30±9.58 30.99±10.71
Vitality (SF-36, n = 139)4 10.59±4.31 10.48±4.34 10.71±4.31
Affect regulation (SANS, n = 141)3 10.11±8.6 11.34±9.1 8.86±7.94
Relational competencies (IIP-32, n = 139)3 77.96±17.43 78.82±18.09 77.06±16.8
Social relationships (self; Q-LES-Q, n = 140)4 33.99±7.86 33.03±8.09 34.94±7.55
Social relationships (observer; SANS, n = 140)3 10.44±5.9 11.38±6.24 9.46±5.4

Values are means ± SD or n (%).

1
Including primary diagnoses within F1 (n = 6, 4%), F4 (n = 16, 11%), F5 (n = 3, 3%) and F6 (n = 14, 10%).
2
Overlapping categories, not mutually exclusive.
3
Negative outcome: high scores indicate poor clinical outcome.
4
Positive outcome: high scores indicate good clinical outcome.

rated adherence and competence, and across 34 ran-

observer-rated: mean = 0.78). ‘Proscribed’ principles
domly selected videotaped sessions for observer-rated
were rarely used (self-rated: mean = 0.06; observer-rat-
adherence and competence [25]. In terms of adherence,
ed: mean = 0.09). Competence ratings were high for all
‘unique and essential’ principles were commonly used
categories of principles (ranging from 2.70 to 3.07 for
(self-rated: mean = 2.74; observer-rated: mean = 2.72;
self-rated and from 2.63 to 3.08 for observer-rated com-
all on a scale from 0 to 4), as were ‘essential but not
petence). This indicates that the principles were typi-
unique’ principles (self-rated: mean = 2.11; observer-
cally applied in a competent way [17]. Contents of MT
rated: mean = 2.14). ‘Acceptable but not necessary’
sessions provided as part of this study have also been
principles were less common (self-rated: mean = 0.75;
analysed elsewhere [68, 69].
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Motivation DOI: 10.1159/000348452
Table 2. Effects of MT vs. TAU on continuous outcomes

Variable Excluding first 10 participants Including all participants

difference p value effect size difference p value effect size

between d (95% CI)2 between d (95%
groups (SE)1 CI)2 groups (SE)1

Negative symptoms (SANS)3 –12.09 (3.43) 0.000*** –0.54 (–0.84,–0.24) –8.54 (3.62) 0.018* –0.38 (–0.7,–0.06)
General symptoms (BSI-18)3 –2.57 (2.87) 0.371 –0.16 (–0.52, 0.2) –0.3 (2.94) 0.919 –0.02 (–0.39, 0.35)
Functioning (GAF)4 6.99 (2.38) 0.003** 0.64 (0.21, 1.06) 4.9 (2.35) 0.037* 0.45 (0.03, 0.86)
Clinical global impressions (CGI-S)3 –1.06 (0.25) 0.000*** –0.91 (–1.33,–0.5) –0.56 (0.31) 0.065 –0.49 (–1.01, 0.03)
Activity and engagement in music (IiM A&E) 4 –1.45 (1.65) 0.381 –0.17 (–0.54, 0.21) –1.9 (1.49) 0.201 –0.22 (–0.56, 0.12)
Social avoidance through music (IiM SA)3 –1.22 (0.45) 0.007** –0.53 (–0.92,–0.15) –0.73 (0.44) 0.095 –0.32 (–0.69, 0.06)
Motivation for change (URICA)4 –4.45 (3.15) 0.157 –0.37 (–0.88, 0.14) –2.6 (3.26) 0.426 –0.22 (–0.75, 0.32)
Motivation (SANS)3 –2.24 (1) 0.026* –0.54 (–1.01,–0.06) –1.12 (1.04) 0.281 –0.27 (–0.76, 0.22)
Self-efficacy (GSE)4 2.12 (1.96) 0.280 0.23 (–0.18, 0.63) 1.72 (2) 0.389 0.18 (–0.23, 0.6)
Self-esteem (RSE)4 0.83 (1.72) 0.631 0.08 (–0.25, 0.42) –0.09 (1.73) 0.960 –0.01 (–0.34, 0.33)
0.34 0.87) 4
(–0.18,(SF-36)
Vitality 2.87 (1.08) 0.008** 0.67 (0.18, 1.16) 1.48 (1.15) 0.196
Affect
–0.28 regulation
(–0.57, 0) (SANS)3 –3.03 (1.27) 0.017* –0.35 (–0.64,–0.06) –2.45 (1.26) 0.051
Relational competencies (IIP-32)3 –0.64 (3.45) 0.854 –0.04 (–0.42, 0.35) –1.27 (3.15) 0.687 –0.07 (–0.43, 0.28)
Social relationships (self; Q-LES-Q)4 2.91 (1.81) 0.108 0.37 (–0.08, 0.82) 2.8 (1.9) 0.140 0.36 (–0.12, 0.83)
Social relationships (observer; SANS)3 –3.16 (1.59) 0.047* –0.54 (–1.06,–0.01) –2.52 (1.43) 0.078 –0.43 (–0.9, 0.05)

All analyses ITT.

