Dvorak 2011 PHD Music Therapy Support Groups For Cancer Patients and Caregivers

MUSIC THERAPY SUPPORT GROUPS FOR CANCER PATIENTS AND
CAREGIVERS
by
Abbey Lynn Dvorak
An Abstract
Of a thesis submitted in partial fulfillment
of the requirements for the Doctor of
Philosophy degree in Music
in the Graduate College of
The University of Iowa
July 2011
Thesis Supervisor: Professor Kate Gfeller

1
ABSTRACT
The purpose of this study was to examine the effect of participation in music
therapy support groups (MTSG) on physical, psychological, and social functioning of
cancer patients and caregivers. Participants were 24 cancer patients and 17 caregivers
randomly assigned to experimental (n=21) or wait-list control (n=20) groups. All
participants completed the Music Therapy Support Group Assessment Form (MTSG-AF)
beforehand to provide demographic information and music preferences. The primary
dependent variables were mood, coping, social support, and quality of life as measured
by the Profile of Mood States (POMS), the State Trait Anxiety Inventory-State (STAI-S)
and Trait (STAI-T) scales, the Personal Resource Questionnaire 85-Part 2 (PRQ85-Part
2), and the Functional Assessment of Cancer Therapy-General Form (FACT-G). These
measures, completed by all participants at baseline, midpoint, and end of three weeks,
assessed the long-term effect (three weeks) of participation in the MTSG. The MTSG
Numerical Rating Scales (MTSG-NRS) were used to evaluate the short-term effect of
each 60-minute music therapy session on mood, pain, stress, anxiety, and quality of life.
Experimental participants completed six music therapy support group sessions
over a three-week period in which several music therapy interventions were utilized:
singing, songwriting, playing instruments, movement with music, creative arts with
music, and music-assisted relaxation. The wait-list control group had the opportunity to
participate in music therapy sessions after their control period was over. In addition,
experimental group participants (MTSG) and wait-list control group participants, who
completed music therapy sessions after their control period was over, filled out the Music
Therapy Support Group Evaluation Questionnaire (MTSG-EQ).
The data from the POMS, STAI-S, STAI-T, PRQ85-Part 2, and FACT-G
questionnaires were analyzed using five individual repeated measures analysis of

variance. The MTSG group showed a significant improvement in mood (as measured by
2
the POMS) and a significant decrease in anxiety (as measured by the STAI-S) as a result
of participation in the music therapy support groups; the control group showed no
significant change over time. The MTSG also showed improvement, though non-
significant, on social support and quality of life; the control group remained stable on
these measures over time. Data from the MTSG-NRS were analyzed using a Wilcoxon
Rank Sum test. Analyses revealed that the MTSG achieved significant improvement in
mood and significant decrease in stress and anxiety throughout each 60-minute music
therapy session. Participation in the MTSG significantly decreased the perception of pain
and significantly improved quality of life in four of six sessions.

Ratings and open-ended remarks from the Music Therapy Support Group
Evaluation Questionnaire (MTSG-EQ) showed high levels of satisfaction with the
MTSG. The experimental group participants rated the overall experience as excellent
(n=9) or good (n=9), and felt they benefited from participation. The top five benefits
included: improved mood, reduced stress, provided support, improved communication,
and learned new skills. The three therapeutic interventions rated as most enjoyable were
playing instruments, relaxing with music, and listening to music; the three interventions
considered least enjoyable or least therapeutic were songwriting, drawing to music, and
singing. Participants responded that they would recommend music therapy to others in a
similar situation.
Abstract Approved: ____________________________________

Thesis Supervisor
____________________________________
Title and Department
____________________________________
Date
MUSIC THERAPY SUPPORT GROUPS FOR CANCER PATIENTS AND
CAREGIVERS
by
Abbey Lynn Dvorak
A thesis submitted in partial fulfillment

of the requirements for the Doctor of
Philosophy degree in Music
in the Graduate College of
July 2011
Thesis Supervisor: Professor Kate Gfeller

UMI Number: 3473167
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Copyright by
ABBEY LYNN DVORAK
2011
All Rights Reserved
Graduate College
Iowa City, Iowa
CERTIFICATE OF APPROVAL
_______________________
PH.D. THESIS
_______________
This is to certify that the Ph.D. thesis of
Abbey Lynn Dvorak
has been approved by the Examining Committee

for the thesis requirement for the Doctor of Philosophy
degree in Music at the July 2011 graduation.
Thesis Committee: __________________________________

Kate Gfeller, Thesis Supervisor
__________________________________
Don Coffman
__________________________________
Mary Cohen
__________________________________
Mary Adamek
__________________________________
Jacob Oleson
I would like to dedicate this dissertation to my husband, Travis.
His love, support, and understanding made my dreams a reality.
I would also like to dedicate this dissertation to my family.

Your faith, strength, and encouragement got me where I am today.
Lastly, I would like to dedicate this endeavor to loved ones no longer with us.
You continue to inspire me every day.
ii
Music takes us out of the actual, and whispers
to us dim secrets that startle our wonder as to
who we are, and for what, whence, and whereto.
Ralph Waldo Emerson
Music expresses that which cannot be put

into words and cannot remain silent.
Victor Hugo
Where words fail, music speaks.

Hans Christian Andersen
iii
ACKNOWLEDGMENTS
Many people and organizations assisted in the completion of this project; without
each and every one of them, the music therapy support groups would not have been
possible. I would like to express my appreciation to Tom and Lucy Ott and the American
Music Therapy Association for their support, encouragement, and financial assistance
through the Arthur Flagler Fultz Research Fund Award. I would also like to thank the
remarkable men and women who participated in the music therapy support groups. Your
spirit, strength, and courage continue to teach and inspire others.
My dissertation committee members are amazing people, and I would like to

express my sincere appreciation of all their time and hard work. Dr. Kate Gfeller
provided wisdom, expertise, and excellent guidance when I needed it most. She
continued to have faith in me throughout the years and believed in the importance of this
project. Her dedication to each of her students, to her research, and to the music therapy
profession is inspiring.
Dr. Mary Adamek inspired me from the very beginning of my music therapy
career and continued to challenge me to be a better teacher, clinician, and supervisor. Dr.
Don Coffman asked the right questions and provided wonderful research guidance, as did
Dr. Jacob Oleson, who supplied excellent statistical assistance. Dr. Mary Cohen offered
encouragement with my writing and motivation with coffee shop classes after the flood.
In addition, I would like to thank the members of my research team for their
invaluable assistance with patient referrals and research advice. Dr. Geraldine Jacobson,
Dr. Sonia Sugg, Dr. Nicole Nisly, and Sharon Baumler supported the research, served on
the research team, and encouraged nurses and other physicians to assist in recruitment.
Dr. Richard Shields assisted with initial research methodology design; Jean Arndt
provided referral guidance; Jane Hershberger provided expertise in participant

recruitment; Kris Sargent assisted at Mercy Medical Center; Emily Lundt provided
iv
statistical analyses and consultation; Jeanne Kolker edited and revised documentation;
Ginny Driscoll helped with the IRB process; Megan Keith transcribed the music; and
Jane Utech provided my first opportunity to work in the cancer center. Joey Walker
served as a music therapy consultant for group topics and interventions and continues to
be a role model and friend.
My special thanks go to my friends and colleagues Kirsten Nelson and Kim
Hawkins, my supervisor Diane Denneny, and managers Ken Leo and Libby Kestel at The
University of Iowa Hospitals and Clinics. Their combined support, friendship, and
encouragement helped me at a time when I needed it the most. In addition, I would like
to thank the members of the Department of Rehabilitation Therapies who supported this
research project and provided coverage when needed. Furthermore, I would like to thank
Kelly Lamb, Kim Mueller, and Phonsavanh Lovan at the Russell and Ann Gerdin
American Cancer Society Hope Lodge in Iowa City for their openness and willingness to
provide music therapy for their guests.
I would also like to express my sincere appreciation to Dr. Barbara Reuer who
first introduced me to the music therapy support group model during internship. Those
experiences and her indomitable spirit influenced my life and research. In addition, I
would like to thank Dr. Deforia Lane for sharing her experiences with me regarding
music therapy in support groups. Furthermore, I would like to express appreciation to the
music therapists working in cancer care, especially those who shared their knowledge and
expertise through published writing and personal communication.
Last, but definitely not least, I want to thank my family, both biological and those
“adopted” through the years. My gratitude for your unswerving faith, humor, optimism,
genuineness, and understanding is endless. Your support and sacrifice throughout the
years has not gone unnoticed. Although we may be apart, we are always together in
spirit. Thank you!
v
ABSTRACT
therapy support groups (MTSG) on physical, psychological, and social functioning of
cancer patients and caregivers. Participants were 24 cancer patients and 17 caregivers
randomly assigned to experimental (n=21) or wait-list control (n=20) groups. All
participants completed the Music Therapy Support Group Assessment Form (MTSG-AF)
beforehand to provide demographic information and music preferences. The primary
dependent variables were mood, coping, social support, and quality of life as measured
by the Profile of Mood States (POMS), the State Trait Anxiety Inventory-State (STAI-S)
and Trait (STAI-T) scales, the Personal Resource Questionnaire 85-Part 2 (PRQ85-Part
2), and the Functional Assessment of Cancer Therapy-General Form (FACT-G). These
measures, completed by all participants at baseline, midpoint, and end of three weeks,
assessed the long-term effect (three weeks) of participation in the MTSG. The MTSG
Numerical Rating Scales (MTSG-NRS) were used to evaluate the short-term effect of
each 60-minute music therapy session on mood, pain, stress, anxiety, and quality of life.
Experimental participants completed six music therapy support group sessions
over a three-week period in which several music therapy interventions were utilized:
singing, songwriting, playing instruments, movement with music, creative arts with
music, and music-assisted relaxation. The wait-list control group had the opportunity to
participate in music therapy sessions after their control period was over. In addition,
experimental group participants (MTSG) and wait-list control group participants, who
completed music therapy sessions after their control period was over, filled out the Music
Therapy Support Group Evaluation Questionnaire (MTSG-EQ).
questionnaires were analyzed using five individual repeated measures analysis of

variance. The MTSG group showed a significant improvement in mood (as measured by
vi
the POMS) and a significant decrease in anxiety (as measured by the STAI-S) as a result
of participation in the music therapy support groups; the control group showed no
significant change over time. The MTSG also showed improvement, though non-
significant, on social support and quality of life; the control group remained stable on
these measures over time. Data from the MTSG-NRS were analyzed using a Wilcoxon
Rank Sum test. Analyses revealed that the MTSG achieved significant improvement in
mood and significant decrease in stress and anxiety throughout each 60-minute music
therapy session. Participation in the MTSG significantly decreased the perception of pain
and significantly improved quality of life in four of six sessions.

Ratings and open-ended remarks from the Music Therapy Support Group
Evaluation Questionnaire (MTSG-EQ) showed high levels of satisfaction with the
MTSG. The experimental group participants rated the overall experience as excellent
(n=9) or good (n=9), and felt they benefited from participation. The top five benefits
included: improved mood, reduced stress, provided support, improved communication,
and learned new skills. The three therapeutic interventions rated as most enjoyable were
playing instruments, relaxing with music, and listening to music; the three interventions
considered least enjoyable or least therapeutic were songwriting, drawing to music, and
singing. Participants responded that they would recommend music therapy to others in a
similar situation.
vii
TABLE OF CONTENTS
LIST OF TABLES............................................................................................................. xi
LIST OF FIGURES ......................................................................................................... xiii
CHAPTER
I. INTRODUCTION ............................................................................................1
Biopsychosocial Model of Health and Illness ..................................................3
Physical Effects of Cancer.........................................................................3
Psychological Effects of Cancer................................................................4
Social Effects of Cancer ............................................................................7
Quality of Life in Cancer Survival ...................................................................8
Support Group Interventions ..........................................................................10
Music Therapy and the Biopsychosocial Model ............................................11
Music Therapy.........................................................................................11
Music Therapy and Cancer Care .............................................................12
Need for the Study ..........................................................................................14
Purpose of the Study.......................................................................................15
Statement of the Problem ...............................................................................15
Research Variables .........................................................................................16
Research Hypotheses ......................................................................................17
Definition of Terms ........................................................................................19
II. REVIEW OF LITERATURE .........................................................................21
Introduction ....................................................................................................21
Music Therapy and Physical Needs................................................................21
Pain ..........................................................................................................22
Immune Response ...................................................................................28
Nausea and Fatigue..................................................................................30
Music Therapy and Pyschological Needs.......................................................31
Coping .....................................................................................................32
Mood........................................................................................................39
Quality of Life .........................................................................................41
Music Therapy and Social Needs ...................................................................43
Social Support .........................................................................................44
Support Groups in Cancer Care...............................................................46
Music Therapy Support Groups ..............................................................48
Music Therapy and Support for Caregivers ............................................50
Summary of Findings Related to the Design of the Study .............................53
III. METHODOLOGY .........................................................................................55
Introduction ....................................................................................................55
Research Questions.........................................................................................56
Research Hypotheses ......................................................................................57
Participants .....................................................................................................59
Eligibility Criteria....................................................................................59
Exclusion Criteria....................................................................................60
viii
Sampling Design .....................................................................................60
Power and Effect Size .............................................................................61
Instrumentation ...............................................................................................61
State Trait Anxiety Inventory (STAI-S, STAI-T) ......................................62
Profile of Mood States (POMS)...............................................................63
Functional Assessment of Cancer Therapy-General (FACT-G) .............64
Personal Resource Questionnaire 85-Part 2 (PRQ85-Part 2)................65
Music Therapy Support Group Numerical Ratings Scales (MTSG-
NRS).........................................................................................................67
Music Therapy Support Group Assessment Form (MTSG-AF) .............68
Music Therapy Support Group Evaluation Questionnaire (MTSG-
EQ) ..........................................................................................................69
Procedures ......................................................................................................69
Pre-Treatment: Recruitment and Informed Consent ..............................70
During Treatment: Methods and Testing ...............................................71
Post-Treatment: Compensation and Follow-Up.....................................76
Data Analyses .................................................................................................76
Missing Values ........................................................................................76
Statistical Analysis ..................................................................................76
Limitations and Delimitations ........................................................................78
Delimitations ...........................................................................................78
Limitations...............................................................................................79
IV. RESULTS .......................................................................................................81
Music Therapy Support Group Assessment Form (MTSG-AF) ....................81
Data Analysis..................................................................................................91
Profile of Mood States (POMS)...............................................................93
State Trait Anxiety Inventory-State Anxiety (STAI-S) .............................97
State Trait Anxiety Inventory-Trait Anxiety (STAI-T) ...........................101
Personal Resource Questionnaire 85-Part 2 (PRQ85-Part 2)..............104
Functional Assessment of Cancer Therapy-General (FACT-G) ...........107
Music Therapy Support Group Numerical Ratings Scales (MTSG-
NRS).......................................................................................................111
Additional Data: Wait-List Control Group...........................................115
Music Therapy Support Group Evaluation Questionnaire (MTSG-EQ)......116
Summary.......................................................................................................123
V. SUMMARY, DISCUSSION, CONCLUSIONS, AND
RECOMMENDATIONS..............................................................................125
Summary.......................................................................................................125
Discussion.....................................................................................................127
Psychological Outcomes of MTSG Participation..................................128
Physical Outcomes of MTSG Participation ..........................................132
Social Outcomes of MTSG Participation ..............................................133
Quality of Life Outcomes in MTSG Participation ................................135
Importance of a Variety of Interventions ..............................................137
Awareness of Group Process in MTSG.................................................140
Conclusions ..................................................................................................141
Clinical Implications.....................................................................................143
Recommendations for Further Research ......................................................145
ix
APPENDIX A PERSONAL RESOURCE QUESTIONNAIRE 85 PART 2 (PRQ85-
PART 2) ........................................................................................................147
APPENDIX B MUSIC THERAPY SUPPORT GROUP NUMERICAL RATING
SCALES (MTSG-NRS) ..................................................................................150
APPENDIX C MUSIC THERAPY SUPPORT GROUP ASSESSMENT FORM
(MTSG-AF) ..................................................................................................152
APPENDIX D MUSIC THERAPY SUPPORT GROUP EVALUATION
QUESTIONNAIRE (MTSG-EQ).................................................................157
APPENDIX E UNIVERSITY OF IOWA INFORMED CONSENT .............................161
APPENDIX F MERCY MEDICAL CENTER INFORMED CONSENT .....................167
APPENDIX G RECRUITMENT MATERIALS ...........................................................172
APPENDIX H MTSG GROUP PROTOCOL AND INTERVENTION

DESCRIPTION ............................................................................................180
APPENDIX I PARTICIPANT IDENTIFIED FAVORITE SONGS AND
ARTISTS FROM THE MTSG-AF ..............................................................195
APPENDIX J PARTICIPANT COMMENTS AND EXPECTATIONS FROM
THE MTSG-AF ............................................................................................198
APPENDIX K PARTICIPANT COMMENTS FROM THE MTSG-EQ ......................202
APPENDIX L GROUP MATERIALS...........................................................................215
APPENDIX M LETTERS OF PERMISSION TO CONDUCT RESEARCH...............227
APPENDIX N LETTERS OF PERMISSION FOR GROUP MATERIALS.................235
APPENDIX O LETTERS OF PERMISSION FOR MEASUREMENT FORMS .........239
REFERENCES ................................................................................................................246
x
LIST OF TABLES
Table
1. Number of Participants in Experimental Groups by Subgroup ................................72
2. Demographic Information at Baseline by Treatment Group (N=41)........................82
3. Age of Participants at Baseline by Treatment Group (N=41)...................................83
4. Health Status and Religious Affiliation at Baseline by Treatment Group
(N=41).......................................................................................................................84
5. Patient Type and Stage of Cancer at Baseline by Treatment Group (n=24) ............85
6. Patient Current and Past Cancer Treatments by Treatment Group (n=24)...............86

7. Caregiver Relationship with Cancer Patient by Treatment Group (n=17) ...............87
8. Previous Music Experiences of All Study Participants (N=41)................................88
9. Preferred Music Styles of All Study Participants (N=41) ........................................90
10. Participant Pre-Session Interest in Music Therapy Interventions (N=41) ................91
11. Descriptive Statistics of the POMS by Time (N=41)................................................93
12. Descriptive Statistics of the POMS by Patient and Caregiver for the
Experimental Group (n=21)......................................................................................94
13. Overall p-Values for Effects of the POMS (N=41) ..................................................95
14. Follow-Up p-Values for POMS Differences of Subgroup Means (N=41) ...............96
15. Descriptive Statistics of the STAI-S by Time (N=41)...............................................97
16. Descriptive Statistics of the STAI-S by Patient and Caregiver for
Experimental Group (n=21)......................................................................................98
17. Overall p-Values for Effects of the STAI-S (N=41)..................................................99
18. Follow-Up p-Values for STAI-S Differences of Subgroup Means (N=41).............100
19. Descriptive Statistics of the STAI-T by Time (N=41).............................................101
20. Descriptive Statistics of the STAI-T by Patient and Caregiver for
Experimental Group (n=21)....................................................................................102
21. Overall p-Values for Effects of the STAI-T (N=41)................................................103
22. Descriptive Statistics of the PRQ85-Part 2 by Time (N=41) .................................104
xi
23. Descriptive Statistics of the PRQ85-Part 2 by Patient and Caregiver for
24. Overall p-Values for Effects of the PRQ85-Part 2 (N=41)....................................106
25. Follow-Up p-Values for PRQ85-Part 2 Differences of Subgroup Means
(N=41).....................................................................................................................107
26. Descriptive Statistics of the FACT-G by Time (N=41) ..........................................108
27. Descriptive Statistics of the FACT-G by Patient and Caregiver for
28. Overall p-Values for Effects of the FACT-G (N=41) .............................................109
29. Experimental Group Wilcoxon Signed Rank for Anxiety and Stress MTSG-
NRS (n=21) .............................................................................................................112
30. Experimental Group Wilcoxon Signed Rank for Pain MTSG-NRS (n=21)............113
31. Experimental Group Wilcoxon Signed Rank for Mood and Quality of Life
MTSG-NRS (n=21)..................................................................................................114
32. Wait-List Control Group Wilcoxon Signed Rank for Anxiety, Stress, Pain,
Mood, and Quality of Life MTSG-NRS (n=21) ......................................................115
33. Experimental Group Participants Overall Experience with the MTSG (n=18)......117
34. Perception of Benefit from Participation in Music Therapy by Treatment
Group (n=31) ..........................................................................................................117
35. Experimental Group Perceived Benefit of MTSG Participation (n=18) ................118
36. Control Group Perceived Benefit of Music Therapy Session Participation
(n=13) .....................................................................................................................119
37. Experimental Group Most Enjoyable/Most Therapeutic Parts of the MTSG
(n=18) .....................................................................................................................120
38. Experimental Group Least Enjoyable/Least Therapeutic Parts of the MTSG
(n=18) .....................................................................................................................121
39. Recommendation of Music Therapy to Others by Treatment Group (n=31) .........121
40. Primary Themes Generated by Written Comments from the MTSG-EQ ..............122
xii
LIST OF FIGURES
Figure
1. MTSG Recruitment, Testing, and Measurement Protocol .......................................75
2. POMS Subgroup Means Over Time by Group (N=41) ............................................95
3. STAI-S Subgroup Means Over Time by Group (N=41)............................................99
4. STAI-T Subgroup Means Over Time by Group (N=41) .........................................103
5. PRQ85-Part 2 Subgroup Means Over Time by Group (N=41)..............................106
6. FACT-G Subgroup Means Over Time by Group (N=41).......................................110
xiii
1
CHAPTER I
INTRODUCTION
Cancer describes more than 100 diseases in which abnormal cells divide
uncontrollably, invade healthy tissue, and spread throughout the body (National Cancer
Institute [NCI], 2008). Cancer begins when these abnormal cells do not follow the
normal progression of division, maturation, and death; the immune system, which
typically repairs or destroys these cells, functions inappropriately (Mackay, Jemal, Lee,
& Parkin, 2006).
Anyone may develop cancer, depending on external (tobacco, radiation,

chemicals, infectious organisms) and internal (mutations, hormones, immune conditions)
factors (American Cancer Society [ACS], 2010). Men have a one in two lifetime risk of
developing cancer and women have a one in three risk, with a 17.7% probability of
developing cancer before age 65 (Mackay et al., 2006). Risk increases as people age,
with about 78% of new cases occurring in people 55 and older (ACS, 2010).
Furthermore, cancer is now the number two leading cause of mortality, accounting for
nearly one out of four deaths (ACS, 2010).
In the United States, the National Cancer Institute estimated that 1,529,560 people
were diagnosed and 569,490 died of cancer in 2010 (Howlader et al., 2011) with
prostate/breast, lung, and colorectal cancers the most common types diagnosed (Ferlay et
al., 2010). Cancer is not limited to the United States, but is a worldwide problem. The
International Agency for Research on Cancer, part of the World Health Organization,
estimated that 12.7 million people worldwide are diagnosed and more than 7.6 million
die from cancer each year (Ferlay et al., 2010).
Even though the statistics may be daunting, the National Cancer Institute (NCI)
and Center for Disease Control (CDC) estimated that the number of cancer survivors is
growing in the United States from three million people in 1971, to 9.8 million in 2001, to
11.7 million in 2007 (approximately 3.9% of the population) (Rowland, 2011). Some
2
survivors may be cancer free and others currently undergoing treatment (Howlader,
2011). Over 66% of all Americans diagnosed with cancer are expected to be alive at
least five years from initial diagnosis, with 25 million people worldwide surviving for
years afterward (Zebrack & Cella, 2005). People are surviving with cancer longer,
perhaps due to better detection, improved diagnostic methods, advances in treatments,
and better follow-up (Rowland, 2011).
As a result of these advances, cancer is curable for some, and a chronic condition
for others (Rowland, 2011). Treatments may include surgery, radiation, chemotherapy,
hormone therapy, and immunotherapy (Stephens & Aigner, 2009). The treatments
depend on the initial site of diagnosis and stage of the disease, with early stages involving
one tumor, while more advanced stages involve larger tumors, lymph nodes, or cancer
spreading (metastasizing) to other parts of the body (Mackay et al., 2006). The National
Institute of Health estimates overall costs associated with cancer at $263.8 billion for
treatments (direct costs) and lost productivity (indirect costs) (ACS, 2010).
Although cancer treatments extend life expectancy, the treatments often leave
patients with deficits. These deficits may have long-term physical, psychosocial,
medical, vocational, and economic effects on patients, families, health providers, and
government institutions (Bradley, Given, Given, & Kozachik, 2005). Because survival
rates are increasing and people are living longer with cancer, it is necessary to address the
impact of cancer on physical and psychosocial needs of survivors in order to improve
quality of life (Rowland, 2011).
The purpose of this study is to investigate the use of music therapy in support
groups for cancer patients and caregivers (family members or friends who provide care
for a person who is ill) in order to improve physical and psychosocial well-being. The
following sections will address physical, psychological, and social needs of cancer
survivors and demonstrate how music therapy may provide support using a
biopsychosocial model of health and illness.
3
Biopsychosocial Model of Health and Illness

Cancer affects physical, psychological, and social functioning of cancer patients
and families (Bradley, Given, Given, & Kozachik, 2005); thus cancer, and cancer
interventions may successfully fit within a biopsychosocial model of health and illness
(Sarafino, 2006). The biopsychosocial model was first proposed by George Engel (1977)
as a challenge to the traditional biomedical model of healthcare. This model of health
and illness addresses biological (function, structure, and physical characteristics),
psychological (cognition, emotions, and motivation), and social (values, family, and
community influences) factors that interact with one another, and affect overall health
(Sarafino, 2006).
For patients with cancer, the diagnosis and accompanying treatments and side
effects are likely to cause physical, psychological, and social distress that decrease well-
being and quality of life. Common physical problems include pain, stress, nausea,
dyspnea, fatigue, neuropathy, disability, and depressed immune functioning.
Psychological distress may include changes in mood, depression, anxiety, and quality of
life (Montazeri, 2008; Osborn, Demoncada, & Feuerstein, 2006). Social factors, such as
social support, increased isolation, and decreased activities, also affect patient
functioning (Cohen & Wills, 1985; Spiegel, 2011; Uchino, 2004).
Physical Effects of Cancer
Cancer is a physically stressful event, with acute or chronic physical problems
and disability occurring as a result of the disease as well as treatment (Petrie & Reynolds,
2007). Stress affects physical functioning of both cancer patients and caregivers, and
exacerbates already distressing symptoms (Uchino, 2004). Stress is a normal and natural
phenomenon, with both physical and psychological components that help people respond
to circumstances in which they perceive a discrepancy between the demands of a stressor

and their own biological, psychological, or social resources (Lazarus, Folkman, Gruen, &
DeLongis, 1986; Sarafino, 2006). However, over time, the chronic, cumulative stress
4
associated with cancer may lead to immune, endocrine, and autonomic nervous system
abnormalities (Uchino, 2004). These abnormalities may lead to increased cortisol,
cytokine, or norepinephrine levels associated with decreased resistance and increased
tumor growth (Spiegel, 2011); these changes are harmful, as cancer patients may already
suffer from immune system suppression side effects of chemotherapy drugs and radiation
therapy (Bauer-Wu & Post-White, 2005). However, interventions that help manage
stress and/or mood may also modulate immunity (Keller, Schleifer, Bartlett, Shiflett, &
Rameshwar, 2000).
A normal response to acute stress, also known as the “fight or flight” response,
involves a primary (evaluation of the stressor as positive or negative) and secondary
(assessment of resources to cope with stressor) appraisal (Lazarus, 1993). Based on this
appraisal of the situation, sympathetic nervous system arousal (increased heart rate, blood
pressure, respiration rate, and corticosteroid and/or catecholamine release) occurs, or the
parasympathetic nervous system brings the body back to homeostasis (Sarafino, 2006;
Scartelli, 1989). In accordance with this physiological arousal, Selye (1956) proposed a
General Adaptation Syndrome response in which three phases occur: (a) an initial alarm
reaction, (b) recovery, resistance or adaptation to the stressor, and in the case of chronic
stress, (c) exhaustion, depletion of energy, and in severe cases, death. However,
emotional and social support interventions appear to have a positive influence on this
stress response, with increased evidence that psychosocial support improves quality of
life (Spiegel, 2011).
Psychological Effects of Cancer
Life-threatening diseases, such as cancer, are devastating and require survivors to
make psychological, social, and behavioral adjustments (Gfeller, 2008). These
adjustments are not easy, nor is coping with feelings of fear, stress, guilt, worry, anxiety,
depression and loss of control associated with months and years of treatment and follow-
up (Adler & Page, 2008). Coping, in the context of health care, is a dynamic and
5
multidimensional process, which, for the purposes of this thesis will be defined as a
“behavioral or psychological process that is activated following threat for the purpose of
mitigating or eliminating threat” (Lazarus, 1966, p. 28). Coping may change over time,
and coping techniques may vary according to the threat and appraisal of the situation
(Lazarus, 1993). Several theoretical models differentiate between types of coping
strategies.
Lazarus and Folkman (1984) identify coping techniques as either problem-
focused or emotion-focused. Problem-focused coping involves directly altering the stress
by changing the environment, expanding resources, or reducing demands of the stressful

situation; emotion-focused coping aims at controlling the emotional response through
changes in behavioral or cognitive approaches (Lazarus & Folkman, 1984; Sarafino,
2006). Other models also differentiate between attempts to change the stressor or evade
the situation, using terms such as “approach” and “avoidance” coping strategies or
“active” and “passive” responses (Roesch & Weiner, 2001; Sarafino, 2006).
Because coping is complex, may change over time, and the approach utilized may
vary according to appraisal of the situation, measurement of the coping process is varied.
Researchers may measure changes in coping styles, psychological adjustment, or specific
outcomes related to perception or cognitive appraisal (e.g., perceived anxiety, stress,
pain) (Fawzy, Fawzy, & Canada, 2001; Folkman & Lazarus, 1994; Lazarus, 1999).
Psychosocial interventions may alter coping behaviors associated with pain, stress,
anxiety, and other unpleasant emotional experiences, which contribute to psychological
distress, a significant and ongoing problem with many cancer patients (Carlson et al.,
2004).
The National Comprehensive Cancer Network, as part of the NCCN Guidelines in
Oncology, defines distress as a “multifactorial unpleasant emotional experience of a

psychological (cognitive, behavioral, emotional), social, and/or spiritual nature that may
interfere with the ability to cope effectively with cancer, its physical symptoms and its
6
treatment” (NCCN, 2010, p. 6). The NCCN guidelines view distress along a continuum,
“ranging from common normal feelings of vulnerability, sadness, and fears to problems
that can become disabling, such as depression, anxiety, panic, social isolation, and
existential and spiritual crisis” (NCCN, 2010, p. 6).
The most frequently reported types of emotional distress resulting from cancer
diagnosis and treatment are anxiety and depression (Maly, Umezawa, Leake, & Silliman,
2005). These emotions are associated with impaired quality of life (Frick, Tyroller, &
Panzer, 2007), with depression connected to higher ratings of pain, more severe fatigue,
and poorer social, physical and functional well-being (Bloch et al., 2007). Studies
suggest that approximately 25% of cancer patients experience significant depression
(Carr et al., 2002) and 38% (Mehnert & Koch, 2008) to 48% experience significant
anxiety (Stark et al., 2002).
Many times the impact of cancer on the patient’s family is equal to or more
devastating than it is for the patient (Grunfeld et al., 2004). In a study by Greenburg
(2007), 200 caregivers of advanced-stage cancer patients completed interviews, with 13%
of caregivers meeting criteria for a psychiatric disorder (depression and anxiety disorder).
Family caregivers reported clinically significant levels of mood disturbance with distress
levels comparable to or higher than those of the cancer patient (Steinglass, 2000).
Caregivers also reported lower physical and psychological well-being (Greenburg, 2007),
which in turn affects the adjustment of the individual with cancer (Bloom, 2000).
Compromised mental health for patients and caregivers may persist for at least
three years after diagnoses (Greenburg, 2007) with spouses, typically the caregiver,
experiencing psychological distress that persists over a longer period of time (Maly et al.,
2005). Caregivers may also suffer from feelings of fear, loss, guilt, stress, worry, panic,
anxiety, sadness, alienation, helplessness, loss of socialization, and increased marital

conflicts (Greenburg, 2007). These feelings, along with depressive symptoms, affect
both patients and caregivers throughout all stages of cancer care and may result from
7
treatment disappointments, complications of therapy, and progressive illness (Lorenz &

Lynn, 2006).
Social Effects of Cancer
Although physical and psychological effects of cancer are disturbing to both
cancer patients and caregivers, social support may serve as a buffer to reduce distress
(Delongis, Folkman, & Lazarus, 1988). Social support is a complex process involving
structural and functional factors (Uchino, 2004). Early theorists identified social support
as being part of a mutual network (structure) in which supportive messages are shared
(Cobb, 1976), while others described social support in a biological sense, as a survival
mechanism (function) that modifies resistance to disease (Cassell, 1976). The structure
of social support involves the existence and interconnection of social ties and roles, as
well as the size of the social network, amount of contact, type of relationship, density
(interconnection between people), centrality (links with others), multiplexity (multiple
role relationship), reciprocity (exchange between people), and strength of ties (voluntary
or obligatory relationships) (Uchino, 2004).
For example, in a study of social connections and cancer incidence, mortality, and
prognosis, researchers followed 6,848 adults for 17 years. Women who had smaller
networks and felt isolated had a significantly increased risk of dying from cancer of all
types; men with fewer social connections showed significantly poorer cancer survival
rates (Reynolds & Kaplan, 1990). Overall, people in large networks reported better
physical and social functioning with more opportunities for support (Cohen & Wills,
1985).
In addition to the structure of the support network, social support may also refer
to the “psychological and material resources intended to benefit an individual’s ability to
cope with stress” (Cohen, 2004, p. 676). The types of resources offered might be:
emotional (caring expressions), informational (advice and guidance), tangible (material
aid), and belonging (shared social activities or sense of belonging) (Uchino, 2004).
8
Family members can create a positive emotional climate to help patients

successfully regulate emotional, physiological and immunological functioning during
cancer treatment by buffering the effects of stress (Cohen & Wills, 1985). Partners,
children, and other family members may provide key emotional or informational support
to alleviate depression and anxiety, with partners generally considered the most important
source of support for patients diagnosed with cancer (Grunfeld et al., 2004). In a study
by Maly et al. (2005), support from partners and adjustment of both partners and children
independently predicted less depression and anxiety among study participants. In
addition, having a significant other in their life to listen to concerns or worries predicted
fewer depressive symptoms and less anxiety (Maly et al., 2005).
Family support is not only important for psychological reasons. Married
individuals diagnosed with late stage cancer may live longer than individuals who are
single, divorced, or widowed (Lai et al., 1999). Poor social and family relationships may
predict higher rates of disease progression and death for cancer patients (Funch &
Marshall, 1983; Weihs & Reiss, 2000). Chronic illness, such as living with cancer, may
put a strain on existing social support networks, with spouses or primary caregivers
bearing the burden of stressors (Petrie & Reynolds, 2007). Caregivers may neglect their
own health, put themselves at risk for stress-related illnesses, neglect their own support
networks, and experience a decline in quality of life (Grunfeld et al., 2004).
Quality of Life in Cancer Survival
Both cancer patients and caregivers may feel social, physical, vocational,
psychological, and economic distress as a result of cancer and its treatment (Greenburg,
2007). The distress associated with cancer impacts quality of life (QOL), an important
factor to consider when evaluating healthcare outcomes (Ferrans, 2005). However,
quality of life is a subjective viewpoint of overall well-being, and may be based on

expectations, experiences, perceptions, values, and judgments, and is influenced by
9
physical, psychological, social, economic, and political environments (Revicki et al.,

2000).
An important distinction must be made between quality of life and health-related
quality of life. Quality of life involves all aspects of life, while health-related quality of
life is specific to the impact of disease and treatment. Although definitions vary, health-
related quality of life may be defined as the “subjective assessment of the impact of
disease and its treatments across the physical, psychological, social and somatic domains
of functioning and well-being” (Revicki et al., 2000, p. 888). Diminished health-related
quality of life of cancer patients may result from changes in physical functioning due to
treatments and surgery; somatic functioning due to increased pain, nausea, or fatigue;
psychological functioning due to increased stress, depression, and anxiety; and social
functioning due to increased isolation and changes in support networks (Sarafino, 2006;
Spiegel, 2011).
However, patients are not the only ones affected by cancer. Cancer affects the
quality of life of the whole family, not just the person with the disease (NCI, 2003). In
fact, the Office of Cancer Survivorship in the National Institute of Health considers any
individual a cancer survivor “from the time of diagnosis through the balance of his or her
life” with friends and family members included in the definition (Altekruse et al., 2010,
p. 1).
With each person diagnosed, millions of family members are affected. The
National Family Caregivers Association (NFCA, 2000) estimated that more than 25% of
the U.S. population provided care to a family member or friend with chronic or terminal
illness, while an AARP Caregiver Identification Study (2001) estimated the number
closer to one-third of the population, or approximately 65 million people. A survey of
1480 caregivers in 2009 indicated that 7% provided unpaid care for a family member
with cancer, with cancer considered a “high burden” situation (“Caregiving in the U.S,”
2009). This same survey demonstrated that caregivers in high burden situations were
10
twice as likely to report their own health declined as a result of caregiving than those
caregivers in medium or low burden situations.
Support Group Interventions
Both cancer patients and caregivers may have unmet physical, psychological, and
social needs, but caregivers may overlook their own needs as the medical needs of the
cancer patients take precedence (Adler & Page, 2008). Because the inter-relationship of
cancer patients and caregivers influence physiological and psychological well-being of
both individuals, supportive interventions are needed for both parties. One way to
provide support, decrease isolation, manage stress, and improve coping is the use of
psychosocial groups, such as support groups (Fawzy, Fawzy, & Canada, 2001).
In response to the need to decrease isolation and improve social support, support
groups provide opportunities for individuals to interact with others who have gone
through a similar experience and can relate to the cancer patient or caregiver (Bloom,
2000). Participants gain and give emotional support regarding similar cancer
experiences, and use those experiences to buffer fear and anxiety, share thoughts and
feelings, expand social networks, and improve coping resources (NCI, 2008; Weis,
2003). In a study regarding support group interventions for women following a breast
cancer diagnosis, Helgeson, Cohen, Schulz, and Yasko (1999) found individuals with low
emotional support in their own networks benefited most from peer support interventions.
One approach that can help maximize the potential social support of family
members is through multiple family (patient and caregiver) support groups. Supportive
approaches focusing on both patients and caregivers maximize well-being and ameliorate
many debilitating consequences of living with a cancer diagnosis regardless of cancer
stage (Lorenz & Lynn, 2006). Working with the family instead of separating members
allows the family to mobilize resources, prevent isolation from natural social supports,
reduce the impact of chronic illness on family life, and create better understanding
between family members (Steinglass, 2000). The establishment of a community of
11
families with similar experiences also allows for multiple perspectives on illness and
management, collaborative problem-solving across families, and realization that family
reactions, feelings, and struggles are normal (Steinglass, 2000).
Music therapy is a multi-faceted treatment modality that may positively affect
physical, psychological, and social functioning of cancer patients and caregivers, and
may serve as an essential component of the biopsychosocial model of health and illness
(Gfeller, 2008). Music therapy may be a positive form of social support for both patients
and caregivers by using the components of music and a therapeutic relationship to
improve health outcomes (Dileo & Bradt, 2005). It is the use of music therapy as social
support for patients and caregivers that is the focus of this investigation.
Music Therapy and the Biopsychosocial Model
Music Therapy
Music Therapy is an established healthcare profession that uses music to address
physical, emotional, social, cognitive, and spiritual needs of people of all ages (American
Music Therapy Association [AMTA], 2010). Music therapists employ a variety of
clinical music-based techniques to improve the quality of life for people with a variety of
illnesses or disabilities, and use music and music-based interventions based on patient
needs and preferences. The World Federation of Music Therapy specifically defines
music therapy in the following statement:
Music Therapy is the use of music and/or its musical elements (sound, rhythm,
melody and harmony) by a qualified music therapist, with a client or group, in a
process designed to facilitate and promote communication, relationships, learning,
mobilization, expression, organization and other relevant therapeutic objectives in
order to meet physical, emotional, mental, social and cognitive needs. Music
Therapy aims to develop potentials and/or restore functions of the individual so
that he or she can achieve better intrapersonal and/or interpersonal integration
and, consequently, a better quality of life, through prevention, rehabilitation or
treatment. (WFMT, 2011, p.1)
Early music therapy pioneers, such as Gaston (1968), acknowledged the power of
music when used in a group setting, allowing participants to socialize, connect, and share
experiences with others. As indicated in the definition above, music therapists use the
12
inherent physical, psychological, and social components of music to improve therapeutic

outcomes. Because music is used and enjoyed by all ages and cultures, music therapy
can accommodate a broad range of patient needs and responses (Gfeller, 2008). For
example, Merriam (1964) identified several ways that people use music in society,
including music as an influence on physical response, a type of communication, a form of
emotional expression, as symbolic representation, and as a way to enforce social norms.
In addition, music may be used to validate social institutions and religious rituals,
contribute to the continuity and stability of culture, contribute to the integration of
society, provide aesthetic enjoyment, and provide entertainment (Merriam, 1964).

Music, because it affects people physically, emotionally, and socially, is a unique
treatment approach that may be used successfully in a biopsychosocial model in cancer
care.
Music Therapy and Cancer Care
Prior research on therapeutic uses of music and clinical music therapy identify
benefits to cancer patients in meeting physical, psychological, and social needs.
Therapeutic uses of music may include receptive (music listening) and interactive
(singing, playing, composing, moving) interventions when addressing goal areas (Burns
et al., 2008). Following the biopsychosocial model, music may affect physical
functioning of cancer patients, including perceived pain (Beck, 1991; Flaugher, 2002;
Kerkvlier, 1990; Krout, 2003a; Magill, 2001; Siedliecki & Good, 2006), stress (Pelletier,
2004), nausea and emesis (Ezzone, Baker, Rosselet, & Terepka, 1998; Standley, 1992),
fatigue (Boldt, 1996), perception of disability (Siedlecki & Good, 2006), and immune
system functioning (Burns, Harbuz, Hucklebridge, & Bunt, 2001).
Prior research also examined the effects of music on psychological distress,
associated with mood (Burns, 2001; Waldon, 2001), depression (Stordahl, 2009), anxiety
(Bulfone, Quattrin, Zanotti, Regattin, & Brusaferro, 2009; Clark et al., 2006; Haun,
Mainous, & Looney, 2001; Horne-Thompson & Grocke, 2008; Nilsson, 2008; Smolen,
13
Topp, & Singer, 2002), and improved quality of life (Burns, 2001; Furioso, 2002; Hanser
et al., 2006; Hilliard, 2003). Some studies focused on the use of music to reduce
emotional distress associated with particular treatments associated with cancer, such as
surgery (Walworth, Rumana, Nguyen, & Jarred, 2008), breast biopsy (Haun, Mainous, &
Looney, 2001), radiation (Clark et al., 2006; Smith, Casey, Johnson, Gwede, & Riggin,
2001), chemotherapy (Ferrer, 2007; Weber, Nuessler, & Wilmanns, 1997), bone marrow
biopsy and aspiration (Shabanloie, Golchin, Esfahani, Dolatkhah, & Rasoulian, 2010),
and stem cell transplantation (Cassileth, Vickers, & Magill, 2003).
Research and clinical reports indicate that music therapy may focus on various
social factors to support patients and caregivers. Social factors have included changes in
identity, body image, improved mood, group cohesiveness, family role performance, and
improved quality of life. Therapy interventions have included group improvisation,
community singing, music psychotherapy, and other forms of active music making
(Allen, 2010; Burns et al., 2001; Daykin, McClean, & Bunt, 2007; Furioso, 2002; Rykov,
2008; Waldon, 2001; Young, 2009). In addition, a few music therapy studies in cancer
care involved social outcomes in groups with family members, including caregivers and
children. These include: palliative care experiences with music to connect with family
members (O’Callaghan, 1996; O’Callaghan & McDermott, 2004), and bereavement
support groups for children and adolescents (Dalton & Krout, 2005; Krout, 2005;
McFerran, Roberts, & O’Grady, 2010).
These studies suggest that participation in music therapy support groups can be
beneficial to cancer patients, though studies explicitly including caregivers are sparse
within the music therapy literature. Extant studies of group music therapy have not
directly assessed benefit to caregivers, who have physical, psychological and social needs
of their own, but may have difficulty finding resources to provide support for their loved
ones and themselves. The support of caregivers is essential to patient adjustment to
14
illness, and supportive interventions involving both cancer patients and caregivers are
warranted.
Need for the Study
A growing body of literature indicates that music therapy may improve outcomes
for cancer patients and caregivers in physical, psychological, and social functioning.
Although the effects of music on physical and psychological factors such as mood,
anxiety, pain, and quality of life are frequently studied in larger, quantitative, randomized
trials, the influence of social support in music therapy group interventions needs further
scrutiny. Previous studies of music therapy groups for cancer patients indicate potential
social benefit. However, small sample sizes, lack of randomization, and lack of control
groups for comparison signal a need for further research in the field. Allowing cancer
patients and caregivers to both participate in a group provides a more natural support
network than working with strangers, contributes to shared experiences and memories,
and incorporates new stress management skills for use and practice together.
Furthermore, a study that includes the caregiver as well as patient is an acknowledgement
of the significant needs of the caregiver, and presents an opportunity to systematically
evaluate potential benefit of music therapy for the caregiver, who is often called the
second-order patient (Adler & Page, 2008).
Because music therapy can be readily designed for group work and fits into the
biopsychosocial model of health and illness, music therapy support groups have the
potential to assist both patients and caregivers in physical, psychological, and social
functioning. A quantitative, randomized study of music therapy support groups for
cancer patients and caregivers will extend and deepen the literature regarding music
therapy and social support, and evaluate the possible benefit and effectiveness of music
and music-based interventions when working with groups in cancer care settings. In
particular, this study contributes to an area largely undocumented, with the direct
15
participation of both cancer patients and their caregivers in the music therapy support
groups.
Purpose of the Study
The purpose of this study was to examine the effects of participation in music
therapy support groups on physical, psychological, and social functioning of cancer
patients and caregivers. This study examined the effect of six music therapy support
group sessions on the following outcomes: mood, coping (as measured through
assessment of pain, stress, anxiety), social support, and quality of life. Both the long-
term and short-term effects of these variables were examined from beginning to end of
the overall group experiences, as well as in response to individual sessions.
Statement of the Problem
Two primary questions are investigated in this study: (a) Can cancer patients and
caregivers experience significant improvement in physical, psychological, and social
measures in response to a three-week treatment period? and (b) Can cancer patients and
caregivers achieve short-term benefits as a result of 60-minute group music therapy
sessions? The first question investigated possible changes in mood, coping (anxiety),
social support, and health-related quality of life of participants over the three-week
treatment period.
1a. Will participation in a six-session music therapy cancer support group make a
difference in perceived mood of cancer patients and caregivers?
1b. Will participation in a six-session music therapy cancer support group make a
difference in perceived coping of cancer patients and caregivers?
1c. Will participation in a six-session music therapy cancer support group make a
difference in perceived social support of cancer patients and caregivers?
1d. Will participation in a six-session music therapy cancer support group make a
difference in perceived health-related quality of life of cancer patients and
caregivers?
16
The second question examined changes over a shorter duration of time. This area
considered possible changes in perceived mood, pain, stress, anxiety, and quality of life
during each individual 60-minute treatment session.
2a. Will participation in each individual 60-minute session of a music therapy
cancer support group make a difference in perceived mood of cancer patients and
caregivers?
2b. Will participation in each individual 60-minute session of a music therapy
cancer support group make a difference in perceived pain of cancer patients and
caregivers?
2c. Will participation in each individual 60-minute session of a music therapy
cancer support group make a difference in perceived stress of cancer patients and
caregivers?
2d. Will participation in each individual 60-minute session of a music therapy
cancer support group make a difference in perceived anxiety of cancer patients
and caregivers?
2e. Will participation in each individual 60-minute session of a music therapy
cancer support group make a difference in perceived quality of life of cancer
patients and caregivers?
Research Variables
The independent variable for this study was participation in a music therapy
cancer support group. The dependent variables included changes in perceived (a) mood
as measured by the Profile of Mood States (POMS), (b) coping as characterized by
amount of perceived anxiety, and measured by the State Trait Anxiety Inventory (STAI-S),
(c) social support as measured by the Personal Resource Questionnaire 85-Part 2
(PRQ85-Part 2), and (d) health-related quality of life as measured by the Functional
Assessment of Cancer Therapy-General Form (FACT-G). Other dependent variables
included changes in perceived pain, mood, stress, anxiety, and quality of life as measured
17
by pre- and post-session 11-point (0-10) Music Therapy Support Group Numerical
Rating Scales (MTSG-NRS).
Research Hypotheses
The first research hypothesis, divided into four sub-hypotheses, studied the effect
of mood, coping, social support, and health-related quality of life of participants across
the entire six-session treatment period.
1a. Participation in a six-session music therapy support group will improve
perceived mood of participants as measured by a decrease in the Total Mood
Disturbance Score on the Profile of Mood States (POMS).

1b. Participation in a six-session music therapy support group will improve
perceived coping of participants as measured by a decrease in anxiety scores on
the State Trait Anxiety Inventory-State Form (STAI-S).
1c. Participation in a six-session music therapy support group will improve
perceived levels of social support of participants as measured by an increase in
scores on the Personal Resource Questionnaire 85-Part 2 (PRQ85-Part 2).
1d. Participation in a six-session music therapy support group will improve
perceived levels of health-related quality of life of participants as measured by an
increase in scores on the Functional Assessment of Cancer Therapy-General
Form (FACT-G).
The second research hypothesis, divided into five sub-hypotheses, reviewed
changes in perceived mood, pain, stress, anxiety, and quality of life of participants during
each individual 60-minute music therapy treatment session.
2a. Participation in a music therapy support group will improve perceived mood
of participants within each individual 60-minute treatment session as measured by
an increase of scores on pre- and post-Music Therapy Support Group Numerical

18
2b. Participation in a music therapy support group will decrease perceived stress
a decrease of scores on pre- and post-Music Therapy Support Group Numerical
2c. Participation in a music therapy support group will decrease perceived
anxiety of participants within each individual 60-minute treatment session as
measured by a decrease of scores on pre- and post-Music Therapy Support Group
Numerical Rating Scales (MTSG-NRS).
2d. Participation in a music therapy support group will improve perceived pain of
participants within each individual 60-minute treatment session as measured by a
decrease of scores on pre- and post-Music Therapy Support Group Numerical
2e. Participation in a music therapy support group will improve perceived quality
of life of participants within each individual 60-minute treatment session as
measured by an increase of scores on pre- and post-Music Therapy Support Group
19
Definition of Terms
Anxiety An unpleasant feeling in response to a perceived threat or
stressor that is influenced by physical, psychological, and
social processes.
Caregiver An unpaid, informal, care provider (spouse, family, friend,
child) of a cancer patient.
Coping The thoughts and feelings used to deal with stress, pain,
and anxiety. A dynamic and multidimensional “behavioral
or psychological process that is activated following threat

for the purpose of mitigating or eliminating threat”
(Lazarus, 1966, p. 28).
Distress A continuum of unpleasant emotional experiences of a
psychological, social, or spiritual nature that interferes in
the ability to effectively cope with cancer, symptoms, and
treatments (NCCN, 2010).
Health-Related The subjective assessment of cancer and treatments on
Quality of Life physical, psychological, social, and functional well-being
(Revicki et al., 2000).
Mood A transient feeling or affect of longer duration that is
influenced by external and internal processes (Watson,
2000).
Pain An unpleasant sensation of varying degrees, which includes
physical, psychological, and behavioral processes
(Sarafino, 2006).
Social Support The structure and function of resources and relationships

that assist in coping with stress (Uchino, 2004).
20
Stress A circumstance in which a perceived discrepancy exists

between the demands of the stressor and personal
biological, psychological, or social resources.
Quality of Life Subjective viewpoint of overall well-being, influenced by
physical, psychological, social, economic, and political
environments (Revicki et al., 2000).
21
CHAPTER II
REVIEW OF LITERATURE
Introduction
The present study focuses on the effects of participation in music therapy support
groups (MTSG) on the physical, psychological, and social experiences of adult cancer
patients and caregivers. The overarching structure for examining relevant factors is the
biopsychosocial model of health and well-being in relation to the experiences of cancer
patients and their caregivers. A number of subtopics inform this research topic, including
literature from the fields of nursing, oncology, health psychology, and music therapy.
Relevant literature includes studies associated with biological or physical aspects of
cancer care, such as pain, nausea, fatigue, and immune functioning. Psychological
aspects (e.g., mood, stress, anxiety, and quality of life) and social aspects, (e.g., isolation,
connection, and social support), which interact with physical well-being, will also be
presented. Each aspect is discussed separately; however, within this model, physical,
psychological, and social processes all interact and are affected by one another. Thus, it
can be difficult to make clear distinctions among these three areas.
A brief theoretical discussion of the therapeutic benefit of music, as well as
applied music therapy studies are included for each area (biological, psychological,
social). Given the vast extant literature related to each area, the theoretical description is
not meant to be all-inclusive, but rather, provides a foundation regarding the effect of
music on physical, psychological, and social processes.
Music Therapy and Physical Needs
The biopsychosocial model identifies biological factors as the physiological
function and structure of a person, with healthy functioning depending on the way those
components operate and interact (Sarafino, 2006). The uncontrolled cell growth
associated with cancer wreaks havoc on typical functioning of the affected body systems,
and can cause considerable pain and uncomfortable physical symptoms. Unfortunately,
22
many of the treatments used to combat the disease process are also painful or distressing,
and may cause additional pain, stress, nausea, fatigue, and diminished immune
functioning (Gatchel & Kishino, 2011). Medical professionals try to alleviate these
symptoms through medication, but many patients experience distressing side effects or
pain despite availability of pharmacological interventions.
The following section describes a primary physical concern, pain, as well as uses
of music as part of pain management. Music therapy may offer an effective adjunct
therapy to decrease distressing side effects and reduce the amount of medications needed,
thereby providing a measurable relief in symptoms (Olofsson & Fossum, 2009).

Pain
Pain is a complex and subjective phenomenon, which includes physical (e.g.,
tissue damage), psychological (e.g., psychogenic pain), and behavioral processes
(Sarafino, 2006). It can be acute or chronic. Acute pain lasts for less than six months,
while chronic pain lasts for more than six months and may begin with an acute episode
that does not decrease with time or treatment. Cancer patients may suffer from both
acute and chronic pain, depending on tumor type and location, surgical procedures, and
resulting disability associated with some cancer treatments (McMenamin, 2011).
According to Sarafino (2006), pain signals are transmitted to and processed by several
areas of the brain including the thalamus, motor and sensory areas of the cerebral cortex,
limbic system, and hypothalamus, which are also implicated in mood, motivation, and
general emotional state.
Pain signals affect not only physical sensations of pain but emotional and
psychological states as well. In turn, psychological and social factors, such as fear,
tension, anxiety, isolation, and loss of control may worsen feelings of physical pain
(Gfeller, 2008). Anxiety associated with pain may promote inactivity, contribute to
muscle tension, and increase arousal, all of which exacerbate pain (Gatchel & Kishino,
23
2011). This cycle of pain, emotional distress, and behavioral compensation may continue
unless modified by an intervention.
The Gate Control Theory of Pain helps to explain the interaction of physical,
psychological, and social factors in pain perception (Melzack & Wall, 1982). According
to this theory, the central nervous system (CNS) can only process limited amounts of
information at once, with a neural “gate” opening or closing, depending on the amount of
noxious stimulation, competing stimuli from other peripheral fibers, and the messages
that descend from the brain (Melzack & Wall, 1982; Sarafino, 2006). This theory helps
explain the influence of anxiety, tension, and depression on pain perception, and the
effectiveness of music as a competing stimulus.
Therapeutic uses of music may moderate pain perception through active focus or
distraction, mood alteration (e.g., reduced anxiety, provision of pleasing activity,
enjoyment, improved environment), enhanced control (e.g., information agent),
utilization of prior skills, and promotion of relaxation through sensory, cognitive, and
emotional pathways (Gfeller, 2008; Magill-Levreault, 1993). The multi-dimensional
nature of music may modify these pathways, stimulate endorphin production, and
promote endogenous pain modulation (Beck, 1991). This may be possible in part
through two neurotransmitters, serotonin and norepinephrine, which are involved in both
pain perception and mood regulation (Gatchel & Kishino, 2011). Music may reduce
patient anxiety, which in turn can enhance the effectiveness of anesthetics and analgesics,
allowing for a smaller dosage with fewer side effects.
According to a survey of music therapists and hospice nurses (Groen, 2007),
music listening was the most frequently reported technique used to treat pain by music
therapists (93%), especially for chronic pain symptoms. The use of music listening is
described in the following section.

24
Music Listening: Nursing Studies

Hospitalized patients suffering from acute or chronic pain may use music
listening as a form of distraction, relaxation, focus of attention, masking agent for sounds,
or as a comforting environmental stimulus (Gfeller, 2008). Music listening to reduce
pain has been the focus of a number of studies conducted by nurses. Because nurses
usually do not have the expertise or training to provide live music, these studies typically
use recorded music that is either experimenter-selected (based upon acoustic
characteristics of music intended to maintain focus or to promote relaxation) or patient-
selected music delivered via a sound system.

A systematic review by Nilsson (2008), whose disciplinary background is
nursing, examined the effects of music-listening interventions on anxiety and pain of
adult surgical patients. Only studies utilizing randomized controlled trials with a
recorded music-listening intervention performed were included in the review. Forty-two
studies with outcome measures of pain, stress, and anxiety were reviewed. The majority
of studies used patient self-selected music (n=29). Patient-selected music may be used
for a variety of reasons associated with cognitive approaches to pain management (e.g., to
increase patient control over the environment; to maximize attention to the music as
opposed to the pain; to provide a familiar stimulus in an unfamiliar environment).
Twenty-four studies measured music effects on anxiety; significant reductions occurred
in 12 out of 24 studies (50%). Twenty-two studies measured music effects on pain;
significant reductions in pain were documented in 13 out of 22 studies (59%). In
addition, seven out of 15 studies, using dosage of analgesics as a measurement of pain
reduction, showed significant reduction in medication levels. Reduction in analgesic use
is an important outcome, especially for those suffering from long-term chronic pain, in
order to optimize cognitive functioning, reduce dependency on chemical pain relief, and
reduce patient care costs.
25
Good, Stanton-Hicks, Grass, Anderson, Lai, Roykulcharoen, and Adler (2001)

studied music listening and relaxation techniques to reduce acute postsurgical pain in 500
patients assigned to one of four groups: (a) jaw drop relaxation technique, (b) soothing
music over headphones, (c) relaxation and music, and (d) control group receiving
standard care. All three treatment groups had significantly less pain than the control
group at all measurement points.
Music preference and the perceived importance of music in the lives of
participants may influence the response to music-listening interventions. Huang (2006)
studied the effect of music listening on cancer pain with 126 hospitalized patients,
randomly assigned to an experimental group with music or a no-music control group.
Experimental group participants were given the choice of harp and piano music or music
specific to their own culture (folk or religious music). Patients listened to 30 minutes of
their preferred music, while the control group rested in bed. Participants in the
experimental music-listening group had significantly less pain sensation and distress than
the control group.
Another study, using survey methodology, examined the impact of patient-
preferred music in pain management (Mitchell, MacDonald, Knussen, & Serpell, 2007).
The researchers, from surveys with 318 chronic pain sufferers about uses of music for
pain management, found that listening to preferred music helped distract from pain
sensations and improved quality of life. However, the impact of music on physical (e.g.,
better sleep, more energy), psychological (e.g., better mood), and social (e.g., quality of
life, engagement in daily routines) outcomes was greater for those patients for whom
music was personally important. This study also determined that preferred music may
provide comfort and familiarity in an otherwise stressful environment. Participants may
choose music based on positive messages inherent in the lyrics, or may associate positive
feelings or memories with familiar pieces. The familiarity and positive thoughts and
26
feelings associated with the music may provide a competing stimulus for the nervous
system, decreasing the perception of pain.
The choice of music (patient-selected or researcher-selected) was the focus of
several music-listening studies with cancer patients. Zimmerman, Pozehl, Duncan, and
Schmitz (1989) found that patient-preferred music, along with the suggestion that music
may help manage pain, may facilitate a relaxation response, thereby decreasing muscle
tension and the perception of pain. Flaugher (2002), however, in a study involving music
listening for chronic pain, anxiety, and depression with cancer patients, found no
significant difference in response between patient-selected and researcher-selected music

(new age music). The findings showed a significant overall decrease in pain perception
in the groups listening to music (compared with a no-music control group), with no
significant changes in perception of depression or anxiety. The findings suggest that
music, whether chosen by the health care provider for particular acoustic characteristics,
or by the patient based upon personal preference, can decrease the perception of chronic
pain. The most suitable choice may be related in part to the application of music for
distraction as opposed to relaxation response.
Other studies have found either highly variable responses among patients in
response to music for pain control (Cuenot, 1994; Beck, 1991), or no significant
advantage in music listening (Kwekkeboom, 2003). Beck (1991) determined a high
variability in mood responses between and within participants, with some participants
preferring the music intervention, finding it relaxing and distracting; others did not prefer
the music and reported that the music did not affect feelings of control.
Active Music Engagement: Music Therapy
Music listening, as indicated in nursing literature, may be an effective adjunct
treatment for pain management in cancer care. However, music listening and clinical
music therapy practice are two different things. Music therapy involves an “active
intervention overseen by a music therapist and is different from passive listening to
27
music” (Bardia, Barton, Prokop, Bauer, & Moynihan, 2006, p. 5458). Active
engagement in music therapy interventions, such as singing, playing, moving, creating,
and composing, may distract participants from pain as well as enhance mood, increase
personal sense of control and efficacy, and provide perceived social support from the
therapist.
While active music engagement is commonly used in clinical practice, and benefit
is measured through clinical progress notes, to date there are few published research
studies involving adult cancer patients, pain management, and active music engagement.
In three palliative care case studies (palliative care is intended to provide comfort and
pain relief), Magill-Levreault (1993) demonstrated that the “dynamic and
multidimensional qualities of music” provide an effective therapeutic tool to “soothe pain
and ease suffering” (p. 47). The author noted that music has the potential to “engage,
activate, and alter affective, cognitive, and sensory processes through distraction,
alteration of mood, improved sense of control, the use of prior skills, and relaxation” (p.
47). The researcher also emphasized that the implementation of music therapy must take
into account mood, coping abilities, medical status, and prior musical experiences, and
has the potential to decrease isolation by supporting and reconnecting families.
O’Callaghan (1996) presented three case studies in which music therapy
techniques, based on individualized needs of each patient, alleviated pain experiences of
cancer patients and their significant others. The live music therapy experiences,
combined with the relationship developed between music therapist and patient, allowed
for individualized and multidimensional pain management. Because pain sensation
varies from person to person, from moment to moment, and involves biological,
psychological, and social responses, the live music therapy interventions offer flexibility
and immediacy of response. The case studies also emphasized the importance of
allowing patient choice whenever possible, and using live music, counseling techniques,
songwriting, imagery, and improvisation to alleviate pain sensation.
28
In summary, extant research supports the use of music in pain management

through emotional, cognitive, and sensory pathways. Both the use of preferred patient
music or music selected by the researcher with specific relaxation criteria in mind may be
used for pain management in cancer care. However, individual responses to music
interventions in pain management may vary according to the perceived importance of
music in the lives of participants. These studies informed the selection of musical stimuli
for the current intervention as well as the choice of possible dependent measures.
Immune Response
The field of psychoneuroimmunology studies the interaction of psychological,

neurological, and immunological functioning on health. The brain and immune system
interact and regulate each other, with psychological processes influencing the network
(Maier, Watkins, & Fleshner, 1994). Biochemical agents related to immunity and stress,
such as cortisol, interleukin-1, immunoglobulin A, and plasma B-endorphin, may
measure neuroendocrine changes (Nilsson, 2008). Recent studies in music therapy,
nursing, medicine, and psychology indicate a relationship between music, stress, and
immunity. Music therapy can enhance immune functioning by improving mood and
decreasing stress and anxiety. Although the connection between music therapy and
immune system functioning is not a focus of this study, the physical functioning of
cancer patients may be affected by this relationship.
Research on Healthy Adults
Bartlett, Kaufman, and Smeltekop (1993) studied the effects of music listening
and creative experiences (writing, drawing, imagery) on the immune system as measured
by interleukin-1 and cortisol in 36 healthy adult subjects, divided into two experimental
and two control groups. Both experimental groups had significant decreases in cortisol,
with a significant increase in interleukin-1 in one experimental group after an immediate

post-test blood draw. In another study of 28 healthy adults, McKinney, Antoni, Kumar,
Tims, and McCabe (1997) studied the effects of Guided Imagery and Music Therapy
29
(GIM) on mood and cortisol. The experimental group demonstrated a significant

improvement of mood and significant decrease in cortisol; changes in mood predicted
changes in cortisol, indicating a connection between music, mood, and immunity. In
contrast, a study on the effects of music and imagery on plasma B-endorphin in 78
healthy undergraduate students indicated no significant difference between experimental
and control groups (McKinney, Tims, Kumar, & Kumar, 1997). In summary, these
studies indicated that music interventions may modify immune response and
psychological correlates.
Research in Clinical Music Therapy