1
Estimate from GEE.
2
Effect sizes were calculated by dividing the difference between groups from this table by the common SD from table 1.
3
Negative outcome: high scores indicate poor clinical outcome; negative differences indicate effects in favour of MT.
4
Positive outcome: high scores indicate good clinical outcome; positive differences indicate effects in favour of MT.
* p < 0.05; ** p < 0.01; *** p < 0.001.

Effects of MT
cial relationships (observer-rated) and social avoidance
The GEE results for continuous outcomes are shown
through music. Effects on the remaining variables were
in table 2. The effect on the primary outcome, negative
smaller than medium (d < 0.50; fig. 2, left panel). The
symptoms, was significant in favour of MT (p < 0.001)
right panel of figure 2 shows how including the first
with an effect size in the medium range (mean
10 participants reduced the effect sizes.
difference in SANS scores 12.09, d = 0.54; table 2).
No adverse events were observed. We noted that
Among the sec- ondary outcomes, effects on
drop- out rates were lower in MT than in TAU at 1 and
functioning, clinical global impressions, social
3 months (1 month: 2 vs. 11, OR 6.24, p = 0.02; 3
avoidance through music, and vitality were all
months: 7 vs. 17, OR 2.85, p = 0.04; see numbers lost in
significant (all p < 0.01; table 2). Tendencies were
fig. 1) but not at 9 months.
found for motivation, affect regulation and social rela-
tionships (all p < 0.05; table 2). Including the first 10
Sensitivity Analyses and Therapist Effects
par- ticipants reduced the effects considerably, but the
Model diagnostic plots for the primary outcome
effect on the primary outcome remained significant (p =
showed no associations between fitted values and
0.018; table 2). The GEE model for improvement in
residu- als. The effect of MT remained significant: (1)
clinical global impressions (CGI-C) showed a tendency
when age and sex were entered as additional
in favour of MT (log odds 1.45, SE 0.58, p = 0.013).
confounders, (2) when the last observed value was
The effect on this outcome corresponded to an odds
inserted for missing data (last observation carried
ratio (OR) of 4.28 (95% CI 1.37–13.42). Figure 2 shows
forward), (3) when the baseline value was inserted for
all effect sizes and confidence intervals. It can be seen
missing data and (4) when unblinded participants were
that the largest effect (d > 0.80) was observed on
excluded. Therapist effects were negli- gible: less than
clinical global impressions, followed by medium-to-
0.1% of the variance was due to site and therapist.
large effects (0.50 < d < 0.80) on vitality, functioning,
negative symptoms, motivation, so-
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326 Psychother Psychosom 2013;82:319–331 Gold et al.

DOI: 10.1159/000348452
 Clinical global impressions
Vitality Functioning Negative symptoms
Motivation Social relationships (observer) Social avoidance through music Social relationships (self)
Affect regulation Self-efficacy General symptoms
Self-esteem Relational competencies
Activity and engagement in music
Motivation for change

–0.8–0.5–0.2 0.20.50.8 –0.8–0.5–0.2

Effect size (excl. first 10)Effect size (incl. all participant

Fig. 2. Effect sizes of MT vs. TAU. All analyses were ITT. Effect sizes and 95% CIs were reversed where necessary so that a
positive effect size always indicates an effect in favour of MT. Effect sizes excluding the first 10 participants and effect sizes
including all participants are shown.

Discussion
Our results on attendance rates are also interesting.
All participants allocated to MT received at least some
Following previous trials documenting the effects of
sessions; two thirds of them received at least 18
MT in specific serious mental disorders such as schizo-
sessions. Dropout rates as well as non-completer rates
phrenia [12], depression [13] and substance abuse [16],
were gen- erally low. This compares favourably to
this practice-based trial suggests the effectiveness of
previous studies [10, 11, 63, 70], especially when
MT in mental health care clients with low therapy
considering that this study was focused on clients with
motiva- tion. Compared to previous trials, this trial was
low motivation for therapy. The comparison of dropout
more pragmatic [31], i.e. more targeted at effectiveness
rates between groups (where dropout was defined as not
in real clinical practice than at efficacy in optimal
attending the psychiatric assessment) also suggested that
circumstanc- es. This was reflected in several
MT might help to keep clients in contact with
dimensions: inclusion criteria were broad and in line
psychiatry.
with common referral criteria for MT; procedures for
assessment and therapy were placed in a usual clinical
For Whom Does MT Work?
setting; the control condi- tion was the best usually
One of the most difficult questions in MT is which
available treatment, and out- comes were also broad.
cli- ents will benefit from it the most. Previous studies
Thus, although the question of efficacy versus
have typically focused on medical diagnosis, which has
effectiveness is not a dichotomy [31], the present study
obvi- ous advantages when communicating findings
demonstrated the effectiveness of MT in routine adult
within a medical system. Factors such as treatment
mental health care. It should be noted that this
history are only beginning to be incorporated into trial
effectiveness was found in addition to an al- ready
designs [71]. Without aiming to diminish the importance
highly developed and often intensive standard
of medical diagnoses, the present study adds other
treatment.
dimensions that previous authors have suggested may
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be of importance.