Research indicated that both music listening and interactive music (active music
engagement) may modify immune system functioning. In a study by Burns, Harbuz,
Hucklebridge, and Bunt (2001), music therapy groups for 29 cancer patients compared
the effects of listening to music while relaxed with active music improvisation over two
days. Both conditions increased well-being, decreased tension, and decreased cortisol
levels, while the listening experience also increased salivary immunoglobulin A (Burns et
al., 2001). The study indicated a possible link between positive emotions and the
immune system, and a link between listening to music in a relaxed state and
improvisation to changes in psychological and physical measurements (Burns et al.,
2001).
Group drumming, a form of active music making and rhythmic improvisation,
modulated neuroendocrine and neuroimmune responses in 111 people in an outpatient
medical clinic (Bittman et al., 2001). Patients exhibited increased
dehydroepiandrosterone-to-cortisol ratios, increased natural killer cell activity, and
increased lymphokine-activated killer cell activity. This study provides evidence of the
impact of interactive music, not just music listening, on immune functioning. Both
receptive (music listening, imagery) and interactive (improvisation, group drumming)
music therapy experiences appear to modulate immune system functioning.
30
Nausea and Fatigue

In addition to pain and immune system function, cancer patients deal with
unpleasant side effects of treatments that affect well-being and overall quality of life.
Nausea and fatigue, resulting from radiation and chemotherapy treatments, affect
physical functioning; this in turn affects psychological and social functioning. Although
not a specific focus of the present study, these symptoms impact physical and functional
well-being, both important aspects of health-related quality of life (HRQOL). Nausea
and fatigue are indicators of HRQOL in many oncology measurement tools, including the
FACT-G used in the present study (Cella, Tulsky, Gray, Sarafian, Linn, Bonomi et al.,
1993). Music therapy studies in this area are sparse, but indicate a benefit to using music
therapy interventions with patients suffering from nausea and fatigue associated with
cancer.
Nausea
Although prevalence and severity of nausea in response to chemotherapy has
decreased thanks to antiemetic medications, there are individuals who still experience
nausea and the resulting lack of appetite, which can severely affect the health of cancer
patients. Standley (1992) studied the effects of music on nausea and emesis of 15 cancer
patients receiving chemotherapy treatments. The experimental music groups reported
less nausea and increased length of time before nausea began than the control groups. In
another study involving music therapy as an adjunct to antiemetic therapy, Ezzone,
Baker, Rosselet, and Terepka (1998) also demonstrated a reduction in nausea and
vomiting with the use of music in patients undergoing chemotherapy.
Fatigue
Cancer-related fatigue is a common and distressing symptom that may cause
exhaustion, inactivity, and an inability to complete daily tasks (“Fighting Cancer

Fatigue,” NCCN, 2011). Music therapy interventions that promote activity and
motivation may be helpful in this area.
31
Boldt (1996) studied the effects of music therapy on motivation, well-being,

physical comfort, and exercise endurance of six bone marrow transplant patients.
Subjects served as their own controls in a music/nonmusic reversal design, with
interventions of live and recorded music for participation, relaxation and imagery,
progressive relaxation exercise, range of motion exercise, and aerobic exercise.
Measurements included pre- and post-self-report measures for relaxation, comfort, pain,
and nausea; observational behavior scale, timing of sessions, and stage of protocol
participant reached (completed by the researcher); and an end-of-study effectiveness
questionnaire. The results of the study indicated that music helped to increase exercise
endurance in long-term patients. Patients reported that they preferred the relaxation and
comfort they received from the music sessions, particularly the relaxation/imagery
exercises with music.
Overall, these studies provide evidence of possible improved physiological
functioning as a result of the use of music interventions in cancer care. Music may
decrease the effects of stress and pain, improve immune system functioning, and modify
nausea and fatigue. However, as indicated in the biopsychosocial approach to health,
physical functioning interacts with and is affected by psychological factors, such as
cognition and emotional response.
Music Therapy and Psychological Needs
Psychological factors in the biopsychosocial model include behaviors and mental
processes that involve cognition, emotion, and motivation (Sarafino, 2006). Cognition
includes mental activity associated with learning, thinking, perceiving, interpreting, and
problem solving (Sarafino, 2006). Emotion involves a complex process that affects and
is affected by physiological, cognitive, behavioral, and social factors (Pellitieri, 2009).
As noted earlier, psychological processes can influence physical functioning, including

perception of pain, immune response, and fatigue.
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Music affects psychological experiences through modulation of attention

(captures attention and distracts from pain), emotion (evokes emotions or recalls
memories), cognition (connects subjective, social, and cultural meanings), behavior
(conditions and reinforces new or learned behavior), and communication (promotes
nonverbal, cohesive, interpersonal interactions) (Hillecke, Nickel, & Bolay, 2005).
Theoretically, the connection between music and emotion has been explained by
expressionistic and referentialist perspectives (Berlyne, 1971; Gfeller, 2002, 2008;
Kreitler & Kreitler, 1972; Meyer, 1956). The expressionist perspective attributes
emotional response to the structural elements of the music itself (e.g., tempo, mode,
complexity, expectations), while a referentialist perspective states that emotional
responses are the result of “extramusical associations” learned from life experiences
(Gfeller, 2008, p. 62). In other words, music may affect emotional response through the
inherent nature of the music itself, or through subjective associations based on past
social, cultural, and emotional experiences. How effectively an individual responds
psychologically to physical as well as psychological stressors is often referred to as
coping, the subject of the following section.
Coping
As indicated in Chapter One, coping is a multidimensional process activated
following a threat, with coping techniques utilized to deal with the perceived stressor
(Lazarus et al., 1986). Effective coping is associated with a reduction of stress or anxiety
in response to a stressor. Cancer is a significant health threat, which often requires
psychological adjustment. Music therapy may improve coping through increased sense
of control, relaxation, and distraction.
Stress
Stress may be physical, psychological, and social, with the response to stress
mediated by appraisal of the situation and perceived available resources for coping
(Lazarus, Folkman, Gruen, & DeLongis, 1986). Over time, chronic stress associated with
33
cancer may lead to increased tumor growth, immune system dysfunction, and decreased
quality of life (Uchino, 2004). Cancer patients and caregivers may feel stress due to the
diagnosis and resulting treatments, along with resulting pain, fear, worry, anxiety,
depression, and distress. Distress associated with perceived helplessness and loss of
control may increase the production of cortisol and catecholemines, increasing
physiological arousal (Sarafino, 2006). Music may decrease stress through relaxation
and distraction, and may provide patients with a sense of control over their
circumstances. In turn, these psychological factors help decrease physiological arousal
due to stress.
Relaxation and Distraction
Music can modify the effects of stress by assisting in relaxation or distraction. In
a meta-analysis of music therapy research in medical and dental treatments, music
demonstrated an average effect size of .98 across 55 dependent variables (Standley,
1986). Music enhanced the effects of anesthetics and analgesics, reduced the length of
hospitalization, reduced anxiety associated with surgical procedures, and reduced
discomfort for many different types of patients. Measurement tools described in the
meta-analysis included physiological measures (blood pressure, pulse, amount of
medication, and blood analysis of stress hormone levels), behavioral observations (overt
anxiety responses, time in recovery room, length of hospitalization), and participant self-
report. Factors associated with greater benefit included the use of patient preferred
music, association of music with pleasant verbal associations, allowing patients to control
as many circumstances as possible, and verbal support and prompts by the therapist.
Decreased Arousal
A meta-analysis by Pelletier (2004) demonstrated that music combined with
relaxation techniques had a significant impact on decreasing undesirable arousal due to

stress, particularly in conjunction with verbal suggestion. Music selected according to
structural characteristics for relaxation response as determined in prior studies (slower
34
tempo, low pitches, regular rhythmic patterns, dynamic stability, no lyrics) was more
effective than subject-selected music. Other findings from the meta-analysis included
that people who participated in multiple sessions and those with musical backgrounds
may experience greater benefits. Pelletier also found that self-report and behavioral
measures were as effective in measuring outcomes as physiological recordings.
In a review of music-listening interventions by Nilsson (2008), music studies
involving arousal due to stress were included. Twenty-four studies measured the effect
of music on vital signs, with outcome measures of blood pressure, heart rate, respiratory
rate, oxygen saturation, skin temperature, blood flow, cardiac output, and electrodermal
activity. Six out of 22 studies indicated a significant decrease in heart rate (27%) and
blood pressure (27%); a proportion of the studies demonstrated a significant decrease in
respiratory rate, oxygen saturation, skin temperature, and cardiac output. Four studies
measured the effects of music listening on stress and immune function, with cortisol the
most commonly measured, of which one study reported a significant reduction.
In summary, music therapy interventions may modify perceived stress by
providing relaxation and distraction, supporting a sense of control over stressful
circumstances, and decreasing physiological arousal due to stress, which in turn affects
health functioning. Although there is conflicting evidence regarding the use of patient-
preferred or researcher-selected music, stress-reduction techniques such as music therapy
may benefit patients undergoing cancer-related stress.
Anxiety
In addition to the stress associated with cancer, several studies in music therapy
and related fields indicated the benefits of music for decreasing anxiety. In a review of
studies on music-listening interventions in nursing literature regarding anxiety and pain
management, Nilsson (2008) reported that 59% of the studies demonstrated significant
decreases in anxiety as a result of music intervention versus control. Music may be used
as an active focus or distraction, an outlet for emotional expression, or as a psychological
35
tool to decrease physical responses associated with anxiety (e.g., muscle tension, heart
rate, blood pressure). Some studies used patient-selected or researcher-selected music
listening; other studies utilized live, interactive music therapy interventions facilitated by
a trained music therapist.
Receptive Interventions: Researcher-Selected Music
Recorded music listening is inexpensive, noninvasive, easily utilized in a busy
oncology setting (Bulfone et al., 2009), and can be implemented by medical staff who
lack specialized training required for live, interactive music (Olofsson & Fossum, 2009).
Bulfone, Quattrin, Zanotti, Regattin, and Brusaferro (2009) studied the effect of music
listening on anxiety of 60 breast cancer patients undergoing 12 weeks of postsurgical
chemotherapy treatment. Participants were randomly assigned to the experimental group
(music listening) or a control group (no music). Experimental group participants listened
to 15 minutes of researcher-selected predetermined music, with a significant difference in
anxiety reported. The researchers suggested that music listening may reduce anxiety and
physiological arousal, enhance a sense of well-being and control, and therefore, improve
the quality of life of breast cancer patients. They noted, however, that some patients may
not enjoy listening to these predetermined categories, and may find their own music
preferences more relaxing. In another study, Shabanloie, Golchin, Esfahani, Dolatkhah,
and Rasoulian (2010) investigated the effects of music listening on pain and anxiety in
100 patients undergoing the painful procedure of bone marrow biopsy and aspiration.
Experimental group participants, who listened to slow, steady, instrumental music around
70 to 80 beats per minute, demonstrated significantly less state anxiety and pain than
control participants.
Some studies have combined researcher-selected music along with other
conditions such as imagery or visualization techniques. For example, Goodwin (2004)

studied the effect of guided imagery on coping, emotional expressiveness, and
psychological well-being of 52 breast cancer patients. Women were randomly assigned
36
to guided imagery with relaxation music or a relaxation music-only group. Depression,

anxiety, and psychological distress decreased for women in both music groups.
Participants reportedly enjoyed the experience, found it helpful and relaxing, and would
recommend it to others. Harper (2001) studied the effectiveness of music and
visualization on coping in 40 cancer patients undergoing chemotherapy. Visualization
interventions involved two coping styles (problem-focused and emotion-focused) with
background music. These conditions were contrasted with control conditions of
background music-only and no music. All of the active interventions (visualization and
music) demonstrated positive effects on psychological and physical health, and reducing
treatment-related anxiety.
Burns, Azzouz, Sledge, Rutledge, Hincher, Monahan, and Cripe (2008) studied
the effects of music imagery on affect, fatigue, and anxiety of 30 adult hospitalized
leukemia patients randomly assigned to music imagery or control (standard care) groups.
Although not significant, both groups improved over time in regard to affect, fatigue, and
anxiety. However, the extent of improvement appeared to depend upon individual
participant characteristics (e.g., lower baseline negative affect).
Receptive Interventions: Patient-Preferred Music
Clark, Isaacks-Downton, Wells, Redlin-Frazier, Eck, Hepworth, and
Chakravarthy (2006) studied the use of preferred music listening to reduce emotional
distress (anxiety, depression, treatment-related distress) and symptom activity (fatigue,
pain) in 63 cancer patients receiving radiation therapy. Participants were randomized to a
treatment (music condition) or control (standard care) group and measures obtained
before, during, and after radiation treatment. A music therapist interviewed participants
in the experimental group to discuss music preferences, demonstrate relaxation
techniques, and create a 90-minute individualized tape for use during treatment.
Treatment participants reported lower anxiety and distress levels than the control group;
there were no significant differences in pain, fatigue, or depression between groups.
37
Another study, using questionnaire methodology with 35 cancer patients, indicated that
preferred music listening may help with distraction, relaxation, and imagery (Weber,
Nuessler, & Willmanns, 1997). In summary, receptive music-listening interventions may
provide a focus for relaxation, a distraction from stressful procedures, and provide a more
positive environmental stimulus.
Interactive Music Therapy Interventions
A music therapist is specially trained to utilize the therapeutic qualities of music
to assist in meeting the needs and goals of patients. Although receptive music therapy
interventions can be inexpensive and easily utilized in a busy hospital environment,

interactive music therapy approaches allow more flexibility in the music and activities;
takes music preferences into account; and engages participants physically,
psychologically, and socially. For example, Bailey (1983) studied the effect of live
music therapy (singing with guitar accompaniment) or recorded music on anxiety in 50
hospitalized cancer patients. Participants in the live music condition reported
significantly less Tension/Anxiety and more Vigor as measured in the Profile of Mood
States; patients listening to live music also reported significant changes in physical
discomfort and recommended the sessions to others. This study indicated the benefits of
live music when compared to recorded music in effectively reducing anxiety, improving
vigor, and decreasing discomfort.
Ferrer (2007) investigated the use of live music on anxiety, negative reactions
(fatigue, worry, and fear), and positive reactions (comfort and relaxation) with 50 cancer
patients undergoing chemotherapy treatment. Participants were randomly assigned to
experimental (music) or control (standard care) groups, with experimental participants
receiving 20 minutes of familiar, patient-preferred, live music during chemotherapy.
Results indicated significant improvement in fear, anxiety, fatigue, relaxation, and

diastolic blood pressure in the experimental group; no significant differences between
groups were found for worry, comfort, heart rate, and systolic blood pressure.
38
One music therapy research study controlled for the attention of a caring person
as an influential factor in intervention benefit. Horne-Thompson & Grocke (2008)
examined the effect of a single music therapy session in reducing anxiety in 25 terminally
ill participants (24 with a cancer diagnosis) randomized to experimental (music therapy
session) or control group (non-music activity with a volunteer). Music therapy
techniques (e.g., live familiar music, singing, music with imagery and relaxation,
improvisation, music-assisted counseling, reminiscence, music listening), were facilitated
by a music therapist. Control group participants spent time with a volunteer who would
read, talk, or provide emotional support, but not use music. Experimental group
participants had significantly reduced anxiety, pain, tiredness, and drowsiness. This
study emphasized the contribution of preferred music in reducing anxiety above and
beyond the attention of a supportive person.
Patient Preference in Types of Music Therapy Interventions
Both recorded and live music therapy interventions may provide relief when
coping with anxiety. However, patient preference should be taken into account when
planning specific therapy interventions. Burns, Sledge, Fuller, Daggy, and Monahan
(2005) studied 65 cancer patients’ interest in music therapy in order to determine the
preference for particular types of music therapy interventions (e.g., receptive, interactive,
none) in conjunction with specific individual characteristics: 68% were interested in
music listening, 17% preferred music making, and 15% were not interested in either type.
Patients interested in music listening had significantly more anxiety and higher negative
affect than patients interested in music making or those not interested in an intervention.
Also, patients selecting a music therapy intervention had higher scores on Seeking Social
Support. Participants interested in music making or listening perceived significantly
fewer barriers and more benefits to that type of intervention. This study indicates that
patient characteristics and preferences should be taken into account in therapy planning.
39
As indicated, both receptive and interactive music therapy interventions may

decrease anxiety in cancer patients undergoing treatment. Music therapy interventions
involving music listening may use researcher-selected music or patient-selected music,
but patient preference must be taken into account. Interactive music therapy
interventions allow for a more flexible medium in which patients may select preferred
music and engage in active music making. In addition, preconceived perceptions of
barriers and benefits to specific interventions may affect participant response.
Mood
A response to stressful circumstances is not only influenced by cognitive

appraisal, but by emotional response. An emotion is a brief, intense, organized, and
“highly structured reaction to an event that is relevant to the needs, goals, or survival of
the organism,” while a mood is a “transient episode of feeling or affect” of longer
duration (Watson, 2000, p. 2). Mood includes all feeling states and is strongly influenced
by both external and internal processes (Watson, 2000). “Music has a powerful effect on
mood and can modulate disturbing and discomforting symptoms, soothe anxiety and
tension, and create a sense of peace and order” (Magill-Levreault, 1993, p. 44). Music
has the potential to meet people on emotional and spiritual levels (Olofsson & Fossum,
2009), and be an uplifting or stimulating experience (Horne-Thompson & Grocke, 2008).
Several music therapy studies in cancer care use receptive (music listening, imagery) and
interactive (singing, songwriting, improvisation) music interventions to improve mood.
Receptive Music Therapy Interventions
Receptive music therapy techniques, such as music listening and imagery,
improve mood, which in turn affects physical, psychological, and social well-being.
Burns (2001) studied the effect of the Bonny Method of Guided Imagery and Music
(GIM) on mood and quality of life of eight cancer survivors randomly assigned to
experimental (10 weeks of GIM sessions) and wait-list control groups. The experimental
group showed a significant decrease in POMS Total Mood Disturbance and an increase in
40
quality of life scores when compared to the control group. In addition, POMS subscale
scores of Anger/Hostility, Depression/Dejection, Fatigue/Inertia,
Confusion/Bewilderment, and Vigor/Activity improved in the experimental group, with
benefits maintained through a six-week follow-up.
McKinney, Antoni, Kumar, Tims, and McCabe (1997) studied the effects of GIM
on mood and cortisol levels of 28 healthy adults randomized to an experimental or wait-
list control group. All participants completed the POMS and donated 15 cc of blood.
The experimental group reported significant decreases in Total Mood Disturbance,
Depression/Dejection and Fatigue/Inertia; scores were maintained at the six-week follow-

up. Changes in mood were predictive of cortisol changes in all participants, with
frequency of daily stressors at follow-up predicting mood change. Thus, stressful life
events may contribute to changes in mood.
These studies demonstrate that music listening, when combined with the
psychological act of imagery, improved mood with changes maintained at six weeks. In
addition, aspects of functioning that contribute to mood, such as fatigue, anger, and
depression, were also affected. These changes were associated with physiological
cortisol levels, demonstrating that psychological changes in mood as a result of receptive
music experiences affect physical health.
Interactive Music Therapy Interventions
Hanser, Bauer-Wu, Kubicek, Healey, Manola, Hernandez, and Bunnell (2006)
studied the effects of interactive music therapy sessions (live music, songwriting,
improvisation) on quality of life, psychological distress, and spirituality of 70 stage IV
breast cancer patients. Participants rated their current feelings of relaxation, comfort, and
mood on a Visual Analog Scale; heart rate and blood pressure were also measured. No
significant differences in quality of life or psychological distress were found between the
two groups. However, significant improvements in mood, relaxation, and comfort, and
significant decreases in heart rate were observed after each music therapy session.
41
Cassileth, Vickers, and Magill (2003) studied the effects of music therapy on
mood disturbance with 62 hospitalized cancer patients randomly assigned to an
experimental group (music therapy) or control (standard care). Experimental group
participants received individualized live music therapy sessions from trained music
therapists for 20 to 30 minutes. Patients in the experimental group reported significantly
less mood disturbance, with a decrease of 28% in the Tension/Anxiety and
Depression/Dejection subscales.
Group music therapy sessions may also provide a significant improvement in
mood. Waldon (2001) studied the effect of music therapy on mood states and group
cohesiveness of 11 cancer patients. Participants experienced four weeks of music making
and four weeks of music responding in a repeated-measure/counterbalanced design with
no control group. Participation significantly improved mood in both groups, with no
significant difference between the two treatment conditions and no statistical significance
for group cohesiveness measures. Although no control group was utilized, this study
provided evidence that interactive music therapy interventions (music making) in a group
setting may improve mood in cancer patients.
Quality of Life
Receptive and interactive music therapy interventions may alleviate physical and
psychological symptoms and improve quality of life, an important outcome criteria when
judging the impact of psychosocial interventions (Weis, 2003). Quality of life and
health-related quality of life are somewhat different, and definitions may vary. Health-
related quality of life (HRQOL) focuses on quality of life in regard to illness and
treatment, while quality of life (QOL) refers to all aspects of life, including cultural,
political, or societal issues (Ferrans & Hacker, 2011). HRQOL involves physical, social,
emotional, and functional well-being, all of which combine into perceived overall well-
being (Ferrans & Hacker, 2011). Although some studies related to quality of life were
discussed elsewhere in this review of literature because of the interaction with physical,
42
psychological, and social functioning, still others indicate benefit in the areas of music
and life quality.
Kruse (2003) identified several quality-of-life issues in a survey of music
therapists in cancer care. The three most common goal areas were psychosocial needs,
anxiety management, and pain management. Music therapists also reported using music:
(a) to promote expression of feelings or emotions, (b) as a cue or prompt for relaxation,
(c) to promote expression of spirituality or end-of-life concerns, (d) to promote cognitive
processing and expression of thought, and (e) as a social catalyst for family or group
interaction (Kruse, 2003). The music therapy interventions utilized were varied,
depending on patient need, and included: melodic improvisation, group drumming,
guided imagery, active music making, passive music listening, relaxation with music, and
singing (Kruse, 2003).
Bozcuk, Artac, Kara, Ozdogan, Sualp, Topcu, Karaagacll, Ylldlz, and Savas
(2006) studied the effect of open field music listening on quality of life in 18 breast
cancer patients receiving chemotherapy. No significant differences were found in QOL
scores, but older patients (age 45 and older) showed significance for insomnia and
appetite loss scale scores. Researchers contributed this effect to the standard music
chosen for the study; younger patients may have disliked the music. Previous studies
have shown the importance of patient preference and choice and control when listening to
music. The uncontrollable exposure to the open field music may have caused a negative
reaction in some participants, especially if the music was disliked or unfamiliar.
In a survey of psychosocial coping techniques and supportive care services used
by cancer patients, Zaza, Sellick, and Hillier (2005) reported the three most common
techniques used by the 292 study participants were prayer, listening to music, and
religious support. These three techniques were preferred over other techniques that
patients were unaware of or unfamiliar with, indicating that familiarity and ease of use
are factors in chosen coping techniques.
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Although many studies indicate changes in QOL due to individualized music

therapy interventions, group sessions can also be effective. In a study of interactive
group music therapy, Furioso (2002) studied coping, psychosocial adjustment, and
quality of life in five breast cancer patients. Participants reported significantly improved
quality of life, health, and functioning (Furioso, 2002). In summary, music therapy
interventions influence psychological processes, which in turn affect and are affected by
physical and social processes. Stress and anxiety may decrease, and mood and quality of
life improve as a result of receptive or interactive music therapy interventions.
Music Therapy and Social Needs

In the biopychosocial model, social factors involve relationships and interactions
with other people, including such factors as isolation, connection, and social support
(Sarafino, 2006). Music can be a social process (Pellitteri, 2009) that “enhances
expression and communication” and may “diminish isolation by reuniting patients with
their families and significant others” (Magill-Levreault, 1993, p. 47). Music as a nursing
intervention is limited to music listening, while music therapy in a “psychosocial context
is offered for psychotherapy, symptom alleviation, and recreational, social, spiritual,
emotional, or physical purposes” (Olofsson & Fossum, 2009, p. E227). In addition, when
only utilizing receptive music-listening interventions, the “changing dynamics of social
interactions and relationships are not always addressed” (Hanser, 2006, p. 64).
Small (1998), a musicologist who studies functions of music in society, noted that
“music is not a thing at all but an activity, something that people do” (p. 2), such as
singing, playing, listening, composing, and dancing (p. 9). Through active participation
in music, a pattern of relationships is established, which “connects us to ourselves, to
other humans, and to the rest of the living world, and those are matters which are among
the most important in human life” (Small, 1998, p. 200). This interactive concept of
music demonstrates the social relationships and connections that are possible through live
44
music therapy interventions not possible through receptive techniques alone. Thus,
music is a tool to explore, affirm, and celebrate human relationships.
Social Support
Music Therapy and Psychosocial Interventions
Some studies indicated a benefit in using music therapy combined with
psychotherapy or cognitive behavioral therapy. For example, Magill, Levin, and Spodek
(2008) studied the effect of a combined music therapy and cognitive behavioral therapy
session with 39 critically ill cancer patients. Sessions involved patient-selected songs
played and sung by the music therapist; patients were invited to participate at their
comfort level. Participants showed a statistically significant improvement in distress
scores as a result of the interactive experience. A qualitative thematic analysis of
participant discussion topics indicated that the following issues emerged as important:
hope, faith, family, creativity, hopelessness, abandonment, meaning in life, and fear of
death. “Music therapy offers a supportive framework that can facilitate communication,
enhance comfort via familiar music and lyrics, improve mood, inspire reflection, and
strengthen faith. Singing with others enhances perceived support, diminishes isolation,
and increases social integration” (Magill et al., 2008, p. 1216).
Allen (2010) studied the impact of a group music psychotherapy condition when
compared with a standard cognitive behavioral support group on identity, role
performance, self-esteem, and body image with 11 breast cancer survivors. Participation
in the music psychotherapy group allowed participants to “identify, explore, and develop
new ways of coping in a safe and supportive environment” (Allen, 2010, p. 60). Results
indicated a significant improvement in identity, body image, and family role performance
for participants in the group music condition; no significant differences were found in
academic/work performance, self-esteem, and self-concept scores. A small sample size,

lack of a control group, and previous participation in other support groups may have
influenced the results.
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Although not a traditional psychosocial intervention, community-based music

groups combine music and social connections. Young (2009) discussed the benefit of
community-based music groups for cancer patients, especially for those who may feel
uncomfortable in traditional group therapy. Active participation in a music group may
foster social interactions, promote emotional expression, and enhance confidence and
sense of accomplishment. Community-based groups “result in extremely rewarding,
healing, and powerful experiences for all persons involved” (Young, 2009, p. 23). These
observations, while they suggest possible benefit of participation in community-based
groups, would be strengthened through systematic evaluation of outcomes.

Interactive Music Therapy Groups for Cancer Patients
Participation in interactive music experiences with others in similar circumstances
may improve social support. Daykin, McClean, and Bunt (2007) completed semi-
structured interviews with 23 cancer patients after attending group music therapy
sessions. Participants completed 90-minute music therapy sessions involving interactive
music, specifically percussion improvisation. The music therapy experiences involving
choice, enrichment, creativity, and identity contrasted with ideas that surfaced during
cancer such as limitation, restriction, isolation, and disempowerment. In addition,
researchers noted that the perceived benefits of music therapy may depend on
participants’ previously conceived socially constructed ideas about music and creativity.
Music therapy groups provide opportunities for cancer patients and/or caregivers
to support one another, express thoughts and feelings, and improve coping skills.
Waldon (2001) described a rationale for providing group music therapy for cancer
patients: (a) group therapy reduces fear and anxiety while providing support and
reassurance, (b) treating groups instead of individuals is more cost-effective, (c) lack of
social activity and resulting psychosocial isolation is problematic for cancer patients, and
(d) music is valuable as a form of social integration, and may serve to enhance cancer
support group interventions.
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Research involving the benefits of music therapy interventions facilitated in social

groups in cancer care is minimal. Although previous studies indicated benefit, the
research is limited because of small sample sizes, lack of control groups, lack of
randomization, and lack of quantitative studies in this area. Because music therapy may
benefit cancer patients and caregivers when utilized in a group setting, more research that
directly addresses these methodological concerns and this topic is needed.
Support Groups in Cancer Care
The National Cancer Institute defines support groups as “a group of people with
similar disease who meet to discuss how better to cope with their disease and treatment”
(NCI, 2008). Social support interventions are important for cancer patients and
caregivers because (a) social isolation increases health risks, (b) the perception of support
lowers stress levels, and (c) ineffective natural supports (such as well-intentioned
network members) may be remediated or replaced (Gottlieb, 2007). Cancer support
groups are “designed to provide a confidential atmosphere where cancer patients or
cancer survivors can discuss the challenges that accompany the illness with others who
may have experienced the same challenges” (NCI, 2008). In addition, these support
groups may include cancer patients, cancer survivors, family members, and friends, and
may vary according to size, type, frequency, and stage of cancer.
Weis (2003) described general characteristics and approaches of support groups
for cancer patients and caregivers. Support groups are provided for cancer patients in a
variety of settings and types, and may include methods such as relaxation, health
education, neuropsychological training, behavioral training, art therapy (art, music,
dance), and psychoeducation. Two basic approaches to support groups include
affectively oriented groups (long-term, open-ended groups aimed at sharing feelings and
expressing emotions) and educational groups (short-term groups with a formal structure
focused on self-efficacy and empowerment). These educational support groups may vary
in length, and may focus on providing information about cancer, stress-management
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techniques, behavioral training, problem solving, and self-control strategies such as

relaxation. Group therapies that focus on psychosocial interventions are intended to help
cancer patients cope with the most distressing phases of cancer, such as during diagnosis,
acute care and treatment, rehabilitation and after-care, after recurrence, and during
palliative care (Weis, 2003).
Social support includes perceived support from caregivers, family, and friends,
and is important to the overall health and well-being of cancer patients. Support from
caregivers, typically spouses, is vital for cancer patients during all stages of illness. The
following studies indicate the importance of social support for individuals in isolated
environments, cancer patients in the community, spouses of cancer patients, and families
of cancer patients.
Cancer Social Support Research
Jenks Kettmann and Altmaier (2008) studied the role of social support in
depression among 86 bone marrow transplant (BMT) patients in protective environments.
Their study suggests that strengthening or increasing social support networks of patients
may decrease depressive symptoms and improve psychosocial adjustment of patients,
especially for patients who are typically isolated from others due to diminished immune
system functioning. Similarly, Craig (2005) found a significant positive relationship
between social support and hope, resilience, and self-esteem; increased hope was also
associated with greater resilience and self-esteem.
Several studies have indicated that spouses of cancer patients, as well as the
patients themselves, may benefit from peer support associated with educational
counseling in regard to self-care, marital quality, and coping with stress (Brodeur, 2005;
Lewis, Cochrane, Fletcher, Zahlis, Shands, Gralow, Wu, & Schmitz, 2007). Researchers
found a statistically significant improvement in depressed mood, anxiety, and self-

efficacy total scores, as well as the self-care and wife-focused subscales. In addition,
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peer support significantly improved scores regarding spousal skills, wife support, marital
quality, and self-care.
Brodeur (2005) completed a longitudinal qualitative and quantitative study
involving a community-based intervention that used art and multifamily support groups
to improve communication and cohesion for families living with chronic illness.
Participants experienced higher levels of family cohesion, lower levels of family conflict,
increased perception of social support, and fewer negative mental health symptoms
following the intervention.
These studies highlight different psychosocial approaches to social support in

cancer care, such as community-based interventions, educational counseling
interventions, and already established community support groups. Music therapy,
another type of psychosocial intervention, may be successfully utilized in a support group
model, and forms the basis of the present study.
Music Therapy Support Groups
Music Therapy in Support Groups
Music therapy has been used in a variety of support groups focusing on specific
outcomes. Dalton and Krout (2005) utilized music therapy for a bereavement support
group for adolescents. They found a seven-week songwriting group treatment protocol
helped participants improve their grief-processing scores when compared to participants
in the control group. Krout (2005) used music therapist-composed songs for creating
participant connections, discussing group topics, and creating group rituals in a onetime
grief-related support group for adolescents.
In a qualitative, phenomenological study of five children in an arts therapy
support group for grieving children, music therapist Heather Mohan Van Heerden (2006)
found the groups provided a “community of belonging for grieving children” and a
“space where they felt safe, comforted, relaxed, and understood” (p. 878). In addition,
music therapy was used in a combination of caregiver support group and memory
49
training/music therapy study of dementia patients and their caregivers. However, no

significance was found between the control and treatment groups on behavioral and
psychological symptoms or caregiver burden (Berger, Bernhardt, Schramm, Muller,
Landsiedel-Anders, Peters, Kratzsch, & Frolich, 2004).
These studies regarding music therapy in support groups focused on children,
adolescents, and dementia patients and their caregivers. Relatively little research is
documented for adult cancer patients and caregivers in music therapy support groups.
Music Therapy Support Groups for Cancer Patients
Although not specifically called a music therapy cancer support group, a 1996
Music Weekend for Women with Cancer centered on using music for reflection,
relaxation, communication, enjoyment, and emotional expression (Tobia, Shamos,
Harper, Walch, & Currie, 1999). Questionnaires were collected prior to the weekend
session to gather background data about cancer patients and families, and three months
after the weekend to study changes in music usage and mood. Although the findings
were not significant due to the small number of participants, data indicated music may
play a positive role in helping patients and families cope with cancer (Tobia et al., 1999).
Rykov (2008) provided creative group music experiences and explored
perspectives of the adult cancer participants in a qualitative study involving a music
therapy support group. The 10 cancer patient participants experienced the group as a
“profound, nonverbal connection to themselves, to each other, and connection to
something larger–the music–beyond themselves” (Rykov, 2008, p. 199). The music
therapy experiences included a variety of techniques, such as improvisation, music
listening, song choice and singing, imagery and music, creative arts, and journaling
(Rykov, 2008). Participants noted that improvised music-making sessions were
“empowering” and provided “feelings of control during a time of loss-of-control inflicted

by the disease and ensuing experiences of illness” (Rykov, 2008, p. 199). Creative group
music-making allowed participants to experience connection, control, acceptance, self-
50
acceptance, creativity, joy, and well-being (Rykov, 2008). Two primary categories of
themes resulting from the group experience emerged: burden of cancer (financial
concerns, job loss, acceptance/rejection of a “new normal,” fear, isolation, and loss of
control) and music therapy support groups (transformation, importance of nonverbal,
creative self expression, control and connection). “Self-expression through improvised
music facilitated group cohesion and provided a playful aesthetic context that fostered an
atmosphere conducive to building trust, empathy, and intimacy” (Rykov, 2006, p. 89).
The majority of published music therapy studies associated with support group
experiences for cancer patients and caregivers are qualitative. Although the relevant
primary themes enhance clinicians’ understanding of individual experiences of
participants, the lack of a control group or randomization, and lack of pre-test and post-
test data for changes limits generalization of findings. While the relatively modest body
of studies of music therapy support groups suggests great potential, further research in
this area is warranted, particularly with regard to support groups for both cancer patients
and caregivers, which is relatively unexplored.
Music Therapy and Support for Caregivers
Caregivers are the “informal, unpaid care providers of patients with cancer” and
may be spouses, adult children, family, friends, or neighbors (Snyder, 2005, p. 331). The
burden, or impact, of caregiving is the “effect of the patient’s disease and treatment on
the informal caregiver’s everyday life and overall well-being” (p. 331). Caregivers may
feel emotional distress (fear, guilt, worry, anxiety, strain, depression), physical demands
and changes in social role functioning as a result of caregiving (Snyder, 2005).
Music Listening and Relaxation
The research involving music therapy with caregivers is sparse, usually focusing
on family caregivers of hospice patients. Choi (2010) examined the effectiveness of

music and progressive muscle relaxation (PMR) on anxiety, fatigue, and quality of life of
32 hospice caregivers. No significant differences were found between conditions, but the
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music groups (music and music combined with PMR) exhibited a greater decrease in
anxiety and fatigue than the no-music groups (silence and PMR). In addition, both
anxiety and fatigue scores decreased across sessions, which may indicate a “cumulative
effect” possibly demonstrating that only four sessions may not be enough time to modify
quality of life (Choi, 2010, p. 65). Furthermore, the researcher found significant
correlations between anxiety and fatigue, anxiety and quality of life, and fatigue and
quality of life. This study provided evidence that music listening combined with
relaxation techniques may be a beneficial coping strategy for caregivers.
Interactive Music Therapy Techniques

Although caregivers may not be the focus of music therapy research in cancer
care, many times they are included in clinical sessions to provide support for their loved
ones. “Times in music therapy can provide caregivers with moments of intimacy and
meaning, leading to memorable sentiments of love, contentment, and healing” (Magill,
2009, p. 37). Magill (2006) included caregivers in the sessions and demonstrated
techniques to lessen pain and discomfort for their loved ones. Music therapy sessions
with cancer patients and caregivers utilized both vocal techniques (pre-composed songs,
lyric improvisation, songwriting, chanting, and toning) and instrumental techniques
(improvisation, music listening, and music meditation). Ninety hospice patients
completed pre-test and post-test scores on pain, fatigue, anxiety, nausea, and depression.
The post-test scores demonstrated improvement in each area, and indicated further
benefit of using music to ameliorate cancer symptoms. Although the scores focused on
cancer patients, the caregivers also benefited as a result of participation in the sessions.
Caregiver Empowerment Experiences
Caregivers may feel helplessness and loss of control as they watch their loved
ones suffer. Music therapy techniques may provide comfort and support to both patients
and caregivers. In addition, music therapists can demonstrate techniques the caregivers
may adopt to provide comfort for patients when clinical music therapy services are not
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available. In a qualitative study, Magill (2009) analyzed narratives from sessions with
patients and caregivers and examined the role of music therapy strategies on caregiver
reported sense of empowerment. The three music therapy strategies used to support
empowerment were: use of the voice as a medium for communication, creation of audio
recordings, and mindful music listening. Primary themes regarding music therapy from
the perspective of the caregivers included joy, peace, comfort, aesthetic beauty, relief
from distress, and a sense of meaning. This study indicated the importance of music
therapy from a caregiver point of view, and the importance of music therapy
interventions in promoting a sense of empowerment to reduce feelings of helplessness.

O’Callaghan (2001), using a qualitative approach, studied patient, visitor, and
staff experiences of music therapy in a cancer hospital. Over a three-month period, 128
participants completed feedback forms that were analyzed for primary themes. Several
categories and themes arose related to physical, psychological, and social well-being,
with participants acknowledging the importance of the social context of music. One
important theme included: “Music therapy or music can be associated with human
relationships, characterized by the affirmation of one’s social presence embodied in
positive and negative memory association or through community building” (p. 158).
Music therapy provided opportunities for patients and caregivers to connect with others
and come to terms with relationships. This study provided qualitative evidence of both
patient and caregiver positive response to music therapy sessions, and the nature of music
therapy interventions that allows people to make connections with others.
As demonstrated, the majority of research in cancer care involving music therapy
and caregivers is limited to hospice and palliative care. Music therapy sessions may
decrease symptoms in cancer patients and empower caregivers, providing support for
both parties and thereby improving social relationships. More research is needed
regarding patient and caregiver response to music therapy in oncology settings in order to
53
determine the perceived social benefit of music in other stages of cancer diagnosis,
treatment, and survivorship.
Summary of Findings Related to the Design of the Study
This review of literature demonstrated a need for further research in music
therapy and cancer care, specifically in the areas of music therapy support group
experiences for both cancer patients and caregivers, and expanding the literature
regarding music therapy and caregiver response. The following summarizes key findings
and their relationship to the study:
1. The multifaceted nature of music affects physical, psychological, and social

functioning of cancer patients and caregivers. Music may ameliorate physical
effects such as pain, fatigue, nausea, and immune function, as well as
psychological effects of stress, mood, anxiety, and quality of life. The selection
of preferred and meaningful music, as well as the perceived importance of music
in participants’ lives, may influence response to research interventions. These
studies inform the current study regarding choices of music, and appropriateness
of music therapy interventions in order to measure the long-term effects of music
therapy interventions on mood, coping, social support, and quality of life and the
short-term effects on stress, pain, anxiety, mood, and quality of life for cancer
patients and their caregivers.
2. Music can be a social experience, and group music therapy experiences may
decrease isolation and increase social support of cancer patients and caregivers.
Music therapy research in cancer care, specifically involving the benefits of a
combination of interventions facilitated in social groups, is minimal. The
research is limited because of small sample sizes, lack of control groups, lack of
randomization, and lack of quantitative studies in this area. The current study
utilized a quantitative, randomized design with a control group and sufficient
sample size to increase ability to document potential treatment benefits.
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3. The majority of music therapy studies associated with support group experiences
for cancer patients and caregivers are qualitative. Although the relevant primary
themes allow clinicians to better understand the individual experiences of
participants, lack of a control group for comparison or randomization, and lack of
pre-test and post-test data for quantitative change limit the generalization of
results. This study used pre-test and post-test data over the course of the study and
each individual session to compare responses of cancer patients and caregivers.
!" The majority of research in cancer care involving music therapy and caregivers is
limited to hospice and palliative care. Music therapy sessions may also decrease
symptoms in cancer patients still actively engaged in treatment, and empower
caregivers, improving their supportive interactions and social relationships. More
research is needed regarding patient and caregiver response to types of music
therapy interventions in order to determine perceived benefit in other stages of
cancer diagnosis, treatment, and survivorship. In order to address this lack of
documented research, the current study included both cancer patients and
caregivers in multi-week music therapy support groups comprised of varying
forms of music engagement. #
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CHAPTER III
METHODOLOGY
Introduction
As indicated in Chapter One and Chapter Two, music is a multifaceted art form
that affects physical, psychological, and social functioning of cancer patients and
caregivers. Shared musical experiences can readily encourage social interaction; thus,
group music therapy experiences may decrease isolation and increase the social support
networks of cancer patients and caregivers. In addition, the combination and interaction
of both patients and caregivers in music therapy support groups may enhance natural
social support networks and affect overall well-being. While the social benefits of music
therapy are a basic premise of the profession since its inception (Davis & Gfeller, 2008),
systematic evaluation of social support with cancer patients and caregivers is currently
limited in breadth and depth. Furthermore, the generalizability of the modest body of
extant studies in this area is limited due to small sample sizes and lack of randomized
controlled trials.
The purpose of this study was to examine the effect of participation in six music
therapy support group sessions on mood, coping, social support, and quality of life of
cancer patients and their caregivers. The effects of these variables were examined from
beginning to end of the overall group experiences (long-term effects), as well as in
response to individual sessions (short-term effects).
The research design was an experimental, randomized controlled trial, utilizing an
experimental group and a wait-list control group. The research protocol included four
different self-report questionnaires completed at baseline, midpoint, and end of the three
weeks. In addition, a rating scale was completed before and after each of the six
individual 60-minute sessions. The purpose of the design was to compare both long and
short-term effects of participation in a six-session music therapy support group
throughout the overall three-week time period and for each individual 60-minute session.
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The independent variable for this study was participation in a music therapy
cancer support group. The long-term (three week) dependent variables included changes
in perceived (a) mood as measured by the Profile of Mood States (POMS), (b) coping as
measured by the State Trait Anxiety Inventory-State Scale (STAI-S), (c) social support as
measured by the Personal Resource Questionnaire 85-Part 2 (PRQ85-Part 2), and (d)
quality of life as measured by the Functional Assessment of Cancer Therapy-General
Form (FACT-G). In addition, the State Trait Anxiety Inventory-Trait Scale (STAI-T), was
administered at baseline, midpoint, and post-treatment to confirm that the experimental
and control group were equivalent in their typical level of anxiety, as well as to confirm
the stability of trait anxiety over the period of the study. The short-term (60-minute
session) dependent variables included changes in perceived mood, pain, stress, anxiety,
and quality of life as measured by pre- and post-session 11-point (0-10) Music Therapy
Support Group Numerical Rating Scales (MTSG-NRS).
Research Questions
Two primary research questions were investigated in this study: (a) change over
the entire three-week treatment period, and (b) change over each 60-minute group music
therapy session. The first question investigated possible changes in mood, coping, social
support, and quality of life of participants over the entire three-week treatment period.
1a. Will participation in a six-session music therapy cancer support group make a
difference in perceived mood of cancer patients and caregivers?
1b. Will participation in a six-session music therapy cancer support group make a
difference in perceived coping, as measured by a change in anxiety, of cancer
1c. Will participation in a six-session music therapy cancer support group make a
difference in perceived social support of cancer patients and caregivers?

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1d. Will participation in a six-session music therapy cancer support group make a
difference in perceived health-related quality of life of cancer patients and
caregivers?
The second research question examined changes over a shorter duration of time.
This second question investigated possible changes in perceived mood, pain, stress,
anxiety, and quality of life during each individual 60-minute treatment session.
2a. Will participation in each individual 60-minute session of a music therapy
cancer support group make a difference in perceived mood of cancer patients and
caregivers?
2b. Will participation in each individual 60-minute session of a music therapy
cancer support group make a difference in perceived pain of cancer patients and
caregivers?
2c. Will participation in each individual 60-minute session of a music therapy
cancer support group make a difference in perceived stress of cancer patients and
caregivers?
2d. Will participation in each individual 60-minute session of a music therapy
cancer support group make a difference in perceived anxiety of cancer patients
and caregivers?
2e. Will participation in each individual 60-minute session of a music therapy
cancer support group make a difference in perceived quality of life of cancer
Research Hypotheses
The first research hypothesis, divided into four sub-hypotheses, studied the effect
of mood, coping, social support, and quality of life of participants across the entire six-
session treatment period.

58
1a. Participation in a six-session music therapy support group will improve

perceived mood of participants as measured by a decrease in the Total Mood
Disturbance Score on the Profile of Mood States (POMS).
1b. Participation in a six-session music therapy support group will improve
perceived coping levels of participants as measured by a decrease in anxiety
scores on the State Trait Anxiety Inventory-State Scale (STAI-S).
1c. Participation in a six-session music therapy support group will improve
perceived levels of social support of participants as measured by an increase in
scores on the Personal Resource Questionnaire 85-Part 2 (PRQ85-Part 2).

1d. Participation in a six-session music therapy support group will improve
perceived levels of quality of life of participants as measured by an increase in
scores on the Functional Assessment of Cancer Therapy-General Form
(FACT-G).
The second research hypothesis, divided into five sub-hypotheses, reviewed
changes in perceived mood, pain, stress, anxiety, and quality of life of participants during
each individual 60-minute music therapy treatment session.
2a. Participation in a music therapy support group will improve perceived mood
an increase of scores on pre- and post-Music Therapy Support Group Numerical
2b. Participation in a music therapy support group will decrease perceived stress
a decrease of scores on pre- and post-Music Therapy Support Group Numerical
2c. Participation in a music therapy support group will decrease perceived

anxiety of participants within each individual 60-minute treatment session as
59
measured by a decrease of scores on pre- and post-Music Therapy Support Group

2d. Participation in a music therapy support group will improve perceived pain of
participants within each individual 60-minute treatment session as measured by a
decrease of scores on pre- and post-Music Therapy Support Group Numerical
2e. Participation in a music therapy support group will improve perceived quality
of life of participants within each individual 60-minute treatment session as
measured by an increase of scores on pre- and post-Music Therapy Support Group

Participants
Participants were 41 cancer patients (n=24) and caregivers (n=17) randomly
assigned to an experimental (n=21) or wait-list control condition (n=20). People were
recruited from the Holden Comprehensive Cancer Center at The University of Iowa
Hospitals and Clinics, Russell and Anne Gerdin American Cancer Society (ACS) Hope
Lodge in Iowa City, Mercy Medical Center in Cedar Rapids, and from the local and
regional communities. Nursing and physician team members identified participants as
appropriate for recruitment, or participants contacted the primary investigator
independently as a result of information provided in the Institutional Review Board
(IRB)-approved flyer, news releases, and advertisements.
Eligibility Criteria
Patient participants were eligible for the study if they met the following criteria:
1. Adults over age 18, diagnosed with cancer
2. Currently undergoing treatment or last treatment appointment within one year of
the first group music therapy session

3. At least one week after surgery before music therapy sessions begin
4. English as their primary language
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5. Ability to read and write in English

6. No dementia or central nervous system (CNS) involvement that would affect
enjoyment of music or participation in group
7. Ability to hear and speak
8. Physically able to attend a support group twice weekly for three weeks
9. If possible, have a caregiver (family member or close friend) to attend group
Caregiver participants (spouse, parent, friend, child), identified by the patient,
were eligible for the study if they met the following criteria:
1. Must be 18 years or older

2. English as their primary language
4. No dementia or CNS involvement
6. Physically able to attend a support group twice weekly for three weeks
Exclusion Criteria
Those who responded to the invitation to participate in the study were excluded
from participation if, at the onset of the study, they were:
1. In hospice care
2. Unable to travel to attend the group
3. Uncomfortable attending groups because of a suppressed immune system in
which exposure to crowds would be contraindicated.
In addition, participants could withdraw from the study if they became too
medically fragile to continue, if they did not meet criteria at any point in the study, or if
hospice was determined to be a more appropriate type of treatment.
Sampling Design
Participants who signed the Informed Consent Document were randomly assigned
to an experimental group or a wait-list control group. The wait-list group was offered an
61
opportunity for treatment following completion of the control-group period of this study.
A 1:1 ratio was used with a random list generator for the assignment to experimental and
control groups. The randomized list was populated depending on the date consent was
signed.
Power and Effect Size
This study was limited to 41 participants (n=20 control, n=21 treatment) because
of time, location, feasibility, and financial considerations. However, the limited sample
size still allowed for statistical significance and clinical meaningfulness as outlined
below.
An independent t-test can be used for power calculation of change scores, if
normality is assumed for the data. Although the independence of 20 subjects in each
group is not fully possible, given that some patients were paired with caregivers, this
circumstance was addressed by examining correlation between responses of caregivers
and patients. With 20 subjects in each group, the analyses chosen for this study would be
able to detect an effect size of 0.9091 of change scores with 80% power and 5% type I
error rate. In a worst-case scenario, the researcher expected no less than 17 subjects to
finish, which would result in an effect size of 0.9910 of change scores detected by the
study.
Instrumentation
In order to measure long-term (three week) outcomes, all participants (N=41)
completed the Profile of Mood States (POMS), State Trait Anxiety Inventory-State (STAI-
S) and Trait (STAI-T) scales, Personal Resource Questionnaire 85-Part 2, (PRQ85-Part
2) and the Functional Assessment of Cancer Therapy-General Form (FACT-G) at
baseline, midpoint, and end of the three weeks. Pre- and post-Music Therapy Support
Group Numerical Rating Scales (MTSG-NRS) measured short-term (60-minute)

outcomes of mood, pain, stress, anxiety, and quality of life as a result of participation in
each music therapy session.
62
Participants also completed the Music Therapy Support Group Assessment Form
(MTSG-AF) to provide demographic information, music preferences, and expectations
for group before sessions began. After sessions concluded, all participants in the
experimental group and those in the wait-list control group who completed music therapy
sessions after their control group period was over completed the Music Therapy Support
Group Evaluation Questionnaire (MTSG-EQ) to provide feedback and information
regarding their experiences with the music therapy sessions. The measures are described
in the following sections.
State Trait Anxiety Inventory (STAI-S, STAI-T)

The State Trait Anxiety Inventory (STAI) (Spielberger, 1983) is a standardized
measure that distinguishes between the temporary condition of state anxiety and the
longstanding quality of trait anxiety, and distinguishes between anxiety and depression
(Lipscomb, Gotay, & Snyder, 2005). The state-anxiety scale (STAI-S) measures how
participants feel at the present moment by rating the intensity of their feelings from 1)
“not at all” to 4) “very much so” (Spielberger, 1983). The trait-anxiety scale (STAI-T)
measures how participants generally feel by rating the frequency of their feelings from 1)
“almost never” to 4) “very much so.” The items are given weighted scores from one to
four, with a higher score indicating more anxiety.
Each scale includes 20 items, with scores for each of the scales ranging from 20 to
80 (Spielberger, 1983). Coefficients range from 0.65 to 0.86 for trait anxiety and 0.16 to
0.62 for state anxiety. The low stability level of the state-anxiety scale is expected
because of the transient nature of state anxiety (Lipscomb et al., 2005). The STAI is used
in many cancer studies with validity correlations ranging from 0.52 to 0.82.
Norms for the STAI include an alpha of .93 for state anxiety with mean scores in
working adults of 35.72 for males and 35.20 for females, and standard deviations of 10.4
for males and 10.61 for females (Spielberger, 1983). Trait anxiety includes an alpha of
.91, with mean scores in working adults of 34.89 for males, and 34.79 for females, with
63
standard deviations of 10.4 for males and 10.61 for females. Norms for general medical
and surgical patients include a mean of 42.38 and standard deviation of 13.79 for state
anxiety, and a mean of 41.91 and standard deviation of 12.70 for trait anxiety.
In a review of randomized controlled trials involving music listening in the
nursing literature, the STAI was a common tool used to measure anxiety. Nilsson (2008)
reported the STAI was used in 19 out of 24 studies, with anxiety significantly reduced in
the experimental group as a result of the music intervention in roughly half of them.
Various studies utilized the STAI to measure changes in anxiety as a result of music
interventions in studies by Bulfone et al. (2009), Burns et al. (2005), Burns et al. (2008),
Harper (2001), Pothoulaki et al. (2008), Shabanloie et al. (2010), and Smith et al. (2001).
Thus, this measure appears to be sensitive enough to document change in anxiety as a
result of treatment interventions. Therefore, a change in the perception of anxiety of
participants indicates a change in ability to cope with aversive or stressful circumstances
(Sarafino, 2006).
Profile of Mood States (POMS)
The Profile of Mood States (POMS) is a standardized instrument used in a number
of cancer studies to assess mood, with six subscales to distinguish mood states and mood
changes associated with research and clinical interventions (Lipscomb et al., 2005). The
original measurement tool was published in 1971, with a revised version in 1992, and a
more current 2008 booklet. According to McNair and Heuchert (2005), in the early
1990s alone, more than 3800 authors cited the POMS in 1,000 reports published in 400
journals. In addition, cancer research papers used the POMS in more than 250 citations.
The POMS assesses mood using a 65-item five-point adjective rating scale in
which participants rate how they feel right now or how they felt during the past week;
points range from 0) “not at all” to 4) “extremely” (McNair, Lorr, & Droppleman, 1992).
The items are separated into six domains or subscales, which include Tension-Anxiety
(T), Depression-Dejection (D), Anger-Hostility (A), Vigor-Activity (V), Fatigue-Inertia
64
(F), and Confusion-Bewilderment (C). The subscales have a mean standard score of 50
with a standard deviation of 10, with all items weighted the same direction except for
“relaxed” in the tension-anxiety subscale and “efficient” in the confusion subscale
(McNair et al., 1992).
The sum of subscale scores presents a Total Mood Disturbance score (TMD),
with higher scores indicating more mood disturbance. All the subscales are added
together, except for Vigor-Activity (V), which is subtracted from the score. According to
McNair and Heuchert (2005), in an adult normative sample, the means (M) and standard
deviations (SD) for the subscales included: (a) T subscale M = 7.7, SD = 5.9; (b) D
subscale M = 8.0, SD = 9.3; (c) A subscale M = 7.6, SD = 7.5; (d) V subscale M = 19.3,
SD = 6.7; (e) F subscale M = 8.0, SD = 5.9; and (f) C subscale M = 5.7, SD = 4.4. The
overall TMD score mean was 17.7 with a standard deviation of 33. However,
hospitalized patients have more mood disturbance with mean scores of T = 23.5, D =
30.6, A = 13.7, V = 8.0, F = 14.6, and C = 15.9 (McNair & Heuchert, 2005).
The Profile of Mood States has an internal consistency of .87 to .95 (Lipscomb et
al., 2005), and test-retest reliability ranging from .65 to .74 in the six subscales (McNair
& Heuchert, 2005). In addition, the POMS is a common measurement tool used to study
changes in mood involving music in both nursing and music therapy literature (e.g.,
Burns, 2001; Cassileth et al., 2003; Stordahl, 2009; Waldon, 2001).
Functional Assessment of Cancer Therapy-General Form (FACT-G)
The Functional Assessment of Cancer Therapy General (FACT-G) Version 4 is a
standardized self-report questionnaire that measures health-related quality of life in
cancer patients of any tumor type, and assesses physical, emotional, functional, and social
well-being of patients receiving cancer treatment (Cella, Tulsky, Gray, Sarafian, Linn,
Bonomi et al., 1993). The FACT-G questionnaire is one quality of life measurement that
is part of the larger Functional Assessment of Chronic Illness Therapy (FACIT)
measurement system. In a review of literature of 477 quality of life studies with breast
65
cancer patients, Montazari (2008) indicates that the FACT-G, which may also be called
the Functional Assessment Chronic Illness Therapy General form (FACIT-G), was one of
two most frequently used self-measurement tools.
The FACT-G (Version 4) has 27 items and four subscales, with subscale scores
ranging from zero to 28 for the physical, emotional, and functional subscales and zero to
24 for the emotional subscale (Erickson, 2005). Item scores are added to form subscale
and overall scores, with higher scores indicating less dysfunction and better quality of
life. In order to achieve each subscale score, item responses are added together, reversing
the direction of the score when necessary. The initial score is multiplied by the total
number of items in the subscale, and then divided by the number of items answered. The
subscales are added for a total score out of a possible 108, with a higher score indicating
better quality of life (Erickson, 2005).
Normative data for the general adult population includes a M = 86.5 and SD =
15.2 (Holzner et al., 2004) and normative data for a sample with cancer shows a M = 80.0
with a SD = 17 (Bruckner, Yost, Cashy, Webster, & Cella, 2005). Reliability data for the
FACT-G is reported as an overall score (Cronbach’s alpha) of 0.89, and subscales ranging
from 0.65 to 0.82 (Erickson, 2005). The test-retest reliability coefficients range from .82
to .92 and subscale internal consistency scores range from .60 to .89 (Holzner et al.,
2004).
The Personal Resource Questionnaire 85 Part 2 (PRQ85-Part 2)
The Personal Resource Questionnaire 85 Part 2 (PRQ85-Part 2) is a self-report
inventory that measures the perceived level of social support of individual participants
(Brandt & Weinert, 1981). Brandt and Weinert designed the original Personal Resource
Questionnaire in 1981, with modifications (PRQ82) and refinements leading to the
PRQ85, a self-administered measurement tool (Weinert, 1987). The PRQ85 contains two
parts, with Part One measuring 10 questions regarding life situations and rating the
support given by significant others over the last six months. Participants check one or
66
more resources and indicate satisfaction with support using a six-point rating scale. Part
One produces three scores (network size, number of problems experienced, and degree of
satisfaction with received help) but no total score (Diamond, 2004). Part One was not
used in this study because the questions related to a six-month time period; the length of
the study was three weeks. In addition, the types of questions related to social networks
in 10 specific situations were outside the scope of the study. Please refer to Appendix A
for the PRQ85-Part 2.
Part Two may be administered separately from Part I, and includes a rating scale
(1-7) for 25 statements in which participants rate how strongly they agree or disagree
with each item (Diamond, 2004; Weinert, 1987). The item statements “represent
internalized, subjective feelings” regarding perceived support; therefore, changes may
occur in scores as a result of psychosocial interventions (Diamond, 2004, p. 2). The total
score from the 25 statements is then used for comparison; scores range from 25-175.
Higher scores indicate higher levels of perceived social support (Brandt & Weinert,
1981). Because the measurement tool may be split and only one part used, validity and
reliability scores are separate for each part, with only Part Two scores given below.
Test-retest reliability for 100 adults has been reported at .72, with Cronbach’s
alpha reliability coefficients ranging from .85 to .93 in young, middle, and older adult
studies with varying group sizes (45 to 188 people) (Diamond, 2004). Construct validity
indicated the PRQ measured different constructs from the Beck’s Depression Inventory
(BDI), State Trait Anxiety Inventory (STAI), and Eysenck’s Personality Inventory (PI).
Correlations between the PRQ and BDI were r = -.42, between PRQ and STAI were r =
-.37, and between the Introversion scales from Eysenck’s PI were r = -.28 (Weinert,
1987). Although several music therapy studies utilized the social benefits of group
participation (Allen, 2010; Daykin et al., 2007; Magill et al., 2008; Waldon, 2001;
Young, 2009), no previous music therapy study has utilized the PRQ85-Part 2 as a
measure of social support as an outcome.
67
Music Therapy Support Group Numerical Rating Scales (MTSG-NRS)

Participants in the experimental group completed Music Therapy Support Group
Numerical Rating Scales (MTSG-NRS) regarding levels of pain, mood, stress, anxiety,
and quality of life before and after each music therapy session. The 11-point (0-10)
MTSG-NRS studied short-term effectiveness of music therapy interventions within the
60-minute experimental group sessions. Participants rated each category from zero to 10
both before and after the session, resulting in two numbers that were analyzed for an
interaction. Please refer to Appendix B for the pre- and post-MTSG-NRS.
Numerical Rating Scales are used in nursing and music therapy literature,
especially when detecting perceived pain and anxiety levels. In a review of nursing
studies involving music listening, Nilsson (2008) reported three studies using a NRS for
anxiety and nine studies using a NRS for pain. NRS scales from 0-10 are found in the
Edmonton Symptom Assessment System in palliative care, with symptoms such as pain,
nausea, appetite, tiredness, drowsiness, depression, well-being, and shortness of breath
measured (Horne-Thompson & Grocke, 2008). In music therapy studies, Clark et al.
(2006) utilized a NRS for distress and pain, and Groen (2007) indicated the NRS was the
second most commonly used pain assessment technique among palliative care music
therapists.
From previous personal clinical experience, a rough approximation of change
would include an increase of three points for mood and quality of life, a decrease in
approximately three points for anxiety and stress, and an approximate decrease of two
points for pain. With a hypothetical mean of five based on the 0-10 point scale and a
hypothetical standard deviation of four points, an increase in two points (mood, quality of
life) would yield an effect size of .75 with a power of .92. A decrease in three points for
anxiety and stress would also yield an effect size of .75 with power at .92. A decrease in
pain of two points would yield an effect size of .50 with power at .60.
68
Music Therapy Support Group Assessment Form (MTSG-AF)