Music Therapy for Clients with Low Motivation Psych

other Psychosom 2013;82:319–331 DOI:
Namely, MT may be most important for those who do
not benefit from other approaches, for example because
they are unable to use verbal discourse therapeutically
[14, 26, 29, 30]. This is not just a ‘residual category’ but
may tell us something about the nature of the
therapeutic poten- tial of music.
How Does MT Work?
Music is a social art [39]. The social aspects of
creating music together in a therapeutic setting are
emphasised by many MT approaches, but especially so
in resource-ori- ented MT [18]. Social abilities, often
quite basic ones, are reflected in the outcomes negative
symptoms, social re- lationships and social avoidance
through music, but also more globally in clinical global
impressions, functioning, motivation and vitality. The
present study suggests that MT helps clients to improve
and develop these abilities. This is important because
impairments in the ability to build and sustain satisfying
relationships with others are at the core of many mental
health problems.
Musical elements are important in early develop-
ment of communication skills in humans [72]. The
abil- ity to communicate musically is engraved early
in our ontogenetic development and precedes the
acquisition of verbal language. The concept of
vitality [72], which can be described in musical
terms, is much more com- prehensive than emotional
expression or communica- tion alone. The potential
of music in this area is reflect- ed in the outcomes of
vitality and affect regulation, but also in some of the
broader outcomes such as negative symptoms.
The social and the developmental perspective togeth-
er may also explain why music is often felt to be
motivat- ing by clients [30]. The motivating feature of
MT is re- flected in this study in several ways. First, the
study showed effects with a population that experiences
little benefit from and motivation for other therapies.
Second, we found MT to have an effect on motivation.
Third, the delayed dropout in the MT group compared
to TAU in- dicated that MT helped to keep participants
in contact with mental health care for a longer time,
which is again likely to reflect their increased
motivation. In contrast, motivation to change showed a
small decreasing ten- dency, as might be expected at the
end of a successful therapy.
Impact of Implementing Trial Procedures
The present study confirmed previous findings that
the first participants in a trial of a complex intervention
may not reflect the typical effects of that intervention
well,
10.1159/000348452 327
due to the impact of implementing trial procedures [64].
Like the previous trials, the present study also used
expe- rienced therapists, so experience with the therapy
method does not explain the shifting effects. Instead, the
(collec- tive) experience of study therapists with
conducting ther- apy in the context of a trial is what
matters. Resource- oriented MT is characterised by a
strong emphasis on the emerging process between
therapist and client, as op- posed to fixed therapeutic
techniques. It may therefore be particularly vulnerable
to disruptions caused by trial pro- cedures, and
especially so when delivered in a one-to-one setting.
Further research will be necessary to fully under- stand
this phenomenon of ‘shifting effects’ [64], and also to
examine more precisely the number of initial partici-
pants after whom effects are likely to stabilise at the
nor- mal level.
Limitations
Since the majority of participants were inpatients at
the time of their enrolment, and most had either a
psychotic or affective disorder, the study is
generalisable primarily to similar settings and
diagnoses. The sample size in this study was sufficient
to detect an effect on a distal end point in an overall
analysis, but limited our ability to perform more
detailed analyses. Another factor that limited test power
was the clinical heterogeneity of our sample in terms of
diagnoses. Additionally, our study did not at- tempt to
control for the unspecific or ‘common’ effects of
therapeutic attention that are shared by all bona fide
mod- els of psychotherapy [21], including MT.
Resource-ori- ented MT is, however, informed by
common factors re- search in psychotherapy [17, 18,
21]. In this approach, im- portance is assigned to factors
that might be seen as coincidental in other approaches
such as credibility, au- thenticity and belief. Empirical
and theoretical research suggests that it is difficult to
separate ‘active’ from ‘non- active’ (or specific from
non-specific) ingredients in psy- chotherapy where both
types of ingredients are of psycho- logical nature [21].
Therefore, it is logically impossible to construct a
convincing ‘placebo’ therapy that contains ex- actly the
same amount of all non-specific ingredients as the
experimental intervention and none of the specific in-
gredients [73]. In another equally important line of
argu- ment, ‘usual care’ or the ‘best available