All participants completed the Music Therapy Support Group Assessment Form
(MTSG-AF) in order to gather information regarding participant demographics, music
preferences, interest in group sessions, expectations for group, and further qualitative
information in order to test for initial differences between the control and experimental
groups. In addition, cancer patients filled out information regarding time since diagnoses
and stage of cancer; caregivers provided relationship information. Based on the survey,
music therapy interventions, while essentially equivalent in format and general methods,
were adapted to meet the health needs and musical preferences of group participants.
The adaptations did not alter the overall group protocol, but allowed the researcher to
plan ahead for possible adjustments in questions and directions. For example, if a breast
cancer participant recently had surgery and had difficulty lifting her arm, the primary
investigator (PI) would demonstrate modified motions or stretches for the movement and
music activity. In addition, one intervention asked participants to share meaningful songs
with others in the group, and previous knowledge of musical preferences was helpful in
facilitation. Furthermore, the assessment allowed the PI to check for unreasonable
expectations that participants may have for the group and to clarify any misconceptions.
The overall group protocol was followed as closely as possible to avoid introducing
potential confounding variables.
The PI developed the MTSG-AF from previous oncology music therapy support
group experiences in the chemotherapy and radiation treatment waiting rooms in the
Holden Comprehensive Cancer Center (HCCC) at the University of Iowa Hospitals and
Clinics. These pilot groups included patient and caregiver participants of all ages and
diagnoses waiting for treatments. The groups were flexible and dynamic, with
participants joining and leaving depending on appointment scheduling. The PI designed

the MTSG-AF in response to a need for further assessment information regarding music
preferences, group expectations, and demographic information in order to make the
69
music therapy experience as effective as possible for the majority of attendees. In

addition, more extensive demographic information, commonly gathered in oncology and
used to compare treatment and wait-list control groups, was added based on research and
clinical practice. Please refer to Appendix C for the Music Therapy Support Group
Assessment Form.
Music Therapy Support Group Evaluation Questionnaire (MTSG-EQ)
Three weeks after completion of the experimental portion of the study, the Music
Therapy Support Group Evaluation Questionnaire (MTSG-EQ) and self-addressed
stamped envelope were mailed to participants to complete and send back to the primary
investigator. All experimental participants and those wait-list control participants who
completed music therapy sessions after their control period was over received a
questionnaire. The questionnaire included both quantitative and qualitative information
for feedback regarding the music therapy sessions. This follow-up form allowed
participants to share information about experiences, both positive and negative, as a result
of their involvement in the study.
The PI developed the MTSG-EQ as a result of the same oncology music therapy
support group experiences in the chemotherapy and radiation treatment waiting rooms.
The pilot evaluation form included four open-ended questions designed to gather
feedback information. After several modifications, the final questionnaire adopted for
the study utilized a combination of closed and open-ended questions. Please see
Appendix D for the Music Therapy Support Group Evaluation Questionnaire.
Procedures
The primary investigator submitted the research study proposal to the Human
Subjects Office of the University of Iowa Institutional Review Board (IRB-1) (see
Appendix E). In addition, because all research studies involving patients in the Holden
Comprehensive Cancer Center (HCCC), located in the University of Iowa Hospitals and
Clinics, must be reviewed and approved by the HCCC Protocol Review and Monitoring
70
Committee (PRMC), a separate proposal was submitted to the PRMC. Furthermore, the
study required nursing staff resources so another proposal was submitted to the Nursing
Research Committee. In order to expand the potential pool of participants by recruiting
in a larger geographic area and larger urban location, a separate IRB proposal was
submitted to the Institutional Review Board of Mercy Medical Center in Cedar Rapids,
IA (see Appendix F). Once all proposals were approved by the separate entities, the PI
began to recruit participants to the study.
Pre-Treatment: Recruitment and Informed Consent
The IRB-approved recruitment materials informed potential participants about the

study and provided the primary investigator’s contact information. Posters were placed
in the hospitals and community, news releases were sent to local newspapers, and
advertisements were placed in the UIHC Noon News, Mercy Newsletter, and local
papers. Recruitment letters, materials, and announcements appear in Appendix G. The
PI presented information to local cancer support groups, hospital medical and nursing
staff in the Holden Comprehensive Cancer Center (HCCC), and local support groups and
community groups. An email was also sent to staff in the HCCC upon approval from
administration and the Human Subjects Board.
Once staff identified potential subjects, or subjects contacted the researcher
independently, the primary investigator met with both cancer patient and caregiver, if
possible. While meeting with subjects, the PI provided them with the IRB-approved
Informed Consent Document and answered any questions. If the caregiver was not
present, the subjects were asked to have their caregiver (spouse, parent, child, friend)
contact the PI within one week to schedule an appointment to complete materials. If
participants requested time to discuss participation together or take the document with
them to read, additional time was granted. These meetings took place in the University
of Iowa Hospitals and Clinics Department of Rehabilitation Therapies, a conference room
at the American Cancer Society Hope Lodge in Iowa City, Mercy Medical Center in
71
Cedar Rapids, or in the Holden Comprehensive Cancer Center, depending on

convenience for the potential participants.
After Informed Consent was obtained, the participants completed the Music
Therapy Support Group Assessment Form (MTSG-AF), State Trait Anxiety Inventory
(STAI), Profile of Mood States (POMS), Functional Assessment of Cancer Treatment-
General Form (FACT-G), and the Personal Resource Questionnaire 85-Part 2 (PRQ85-
Part 2). These self-report questionnaires provided baseline data for comparison with
subsequent measures following treatment.
Once forms were completed, participants were assigned a research identification

number (RIN) used on all testing materials for confidentiality purposes. Each RIN was
stored separately from personal identification information for the duration of the study,
with all materials stored in locked filing cabinets to which only the PI had access.
Because of ethical considerations (not withholding potentially beneficial treatment),
participants were then randomly assigned (with their caregiver) to treatment groups or
wait-list control groups. The wait-list control groups were offered an opportunity for
treatment following their completion of the control group period of the study. Before
each treatment group began, participants provided their schedule availability and the PI
scheduled groups during days and times convenient to the participants in that particular
group.
During Treatment: Methods and Testing
Logistics
The Music Therapy Support Group (MTSG) sessions were held at the American
Cancer Society (ACS) Russell and Ann Gerdin Hope Lodge in Iowa City (four groups),
and the Watts Medical Library in Mercy Medical Center (MMC) (one group). The ACS
Hope Lodge groups were facilitated in a conference room while the MCC group met in a
sitting area of the library after hours. The groups were facilitated, as much as possible,
72
away from the hospital milieu in order to improve acceptance and decrease previous
negative associations with treatment symptoms in hospital environments (Weis, 2003).
Five experimental groups, ranging in size from three to six participants (M = 4.2
participants), were facilitated in June, July, and August-September, 2010; and January-
February and March, 2011 (see Table 1). Experimental group participants (n=21)
completed six music therapy support group sessions over a three-week period in which
several music therapy interventions were utilized, including singing, songwriting, playing
instruments, movement with music, creative arts with music, and music-assisted
relaxation.
Table 1
Number of Participants in Experimental Groups by Subgroup
________________________________________________________________________
Experimental Group Total Caregivers Cancer Patients
________________________________________________________________________
June 5 2 3
July 6 3 3
August-September 3 1 2
January-February 4 2 2
March 3 1 2
Average Number Per Group 4.2 1.8 2.4
________________________________________________________________________
The wait-list control group participants (n=20) included cancer patients (n=12)
and caregivers (n=8) who had the opportunity to complete music therapy sessions after
their control period was over. These participants did not need to complete the MTSG
protocol, but instead chose from the following music therapy interventions: relaxation
73
with music (n=6), participating in entire MTSG protocol (n=3), playing instruments
(n=2), recording a CD (n=2), singing preferred songs (n=1), songwriting (n=0), and
creative arts with music (n=0). Six control group participants, due to personal time and
travel constraints, did not complete a music therapy session after their control group
period was over.
Materials
Music therapy support groups were conducted twice weekly for 60 minutes over
the course of three weeks. The music therapy interventions focused primarily on the
dependent variables of improving mood, coping, social support, and quality of life. In
order to modify these areas, the music therapy sessions included the following treatment
aims: (a) increase communication between patient and family member, (b) provide
increased social support by expanding the social networks of program participants, (c)
increase emotional expression and creativity, (d) improve mood and decrease depressive
symptoms, (e) improve relaxation and stress-management techniques, and (f) improve
overall quality of life of participants.
Each session included a relevant and meaningful topic designed to assist in
meeting the needs of cancer patients and caregivers. The session topics and interventions
were developed by the principal investigator based on research and clinical work (Antoni,
2003; Gfeller, 2008; Miller & O’Callaghan, 2010; O’Callaghan, 1997; O’Callaghan,
O’Brien, Magill, & Ballinger, 2009; Pelletier, 2004; Reuer, 2006; Standley, 1986; Thaut,
2005), in conjunction with verbal and written feedback from previous participants in
music therapy sessions. In addition, another board-certified music therapist experienced
in music therapy and cancer care reviewed the final selection of topics and interventions.
The session topics included: (a) Stress Management, (b) Emotional Expression, (c)
Wellness, (d) Connection, (e) Creativity, and (f) Hope and Affirmation.
Before and after each group, the treatment participants (patients and caregivers)
completed a self-report measure using a 0-10 Music Therapy Support Group Numerical
74
Rating Scale (MTSG-NRS) in the areas of pain, mood, stress, anxiety, and quality of life.
Within each session, participants engaged in a variety of music therapy techniques,
including songwriting, active music making, music listening and discussion, music-
assisted relaxation, creative arts with music, and movement with music. Please see
Appendix H for MTSG session protocols and a brief description of general categories of
music therapy interventions.
After the third and sixth sessions, all participants completed the STAI, POMS,
FACT-G, and PRQ85-Part 2, gaining multiple measurement points in order to better
understand the dynamism and improvement over time of mood, coping, social support,
and quality of life (King & Hinds, 2003). The self-report questionnaires permitted
comparisons between pre-session and midpoint, midpoint and post, and pre- and post-
data, and allowed multiple comparisons of the dependent variable for all participants.
Pre- and post-group MTSG-NRS measuring mood, pain, stress, anxiety, and quality of life
provided additional data to evaluate the short-term effect of different music therapy
interventions on experimental group participants. Both patients and caregivers completed
the MTSG-NRS before and after the sessions in order to take into account caregiver
response to the interventions. The MTSG-NRS also accounted for individual responses of
patients who, as a result of acute change in health status, may be unable to complete the
entire study protocol.
Wait-list control group participants completed the same forms in the same time
line as the treatment group, but did not attend music therapy groups during their time in
the control portion of the study. Please see Figure 1 for experimental and wait-list
control group timelines. Once they completed the three sets of forms, wait-list
participants could chose to participate either in the music therapy support group protocol
for an additional three weeks, or because of time constraints, participants could attend
individual music therapy sessions of their choice.
75
Figure 1
MTSG Recruitment, Testing, and Measurement Protocol
Recruitment: Nursing or Self-

Referral
Informed Consent Document,

MTSG-AF, POMS, STAI,
FACT-G, PRQ85
Randomly Assigned to
Experimental or Control
MTSG-NRS forms pre- and Wait-list control group

post-MTSG sessions 1, 2, 3 receives no treatment
Completed POMS, STAI, Completed POMS, STAI,

FACT-G, PRQ85 FACT-G, PRQ85
MTSG-NRS sessions 4, 5, 6 Wait-list control group

receives no treatment
Completed POMS, STAI, Completed POMS, STAI,

FACT-G, PRQ85 FACT-G, PRQ85
Completed MTSG-EQ MT Session; No MT

MTSG-EQ Session
76
Post-Treatment: Compensation and Follow-Up

At the end of three weeks, all participants (patients and caregivers) in both the
control and experimental groups completed the STAI, POMS, PRQ85-Part 2, and FACT-
G. After completion of all post-session forms, participants received a $25 gift card to
their choice of Walmart or Target as compensation for their time in the study. In
addition, participants in the experimental group and those in the wait-list control group
who opted to receive music therapy sessions after their control group period received a
Music Therapy Support Group Evaluation Questionnaire (MTSG-EQ) in the mail to
complete and return.
Data Analysis
Missing Values
Missing values are a reality that must be accounted for in any research with
human subjects, including specific items in self-report measures. Because protocols for
human subject testing cannot include coercion, it is essential that participants feel free to
skip questions in a survey as they wish. Thus, most research with human participants
will likely have some missing data. Based on previous clinical experience with this
population, it is anticipated that most participants will likely be cooperative and complete
the majority of questions.
In order to address the occasional missing data point, the researcher and
statisticians were prepared to compute the test scores based on the mean scores rather
than the total score. In this way, if a participant answers 32 questions the average will be
taken out of 32, rather than 33, thereby eliminating (averaging out) the missing value.
However, this technique was not needed because of the low incidence of missing values.
Statistical Analysis
Four self-report questionnaires measured the change in scores of dependent
variables at baseline, midpoint (after the third session), and after the three-week period
77
(after the sixth session). The POMS measured changes in mood, the STAI measured
changes in coping, the PRQ85-Part 2 measured perceived social support, and the FACT-
G measured perceived quality of life. These forms studied the effect of music therapy on
levels of mood, coping, quality of life, and social support within groups and between
groups over time.
Participants completed the self-report questionnaires before the first, and after the
third and sixth sessions, which allowed comparisons between baseline and midpoint
(after the third session), the third and sixth session, and baseline and sixth-session data.
The midpoint data permitted multiple comparisons of the dependent variables and
provided needed analyses in case of participant attrition. Pre- and post-session Music
Therapy Support Group Numerical Rating Scales (MTSG-NRS) measured mood, stress,
pain, anxiety, and quality of life on an 11-point (0-10) scale and provided additional data
to measure the short-term effect of different music therapy interventions on treatment
group participants.
The PI recorded information obtained from the MTSG-AF, STAI, POMS, FACT-
G, PRQ85-Part 2, pre- and post-session MTSG-NRS, and the MTSG-EQ on data
spreadsheets and transferred the data to a statistical software package. The PI and team
biostatisticians analyzed data using a statistical software package (SAS 9.1).
Characteristics at baseline were checked to test whether the random allocation
ruled out possible confounding variables. The unbalanced variables were controlled as
confounding variables. Five separate repeated measures ANOVA were completed on
outcomes of the POMS, STAI-S, STAI-T, PRQ85-Part 2, and FACT-G. The within subject
correlation was modeled the same for all five tests with compound system, which means
the correlation between baseline and session three, baseline and session six, and session
three and six are considered the same. The Tukey-Kramer method was used to adjust p-
values and decrease Type I error due to multiplicity (multiple tests on the same
78
subgroups). The MTSG-NRS scores were analyzed using Wilcoxon Rank Sum tests and
t-tests to determine changes from pre- to post-session.
Limitations and Delimitations
Delimitations
Delimitations are limitations deliberately imposed on a research design and which
restrict generalization of the results (Rudestam & Newton, 1992). In order to generalize
the study results from the experimental situation to a broader context, the research design
must take into account external validity (Tuckman, 1999). The generalizability of the
study was influenced by a) interaction effects of selection bias, b) reactive effects of

experimental arrangements, and c) multiple-treatment interference.
The interaction effects of selection bias refer to the characteristics of the samples
for the study that may not be representative of the larger population (Tuckman, 1999). In
order to control for extraneous variables, the researcher established eligibility criteria,
which although helpful to define the population, may have limited generalizability of the
results. For example, the overall population was adult cancer patients currently
undergoing treatment or within one year of treatment. This study occurred in the
Midwest, with a majority of the interested potential participants of Caucasian descent
from small towns or cities. The results of the study may not generalize to a more diverse
population from an urban area or from a different part of the country. In addition, certain
eligibility requirements of the study, such as English as a primary language and the
ability to read and write in English, may have limited the ability of the results to
generalize to the broader population of cancer patients whose primary language is not
English or who are not literate.
Moreover, the arrangements of the experiment or the simple experience of
participating in an experiment may have changed the performance of participants (i.e.

Hawthorne Effect) (Tuckman, 1999). Participants may have reacted differently due to
the experimental nature of the study, not necessarily because the treatment was effective.
79
In order to decrease the reactive effect of experimental arrangements, the control group
participants were given the same directions and time frame as the treatment group. The
researcher attempted to minimize the need for participant “performance” by discussing
the importance of answering questions and completing forms honestly no matter what the
participant might feel, and reminding participants that the researcher did not see any data
until after the six-session group was completed.
Participants may also have received several treatments simultaneously throughout
the course of their cancer treatment, resulting in multiple-treatment interference
(Tuckman, 1999). The other treatments, in addition to the experimental treatment, may
interact with one another and affect the results differently than if the participants
experienced only one. In addition, potential individual differences resulting from stage of
cancer, time since diagnosis, different types of pain, responsiveness to treatment, and
personality of participants may influence the study results. Overall, the research design
of the study included attempts by the researcher to maximize control of both internal and
external validity through the use of randomization and a control group.
Limitations
Limitations are restrictions in the study of which the researcher has no control and
may be a threat to internal validity (Rudestam & Newton, 1992). Limitations of this
study may have occurred in the areas of history, expectancy, and maturation.
Limitations in history refer to unanticipated events that occur during the study that
may affect the dependent variables (Tuckman, 1999). During this study, unanticipated
events included a blizzard, changes in participant health status, and varying length of
time before beginning some groups. A major blizzard swept through the Midwest, which
caused temporary closing of major arterials, so a session was canceled and rescheduled
for one of the groups. In addition, several potential participants cited the extremely cold
temperatures and hazardous driving during the winter as a major reason for not
participating during the months of December and January.
80
The weather was not the only concern of many cancer patients who participated in
the groups. Cancer patients, especially those currently in treatment, may suffer intense
side effects of chemotherapy and radiation such as pain, nausea, fatigue, neuropathy, and
depressed immune system functioning. Some patients undergoing treatment during the
study missed treatment sessions unexpectedly, while those patients finished with their
treatments did not seem to suffer the same health effects.
Another unanticipated event was the varying length of time before beginning
some of the experimental groups. Due to randomization, patients and caregivers were
randomly assigned to the experimental or wait-list control groups. However, some

participants assigned to the experimental group waited longer than others before the
groups commenced. During this length of time, unanticipated changes (e.g. health status)
may have occurred in the participants.
Limitations of expectancy occur when the researcher or participants form
expectations about the anticipated results of the study and behave accordingly (Tuckman,
1999). The participants of the study, especially those in the treatment groups, may have
anticipated outcomes and imposed performance demands upon themselves to behave the
way they thought the researcher wanted them to behave. The researcher may also have
unconsciously behaved in such a way as to affect performance of participants. Although
not a double-blind study, the researcher attempted to minimize expectancy bias by using
research identification numbers on all materials and avoiding the input and analysis of
data forms until after each six-session music therapy treatment group was finished.
Limitations of maturation refer to the processes of change within people that
occur naturally over a length of time (Tuckman, 1999). People naturally adjust and
develop over time, so study results may indicate normal change instead of the effects of
participating in the treatment. In order to minimize this problem, this study incorporated
a control group of similar people expected to have similar experiences during the course
of the treatment.
81
CHAPTER IV
RESULTS
therapy support groups on the outcomes of mood, coping (pain, stress, anxiety), social
support, and quality of life of cancer patients and caregivers. Measurements for both
long-term (six sessions over three weeks) and short-term (each 60-minute session)
outcomes were included. In order to measure the long-term outcomes, all participants
(N=41) completed the Profile of Mood States (POMS), State Trait Anxiety Inventory-
State (STAI-S) and Trait (STAI-T) scales, Personal Resource Questionnaire 85-Part 2,
(PRQ85-Part 2) and the Functional Assessment of Cancer Therapy-General Form
(FACT-G) at baseline, midpoint, and end of three weeks. Pre- and post-Music Therapy
Support Group Numerical Rating Scales (MTSG-NRS) measured short-term outcomes of
mood, pain, stress, anxiety, and quality of life from participation in 60-minute sessions.
Participants also completed the Music Therapy Support Group Assessment Form
(MTSG-AF) to provide demographic information and music preferences before sessions
began. After sessions concluded, all participants in the experimental group and those in
the wait-list control group who completed music therapy sessions after their control
group period was over completed the Music Therapy Support Group Evaluation
Questionnaire (MTSG-EQ) to provide feedback and information regarding their
experiences with the music therapy sessions. The data analyses and results are described
in this chapter, beginning with demographic information gained from the survey.
All participants, in both the experimental (n=21) and wait-list control group
(n=20), completed the Music Therapy Support Group Assessment Form (MTSG-AF) (see
Appendix C) in order to gather demographic information regarding type of participant

(cancer patient or caregiver), age, race, marital status, education, and health rating. Table
2 includes demographic and characteristic information at baseline for both groups.
82
Table 2
Demographic Information at Baseline by Treatment Group (N=41)
________________________________________________________________________
Characteristic Experimental Control Total
n=21 n=20 N=41
________________________________________________________________________
Type of Participant
Cancer Patient 12 12 24
Caregiver 9 8 17
Sex
Female 15 15 30
Male 6 5 11
Race
White 21 18 39
Not Identified 0 2 2
Marital Status
Married 13 14 27
Divorced 3 5 8
Never Married 3 1 4
Widowed 2 0 2
Highest Level of Education
High School Diploma 4 2 6
Some College Classes 4 6 10
Undergraduate Degree 8 7 15
Graduate Degree 5 5 10
________________________________________________________________________
83
Table 3
Age of Participants at Baseline by Treatment Group (N=41)
________________________________________________________________________
Age Statistics Experimental Control Total
________________________________________________________________________
Mean 58.7 47.8 53.2
Median 59.5 47.5 58
Minimum 26 19 19
Maximum 81 64 81
Missing 1 0 1
Count 20 20 40
________________________________________________________________________
The majority of participants in both groups were female, white, married, with at
least some college education. Age, gender, and education were tested for group
difference using Fisher’s exact tests and two-sample t-tests with alpha = .05. Race was
not used in testing group differences because all participants identified themselves as
white or had missing data (n=2). There was no significant difference between groups at
baseline for gender or education. However, a significant age difference was apparent
between treatment groups, with the experimental group being older (p=.02). Thus, age
was included in the repeated measures analysis of variance models to adjust for age
differences between the two groups. Table 3 includes specific information regarding the
age of participants.
Participants indicated their perceived health status, rating their health as poor, fair,
good, very good, or excellent. Religious affiliation information was gathered if topics of
religion or spirituality arose in the group. Table 4 includes health status and religious
84
affiliation information of participants. The majority of participants rated their health as

“good” or better, and selected their religious affiliation as Protestant or Catholic.
Table 4
Health Status and Religious Affiliation at Baseline by Treatment Group (N=41)
________________________________________________________________________
________________________________________________________________________
Health Status
Excellent 2 6 8
Very Good 7 4 11
Good 8 5 13
Fair 2 5 7
Poor 2 0 2
Religious Affiliation
Protestant 5 8 13
Catholic 9 5 14
Jewish 0 0 0
Muslim 0 0 0
Not Affiliated 5 1 6
Other: Christian 2 6 8
________________________________________________________________________
85
Table 5
Patient Type and Stage of Cancer at Baseline by Treatment Group (n=24)
________________________________________________________________________
________________________________________________________________________
Type of Cancer
Anal 1 0 1
Brain 1 1 2
Breast 5 1 6
Cervix 1 1 2
Colon 1 1 2
Esophagus 0 1 1
Hodgkin’s Lymphoma 0 1 1
Lung 1 0 1
Nerve 0 1 1
Neuroendocrine 1 1 2
Pancreas 1 0 1
Tonsil 1 0 1
Uterus 0 1 1
Stage of Cancer
4 3 2 5
3 1 2 3
2 5 4 9
1 0 0 0
0 1 0 1
Don’t Know 2 3 5
________________________________________________________________________
86
Patients with all cancer types could participate in the study, offering the
therapeutic benefits of the music therapy support group to interested participants,
regardless of cancer type or stage. As you will see from Table 5, the majority of patient
participants had a cancer diagnosis of stage two or higher, with breast cancer the most
commonly reported cancer type.
Table 6
Patient Current and Past Cancer Treatments by Treatment Group (n=24)
________________________________________________________________________
________________________________________________________________________
Current Treatment
Radiation 8 6 14
Chemotherapy 7 4 11
Hormone Therapy 3 1 4
No Current Treatment 1 2 3
Surgery 1 1 2
Past Treatments
Surgery 7 4 11
Chemotherapy 6 5 11
Radiation 5 4 9
No Previous Treatment 1 4 5
Hormone Therapy 1 0 1
________________________________________________________________________
Participants also indicated current cancer treatments, as well as all past cancer
treatments. The MTSG-AF allowed for multiple responses in each area. For example, a
87
participant could indicate one current treatment such as radiation, or could indicate
multiple treatments (e.g. radiation and chemotherapy). Most patients, at the time of their
study participation, were currently receiving radiation and/or chemotherapy, and the
majority had received surgery, chemotherapy, and/or radiation in the past. Please see
Table 6 for treatment information.
Table 7
Caregiver Relationship with Cancer Patient by Treatment Group (n=17)
________________________________________________________________________
________________________________________________________________________
Type of Relationship
Spouse 4 5 9
Friend 2 2 4
Parent 2 0 2
Child 1 1 2
Length of Relationship (Years)
0-10 0 1 1
11-20 1 3 4
21-30 2 2 4
31-40 2 0 2
41-50 2 0 2
51+ 1 0 1
Not Indicated 1 1 2
________________________________________________________________________
88
Caregiver participants included information regarding the type of relationship

(spouse, friend, parent, or child) and length of the relationship in years. The majority of
caregivers were spouses or friends, sharing a relationship with their cancer patients of at
least 11 years, with the majority over 21 years. Please see Table 7 for more information.
Table 8
Previous Music Experiences of All Study Participants (N=41)
________________________________________________________________________
Music Experience Percentage of Respondents

________________________________________________________________________
Listen to Music (n=38) 92.68%
Relax with Music (n=32) 78.05%
Exercise with Music (n=21) 51.22%
Enjoy Singing (n=20) 48.78%
High School Choir (n=20) 48.78%
Private Music Lessons (n=15) 36.59%
Play an Instrument (n=15) 36.59%
High School Band (n=11) 26.83%
Church Music Involvement (n=10) 24.39%
Write Poetry/Songs (n=8) 19.51%
Career in Music (n=7) 17.07%
College Choir (n=5) 12.20%
Other (n=5) 12.20%
College Band (n=2) 4.88%
________________________________________________________________________
89
In addition to demographic questions, participants provided information regarding

previous music experiences, music preferences, favorite songs and artists, and various
music therapy interventions of interest. Table 8 includes information regarding previous
music experiences of participants. Participants were instructed to check all musical
experiences that applied. Most participants had previous experiences of listening to
music, relaxing with music, and exercising with music. Several participants also enjoyed
singing and participated in a music group of some kind. A music experience indicated as
“Other” included written replies of college orchestra, junior high choir, outdoor concerts,
dance education, and prayer with music.

Music preferences of participants were important factors to consider when
planning and facilitating groups. Participants were instructed to check all preferred
music styles that applied. Table 9 includes preferred music styles of participants, with
the top five music styles including rock, country, classical, pop, and folk music.
Participants who indicated an interest in the style of “Other” were asked to provide more
information. These other music styles included: blues, oldies, Christian (n=2), soft rock
(n=3), Cajun polka, Dixieland jazz, religious music, and soothing music. Please see
Appendix I for a complete list of favorite songs and favorite artists.
In order to evaluate comfort and preference for music therapy techniques,
participants indicated their interest in types of music therapy interventions (see Table 10).
Participants were asked to select all response options that applied. The majority of
participants indicated interest in listening to music, relaxing with music, and talking
about songs. However, even the lowest-rated interventions had at least 12 participants
who indicated interest. The top areas of interest correspond with participant previous
music experiences in Table 8.
90
Table 9
Preferred Music Styles of All Study Participants (N=41)
________________________________________________________________________
Music Style Percentage of Respondents
________________________________________________________________________
Rock (n=24) 58.54%
Country (n=22) 53.66%
Classical (n=21) 51.22%
Pop (n=18) 43.90%
Folk (n=16) 39.02%
Broadway (n=15) 36.59%
Gospel (n=13) 31.81%
Jazz (n=12) 29.27%
Rhythm & Blues (n=12) 29.27%
Other (n=11) 26.83%
Swing (n=10) 24.39%
World Music (n=9) 21.95%
Heavy Metal (n=4) 9.76%
Rap (n=3) 7.32%
________________________________________________________________________
The Music Therapy Support Group Assessment Form also asked participants
about expectations they had for the music therapy support groups. Participants provided
written feedback, which were categorized into primary themes using content analysis.
The primary themes included: connection and interaction with others, music-specific
expectations, relaxation and stress reduction, cancer recovery expectations, and
91
uncertainty. Please see Appendix J for individual participant comments regarding

expectations grouped according to question and theme.
Table 10
Participant Pre-Session Interest in Music Therapy Interventions (N=41)
________________________________________________________________________
Music Therapy Intervention Percentage of Respondents
________________________________________________________________________
Listening to Music (n=35) 85.37%

Relaxing with Music (n=34) 82.93%
Talking about Songs (n=20) 48.78%
Movement to Music (n=19) 46.34%
Singing (n=17) 41.46%
Songwriting (n=13) 31.71%
Drawing to Music (n=12) 29.27%
Playing Instruments (n=12) 29.27%
________________________________________________________________________
Data Analysis
Repeated Measures Analysis of Variance (ANOVA) allow for repeated
measurements of the same individual over time in order to reduce error and minimize
bias. Repeated measures ANOVA take into consideration two factors: (a) time (within-
subjects factor), and (b) treatment (between-subjects factor). When utilizing the repeated
measures ANOVA, areas of interest include a significant time main effect and a treatment
and time interaction. The interaction allows us to determine, on average, if the outcome
92
measure for the two treatment groups (experimental and control) changes at the same rate
over time (are parallel) or if one group changes more than the other.
Five separate repeated measures ANOVA were completed on outcomes of the
Profile of Mood States (POMS), State Trait Anxiety Inventory-State Anxiety (STAI-S),
State Trait Anxiety Inventory-Trait Anxiety (STAI-T), Personal Resource Questionnaire
85-Part 2 (PRQ85-Part 2), and the Functional Assessment of Cancer Therapy-General
Form (FACT-G). The with-in subject correlation was modeled the same for all five tests,
with compound symmetric determined to be the best correlation. This means the
correlation between baseline and session three, baseline and session six, and session three
and session six are considered the same.
The variables of interest are age, time, and treatment; after adjusting for treatment
and time, age had no significant effect. Tests were conducted at the .05 level of
significance. When preparing the repeated measures ANOVA, a decrease in scores for
the STAI-S and POMS, and an increase in scores for the PRQ85 and FACT-G are
desirable outcomes. A decrease in scores for the STAI-S and POMS are beneficial,
meaning that anxiety and total mood disturbance decreased in participants as a result of
participation in the experimental group. An increase in scores for the PRQ85 and FACT-
G are considered preferred outcomes, meaning that perceived social support and quality
of life were improved as a result of participation. The STAI-T should remain stable over
time, allowing the researcher to examine comparability of experimental and control
groups on typical levels of anxiety.
In addition, multiple tests on the same subgroups may increase the chances of a
Type I error, or receiving a “false positive.” In order to correct for this, the Tukey-
Kramer method was used to adjust p-values and decrease a Type I error due to
multiplicity, or multiple tests on the same subgroups.

93

The Profile of Mood States (POMS) measured mood by combining six subscales
into the Total Mood Disturbance (TMD) score. The TMD score is the sum of the
Tension (T), Depression (D), Anger (A), Fatigue (F), and Confusion (C) subscales, with
the Vigor (V) subscale score subtracted. In other words, TMD = T + D + A + F + C – V.
If someone had a high Vigor score (V) and lower scores in the other areas, then it was
possible for those participants to receive a negative score. For example, a person who
had little mood disturbance and high vigor might have a score like this: 0 + 2 + 2 + 0 + 3
– 10 = -3. A negative score in this case would be beneficial. An increase in the TMD
indicated more mood disturbance, while a decrease in the TMD was beneficial, indicating
the person was less “disturbed” than before.
Table 11
Descriptive Statistics of the POMS by Time (N=41)
________________________________________________________________________
Group Time Count Mean Std Min Max
________________________________________________________________________
Control 1 20 46.7 43.43 -9 124
2 17 49.76 43.4 -8 132
3 20 40.5 45.91 -21 127
Experimental
1 21 37.33 29.1 -5 114
2 21 8.76 22.44 -18 59
3 20 1.3 17.72 -24 39
________________________________________________________________________
Note: For both control and experimental groups, the numbers 1, 2, and 3 indicate baseline
measurement, the second measurement at midpoint, and the final measurement after
groups completed, respectively.
94
Please refer to Table 11 for descriptive statistics of the POMS by time for the
experimental and control groups. In the experimental group, the outcome measurements
were separated for cancer patients and caregivers in order to determine changes in each
type of participant. The descriptive statistics by patient and caregiver for the
experimental group are included in Table 12. Both types of group members in the
experimental group demonstrated change as a result of participation in the MTSG.
Table 12
Descriptive Statistics of the POMS by Patient and Caregiver for the Experimental Group
(n=21)
________________________________________________________________________
________________________________________________________________________
Patient 1 12 38.75 35.13 -5 114
2 12 7.17 22.62 -18 59
3 12 4.17 17.39 -21 39
Caregiver
1 9 35.44 20.32 7 73
2 9 19.89 23.37 -18 45
3 8 -3 18.49 -24 26
________________________________________________________________________
Note: For both patient and caregivers, the numbers 1, 2, and 3 indicate baseline
95
Table 13
Overall p-Values for Effects of the POMS (N=41)
________________________________________________________________________
Outcome Effect p-value
________________________________________________________________________
POMS Treatment .009
Time <.0001
Treatment*Time .0002
________________________________________________________________________
Figure 2
POMS Subgroup Means Over Time By Group (N=41)
Time (Baseline, Midpoint, End of Three Weeks)

96
Table 14
Follow-Up p-Values for POMS Differences of Subgroup Means (N=41)
________________________________________________________________________
Subgroup 1 Subgroup 2 Estimate of Adjusted p-Value
(Group, Time) (Group, Time) Subgroup 1- PR > t
Subgroup 2
________________________________________________________________________
Control Group Differences
C1 C2 2.3 1.00
C1 C3 6.2 .83
C2 C3 3.9 .98
Experimental Group Differences
E1 E2 28.6 <.0001*
E1 E3 35.4 <.0001*
E2 E3 6.8 .76
Comparison of Group Differences
C1 E1 9.4 .96
C2 E2 35.6 .02*
C3 E3 38.5 .01*
________________________________________________________________________
Note: For both control (C) and experimental (E) groups, the numbers 1, 2, and 3 indicate
baseline measurement, the second measurement at midpoint, and the final measurement
after groups completed, respectively.
*Significant at the p < .05.
The interaction between treatment and time was significant in the POMS (see
Table 13), indicating the profiles of experimental and control groups were not parallel
97
across time (see Figure 2). In order to determine significant differences between the
means, follow-up tests were conducted. Table 14 includes the POMS follow-up statistics.
The POMS scores indicated no difference between groups at baseline, but a
significant difference in the experimental group from baseline to the second and baseline
to third measurements. In addition, the experimental group scores were significantly less
than the control group at midpoint and final measurements.
State Trait Anxiety Inventory – State Anxiety (STAI-S)
The State Trait Anxiety Inventory contains both the state (STAI-S) and trait (STAI-
T) anxiety forms. State anxiety, as measured in the STAI-S, is sensitive to changes in

individuals as a result of situational circumstances, including psychosocial interventions.
Table 15
Descriptive Statistics of the STAI-S by Time (N=41)
________________________________________________________________________
________________________________________________________________________
Control 1 20 45.9 15.98 20 78
2 17 47.82 11.19 31 69
3 20 45.55 14.37 21 68
Experimental
1 21 40.67 10.3 24 67
2 21 35.52 11.14 20 65
3 20 31.85 6.29 21 45
________________________________________________________________________
98
Please refer to Table 15 for descriptive statistics of the experimental and control
groups by time. In addition, outcome measurements of the experimental group were
separated for cancer patients and caregivers in order to determine changes within each
type of participant. The descriptive statistics by patient and caregiver for the
experimental group are included in Table 16. Both types of participants in the
experimental group demonstrated change in the STAI-S as a result of participation.
Table 16
Descriptive Statistics of STAI-S by Patient and Caregiver for Experimental Group (n=21)
________________________________________________________________________
________________________________________________________________________
Patient 1 12 40 12.08 24 67
2 12 32.92 12.36 20 65
3 12 31.17 6.67 21 45
Caregiver
1 9 41.56 7.92 28 52
2 9 39 8.75 30 53
3 8 32.88 5.94 25 44
________________________________________________________________________
Note: For both patients and caregivers, the numbers 1, 2, and 3 indicate baseline
Please refer to Table 17 for the overall p-values for state anxiety. The interaction
between treatment and time was significant in the STAI-S scale (see Figure 3). In order to
check for subgroup differences, follow-up tests were performed on the STAI-S. Table 18
includes the adjusted p-values and estimates of subgroup differences for the STAI-S.
99
Table 17
Overall p-Values for Effects of the STAI-S (N=41)
________________________________________________________________________
________________________________________________________________________
STAI-S Treatment .01
Time .02
Treatment*Time .03
________________________________________________________________________
Figure 3
STAI-S Subgroup Means Over Time by Group (N=41)