management strat- egy’ characterises a pragmatic trial
whereas ‘restricted flexibility’ and ‘placebo’ would be
more characteristic of an explanatory trial [31]. TAU (or
standard care) is used as a relevant comparison in many
contemporary trials [13, 16, 74–78]. It is generally
considered as ‘a sensible control in many settings,
(although) it is (by definition) a
328 Psychother Psychosom 2013;82:319–331
DOI: 10.1159/000348452
heterogeneous intervention’ [79] (p. 20). It was also the
most appropriate control condition in this study because
we aimed to examined effectiveness under usual
circum- stances in order to ‘help users choose between
options for care’ [31].
Implications for Practice
Mental health care clients with low motivation are
of- ten referred to MT in clinical practice [26].
Indications for MT, as for other psychotherapies, may
be related more to such ‘soft’ factors than to a particular
psychiatric diagnosis [14]. The findings from the
present study sug- gest that MT may be a valuable
addition to usual mental health care for clients where
verbal psychotherapy is of limited help. Related
findings from observational studies [68], qualitative
research [18] and clinical case studies [18, 69] suggest
that active involvement of clients is cru- cial and that
using music may facilitate the active engage- ment of
clients in a therapeutic process. The concrete form in
which music is used, therefore, needs to be cho- sen
together with the client. In addition to traditional
modalities such as improvisation and listening to music,
there is now some research to suggest that reproducing
music (i.e. singing or learning to play existing pieces)
may be both particularly common and successful with
this client group [68]. The meaning that is ascribed to
the music may also vary. It has been discussed in terms
of concepts such as analogy or metaphor [80], but other
factors such as enjoyment, engagement and meaning are
also important [81]. For the therapist, it is helpful to fo-
cus therapeutic attention on the strengths and potentials
of the clients rather than directing too much attention
towards problems and symptoms [17, 18].
Implications for Research
More research is needed to understand the mecha-
nisms of change in MT. It will be relevant to
determine how variation in treatment fidelity as
measured in the present study might affect its
effectiveness. Future stud- ies of therapies for mental
health care clients with low motivation should further
aim to include cost-effective- ness and head-to-head
comparisons, for example to cognitive behaviour
therapy or to pharmacological treatments (both of
which seem to have limited effects on negative
symptoms) [82]. Also of interest would be studies
comparing resource-oriented MT to other re- source-
oriented therapy and/or to other MT. The pres- ent
study has demonstrated that international multicen-
tre trials of psychosocial interventions are possible.
Standardization of psychosocial therapies is difficult
Gold et al.
and may not be meaningful if done too rigorously [17,
83], but in spite of differences in philosophical and
prac- tical approaches that inevitably exist across
countries, it was possible to find a common basis in this
study. This might pave the way for further international
randomised controlled trials of psychosocial
interventions in the fu- ture [84].
Acknowledgements
This study was supported by grants from the Research
Council of Norway (project No. 186025 in the Mental Health
programme and project No. 158700/V10 in the SHP
programme), the Western Norway Regional Health Authority,
Førde Health Trust, Norway, and the University of Melbourne,
Australia (Melbourne Research Office, International
Collaborative Award). Intramural support was provided by the
participating hospitals: Nordfjord Psychiatric Centre (Sogn og
Fjordane, Norway); Stavanger University Hospi- tal and Jæren
District Psychiatric Centre (Rogaland, Norway); State
Psychiatric Clinic Wagner-Jauregg Linz (Austria), and Sun-
shine Hospital Melbourne (Australia). The funding sources had
no role in the study design, in the collection, analysis and
interpreta- tion of data, in the writing of the report, and in the
decision to submit the paper for publication.
Aslaug Frafjord, Katharina Fuchs, Inger Marie Karterud,
Jason Kenner, Marianne Lygren, Sissel Næsheim and Ingrid
Petersen (in addition to co-authors T.O.H., K.M. and R.R.)
conducted MT. Stig Heskestad helped to implement the study at
Jæren DPS, Rogaland, Norway. Bruce Wampold provided
valuable insights on the analy- sis and interpretation of therapist
effects. We would like to thank all participants for their
willingness to contribute to this research, and all collaborators
for their help with collecting data and ensur- ing data quality.
Disclosure Statement
C.G., K.M., D.G., T.O.H., B.S. and R.R. are clinically trained
music therapists. L.T., T.A., L.E.A., H.R. and J.A. declare that
they have no conflicts of interest.
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