100
Table 18
Follow-Up p-Values for STAI-S Differences of Subgroup Means (N=41)
________________________________________________________________________
Subgroup 2
________________________________________________________________________
Contrl Group Differences
C2 C1 .72 .75
C3 C1 -.35 .87
C3 C2 -1.07 .64
E2 E1 -5.14 .02*
E3 E1 -8.33 .0002*
E3 E2 -3.19 .13
C1 E1 -5.23 .16
C2 E2 -11.10 .005*
C3 E3 -13.22 .001*
________________________________________________________________________
after groups completed.
The experimental group had significant changes over time on the STAI-S from
baseline to midpoint and baseline to final measurement (see Table 18); the control group
did not. No significant differences occurred at baseline between the two groups.
101
However, there was evidence of a significant difference between control and

experimental groups at midpoint and final. Overall, the experimental group state anxiety
decreased over time for the average person; the control group stayed relatively the same.
State Trait Anxiety Inventory – Trait Anxiety (STAI-T)
Trait anxiety is considered a stable measure (how one generally feels), and is
expected to remain relatively stable over time unless influenced by extreme factors that
undermine typical functioning. In this study, the STAI-T permitted a comparison to
confirm whether the two groups were equivalent on this characteristic, and to better
understand changes in anxiety as a result of MTSG participation.
Table 19
Descriptive Statistics of STAI-T by Time (N=41)
________________________________________________________________________
________________________________________________________________________
Control 1 20 41 11.55 22 58
2 17 44.59 10.94 25 60
3 20 43.55 12.55 24 63
Experimental
1 21 39.86 10.59 25 64
2 21 39.48 10.68 26 66
3 20 37.9 8.36 25 55
________________________________________________________________________
102
There were no significant differences between the experimental and control

groups at baseline, suggesting equivalent groups at study onset. Consistent with the
expected outcome, no group difference and no difference within each group occurred
across time. Please see Table 19 for STAI-T descriptive statistics for experimental and
control groups by time.
As shown in Table 19, both groups remained relatively the same, with a slight
decrease in experimental average scores and a slight increase in control average scores.
Further experimental group descriptive statistics of the STAI-T by patient and caregiver
are included in Table 20.
Table 20
Descriptive Statistics of STAI-T by Patient and Caregiver for Experimental Group
(n=21)
________________________________________________________________________
________________________________________________________________________
Patient 1 12 39.42 10.7 25 59
2 12 39 11.62 26 66
3 12 36.5 8.85 25 55
Caregiver
1 9 40.44 11.06 30 64
2 9 40.11 9.94 26 59
3 8 40 7.63 31 52
________________________________________________________________________
Note: For both patients and caregivers, the numbers 1, 2, and 3 indicate baseline
103
Table 21
Overall p-Values for Effects of the STAI-T (N=41)
________________________________________________________________________
________________________________________________________________________
STAI-T Treatment .28
Time .80
Treatment*Time .10
________________________________________________________________________
Figure 4
STAI-T Subgroup Means Over Time By Group (N=41)
Time (Baseline, Midpoint, End of Three Weeks

104
As expected, the STAI-T scale demonstrated no significant treatment, time, or

interaction effects (see Figure 4), meaning there was no difference over time or between
groups for trait anxiety. Please refer to Table 21 for p-values.
Personal Resource Questionnaire 85-Part 2 (PRQ85-Part 2)
The Personal Resource Questionnaire 85-Part 2 (PRQ85-Part 2) measures social
support, with higher scores indicating more perceived available social support. Table 22
contains descriptive statistics of the PRQ85-Part 2 by time, with experimental group data
improving from first to third measurement on average, indicating an increase in perceived
social support. On average, the control group data decreased from first to third
measurement, indicating a slight decline in perceived social support.
Table 22
Descriptive Statistics of PRQ85-Part 2 by Time (N=41)
________________________________________________________________________
________________________________________________________________________
Control 1 20 134.85 25.82 80 175
2 17 138.18 21.14 96 173
3 20 133.35 27.13 72 166
Experimental
1 21 139.43 17.25 107 170
2 21 141.33 18.83 110 169
3 20 145.7 19.94 109 175
________________________________________________________________________
105
Table 23
Descriptive Statistics of PRQ85-Part 2 by Patient and Caregiver for Experimental Group
(n=21)
________________________________________________________________________
________________________________________________________________________
Patient 1 12 144.25 15.25 124 170
2 12 144.92 19.63 114 169
3 12 148.17 19.35 115 174

Caregiver
1 9 133 18.51 107 162
2 9 136.56 17.66 110 160
3 8 142 21.56 109 175
________________________________________________________________________
Note: For both patient and caregiver, the numbers 1, 2, and 3 indicate baseline
A further breakdown of the PRQ85-Part 2 experimental group data into patients

and caregivers (see Table 23) indicated a larger increase in mean scores in caregiver
participants. On average, when compared with patients, caregivers indicated a slightly
larger gain in perceived support (nine points instead of four).
As noted in Table 24, a significant interaction between treatment and time
indicated that the experimental and control group profiles were not parallel across time
(see Figure 5). However, follow-up test results indicated no significantly different
subgroups after adjusting for multiplicity. Please see Table 25 for adjusted p-values and
estimates of subgroup differences.

106
Table 24
Overall p-Values for Effects of PRQ85-Part 2 (N=41)
________________________________________________________________________
________________________________________________________________________
PRQ85 Treatment .38
Time .23
Treatment*Time .05*
________________________________________________________________________
Figure 5
PRQ85-Part 2 Subgroup Means Over Time by Group (N=41)

107
Table 25
Follow-Up p-Values for PRQ85-Part 2 Differences of Subgroup Means (N=41)
________________________________________________________________________
Subgroup 2
________________________________________________________________________
Control Group Differences
C3 C2 -7.51 .24
C3 C1 -1.50 1.00
C2 C1 6.01 .48
E2 E1 1.90 .99
E3 E1 5.88 .43
E3 E2 3.97 .81
E1 C1 4.58 .98
E2 C2 .47 1.00
E3 C3 11.96 .51
________________________________________________________________________
after groups completed, respectively.
Functional Assessment of Cancer Therapy – General Form (FACT-G)
The Functional Assessment of Cancer Therapy-General Form (FACT-G)

measured health-related quality of life. The FACT-G score resulted from addition of four
108
subscales (physical, social, emotional, and functional well-being), and a higher score
indicated better quality of life. Please refer to Table 26 for descriptive statistics of
experimental and control groups by time.
The control participants, on average, demonstrated a decrease in quality of life
while the experimental group average scores remained relatively stable, with a slight
increase. Please see Table 27 for further descriptive statistics by patient and caregiver for
the experimental group. On average, both experimental group patients and caregivers
demonstrated a slight increase in quality of life scores.
Table 26
Descriptive Statistics of FACT-G by Time (N=41)
________________________________________________________________________
________________________________________________________________________
Control 1 20 73.25 16.43 37 101
2 17 68.04 17.35 39 101
3 20 68.97 18.81 35 103
Experimental
1 21 78.27 13.16 53 100
2 21 79.19 14.03 52 102
3 20 79.72 14.25 50 96
________________________________________________________________________
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Table 27
Descriptive Statistics of the FACT-G by Patient and Caregiver for Experimental Group
(n=21)
________________________________________________________________________
________________________________________________________________________
Patient 1 12 80.35 13.54 59 100
2 12 81.54 16.03 52 102
3 12 81.57 13.93 50 96
Caregiver
1 9 75.51 12.87 53 92
2 9 76.05 10.94 57 92
3 8 76.95 15.21 55.83 93
________________________________________________________________________
Note: For both patient and caregiver, the numbers 1, 2, and 3 indicate baseline
Table 28
Overall p-Values for Effects of FACT-G (N=41)
________________________________________________________________________
________________________________________________________________________
FACT-G Treatment .08
Time .56
Treatment*Time .22
________________________________________________________________________
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From the results in Table 28, no significant differences were found for time or
treatment and time interaction. Therefore, experimental and control groups have parallel
profiles, with midpoint and final measurements not significantly different from baseline.
The treatment is marginally significant (.05 < p < .10) indicating possible evidence that
the groups differ in quality of life, but not meeting the p < .05 significance level.
Figure 6
FACT-G Subgroup Means Over Time by Group (N=41)
In summary, the POMS, STAI-S, STAI-T, PRQ85-Part 2, and FACT-G measured

the long-term outcomes of mood, coping (stress, anxiety), social support, and quality of
life. Experimental group participants, as a result of participation in the music therapy
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support groups (MTSG), had significantly improved mood and decreased anxiety. No
significant difference was found in social support and quality of life between groups,
although experimental group data trends indicated possible benefit as a result of
participation in the MTSG. These long-term outcomes measured change over six
sessions (three weeks), but short-term outcomes were also measured. These short-term
outcomes measured the change over the course of each 60-minute music therapy session.
Music Therapy Support Group Numerical Rating Scales (MTSG-NRS)
Experimental group participants completed Music Therapy Support Group
Numerical Rating Scales (MTSG-NRS) for mood, pain, stress, anxiety, and quality of life
at the beginning and end of each music therapy group session. The MTSG-NRS measured
change over 60-minutes as a result of participation in the music therapy interventions.
Wilcoxon Rank Sum tests were performed on the MTSG-NRS to determine if the change
from pre- to post-session was significant in each area. This resulted in 30 tests in the
experimental group, with six sessions (MTSG sessions 1, 2, 3, 4, 5, 6) and five measures
(mood, pain, stress, anxiety, and quality of life) for each session.
Difference scores were calculated as post-score minus pre-score; thus a negative
value for anxiety, stress, and pain difference scores was desirable, indicating by the end
of the session, post-scores were lower than pre-session scores. See Table 29 for statistics
and p-values for the anxiety and stress MTSG-NRS scores and Table 30 for pain MTSG-
NRS scores. Anxiety and stress were significantly reduced in all six sessions, while pain
was significantly reduced in sessions one, four, five, and six; the reduction was not
significant in sessions two and three.
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Table 29
Experimental Group Wilcoxon Signed Rank for Anxiety and Stress MTSG-NRS (n=21)
________________________________________________________________________
Variable Signed Rank Sp-value
________________________________________________________________________
Anxiety
Session 1 -60 .0001*
Session 2 -52.5 .0001*
Session 3 -60 .0001*
Session 4 -45.5 .0002*
Session 5 -42 .002*
Session 6 -52.5 .0001*
Stress
Session 1 -68.5 .0005*
Session 2 -42 .002*
Session 3 -45.5 .0002*
Session 4 -60 .0001*
Session 5 -39.5 .003*
Session 6 -60 .0001*
________________________________________________________________________
*Significant at the p < .05 level.
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Table 30
Experimental Group Wilcoxon Signed Rank for Pain MTSG-NRS (n=21)
________________________________________________________________________
________________________________________________________________________
Pain
Session 1 -18 .008*
Session 2 -11 .094
Session 3 -3 .250
Session 4 -27.5 .002*
Session 5 -10.5 .031*
Session 6 -22.5 .004*
________________________________________________________________________
Conversely, a positive value for mood and quality of life difference scores are
preferred, indicating that by the end of the session the post scores were higher than pre-
session scores. Please see Table 31 for statistics and p-values for the mood and quality of
life MTSG-NRS scores. Mood scores were significantly improved in all six sessions,
while quality of life was significantly improved in sessions two, four, five, and six;
improvement was not significant in sessions one and three.
In summary, Music Therapy Support Group Numerical Rating Scales measured
change in anxiety, stress, pain, mood, and quality of life from beginning to end of each
60-minute music therapy support group session. Anxiety and stress significantly
decreased and mood significantly improved in all six sessions. Pain significantly
decreased in sessions 1, 4, 5, and 6, but no significant difference occurred in sessions 2
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and 3. Quality of life significantly improved in sessions 2, 4, 5, and 6, with no significant

difference in sessions 1 and 3.
Table 31
Experimental Group Wilcoxon Signed Rank for Mood and Quality of Life MTSG-NRS
(n=21)
________________________________________________________________________
________________________________________________________________________
Mood
Session 1 27.5 .002*
Session 2 39 .0005*
Session 3 40.5 .002*
Session 4 60 .0001*
Session 5 45.5 .0002*
Session 6 52.5 .0001*
Quality of Life
Session 1 4.5 .531
Session 2 10.5 .031*
Session 3 28 .028
Session 4 23 .018*
Session 5 27.5 .002*
Session 6 41.5 .002*
________________________________________________________________________
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Additional Data: Wait-List Control Group

After their control period finished, wait-list control participants had the option of
receiving their choice of a music therapy intervention in small group or individual
sessions. Fourteen wait-list control participants completed a music therapy session after
their control group period was over, while six declined due to personal limitations of time
or travel. Participants completed the same MTSG-NRS scores of mood, pain, stress,
anxiety, and quality of life pre- and post-session. This resulted in five tests in the wait-list
group, with one session and five measures (mood, pain, stress, anxiety, and quality of
life).
Table 32
Wait-List Control Group Wilcoxon Signed Rank for Anxiety, Stress, Pain, Mood, and
Quality of Life MTSG-NRS (n=14)
________________________________________________________________________
________________________________________________________________________
Anxiety -39 .0005*
Stress -39 .0005*
Pain -27.5 .002*
Mood 18 .008*
Quality of Life 39 .0005*
________________________________________________________________________
It is important to note that these participants did not need to complete the entire
MTSG protocol. Instead, they chose from one of the following interventions: relaxation
with music (n=6), participating in entire MTSG protocol (n=3), playing instruments
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(n=2), recording a CD (n=2), singing preferred songs (n=1), songwriting (n=0), and
creative arts with music (n=0). Wait-list control participants chose a variety of
interventions based on personal preferences. These sessions were not consistent across
participants in the control group (as was the case in the experimental group) and
therefore, cannot be directly compared through statistical analyses to experimental group
scores. Please see Table 32 for statistics and p-values for the anxiety, stress, pain, mood,
and quality of life MTSG-NRS scores. According to MTSG-NRS scores, anxiety, stress,
and pain were significantly decreased, and mood and quality of life significantly
improved from pre- to post-session.

Music Therapy Support Group Evaluation Questionnaire
The Music Therapy Support Group Evaluation Questionnaire (MTSG-EQ)
included questions regarding overall experiences, perceived benefit of participation, most
enjoyable aspects, least enjoyable aspects, techniques learned or practiced, highlights or
significant moments, and suggestions or recommendations for future group sessions.
Please see Appendix D for the MTSG-EQ. The questionnaire was mailed to every
experimental group participant to gain feedback regarding the MTSG (n=21) and to those
control group participants who completed a music therapy session after their control
group period was over (n=14).
Thirty-one out of 35 questionnaires were returned, at an overall return rate of
88.57%. Participants had the opportunity to rate their overall experience with the music
therapy sessions as excellent, good, neutral, fair, or poor. Please refer to Table 33 for
overall experience information for the experimental group. Although control group
participants did not participate in the MTSG protocol, they could participate in their
choice of music therapy sessions after the control group period was over. All participants
were asked about perception of benefit from participating in music therapy sessions.
Please see Table 34 for benefit information.
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Table 33
Experimental Group Participants Overall Experience with the MTSG (n=18)
________________________________________________________________________
Overall Experience Rating Experimental
________________________________________________________________________
Excellent 9
Good 9
Neutral 0
Fair 0
Poor 0
________________________________________________________________________
Table 34
Perception of Benefit from Participation in Music Therapy by Treatment Group (n=31)
________________________________________________________________________
Benefit Rating Experimental Control
________________________________________________________________________
Yes 17 11
Somewhat 1 2
No 0 0
________________________________________________________________________
Table 35 contains experimental group participant responses for 18 out of 21

questionnaires, an 85.71% return rate. Participants were asked to select all options that
applied. The top five benefits, as indicated by MTSG participants, were: (a) improve
mood, (b) reduce stress, (c) provide support, (d) improve communication, and (e) learn
new skills.
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Table 35
Experimental Group Perceived Benefit of MTSG Participation (n=18)
________________________________________________________________________
Music Therapy Benefit Percentage of Respondents
________________________________________________________________________
Improve Mood (n=16) 88.89%
Reduce Stress (n =14) 77.78%
Provide Support (n =10) 55.56%
Improve Communication (n =10) 55.56%

Learn New Skills (n =9) 50.00%
Reduce Anxiety (n =8) 44.45%
Assist with Coping (n =7) 38.89%
Improve Quality of Life (n =7) 38.89%
Reduce Depression (n =7) 38.89%
Improve Relationships (n =6) 33.33%
Other (n =4) 22.22%
________________________________________________________________________
Note: The other category included the following responses: (a) had fun, (b) provided fun
and laughter, spur creativity, learn you don’t need to have skills to make music, just do it,
(c) laughter in group; and (d) helps when working with people with similar problems.
Control group participants also completed the follow-up questionnaire, but

commented on their chosen intervention (Table 36). Thirteen out of 14 questionnaires
were returned, at a 92.86% return rate. Participants were asked to select all options that
applied. The top five benefits of participating in a chosen music therapy session were (a)
improve mood, (b) learn new skills, (c) reduce stress, (d) provide support, and (e) a tie
between improve relationships, reduce anxiety, and assist with coping.

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Table 36
Control Group Perceived Benefit of Music Therapy Session Participation (n=13)
________________________________________________________________________
Music Therapy Benefit Percentage of Respondents
________________________________________________________________________
Improve Mood (n =9) 69.23%
Learn New Skills (n =9) 69.23%
Reduce Stress (n =8) 61.54%
Provide Support (n =8) 61.54%

Improve Relationships (n =7) 53.85%
Reduce Anxiety (n =7) 53.85%
Assist with Coping (n =7) 53.85%
Improve Communication (n =6) 46.15%
Improve Quality of Life (n =6) 46.15%
Reduce Depression (n =6) 46.15%
Other (n =0) 0%
________________________________________________________________________
Another part of the MTSG-EQ asked participants to indicate the music therapy
interventions they found most enjoyable or most therapeutic. Participants could choose
one or several of the interventions. Please refer to Table 37. The top three interventions
included playing instruments, relaxing with music, and listening to music.
In contrast, participants in the experimental group also indicated the music
therapy interventions they found least enjoyable or least therapeutic. Participants could
choose one or several interventions. Please refer to Table 38. The top three least
enjoyable interventions were songwriting, drawing to music, and singing. Ten
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participants did not choose any of the interventions as least enjoyable, and indicated they
found “everything enjoyable.”
Table 37
Experimental Group Most Enjoyable/Most Therapeutic Parts of the MTSG (n=18)
________________________________________________________________________
________________________________________________________________________
Playing Instruments (n =18) 100.00%

Relaxing with Music (n =14) 77.78%
Listening to Music (n =11) 61.11%
Singing (n =6) 33.33%
Talking about Songs (n =6) 33.33%
Moving to Music (n =5) 27.78%
Songwriting (n =4) 22.22%
Drawing to Music (n =3) 16.67%
Other 0%
________________________________________________________________________
The last question on the MTSG-EQ asked participants if they would recommend
participation in the music therapy sessions to other people in similar circumstances.
Twenty-nine out of 31 participants (93.55%) indicated a positive recommendation (yes).
One experimental participant indicated “maybe,” and wrote: “The leadership is really a
factor. Would definitely recommend Abbey Dvorak's group to anyone.” One control
participant indicated “no” and wrote: “I wanted to be a part of the music support group.”
Please see Table 39 for participant recommendation information by treatment group.
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Table 38
Experimental Group Least Enjoyable/Least Therapeutic Parts of the MTSG (n=18)
________________________________________________________________________
________________________________________________________________________
Songwriting (n =6) 33.33%
Drawing to Music (n =5) 27.78%
Singing (n =5) 27.78%

Moving to Music (n =3) 16.67%
Relaxing with Music (n =2) 11.11%
Talking about Songs (n =2) 11.11%
Listening to Music (n =0) 0%
Playing Instruments (n =0) 0%
Other 0%
________________________________________________________________________
Table 39
Recommendation of Music Therapy to Others by Treatment Group (n=31)
________________________________________________________________________
Recommendation Experimental Control
________________________________________________________________________
Yes 17 13
Maybe 1 0
No 0 1
________________________________________________________________________
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Table 40
Primary Themes Generated by Written Comments from the MTSG-EQ
________________________________________________________________________
Feedback Question Primary Themes
________________________________________________________________________
Most Enjoyable Parts of the Session Self-Expression and Mood
Relaxation and Stress Reduction
New Experiences and New Skills
Therapeutic Connection with Others

Least Enjoyable Parts of the Sessions Self-Consciousness and Self-Doubt
Individual Preferences for Interventions
Continuation of Learned Techniques Greater Awareness and Appreciation
Playing Instruments and Singing
Relaxation and Music Listening
Highlights and Significant Moments Relationships with Group Members
Highlights Regarding Interventions
Suggestions for Future Groups Positive Feedback to Music Therapist
Group Size and Length of Therapy
Specific Intervention Suggestions
Recommendation of Groups to Others Connection with Others
Helpfulness of Music Therapy Interventions
Therapeutic Benefits of Music
Additional Comments Enjoyment, Appreciation, and Thankfulness
Future Planning Considerations
Facilitator-Directed Comments
________________________________________________________________________
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Participants also included written feedback and comments on the MTSG-EQ.

Several questions prompted participants to include qualitative information, with primary
themes generated from feedback questions listed in Table 40. Please see Appendix K for
a brief description of themes and individual comments.
Summary
Based on results from the data analysis, the findings of this study include:
1a. Participation in a six-session music therapy support group significantly improved
perceived mood of participants as measured by a decrease in the Total Mood Disturbance
Score on the Profile of Mood States (POMS).

1b. Participation in a six-session music therapy support group significantly improved
coping levels of participants as measured by a decrease in anxiety scores on the State
Trait Anxiety Inventory (STAI-S).
1c. While changes in the desired direction were documented, no significant differences
were found between experimental and control group participants on social support
measured by the Personal Resource Questionnaire 85-Part 2 (PRQ85-Part 2).
1d. No significant differences were found between experimental and control group
participants on quality of life as measured by the Functional Assessment of Cancer
Therapy-General Form (FACT-G).
2a. Participation in a music therapy support group significantly improved perceived
mood of participants within each individual 60-minute treatment session as measured by
an increase of scores on pre- and post-Music Therapy Support Group Numerical Rating
Scales (MTSG-NRS).
2b. Participation in a music therapy support group significantly decreased perceived
stress of participants within each individual 60-minute treatment session as measured by
a decrease of scores on pre- and post-Music Therapy Support Group Numerical Rating
Scales (MTSG-NRS).
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2c. Participation in a music therapy support group significantly decreased perceived

anxiety of participants within each individual 60-minute treatment session as measured
by pre- and post-Music Therapy Support Group Numerical Rating Scales (MTSG-NRS).
2d. Participation in a music therapy support group significantly decreased perceived pain
ratings of participants in sessions 1, 4, 5, and 6, with no significant difference in sessions
2 and 3 as measured by pre- and post-Music Therapy Support Group Numerical Rating
Scales (MTSG-NRS).
2e. Participation in a music therapy support group significantly improved perceived
quality of life of participants in sessions 2, 4, 5, and 6, with no significant difference

found in sessions 1 and 3 as measured by pre- and post-Music Therapy Support Group
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CHAPTER V
SUMMARY, DISCUSSION, CONCLUSIONS, AND RECOMMENDATIONS
Summary
therapy support groups (MTSG) on mood, coping (pain, stress, anxiety), social support,
and quality of life of cancer patients and caregivers. Participants were 24 cancer patients
and 17 caregivers randomly assigned to experimental (n=21) or wait-list control (n=20)
groups. All participants completed the Profile of Mood States (POMS), the State Trait
Anxiety Inventory-State (STAI-S) and Trait (STAI-T) scales, the Personal Resource
Questionnaire 85-Part 2 (PRQ85-Part 2), and the Functional Assessment of Cancer
Therapy-General Form (FACT-G) at baseline, midpoint, and end of three weeks. These
self-report questionnaires measured the long-term effect (three weeks) of participation in
the MTSG, while Music Therapy Support Group Numerical Rating Scales (MTSG-NRS)
measured the short-term effect of the 60-minute music therapy sessions on mood, pain,
stress, anxiety, and quality of life.
Five experimental groups, ranging in size from three to six participants (M=4.2
participants), were facilitated in June, July, and August-September, 2010; and January-
February and March, 2011. Experimental group participants completed six music
therapy support group sessions over a three-week period. Several music therapy
interventions were utilized including: singing, songwriting, playing instruments,
movement with music, creative arts with music, and music-assisted relaxation. The wait-
list control group had the opportunity to participate in music therapy sessions after their
control period was over. In addition, all participants completed the Music Therapy
Support Group Assessment Form (MTSG-AF) beforehand to provide demographic
information and music preferences. Experimental group participants and wait-list control
group participants who completed music therapy sessions after their control period was
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over also filled out the Music Therapy Support Group Evaluation Questionnaire (MTSG-
EQ).
questionnaires were analyzed using five individual repeated measures ANOVA. The
results indicated a significant improvement in mood (as measured by the POMS) and a
significant decrease in anxiety (as measured by the STAI-S) as a result of participation in
the music therapy support groups when compared to the control group. While changes in
the desired direction occurred, no significant differences were found between
experimental and control group participants on social support or quality of life.

The MTSG-NRS data, analyzed using a Wilcoxon Rank Sum test, found a
significant improvement in mood and significant decrease in stress and anxiety from pre-
to post-music therapy session for all sessions. Participation in the MTSG significantly
decreased the perception of pain in sessions 1, 4, 5, and 6, with no significant difference
in sessions 2 and 3. Quality of life significantly improved in sessions 2, 4, 5, and 6, with
no significant differences in sessions 1 and 3.
Participants in the experimental group and those in the control group who
participated in music therapy sessions after their control period was over completed a
Music Therapy Support Group Evaluation Questionnaire (MTSG-EQ) to provide
feedback regarding the MTSG. Experimental group participants rated the overall
experience as excellent (n=9) or good (n=9), indicated yes (n=17) or somewhat (n=1)
regarding benefit of attending the group, with the top five benefits including: improve
mood, reduce stress, provide support, improve communication, and learn new skills. The
top three most enjoyable or most therapeutic interventions were playing instruments,
relaxing with music, and listening to music; the three least enjoyable or least therapeutic
were songwriting, drawing to music, and singing. Participants would also recommend
music therapy to others in a similar situation.
127
The written comments from the follow-up questionnaire were categorized into
primary themes generated from feedback questions. The most enjoyable parts of the
session included themes of: self-expression and mood, relaxation and stress reduction,
new experiences and new skills, and therapeutic connections with others. The least
enjoyable parts of the sessions included themes about self-consciousness and self-doubt,
and individual preferences for interventions. When asked about continuation of learned
techniques, participants discussed themes related to: awareness and appreciation, playing
instruments and singing, and relaxation and music listening. Highlights and significant
moments of the sessions included feedback about building relationships with group
members and highlights regarding specific interventions. Suggestions for future groups
included positive feedback to the therapist (no change needed), and suggestions related to
group size, length of therapy, and specific interventions. Participants would recommend
the group to future participants because of the connection with others in similar
circumstances, helpfulness of music therapy interventions, and the overall therapeutic
benefits of music. Additional comments included themes of enjoyment, appreciation, and
thankfulness; future planning considerations; and facilitator-directed comments.
Discussion
The present study utilized several quantitative measurement tools in order to gain
information regarding the psychological, physical, and social experiences of cancer
patients and caregivers as they participated in music therapy support groups (MTSG).
The effects of participation in each of the areas are discussed below, and connections
made with previous research in music therapy and cancer care. In addition, participant
comments from primary themes are interspersed throughout the discussion in order to
highlight personal experiences of participants beyond the quantitative data.
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Psychological Outcomes of MTSG Participation

Mood
The present study found a significant improvement in mood as a result of
participation in the music therapy support groups (MTSG), both long-term (over three
weeks) as measured by the POMS and short-term (60-minute sessions) as measured by
the MTSG-NRS. This finding is consistent with previous music therapy studies in cancer
care in which a significant improvement in mood was noted as a result of participation in
music therapy sessions. Waldon (2001) reported significant improvement in mood as a
result of both interactive and receptive group music experiences; Cassileth, Vickers, and
Magill (2003) demonstrated a significant decrease in total mood disturbance as a result of
live music therapy interventions. In addition, Smith, Casey, Johnson, Gwede, and Riggin
(2001); Siedliecki and Good (2006); and Stordahl (2009) also reported significant
decreases in depression.
On the evaluation questionnaire (MTSG-EQ), participants indicated that
improvement of mood was the top perceived benefit of the MTSG sessions, with 88.89%
of participants choosing this outcome as the most beneficial aspect. In addition, several
participants provided written comments regarding mood (see Appendix K for participant
comments). One participant indicated improvement in mood as a result of several
interactive music therapy interventions: “Singing gives you a voice to express yourself,
when otherwise you might not. Actually playing a rhythm lifts yours spirits; it clears
your mind of worries. Moving goes with rhythm to ease tension and improve mood.”
This participant, along with others, described the impact and benefit of the music
modality and participation in the group. However, it is important to note that three
variables were apparent in the music therapy groups that may be lacking in other types of
supportive psychosocial therapies (e.g., traditional psychotherapy). The MTSG was

unique in that it combined the social interaction of peers with similar concerns, the use of
the characteristics of music to modify mood and behavior, and the facilitation of the
129
group by a trained and experienced music therapist. The music may have modified mood
through the structural features of the music or through association of the music with
pleasant memories. However, the music therapist structured music experiences for
successful participation; built rapport with group members and encouraged interaction
among peers; and utilized skills, training, and knowledge in order to allow participants to
be comfortable participating in the groups. An untrained person attempting to facilitate a
similar group may not have the same results as an experienced and board-certified music
therapist.
Coping
The MTSG significantly improved coping by reducing anxiety and stress scores
of patients and caregivers. Both anxiety and stress scores decreased during the 60-minute
music therapy sessions; anxiety also decreased over the three weeks. Anxiety and stress
are discussed separately in the following section.
Anxiety
Anxiety was significantly reduced as a result of participation in the MTSG, both
long-term (three weeks) as measured by the STAI-S, and short-term (all 60-minute music
therapy sessions) as measured by the MTSG-NRS. This outcome is consistent with
studies by Ferrer (2007), Horne-Thompson and Grocke (2008), Harper (2001), and Clark,
Isaacks-Downton, Wells, Redlin-Frazier, Eck, Hepworth, and Chakravarthy (2006) in
which cancer patients demonstrated a significant decrease in anxiety as a result of
participation in music therapy.
Although anxiety declined as a result of the music therapy groups, over half of the
participants did not rate this as a benefit of participation on the evaluation questionnaire.
Only 44.45% of experimental group participants chose “reduce anxiety” from a list of
possible benefits of music therapy participation (refer to Table 34). However, in addition
to significant scores on the STAI-S and MTSG-NRS, written comments provided evidence
that participants did realize the benefits of music therapy for anxiety reduction. Several
130
participants commented that music “reduced tension” and that the groups were a
“wonderful distraction,” and “took my mind off everything else.” One participant also
commented: “Playing the instruments focused my mind on something fun/positive
instead of thinking about my cancer. Relaxing with music reduced the anxiety I had prior
to class.”
These comments, along with the significant scores from both long-term (three
weeks) and short-term (60-minute) measurements indicated the benefits of MTSG
participation. Anxiety was significantly reduced, not just within each session, but over
the entire three-week period. A reduction in anxiety, as a result of participation in the

interactive music therapy experiences, may have allowed participants to better cope with
cancer and its treatment.
Stress
In addition to anxiety, stress was significantly reduced in all six sessions of the
MTSG when measured using the pre- and post-session MTSG-NRS. This finding is
consistent with Pelletier (2004) in which a meta-analysis of quantitative music therapy
research studies showed a significant overall mean effect size in decreasing arousal due
to stress. Although Pelletier also indicated that individual music-assisted relaxation
sessions might be more beneficial than group sessions in reducing arousal due to stress,
the present study indicates that group music therapy sessions may also provide stress-
reduction benefits.
Furthermore, participants identified stress reduction as a key benefit of the MTSG
on the MTSG-EQ, with 77.78% of experimental group responders identifying it as such
(see Table 34). Participants wrote comments that the music “reduced tension and anxiety
at that time (It [cancer treatment] was so stressful.)” and commented on specific
interventions such as “the guided breathing/relaxation really worked to reduce stress.”

Other participants commented on the importance of music therapy in “coping” and
identified that “being able to relax and de-stress during any treatment is, in my opinion,
131
very important.” Another shared “the support group helps a person to understand how
music is very important for helping stress, improving mood, coping, etc.”
Several participants noted an improvement in coping through generalization of
their MTSG experience outside the group. Patients and caregivers made comments
related to changes in empowerment, perception, and vitality as a result of participation in
the MTSG. For example, one participant was empowered by the group and noted: “Just
go for it – just do it – don’t worry about what others are thinking or doing – don’t hold
back.” This sense of increased empowerment as a result of interactive music therapy
groups is consistent with other music therapy studies with cancer patients (Daykin et al.,
2007; Rykov, 2008) and caregivers (Magill, 2009). Interactive music therapy group
interventions promote a sense of empowerment and reduce feelings of helplessness by
allowing participants to creatively express themselves, take control, and make choices
within the supportive context of the MTSG.
Other participants discussed a change in perception regarding the benefits of
using music in their everyday lives. For example, one participant commented: “I think I
am more ‘aware’ in general when I listen to music, and sing along a bit more.” The
therapeutic benefits of music were also noted: “Music gets your mind off things like
pain, cancer treatments, and noisy intimidating cancer machines. I can also be very tired
and the music wakes me up and helps get me going.” Thus, the MTSG allowed
participants to be more aware of and utilize the benefits of using music for relaxation,
distraction, and physical vitality.
One participant, who had diminished her social activities to take care of her
husband as he completed cancer treatments, noted:
I went back to singing with my church group. It does make you feel better. I had
quit because I thought there wasn’t time to do it with my family ill. Then I
realized I was finding the time to meet with you guys so why couldn’t I go back
and sing with the church?
132
As a result of the MTSG, this caregiver returned to an enjoyable social activity, thereby
decreasing her social isolation, reconnecting her with other supportive people in her life,
and improving her ability to cope with cancer and its treatment. Music connected this
participant with her social and spiritual community, as well as the routines of her daily
life. As noted in previous chapters, caregivers may neglect their own health needs as the
needs of their loved ones with cancer take precedence. Thus, returning to this beneficial
social music activity in the community was an important step for this caregiver in taking
care of herself and her own health needs.
Physical Outcomes of MTSG Participation

Pain
In the present study, the perception of pain (as measured by the MTSG-NRS)
significantly decreased for participants in MTSG sessions 1, 4, 5, and 6. This outcome is
consistent with previous music therapy studies in which pain decreased as a result of
music therapy participation (Beck, 1991; Flaugher, 2002; Kerkvlier, 1990; Krout, 2003a;
Magill, 2001; Siedliecki & Good, 2006). In contrast, the present study found no
significant change in pain perception for sessions 2 and 3. A closer look at the MTSG-
NRS scores from the second and third sessions revealed lower than usual pre-session pain
scores on the 11-point (0-10) pain MTSG-NRS. The average pre-session score from the
second session was 1.5, while the average post-session score was .813. In addition, the
third session pre-intervention average score was .895, which declined to an average of
.737. The participants, on average, had low pain scores initially, so the scores did not
have much room to decrease, resulting in a “threshold effect.”
The types of interventions offered in sessions 2 and 3 provide an alternate
explanation for the lack of significance in pain scores. Both of the sessions included
active music making for the first 25 minutes, followed by music-assisted relaxation. The
second session protocol utilized Orff instruments with a pentatonic improvisation and
singing, while the third session involved group drumming (see Appendix H for group
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protocol). Both of these activities required concentration, active engagement, and motor
movement, which may be difficult for participants in pain. In addition, interactive music
therapy techniques are not typically used in pain relief, with music listening or distraction
more commonly utilized (Groen, 2007).
Social Outcomes of MTSG Participation
Although no significant difference in social support (as measured by the PRQ85-
Part-2) was found between the experimental and control group, it is interesting to note
that the average scores in the experimental group improved, while the control group
scores declined slightly. The caregiver participants in the experimental group indicated
greater improvement in perceived social support than patients, although due to the small
sample size, there was not enough power to detect significant differences.
Upon closer look at the demographic information of participants, the majority of
participants were white, female, married, with some college education. The length of
relationship with their caregiver was at least 11 years, with the majority over 21 years.
Married individuals, especially those in established relationships, may already have high
levels of social support from their spouses and families. Therefore, the type and length of
relationship between patients and caregivers may have affected social support data.
In addition, the varying number of participants in each group may have influenced
the perception of social support. Two of the groups only had three participants because
of individual time constraints, and those individuals suggested larger group size as a
possible improvement for future support sessions. The smaller groups may have
contributed to lower perceived social support scores. In addition, some participants were
involved in other supportive groups outside of the MTSG, potentially influencing the
outcome.
Supportive groups may include other support groups, church or community

groups, or in the case of some participants, Hope Lodge. Some participants stayed at
Hope Lodge during their treatments while others lived in the community. While living at
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Hope Lodge for six weeks or longer, social connections with other cancer patients and
caregivers are naturally made as a result of the community atmosphere. People may
already have supportive interactions from staff and peers, which may have affected study
results.
Other participants may not perceive a personal need for participation in therapy or
a support group. One participant commented: “I don’t think I was really in need of a
therapy group. I enjoyed the sessions. I am in other social groups and they help me.”
This participant was absent for two of the six sessions, and another participant
commented on this: “Perhaps make sure that with a smaller group at least, all members
can commit to regular attendance (if not perfect attendance), especially if it only runs for
a short time. It’s disconcerting to have people come and go.” Seven other experimental
participants missed a session in their MTSG, with sickness, moving, hospitalization, and
providing care for another cited as reasons for absence. When working with very sick
cancer patients and stressed caregivers, especially those currently undergoing treatment,
these events are unavoidable and accommodations need to be made. However, regular
attendance affects the cohesiveness of the group and may have contributed to the non-
significant social support scores.
Previous quantitative studies in music therapy and cancer care did not focus on
social support as a research outcome, but instead focused on aspects of social support
such as group cohesion and connection with others. Waldon (2001) found no significant
differences in group cohesiveness scores between receptive and interactive music groups,
while Allen (2010) identified significant improvement in family role performance scores
from participation in a music psychotherapy group when compared to a cognitive
behavioral support group. In addition, qualitative music therapy studies identified
primary themes related to social support, such as isolation and connection (Daykin,
McClean, & Bunt, 2007; Rykov, 2008)
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These qualitative themes identified in other studies were apparent in the written
comments of the MTSG participants. Several participants identified relationships with
other group members as a highlight of group: “I enjoyed meeting the other women. Just
meeting and talking with other sympathetic people is always helpful. We all wished the
group would go on longer.” Another participant shared a similar sentiment: “I'm glad
we all got to know each other. It’s too bad it’s over, because we all would like it to be
longer. I think the talking and music helped all of us.” These connections with other
people may have decreased the sense of isolation of many participants, and one
participant commented: “It helps a great deal to realize that you are not the only one in
this situation.” This feedback indicates that some participants identified their MTSG as a
cohesive group in which peers bonded with each other and developed a group identity
(Weis, 2003).
Peer support may help overcome social isolation, and group cohesion is a key
factor in supportive group therapy (Weis, 2003). Group interactive music-making
experiences develop group cohesion quickly, especially those in which participants
actively engage in the creative process (Nolan, 2005). The music-making activities
focused on working together to accomplish a unified goal, therefore increasing altruism
and cohesiveness (Waldon, 2001). The group cohesiveness theme was apparent in other
comments such as “I enjoyed the rhythm drums and working together as a group” and
“playing music together and with the other group members.” In addition, altruism, the
motivation to help other people, was an important therapeutic factor in participation: “the
class creates laughter, happiness, and helping each other feel better.” Therefore, even
though the quantitative scores did not indicate significant differences in social support,
trends in the data and participant feedback indicated benefit.
Quality of Life Outcomes in MTSG Participation

In the present study, no significant differences were found between experimental
and control group participants in long-term (three weeks) health-related quality of life
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scores as measured by the FACT-G. This result is consistent with previous studies in
cancer care involving a music-listening intervention (Bozcuk et al., 2006) and a
combination of live music, improvisation, and songwriting (Hanser et al., 2006).
However, other studies indicated an improvement in perceived quality of life as a result
of participating in music therapy groups in cancer care (Burns, 2001; Furioso, 2002).
Although health-related quality of life scores did not differ between experimental
and control groups over the three weeks of sessions, significant improvements in
perceived quality of life occurred within four of the six 60-minute sessions as measured
by the MTSG-NRS. Participants indicated improved quality of life in sessions 2, 4, 5, and

6, but no significant change in sessions 1 and 3. Upon closer look at these two music
therapy sessions, several factors may have influenced the quality of life scores.
Quality of life is a subjective assessment of overall well-being, and when faced
with new ideas, people, and activities, participants may have felt insecure or uncertain,
which in turn may have unintentionally increased their emotional distress. The first
group included group guidelines, individual introductions, music-based group cohesion
activities, and an introduction to music-assisted relaxation. The 60-minute timeframe
may not have been enough time to significantly improve quality of life, especially when
participants were coping with the newness of group and the social stress of meeting new
people.
During the third session, quality of life scores increased, demonstrating benefit
but not reaching significance. The first part of the third session involved group
drumming while the second half focused on music-assisted relaxation. This was the only
session in which both pain and quality of life scores were not significant. The unfamiliar
intervention of drumming may have related to the less beneficial results for session three.
Based on the pre-session survey (MTSG-AF) question involving interest in music therapy
interventions, only 29.27% of participants indicated an interest in playing instruments,
and few participants reported experience in playing instruments. This is consistent with
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Burns et al. (2005) in which the majority of people interested in a music therapy
intervention preferred music listening because they perceived fewer barriers and benefits
to that type of intervention. However, although the newness of playing instruments may
have resulted in lack of significant scores in pain and quality of life for two of the six
sessions, 100% of participants indicated on the follow-up evaluation questionnaire
(MTSG-EQ) that playing instruments was the most enjoyable or therapeutic part of the
MTSG.
An alternate explanation for the difference in significance between health-related
quality of life (HRQOL) as measured by the FACT-G and quality of life (QOL) as
measured by the MTSG-NRS may be explained by the conceptual difference between the
two measurement tools. The FACT-G questions related directly to cancer and treatments
in the domain areas of physical, psychological, social, and functional well-being. The
questions were specific and covered aspects of HRQOL within the past seven days.
Many events may happen within a week, and daily stressors and hassles affect
perception, mood, and physical health (McKinney et al., 1997; Sarafino, 2006). Thus,
thinking about the cumulative stress of the week and focusing on statements about
negative symptoms may have influenced scores on the FACT-G. In contrast, the QOL
measurement on the MTSG-NRS was designed to be a subjective 11-point rating (0-10) in
which participants indicated a number that represented their perception of overall life
quality at that moment. Participants may rate their perception of QOL differently when
the measurement tool is not specifically directed at the cancer experience or when
participants are not reminded of stressors of the past week. The MTSG-NRS score
changed during 60 minutes of group music therapy, indicating that participants
acknowledged a change in their perception of overall quality of life.
Importance of a Variety of Interventions

Individual responses to music are varied; therefore, providing a variety of
interactive and receptive music experiences allows for participants to explore new ways
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of using music therapeutically in their lives. The present study included singing,
songwriting, playing instruments (Orff, drums, tone chimes, auxiliary percussion),
movement and music, creative arts with music, music listening and discussion, and
music-assisted relaxation (breathing meditation, autogenic relaxation, progressive muscle
relaxation, music imagery).
When asked about the most enjoyable or therapeutic parts of the session, one
participant responded with several interventions:
Playing with instruments - no wrong notes was rather freeing, just to experiment
with tones and rhythms, bell choir; Relaxation techniques to ease stress is a good
life skill; Drawing - the suggestion to just sit and listen until a picture forms in
your mind - really a neat experience when it happened, just as you said!
Other participants found “unexpected enjoyment playing instruments” and “playing
instruments – you had so many different ones and they were all very different and I felt I
could safely play and experiment with them.” It is interesting to note such positive
response to making music, for few of the participants had extensive musical training or
background. Consequently, these responses demonstrate that appropriately facilitated
music making can be a highly positive experience for nonmusicians.
One participant found a way to use music to cope with anxiety associated with
new or unfamiliar experiences. “Drawing to music was a new experience for me and
paired music, which I am comfortable with, with drawing, which I am not, so it made
drawing more enjoyable.” This participant found benefit in pairing a comfortable activity
with an uncomfortable one. Cancer patients and caregivers face many uncomfortable
events during the cancer experience, and music can be a positive stimulus that helps them
cope with difficult symptoms and treatments.
Many participants expressed gratitude for the variety of experiences, and one
participant encouraged the researcher to “continue to use a variety of techniques and
encourage people to open up and share their thoughts, feelings, and experiences.” The
MTSG model utilized a multi-modal design, with many different music therapy
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interventions incorporated into the six sessions. The multi-modal design allowed
opportunities for “both verbal and non-verbal expression, enhanced support, and
expanded coping strategies” (Monti et al., 2006, p. 364). The interactive music
experiences provided participants with a “tool by means of which our real concepts of
ideal relationships can be articulated, those contradictions can be reconciled, and the
integrity of the person affirmed, explored, and celebrated” (Small, 1998, p. 221).
Another participant wanted the group to “spend more time participating in the
areas that I enjoyed, i.e. drums and rhythm instruments. I just overcame my inhibitions
and we were done.” Overcoming inhibitions was difficult for some participants. The
music therapist told participants the music interventions were structured for success,
meaning that anything they chose to play would sound good. The participants also
understood that they participated at their own comfort level, with no right or wrong
responses. This explanation worked better for some interventions than others.
Some participants expressed self-doubt about participating in certain
interventions, with one participant commenting, “I don’t feel confident about my voice”
and another stating “I don’t sing very well and am not good at or clever enough for
songwriting.” Other participants also indicated self-consciousness about completing
activities in front of others: “The moving to music technique is something that has some
appeal for me, but I felt awkward doing it with others, perhaps because I’m not
comfortable with my body.” These comments are consistent with those expressed by
cancer patients in qualitative studies by Daykin et al. (2007) and Rykov (2008).
While the interventions used in this experiment were relatively uniform across
groups in order to control the treatment variables, these patient responses highlight the
importance of individualizing music therapy interventions, offering choices that enhance
personal control, and structuring new experiences in a manner that fosters success. These
sorts of modifications can be easily integrated into clinical applications of these findings.
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Awareness of Group Process in MTSG

Group process involves the interaction between group members and the
facilitator, including reactions, exchanges, and dynamics (Jacobs, Masson, & Harvill,
2002). The facilitator, in this case the music therapist, must create a safe and supportive
environment in which trust, caring, commonality, and commitment are essential
components to enhance group dynamics and build rapport (Jacobs, Masson, & Harvill,
2002). One participant commented:
I enjoyed getting to know new people in a supportive, safe context in which we

could share our thoughts, feelings, and experiences, with an awareness of the fact
that coping with/dealing with cancer (in either a patient or caregiver capacity) was
the common denominator bringing us together. I was particularly moved by
everyone sharing about why certain songs are significant for them.
This participant comment reflects the importance of the patient-therapist alliance in
music therapy support groups, as with any psychosocial group. The music therapy
support groups creates this alliance and cohesion through three inherent components of
the group: (a) the unique and flexible benefits of the music modality, (b) the essential
skills, leadership, and rapport of the music therapist, and (c) supportive interactions with
others going through similar circumstances.
Sharing personal thoughts, feelings, and insights may be difficult for some
participants, especially during the first few sessions. The music therapist introduced
group guidelines before beginning the first session, encouraging participants to
participate at their own comfort level, respect privacy and confidentiality of group
members, express themselves without fear of criticism or judgment, and support others
through whole-hearted participation even though they may be nervous at first (see
Appendix M for group materials). By providing guidelines for participation and
encouraging their use throughout the six sessions, the music therapist established a
supportive environment and built a positive relationship with group participants.

The rapport with the music therapist and appreciation for the music therapy
sessions were evident in participant comments: “Abbey did a fine job running the
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sessions, offering lots of options, listening to the participants, and planning everything
well.” Another commented: “The leadership is really a factor. Would definitely
recommend Abbey Dvorak’s group to anyone.” Others mentioned: “You are wonderful
at what you do, keep up the good work!” and “Abbey was great! Keep up the good work
(having the support groups). You are helping a lot of people that really need it.”
The trust, caring, rapport, and positive dynamics allowed participants to enjoy
their group experiences. One participant commented:
I enjoyed the music therapy groups. It made me enjoy music more and to share
with others. It made me understand that everyone in the group had, or was going
through some hard times. I think everyone in our group enjoyed the music, and
each other.
Others also expressed appreciation for the experience: “It’s great for passing some time
and socializing and experiencing some fun and relaxation with music” and “The class
was wonderful – thanks! I am so glad I made the phone call.”
Both cancer patients and caregivers benefited from participation in the music
therapy support groups as indicated by the data and content analyses. According to the
data, both types of participants in the experimental groups demonstrated improvement in
physical, psychological, and social outcomes over the three-week period and each 60-
minute music therapy session. Music therapy support groups can be a beneficial adjunct
psychosocial support during cancer treatment for both cancer patients and caregivers.
Conclusions
Based on the results of this study, the conclusions are as follows:
1. Participation in MTSG affects psychological, physical, and social well-being of
cancer patients and caregivers. Both cancer patients and caregivers may benefit,
with desired long-term and short-term outcomes possible as a result of
participation in the interactive group music experiences.
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2. The MTSG sessions combined (a) the unique and flexible benefits of the music
modality, (b) the essential skills, leadership, and rapport of the music therapist,
and (c) supportive interactions with others in similar circumstances.
3. Participation in the group music therapy interventions may significantly improve
mood and significantly decrease anxiety throughout three-week sessions and over
each 60-minute session.
4. Participation in 60-minute group music therapy sessions may significantly reduce
reported stress levels of cancer patients and caregivers.
5. Pain perception may decrease as a result of participation in music therapy support

groups, depending on initial pain level ratings and the music therapy interventions
utilized.
6. Although no significant difference was found in social support data between the
experimental and control groups, trends in the data indicated benefit from
participation in the MTSG, especially for caregivers, who may not have as many
supports available to them.
7. No significant difference was found in health-related quality of life scores over
the three weeks, but short-term quality of life scores were significant in sessions
2, 4, 5, and 6. Quality of life scores in sessions 1 and 3 may have resulted from
the newness and unfamiliarity of the group and music interventions.
8. Participants may feel more comfortable initially or have prior experience with
receptive music interventions, but may benefit from interactive approaches.
Although many participants did not indicate playing instruments as an area of
experience or interest for them in the pre-session assessment form, 100% of
participants rated playing instruments as the most enjoyable or therapeutic part of
the MTSG on the follow-up evaluation questionnaire (MTSG-EQ).

9. The variety of receptive and interactive music therapy interventions allowed
participants to explore new ways to use music therapeutically in their own lives.
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Participant responses to interventions varied, with some participants preferring

one intervention to another.
10. An awareness of group process and group dynamics is essential when facilitating
music therapy support groups. The music therapist must provide a safe and
supportive environment for cancer patients and caregivers to feel comfortable,
openly express themselves, and enjoy the groups.
Clinical Implications
The results of this research indicate that the music therapy support group protocol
can be a beneficial model for music therapists working in cancer care. This controlled
research protocol can be modified or applied to clinical sessions with cancer patients and
caregivers in a variety of ways. Clinical implications from the study are discussed in the
following section.
This was a research study, so the same MTSG research protocol was utilized for
all groups in order to decrease confounding variables. However, music therapists serving
clients in a clinical setting would constantly assess participant response and modify
interventions as a result. The Music Therapy Support Group Assessment Form (MTSG-
AF) could be used to gather important initial information from group members, and from
that information, music therapy interventions specific for that group could be created.
For example, if several participants indicate on the MTSG-AF that they find a particular
song inspiring or helpful during their cancer journey, the music therapist can design an
accessible interactive music experience and utilize it in the group. Incorporating choice
and control and using participant suggestions builds rapport and cohesiveness within the
group.
In addition, because of the nature of research and randomization, the groups
sometimes had a less than ideal combination of participants. Many of the groups had a
combination of people with different types of cancer or in different stages of their cancer
journey. Although this variety allowed for multiple perspectives, clinicians may choose
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to use the MTSG-AF, or a similar assessment form, to match participants to more focused
groups depending on the needs and goals of potential participants. The focused groups
may allow participants to be more cohesive or more involved in the therapeutic process.
When working with cancer patients and caregivers, groups need to be accessible
and flexible. Music therapy clinicians may want to consider facilitating MTSG at places
where cancer patients and caregivers are residing during treatments, such as Hope Lodge
or Ronald McDonald House, or hotels or facilities connected with hospital or medical
centers. Community centers or libraries would also be easily accessible for cancer
survivors and caregivers. In addition, many cancer survivors and caregivers need to
work, so groups need to be held at convenient times. During this current study, several
participants needed to start groups immediately so there were two groups with only three
participants in each. However, this size was not ideal and clinicians are encouraged to
have more participants in each group to increase social networks and decrease initial self-
consciousness.
Although participants may not initially indicate interest in interactive music
therapy interventions, these experiences can be enjoyable and therapeutic for
nonmusicians when structured in an accessible and supportive manner. The live,
interactive music experiences allow participants to make connections to others in the
group. However, music therapy clinicians need to be aware of initial insecurity,
uncertainty, and hesitancy in regards to unfamiliar modalities and adjust their approach
accordingly. In addition, some participants may feel uncomfortable singing or
participating in front of others, especially in smaller groups.
Music therapy clinicians can examine the effectiveness of specific music therapy
interventions or sessions through the use of pre- and post-session data collection. The
data may not only come from the patients, but from the caregivers or other family
members as well. Incorporating the family members into music therapy sessions and
evaluating the effectiveness can become a part of clinical practice protocol. In addition,
145
being aware of conceptual differences between types of data collection methods is

important. For example, the differences between health-related quality of life and quality
of life are not always apparent from the literature, but participants may rate themselves
differently depending on the data collection approach.
Furthermore, clinicians may share the MTSG protocol or adaptations of it with
nurses, physicians, caregivers, and community members so more people may benefit
from music therapy interventions in daily life. Music therapy clinicians may share
information regarding the benefits of music therapy, especially the physical,
psychological, and social benefits inherent in interactive group music therapy

experiences.
Recommendations for Further Research
The following recommendations are suggested for future investigation:
1. Replicate the study with a larger sample size for additional power when testing
for differences between experimental and control group participants.
2. Utilize the music therapy support group (MTSG) study protocol with only cancer
patient participants or only caregiver participants.
3. Facilitate the MTSG protocol with patients of a particular cancer type or stage of
cancer in order to determine benefit in perceived social support.
4. Compare the results of this study with studies involving patients and caregivers
from different races and ethnic groups.
5. Expand the number of sessions or lengthen the amount of time the MTSG meets
and compare changes in social support and quality of life over a different period
of time.
6. Replicate the study with more people in each music therapy group and examine
changes in social support as a result.

7. Examine the differences between age, gender, or personality and response to
particular types of music therapy interventions.
146
8. Allow participants to choose their preferred music therapy intervention and

examine responses as a result.
9. Replicate the study utilizing similar music therapy techniques but facilitate the
least preferred ones (songwriting and drawing with music) differently.
10. Expand the research by using only one type of intervention each session of the
support group in order to better determine effects of particular interventions.
11. Compare a music therapy support group that uses only music-assisted relaxation
techniques with a MTSG that uses only interactive music interventions, and
compare both to wait-list control groups.

12. Allow participants to choose between participation in a music therapy support
group or individual music therapy sessions and examine the results.
In conclusion, the music therapy support group model affects physical,
psychological, and social well-being of cancer patients and caregivers. Both cancer
patients and caregivers may benefit, with desired long-term and short-term outcomes
possible as a result of participation in the interactive group music experiences. The
MTSG was a multifaceted treatment approach that combined the unique and flexible
benefits of the music modality; the essential skills, leadership, and rapport of the music
therapist; and supportive interactions with others in similar circumstances. As a result of
this combination, positive health outcomes of participants were possible.
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APPENDIX A
PERSONAL RESOURCE QUESTIONNAIRE 85 PART 2 (PRQ85-PART 2)

148
149
150
APPENDIX B
MUSIC THERAPY SUPPORT GROUP NUMERICAL RATING SCALES (MTSG-NRS)

151
Music Therapy Support Group Numerical Rating Scale (MTSG-NRS)

Pre-Session Rating Scale
Please circle the number that best reflects how you feel regarding each subject.
Anxiety
Low Anxiety ___________________________________________High Anxiety
0 1 2 3 4 5 6 7 8 9 10
Stress
Low Stress ____________________________________________High Stress
0 1 2 3 4 5 6 7 8 9 10
Pain
No Pain ____________________________________________Severe Pain
0 1 2 3 4 5 6 7 8 9 10
Mood
Low Mood ____________________________________________Great Mood
0 1 2 3 4 5 6 7 8 9 10
Quality of Life
Low QOL _____________________________________________High QOL
0 1 2 3 4 5 6 7 8 9 10
---------------------------------------------------------------------------------
Post-Session Rating Scale
Please circle the number that best reflects how you feel regarding each subject.
Anxiety
Low Anxiety ___________________________________________High Anxiety
0 1 2 3 4 5 6 7 8 9 10
Stress
Low Stress ____________________________________________High Stress
0 1 2 3 4 5 6 7 8 9 10
Pain
No Pain ____________________________________________Severe Pain
0 1 2 3 4 5 6 7 8 9 10
Mood
Low Mood ____________________________________________Great Mood
0 1 2 3 4 5 6 7 8 9 10
Quality of Life
Low QOL _____________________________________________High QOL
0 1 2 3 4 5 6 7 8 9 10
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APPENDIX C
MUSIC THERAPY SUPPORT GROUP ASSESSMENT FORM (MTSG-AF)

153
Music Therapy Support Group Assessment Form

Music Therapy Cancer Support Groups
Thank you for taking the time to fill out an information survey for the music
therapy groups. The information you provide will assist in planning the groups based on
your interests and music preferences, along with other members of the group. There are
no right or wrong answers, and all information from the survey will remain confidential.
Your contact information will be used to schedule research visits or to let you know if a
group is canceled due to weather or illness. Thank you again for your assistance and
participation.
Please check your responses unless otherwise indicated.
SECTION A: CONTACT INFORMATION AND DEMOGRAPHIC DATA
Name __________________________________ Age ________ Female Male
I am a: Person with a Cancer Diagnosis Caregiver (Family Member or Friend)
Home Phone ___________________________________________ Preferred Contact
Cell Phone _____________________________________________ Preferred Contact
E-Mail ________________________________________________ Preferred Contact
Mailing Address __________________________________________________________

________________________________________________________________________
Marital Status: Married Widowed Separated Divorced Never Married
Race: White Asian Latino African American

Native American Other (please specify): ____________________
Highest Level of Education (Please choose one of the following):

Elementary School High School Graduate degree
Some College Classes Bachelor’s Degree Other ________________
Religious Affiliation (Please choose on of the following):

Protestant Catholic Jewish Muslim Other_________________
I am not currently affiliated with or choose not to practice a religion.
How would you describe your current health?

Excellent Very Good Good Fair Poor
------------------------------------------------------------------------------------------------------------
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SECTION B: PERSON WITH A CANCER DIAGNOSIS
Please fill out the following if you are a person with a cancer diagnosis. If you are unsure
of the stage or type of cancer, you might check with your healthcare provider.
If you are a family member or friend, please skip to Section C. After you are done,
please continue to Section D.
Type of Cancer: _________________________ Diagnosis Date: ________________
Stage of Cancer: Stage 1 Stage 2 Stage 3 Stage 4 Don’t Know
What type of treatments are you currently receiving? (Please check all that apply).
Chemotherapy Radiation Surgery Both chemotherapy and radiation
Other _________________ I am not receiving any type of treatment at this time.
What type of treatments have you received in the past? (Please check all that apply).
Chemotherapy Radiation Surgery Both chemotherapy and radiation
Other ________________ I have not received any type of treatment previously.
------------------------------------------------------------------------------------------------------------
SECTION C: FAMILY MEMBER OR FRIEND
Please fill out the following if you are a family member or friend. After you are done,
please continue to Section D.
What is your relationship to the person with cancer? (Please choose one of the following)
Spouse Sibling Parent Son/Daughter Friend
Coworker Other (please specify): _____________________________
How long have you known your family member or friend? _____ Years _____ Months
------------------------------------------------------------------------------------------------------------
SECTION D: MUSIC PREFERENCES AND EXPERIENCES
1. Please indicate your experiences with music in your life by checking each
experience that applies:
High School Choir
High School Band
College Choir
College Band
Private Music Lessons
Play an Instrument _________________
Career in Music ____________________
Enjoy Singing
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Listen to Music
Write Poetry/Songs
Church Music Involvement
Relax with Music
Exercise with Music
Other (please explain): _________________
2. Please indicate the styles of music you are most comfortable with and prefer to listen
to by checking each style below that applies. If you would like to include more
information about a style, feel free to add comments.
Broadway
Classical
Country
Folk
Gospel
Heavy Metal
Jazz
Pop
Rap/Hip-Hop
Rhythm & Blues
Rock
Swing
World Music
Other (please indicate):
_______________________
3. My favorite song is __________________________________________________.
4. My favorite artist is __________________________________________________.
5. Please indicate areas of music therapy you find interesting or would like to learn more
about. Your answers will assist in guiding the music therapy sessions during the
three-week program. (Check all that apply).
Playing instruments
Relaxing with music
Listening to music
Talking about songs
Drawing to music
Moving to music
Singing
Songwriting
Other (please indicate): ________________
6. Have you ever attended a cancer support group before? Yes No

If yes, please explain.
________________________________________________________________________
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________________________________________________________________________
7. Have you ever attended a music therapy group before? Yes No

If yes, please explain.
________________________________________________________________________
________________________________________________________________________
8. What are your expectations for the music therapy cancer support group? What do you
hope to gain or learn as part of your participation in the groups?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Comments:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Thank you for taking the time to fill out this information survey before beginning the
music therapy support group. Your answers from this survey will assist tremendously in
planning sessions. Thank you again!
157
APPENDIX D
MUSIC THERAPY SUPPORT GROUP EVALUATION QUESTIONNAIRE
(MTSG-EQ)
158
Music Therapy Support Group Evaluation Questionnaire
Questionnaire # ___
Thank you for taking the time to participate in the music therapy groups with your family
member or friend. This follow-up questionnaire will assist in evaluating the sessions and
planning for future support groups. There are no right or wrong answers and your
responses will be kept confidential. Please return the questionnaire in the enclosed self-
addressed and stamped envelope. Thank you again for your assistance and participation.
Please check your responses unless otherwise indicated.
Group Attended: Hope Lodge, Iowa City

Mercy Medical Center, Cedar Rapids
UIHC Center, Iowa City
1. Please rate your overall experience with the music therapy support group.
Excellent
Good
Neutral
Fair
Poor
2. Do you feel you benefited from having participated in the music therapy group
with your family member?
Yes
Somewhat
No
3. Did the music therapy support group assist with any of the following?
Check as many as apply.
Reduce Stress
Reduce Anxiety
Improve Mood
Assist with Coping
Provide Support
Reduce Depression
Improve Relationships
Improve Communication
Improve Quality of Life
Learn New Skills
Other (please indicate): _________________
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4. What were the most enjoyable/most therapeutic parts of the music therapy support
groups? (Check as many as appropriate).
Singing
Songwriting
Playing instruments
Relaxing with music
Listening to music
Talking about songs
Drawing to music
Moving to music
Other (please specify): _________________
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Yes
Maybe
No
Why or why not?

________________________________________________________________________
________________________________________________________________________
Additional Comments:
________________________________________________________________________
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________________________________________________________________________
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161
APPENDIX E
UNIVERSITY OF IOWA INFORMED CONSENT

162
FOR IRB USE ONLY

APPROVED BY: IRB-01
IRB ID #: 200804781
APPROVAL DATE: 10/11/10
EXPIRATION DATE: 07/21/11
INFORMED CONSENT DOCUMENT
Project Title: Music Therapy Support Groups for Individuals Diagnosed with
Cancer
and Their Families
Research Team: Abbey Dvorak, MA Kate Gfeller, PhD 
Sharon Baumler, CORLN, MSN Richard Shields, MPT, PhD 
Jane Utech, BSN Jacob Oleson, PhD
Geraldine Jacobson, MD, MPH Dingfeng Jiang, MS
Susan Roman, DO, MS Mary Walker, MA, MT-BC
Nicole Nisly, MD Sonia Sugg, MD
Jane Hershberger, RN
This consent form describes the research study to help you decide if you want to
participate. This form provides important information about what you will be asked to do
during the study, about the risks and benefits of the study, and about your rights as a
research subject.
• If you have any questions about or do not understand something in this form, you
should ask the research team for more information.
• You should discuss your participation with anyone you choose such as family or
friends.
• Do not agree to participate in this study unless the research team has answered
your questions and you decide that you want to be part of this study.
WHAT IS THE PURPOSE OF THIS STUDY?
This is a research study. We are inviting you to participate in this research study because
you are an individual with a cancer diagnosis or a caregiver (family member/friend) of an
individual with cancer.
The purpose of this research study is to examine the effect of a six-session music therapy
support group on mood, coping, social support, and quality of life for individuals
diagnosed with cancer and their caregivers (family members or close friends).
The music therapy support groups will be held twice a week (60 minutes each session)
over the course of three weeks. Participants will be randomly assigned to treatment
groups that begin right away or control groups for which sessions will begin later after
initial enrollment in the study. The groups will meet at the University of Iowa Hospitals
and Clinics, the Russell and Ann Gerdin American Cancer Society Hope Lodge in Iowa
City, or at Mercy Medical Center in Cedar Rapids. All participants will complete some
163
forms prior to participation in the music therapy support groups. Some participants will
wait longer than others to begin their groups.
HOW MANY PEOPLE WILL PARTICIPATE?
Up to 50 people will take part in this study at the University of Iowa.
HOW LONG WILL I BE IN THIS STUDY?
If you agree to take part in this study, you will be randomly assigned to treatment or
control groups. Some people will fill out forms and start the music therapy sessions right
away, while others will fill out forms, wait three weeks, fill out forms, and then begin
music therapy sessions. Both groups will also be mailed a brief questionnaire three
weeks after the last session to complete and return by mail. Your involvement in the
group sessions will last three weeks, though if you are in the group that must wait, the
total time will be up to six weeks.
WHAT WILL HAPPEN DURING THIS STUDY?
If you choose to sign this Informed Consent Document, you will also be asked to fill out
some forms immediately: 1) a survey to gather contact information, information about
your age and health status, music preferences, and music experiences, and 2) and self-
evaluation questionnaires to indicate how you are feeling. The forms will take
approximately 30-45 minutes, and you are free to skip any questions that you would
prefer not to answer. There are no right or wrong answers on these forms, and all your
information will be kept confidential. If you are not able to complete the paperwork right
now, the researcher will schedule a separate visit for you to complete the forms before the
sessions begin.
After you complete the forms, you will be given the researcher's contact information on a
business card and on this form. Please have your family member or friend, whom you
wish to attend the groups with you, call the researcher to set up an appointment to sign
the Informed Consent Document and complete the forms.
After the initial research visit, randomization will take place. Your group will be
determined purely by chance, like the flip of a coin. Treatment groups will begin within
one week for some participants, while control groups will wait at least three weeks before
beginning.
The music therapist will take into account music preferences and experiences of group
members in planning activities. The activities are designed to be enjoyable for people
with all levels of musical background, including no formal musical training. You need
not read music, have any special musical training, or have any musical talent in order to
participate successfully. If you enjoy listening to some kinds of music, chances are, you
will find the activities fun and easy to do. Activities may include playing instruments that
are designed so anyone may play them, listening to music, talking about music,
164
songwriting, relaxation with music, singing, moving with music, and drawing to music.
Before and after each session, the participants will be asked to evaluate and mark a
number on a form regarding their level of stress, anxiety, pain, mood, and quality of life.
After both the third and sixth session, participants will complete the same forms they
completed during the initial research visit. Three weeks after the last session, you will
receive a follow-up questionnaire with a self-addressed and stamped envelope in the mail
to complete and return.
Audio/Video Recording or Photographs
One aspect of this study involves making audio recordings and video recordings of the
group. The audio recordings and video recordings will be made to demonstrate specific
music therapy techniques used in the group for music therapy, nursing, and medical
presentations. The audio recordings will be made to allow participants in the group to
listen to their group-created songs and music. The primary investigator will have access
to the audio and video recordings, which will be kept and used as a learning tool for
classes and presentations.
WHAT ARE THE RISKS OF THIS STUDY?
You may experience one or more of the risks indicated below from being in this study. In
addition to these, there may be other unknown risks, or risks that we did not anticipate,
associated with being in this study.
Participants may have an emotional response to a song or topic being discussed in the
group. For example, you may recall having heard a song that brings tears to your eyes, or
reminds you of a happy or sad time. If this happens, the researcher will talk with the
participant about his/her response, and if further counseling is needed, a list of
professionals in the area will be provided. Participants always have the option of not
responding or participating in any discussion or music therapy intervention in which they
feel uncomfortable or which the topic is something they would prefer not to discuss. You
may skip any questions on the questionnaire you prefer not to answer.
WHAT ARE THE BENEFITS OF THIS STUDY?
We don’t know if you will benefit from being in this study. However, we hope that, in the
future, other people might benefit from this study because of the knowledge gained
regarding changes in mood, coping, social support, and quality of life from participation
in music therapy support groups.
WILL IT COST ME ANYTHING TO BE IN THIS STUDY?
You will have costs for participating in this research study. You will need to provide
your own transportation to and from each visit. Therefore, you will have your own
personal travel costs for being in this research study. The sessions will be provided free
165
of charge.
WILL I BE PAID FOR PARTICIPATING?
You will not be paid for being in this research study. However, you will receive
compensation in the form of a gift card of your choice from Walmart or Target in the
amount of $25 after you complete the final sixth session forms. If you do not complete
the entire study, you are not entitled to the $25 gift card.
WHO IS FUNDING THIS STUDY?
The Arthur Flagler Fultz Research Grant from the American Music Therapy Association
is funding this research study. This means that the University of Iowa is receiving
payments from The American Music Therapy Association (AMTA) to support the
activities that are required to conduct the study. No one on the research team will receive
a direct payment or increase in salary from AMTA for conducting this study.
WHAT ABOUT CONFIDENTIALITY?
We will keep your participation in this research study confidential to the extent permitted
by law. However, it is possible that other people such as those indicated below may
become aware of your participation in this study and may inspect and copy records
pertaining to this research. Some of these records could contain information that
personally identifies you.
• federal government regulatory agencies,
• auditing departments of the University of Iowa, and
• the University of Iowa Institutional Review Board (a committee that reviews and
approves research studies)
To help protect your confidentiality, we will assign a research identification number

(RIN) to your forms so no one will be able to identify your information. Each RIN will
be stored separately from personal identification information for the duration of the
study, with all materials stored in locked filing cabinets to which only the primary
investigator has access. When materials are transported, they will be placed in a locked
container and taken immediately to the locked filing cabinet. Computer files will be
stored on a password protected flash drive that will also be locked in the same filing
cabinet. If we write a report or article about this study or share the study data set with
others, we will do so in such a way that you cannot be directly identified.
IS BEING IN THIS STUDY VOLUNTARY?
Taking part in this research study is completely voluntary. You may choose not to take
part at all. If you decide to be in this study, you may stop participating at any time. If
you decide not to be in this study, or if you stop participating at any time, you won’t be
penalized or lose any benefits for which you otherwise qualify.
166
WHAT IF I HAVE QUESTIONS?
We encourage you to ask questions. If you have any questions about the research study
itself, please contact: Abbey Dvorak, MA, MT-BC at (319) 356-4718 or Dr. Kate Gfeller
at (319) 356-2014. If you experience a research-related injury, please contact Abbey
Dvorak (319) 356-4718, Sharon Baumler (319) 356-7592, or Jane Utech (319) 356-4422.
If you have questions, concerns, or complaints about your rights as a research subject or
about research related injury, please contact the Human Subjects Office, 105 Hardin
Library for the Health Sciences, 600 Newton Road, The University of Iowa, Iowa City,
Iowa, 52242, (319) 335-6564, or e-mail irb@uiowa.edu. General information about
being a research subject can be found by clicking “Info for Public” on the Human
Subjects Office web site http://research.uiowa.edu/hso. To offer input about your
experiences as a research subject or to speak to someone other than the research staff, call
the Human Subjects Office at the number above.
This Informed Consent Document is not a contract. It is a written explanation of what

will happen during the study if you decide to participate. You are not waiving any legal
rights by signing this Informed Consent Document. Your signature indicates that this
research study has been explained to you, that your questions have been answered, and
that you agree to take part in this study. You will receive a copy of this form.
Subject's Name (printed):

__________________________________________________________
Do not sign this form if today’s date is on or after EXPIRATION DATE: 07/21/11.
_______________________________________________________________________
(Signature of Subject) (Date)
Statement of Person Who Obtained Consent
I have discussed the above points with the subject or, where appropriate, with the
subject’s legally authorized representative. It is my opinion that the subject understands
the risks, benefits, and procedures involved with participation in this research study.
_______________________________________________________________________
(Signature of Person who Obtained Consent) (Date)
167
APPENDIX F
MERCY MEDICAL CENTER INFORMED CONSENT
168
169
170
171
172
APPENDIX G
RECRUITMENT MATERIALS
173
Online and Print Publications
University of Iowa News Item 05xx10 Music Therapy CFP
THIS IS TO RECRUIT SUBJECTS WITH CANCER AND THEIR CAREGIVERS

FOR THE STUDY
IRB Reviewers: In addition to the news release, this text may also be used in UI Health
Care consumer publications (online and print)
At-a-Glance
UI music therapy study for cancer patients invites participants
Adults age 18 and older who have cancer and their caregivers may be eligible to
participate in a University of Iowa research study investigating the effects of music and
music-based activities on mood, coping, social support and quality of life.
Study participants must currently be undergoing treatment for cancer or must have their
last treatment appointment within 12 months of starting the study. Participants must also
have a caregiver, either a family member or close friend, who is willing to participate in
the study.
The study involves six 60-minute group sessions held twice a week for three weeks at UI
Hospitals and Clinics. Sessions could include music-assisted relaxation, singing, playing
instruments and songwriting. No previous musical experience or training is required.
Participants will record their level of stress, anxiety, pain, mood and quality of life before
and after each session, and will complete additional forms about mood, social support
and quality of life. Sessions are provided at no cost and compensation is available.
The study is funded by a $10,000 grant from the American Music Therapy Association.
For more information, contact lead researcher Abbey Dvorak at (319) 356-4718 or
abbey-dvorak@uiowa.edu.
SUBMITTED BY: Jennifer Brown, 319-356-7124

174
Public Service Announcement
University of Iowa News Item 05xx10 Music Therapy CFP
THIS IS TO RECRUIT SUBJECTS WITH CANCER AND THEIR CAREGIVERS

FOR THE STUDY
Release: date, 2010
University of Iowa Public Service Announcement 05xx10 MUSICTHERAPY2010PSA
NOTE TO PSA EDITORS: This 20-second announcement about a University of Iowa

research study may be used anytime before DATE, 2010.
:20 SECONDS
ADULTS WITH CANCER AND THEIR CAREGIVERS ARE INVITED TO

PARTICIPATE IN A UNIVERSITY OF IOWA STUDY ON THE EFFECTS OF
MUSIC AND MUSIC-BASED ACTIVITIES ON MOOD, COPING, SOCIAL
SUPPORT AND QUALITY OF LIFE. FOR INFORMATION, CALL (319) 356-4718.
THAT'S (319) 356-4718.
STORY SOURCE: University of Iowa Health Care Media Relations, 200 Hawkins
Drive, Room W319 GH, Iowa City, Iowa 52242-1009
STUDY CONTACT: Abbey Dvorak, 319-356-4718, abbey-dvorak@uiowa.edu.

MEDIA CONTACT: Jennifer Brown, 319-356-7124, jennifer-l-brown@uiowa.edu
END
DISTRIBUTION: Eastern Iowa and local radio
SPECIAL INSTRUCTIONS: This does not need to be posted to the digest or listserv.
Please list study contact above media contact.
175
Participant Recruitment Checklist for Team Members

PART I: The potential participant must be able to answer “Yes” to the following:
1. Are you over the age of 18?

2. Do you have a cancer diagnosis?
3. Are you currently undergoing treatment or your last treatment appointment will
be within one year of the first group music therapy session?
4. Will you have at least one week after surgery before the music therapy sessions
begin?
5. Is English your primary language?
6. Are you able to read and write in English?
7. Do you have dementia or CNS involvement that may affect enjoyment of music
or participation in group?
8. Do you have the ability to hear and speak?
9. Are you able to attend a support group twice weekly for three weeks?
10. Do you have a caregiver (family member or friend) to attend group with you?
PART II: The potential participant must be able to answer “No” to the following:
1. Are you currently in hospice care?

2. Do you have a suppressed immune system in which exposure to crowds would be
harmful?
Continue onto the next section if the patient answers “No” to all the questions in Part II.
PART III: Follow the steps outlined below to obtain Informed Consent from the person.
1) Contact Abbey Dvorak, the Primary Investigator (PI)

Pager: 6810
Office Phone: (319) 356-4718
Email: abbey-dvorak@uiowa.edu
2) If no answer within five minutes, please give participants Abbey Dvorak’s business
card and ask them to contact her for more information. She will talk with them over the
phone, explain the study, answer any questions, and set up an appointment for
participants to sign the Informed Consent documents and begin the paperwork.
3) If you have any questions, please call the Music Therapy Department at 356-4718 or
email abbey-dvorak@uiowa.edu. Thank you for all your assistance with this process.
176
Email to Staff at UIHC

Re: Music Therapy Groups for Cancer Patients and Caregivers
The UIHC Department of Rehabilitation Therapies and the Holden Comprehensive

Cancer Center are currently recruiting participants for the study, “Music Therapy Support
Groups for Individuals Diagnosed with Cancer and Their Families.”
Participants are eligible for this study if they meet the following criteria:
1. Adults over the age of 18 with a cancer diagnosis

2. Currently undergoing treatment or last treatment appointment within one year of
first group music therapy session
3. At least one week after surgery before music therapy sessions begin
4. English as primary language
6. No dementia or CNS involvement that would affect enjoyment of music or
participation in group
8. Physically able to attend a support group twice weekly for six weeks
9. If possible, a caregiver (family member or friend) to attend group with the patient
Please distribute the attached poster and eligibility criteria to your staff members. If a
patient requests further information, provide them with the poster and my contact
information. Please contact Abbey Dvorak at (319) 356-4718 or abbey-
dvorak@uiowa.edu if you have questions or comments. Thank you for your assistance
in this matter.
Sincerely,
Abbey Dvorak, MA, MT-BC
Music Therapist-Board Certified
Department of Rehabilitation Therapies
University of Iowa Hospitals and Clinics
177
178
IRB-Approved Powerpoint Presentation for Nursing and Medical Staff

179
180
APPENDIX H
MTSG GROUP PROTOCOL AND INTERVENTION DESCRIPTION

181
Music Therapy Support Group (MTSG) Schedule Synopsis

Day 1 – Stress Management
• Introduction of MTSG and Group Schedule/Rituals
o Greet participants at the door and introduce them to pre-session rituals
o Hand sanitizer
o Sign-In sheet
o Name tags
o Folders and MTSG-NRS
• Pre-Session MTSG-NRS
• Discuss “Group Guidelines” Handout
• Introduction of Members
• Egg Pass
o Participants choose egg, color may represent stressor or may name their
stressor (i.e. pain, fatigue, loss of function, etc.)
o Explain that in supportive groups, we help each other balance and cope
with these stressors.
o Perform egg pass, teaching each step, and then add singing
• Tone Chimes with “Lean on Me”
o Introduce and demonstrate tone chimes
o Distribute tone chimes according to colored chords
o Practice chord progression until participants are comfortable
o Add singing, and once participants are comfortable with continuing the
pattern, MT adds guitar to song
• Discuss “Managing Stress with Music and Relaxation” Handout
• Relaxation – Breathing Meditation with recorded music
• Discuss different breathing techniques used for relaxation
182
• Encourage participants to practice breathing techniques with music a few minutes

each day
• Post-Session MTSG-NRS
Day 2 – Emotional Expression
• Brief breathing meditation with live guitar and check-in of members
• Introduction of “Reflection” and Orff Instruments
o Invite participants to visualize imagery during song
o Perform “Reflection” using live singing and C and G bass bars

o Demonstrate C pentatonic Orff instruments and discuss how anything they
play will sound good; access creativity and empowerment
o Group Improvisation with chosen Orff instruments; MT continues playing
bass bars and singing song for support at first; fade the song and continue
to improvise
o Participants may change instruments and continue improvisation
• Process ideas, images, and feelings associated with the “Reflection”
improvisation
• Discuss “Sharing Our Thoughts and Feelings” Handout
• Relaxation – Breathing Meditation review with addition of body-based Autogenic
Relaxation
Day 3 – Music and Wellness
• Group Drumming
183
o Introduce and demonstrate drums; discuss how anything played will sound
good; discuss rhythm of our lives and how our brain naturally responds to
auditory stimulation; entrainment of rhythm with others
o Try different drumming techniques paying attention to group and
individual response to interventions
! Call and Response
! In the Moment Music
! Building the Groove
! 1-8 Letting it Out

! Leadership – Drum how you are feeling/share experience
! May You Walk in Beauty
• Process drumming experience and briefly discuss overview of biopsychosocial
model and wellness
• Relaxation – Breathing Meditation and Autogenic Relaxation review; add
Favorite Place Imagery
• Fill out forms – STAI, POMS, FACT-G, PRQ85
• Ask participants to identify a meaningful song they would like to share with
others at the next session
Day 4 – Connection
• Paddle Drums
o Introduce and demonstrate instrument
o Tandem Drumming Patterns

o Phrases – Create phrases of empowerment (cancer/treatment phrases) and
play rhythms
184
o Rhythm Song – Create phrases that identify group

• Discuss “Songs” Handout
• Participant sharing of meaningful songs (see Appendix X for a list of songs)
o Prior to group, create song packets of songs participants identified as
meaningful to them
o Load recordings onto Ipod and practice playing them live
o Participants may choose live or recorded version of their songs;
encouraged to sing along
o Ask participants to introduce their song, share why the song is meaningful
to them, and why they wanted to share it with others in the group
o MT chosen song - “Stand” by Rascal Flatts
! Discuss lyrics and topic of resilience
! If time, reintroduce tone chimes and invite participants to perform
song; use paper with lyrics and color coding
• Relaxation – Progressive Muscle Relaxation with recorded music
• Discuss “Types of Relaxation” Handout
Day 5 – Creativity
• Discuss creativity and “Songwriting” Handout
o Invite the group to choose a familiar song and try the fill-in-the blank or
piggyback songwriting approaches to personalize the song
o As a group, brain storm ideas and create a song; MT and group sing the
song with new words

• Discuss creative arts and “Mandala” Handout
185
o Discuss mandala and show examples of different styles; no right or wrong

way; personal form of expression
o Play recorded, instrumental music while participants complete mandalas
o With the time left, encourage participants to try another mandala, write
their own individual song, or simply sit and relax with the music
• Ask participants to share their mandala and/or song with the group
Day 6 – Hope and Affirmation
• Movement with Music – Personal Tai-Chi with recorded music
o Ask participants to share an activity they enjoy; as a group create slow,
meditative movements and perform them together
o Practice each movement four times slowly, picturing yourself in that
activity and joy it brings;
o Perform movements four times each around the pattern of the group circle;
after everyone has pattern can close eyes to facilitate imagery with
movement
o During this time, the slow, rhythmic recording assists participants in
timing movements together.
o Process activity including ideas, images, feelings, movements
• Discuss importance of joy, hope, and affirmation
• Introduce Affirmation Blues with Jazz Orff
o Demonstrate singing the affirmation three times with the E blues chord
progression on guitar
o Introduce Orff instruments with modified jazz pentatonic scale (E, G, A,

Bb, B, D)
o Introduce and demonstrate drums and auxillary percussion instruments
186
o Encourage creative improvisation and singing with various positive

affirmations, such as “I am a powerful, positive, and worthwhile human
being.”
o Ask participants to create individual or group affirmations and write them
on the board
o Perform the affirmations using instruments, guitar, and singing
o Process ideas, thoughts, and feelings regarding the activity
• Review importance of music in lives and review physical, psychological, and
social responses they may have to music

• Relaxation – Hope Imagery Exercise with recorded music
• Fill out forms – STAI, POMS, FACT-G, PRQ85
• Receive a thank-you card and gift card of their choice to Target or Walmart
Three Weeks After Session
• Mail the Music Therapy Support Group Evaluation Questionnaire (MTSG-EQ) to
the group participants with a stamped, self-addressed envelope for them to
complete and return
Materials Needed for MTSG Protocol
All Six Sessions: Guitar, iPod, Speaker, Sign-In Sheet, NRS Forms, Handouts, Folders,
Hand Sanitizer, Name Tags, White Board Markers, Pens
Session One: Egg Shakers, Tone Chimes
Session Two: C and G Bass Bars, C Pentatonic Orff Instruments (Xylophones,
Glockenspiels, Metallophones), Mallets
Session Three: Djembes, Doumbeks, Tubanos
Session Four: Paddle Drums, Mallets, Song Packets, Tones Chimes

Session Five: Creative Arts Supplies (Oil Pastels, Colored Pencils, Markers, Crayons)
187
Session Six: Drums, Auxillary Percussion (Maracas, Cabasa, Guiro), Jazz Scale Orff
Instruments (Xylophones, Glockenspiels), Mallets
188
Music Therapy Support Group (MTSG) Intervention Descriptions and Resources

The six major categories of music therapy interventions for the MTSG protocol
include music listening and discussion, songwriting, active music making, music-assisted
relaxation, creative arts, and movement with music. All of the music therapy
interventions included in the MTSG protocol are designed to be enjoyable, with no
previous music skills required. The instruments are set-up or designed in a way that
anyone may play them in order to provide opportunities for success, empowerment, and
group cohesion.
Music Listening and Discussion
Lyric analysis, or song analysis, involves focusing on the words of a song and
discussing how they relate to personal life situations. Patients may discuss feelings,
thoughts, memories, or life events that arise from specific words or phrases chosen by
group members. Songs may be chosen to illustrate topics or for specific purposes by a
trained music therapist.
Lyric analysis is a flexible intervention and may be used in combination with
other techniques to maintain interest and increase group participation. For example, in
order to work on the goal of increasing adaptive coping skills, the song “Stand” by Rascal
Flatts was used to discuss resilience, including different ways to increase the ability to
bounce back from tough life situations. Patients listened and/or sang with the song
played live by the music therapist, and discussed why or how the words were important
to them or how it pertained to their own life. Thoughts, feelings, memories, and life
situations were discussed as superficially or in-depth as comfortable for the participants,
with the music therapist asking open-ended questions when needed to further guide the
process and ensure that all participants had a chance to talk.
189
Example Resources
Nolan, P. (2005). Verbal processing within the music therapy relationship. Music
Therapy Perspectives, 23, p. 18-28.
Pellitteri, J. (2009). Emotional processes in music therapy. Gilsum, NH: Barcelona
Publishers.
Weber, S., Nuessler, V., & Wilmanns, W. (1997). A pilot study on the influence of
receptive music listening on cancer patients during chemotherapy. International
Journal of Arts Medicine 5(2), 27-35.
Songwriting
Songwriting is another important intervention for meeting patient needs in a
group or individual setting. Songwriting techniques may include the Cloze

Procedure/fill-in-the-blank, piggyback songwriting, and original songwriting. The Cloze
Procedure, also known as fill-in-the-blank songwriting, involves using a familiar song
with blanks inserted in specific places, allowing patients to personalize the song with
their own words. Piggyback songwriting also includes using a familiar melody, but
changing all the words in the text. Original songwriting involves writing not only the
words in the text, but also the music, creating a new composition.
Songwriting is a powerful tool for expressing and processing thoughts and
feelings associated with cancer. In addition to individual songwriting, group songwriting
is a valuable intervention for increasing group cohesion; decreasing isolation; supporting
peers; increasing socialization; and identifying, discussing, and processing thoughts and
feelings within a safe, structured, and supportive environment.
Example Resources
Baker, F. & Wigram, T. (Eds). (2005). Songwriting: Methods, techniques, and clinical
applications for music therapy clinicians, educators and students. London: Jessica
Kingsley Publishers.
Brunk, B.K. (1998). Songwriting for music therapists. Grapevine, TX: Prelude Music
Therapy.
O’Callaghan, C.C. (1997). Therapeutic opportunities associated with the music when
using song writing in palliative care. Music Therapy Perspectives, 15, 32-38.
190
O’Callaghan, C., O’Brien, E., Magill, L. & Ballinger, E. (2009). Resounding attachment:
Cancer inpatients’ song lyrics for their children in music therapy. Supportive Care in
Cancer, 17(9), 1149-57.
Active Music Making
A nonverbal expression of feelings may be facilitated through active music
making, including free, thematic, or structured improvisation using drumming, Orff
instruments, pitched or non-pitched percussion, and tone chimes. Free improvisation
involves group or individual playing of pitched or nonpitched instruments and processing
the improvisation afterwards. Thematic improvisation includes choosing a topic,
thought, or feeling to focus on or interpret during music making. Structured
improvisation involves working together in a group towards a common pre-planned goal.

Active music making increases coping skills by providing patients with a unique, multi-
faceted means of emotional and creative expression. It assists in relieving stress and
anxiety by allowing patients to focus on the present moment and distract themselves from
thoughts of the past or worries about the future.
Group music making may also involve singing, which promotes expression of
feelings, supports peer members, and increases group cohesion. Patient song choice
promotes choice and control and allows for individuals to identify and relate to thoughts,
feelings, and memories associated with the music.
Example Resources
Aldridge, G. (1996). A walk through Paris: The development of melodic expression in

music therapy with a breast-cancer patients. The Arts in Psychotherapy, 23(3), 207-
223.
Anshel, A. & Kipper, D.A. (1988). The influence of group singing on trust and
cooperation. Journal of Music Therapy, 25(3), 145-155.
Colwell, C.M., Achey, C., Gillmeister, G., Woolrich, J. (2004). The orff approach to
music therapy. In A.A. Darrow (Ed.) Introduction to approaches in music therapy
(pp. 15-24). Silver Spring, MD: American Music Therapy Association.
Dileo, C. (1999). Songs for living: The use of songs in the treatment of oncology
patients. In C. Dileo (Ed). Music therapy and medicine: Theoretical and clinical
applications (pp. 151-166). Silver Spring, MD: American Music Therapy
Association.
191
Turry, A. & Turry, A.E. (1999). Creative song improvisations with children and adults
with cancer. In C. Dileo (Ed.) Music therapy and medicine: theoretical and clinical
Association.
Reuer, B. (2006). Integrative medicine settings: Music-centered wellness. San Diego,
CA: MusicWorx of California.
Reuer, B., Crowe, B., & Bernstein, B. (2007). Group rhythm and drumming with older
adults: Music therapy techniques and multimedia training guide. Silver Spring, MD:
American Music Therapy Association.
Music-Assisted Relaxation
In music-assisted relaxation, the music therapist may teach or facilitate relaxation
techniques using appropriate live or recorded music. The music may serve as an active
focus, promote a calm environment, and serve as a masking agent for outside noise.
Slow, steady music around 60 beats per minute and with no unexpected changes appears
to be the most conducive to the relaxation response. Music listening decreases arousal
due to stress and assists in physiological relaxation, including lowered heart rate and
blood pressure. While music used for relaxation in an individual setting may include
patient preferences, it is difficult to cater to all patient preferences in a group relaxation
experience.
Relaxation techniques may include breathing, mindfulness-based meditation,
autogenic relaxation, body scanning, directed or scripted imagery, and when appropriate,
progressive muscle relaxation. Progressive muscle relaxation may be counterproductive
with patients suffering from pain in a specific area of the body that is intensified with
tension of the local muscle group.
A music therapist may facilitate relaxation in a group setting by approaching the
experience in three steps: 1) first relax the breathing, 2) then relax the body, and finally,
3) relax the mind. Deep breathing is the fastest and easiest way to access the relaxation
response and is the most accessible to patients in a variety of settings and circumstances.
The music therapist demonstrates appropriate deep breathing, encouraging patients to

breathe in through the nose and out through the mouth, creating a circular pattern of
192
breath. Live or recorded music may be used to provide rhythmic and temporal cues for
breathing, while the music therapist verbally directs the breathing exercise.
In order to then relax the body, the music may slow and change as the music
therapist begins an appropriate body-based relaxation experience such as body scanning,
autogenic relaxation, or progressive muscle relaxation. Patients are encouraged to
continue their deep breathing as they focus on relaxing different muscle groups or parts
of their body as directed. Patients may need a reminder that their mind may wander, but
the whole point of meditation is to bring the mind back to focus.
Although the breathing and body may be relaxed, patients report that their minds
may still race and their thoughts lie elsewhere. The third step involves relaxing the mind
and focusing on specific thoughts or imagery as guided verbally by the music therapist.
Imagery scripts focusing on a favorite place or a relaxing journey appear to be conducive
to relaxing the mind and reducing racing thoughts. After progressing through the three
steps, patients are guided back to the room as the music fades. The relaxation experience
is processed and patients discuss what worked and what did not work for them. Patients
are encouraged to practice relaxation everyday for twenty minutes using their own CDs
or music suggested by the music therapist.
Example Resources
Antoni, M.H. (2003). Stress management intervention for women with breast cancer:
Therapist’s manual. Washington, D.C.: American Psychological Association.
Reuer, B. (2002). Medical settings: Strategies, applications, and sample forms for
therapists. San Diego, CA: MusicWorks Publications.
Scartelli, J.P. (1989). Music and self-management methods: A physiological model. St.
Louis, MO: MMB Music, Inc.
Creative Arts
Creative arts may be combined with music therapy techniques in order to further
assist in nonverbal and creative expression. Free drawing while listening to music,
generating mandalas while listening to various types of music and processing the
193
differences, creating CD covers to represent the self or an individual’s life journey

through music, and processing relaxation imagery through visual representation are all
ways to combine music with the creative arts. One creative arts and music activity
particularly effective with cancer patients, is listening to music while creating mandalas.
Patients reveal inner thoughts and feelings, including ones difficult to express verbally,
through their drawings. The function of the music serves different purposes for
individuals, and may be viewed as background sound, as a medium to assist in focus,
and/or as a means to stimulate creative thinking.
Example Resources
Reuer, B. (2006). Integrative medicine settings: Music-centered wellness. San Diego:

MusicWorx of California.
Rykov, M.H. (2008). Experiencing music therapy cancer support. Journal of Health
Psychology, 13(2), 190-200.
Movement with Music
Music may be used as a rhythmic auditory stimulus for motor movement and may
serve as a motivational tool for continuation of exercise. Cancer patients may suffer from
fatigue, so using stimulative music may energize, motivate, and assist in task completion.
Pairing steady, slower music and meditative movements may promote relaxation. Music
paired with engaging or enjoyable movements allows participants to support each other
while promoting exercise and movement. Group movement activities also increase group
cohesion, allow participants to work together towards a common goal, and increase the
total exercise time of individuals.
Example Resources
Frego, R.J., Liston, R.E., Hama, M., & Gillmeister, G. (2004). The dalcroze approach to
(pp. 15-24). Silver Spring: American Music Therapy Association.
Thaut, M.H. (2002). Physiological and motor responses to music stimuli. In R.F.
Unkefer & M.H. Thaut (Eds). Music therapy in the treatment of adults with mental
disorders: Theoretical bases and clinical interventions (pp. 33-41). St. Louis, MO:
MMB Music, Inc.
194
Thaut, M.H. (2005). Rhythm, music, and the brain: Scientific foundations and clinical
applications. New York, NY: Routledge.
195
APPENDIX I
PARTICIPANT IDENTIFIED FAVORITE SONGS AND ARTISTS FROM THE
MTSG-AF
196
Participants completed the Music Therapy Pre-Session Survey and provided

written information regarding their favorite songs, favorite artists, and expectations for
the music therapy support groups. Favorite songs and artists are listed below.
Favorite Songs
Participants completed the statement: My favorite song is________________________.
Mansion on the Hilltop

Morning Has Broken
Amazing Grace (n=2)
7 x 70
Your Flag Decals Won’t Get You Into Heaven
Lift Me Up
When I Need You
Weekend in New England
Stand
Country Roads
May I Have This Dance (n=2)
Moondance
How Great Thou Art
Closer Walk with Thee
Appalachian Spring
Brown Eyed Girl
Imagine
Free/Into the Mystic
Let is be Said of Us
By Your Side
Friends in Low Places
You Look Wonderful Tonight
You Raise Me Up
Let it Be
The Wind Beneath My Wings
Ordinary Miracles
Favorite Artists
Participants completed the statement: My favorite artist is ________________________.
Emmylou Harris
The Beatles
David Haas
Christ August
Toby Mac
Kutless
Neil Diamond
John Prince
Josh Groban
Anne Murray
197
Helen Reddy
The Carpenters
Journey
Enya
Casting Crowns
Lady Antebellum
Rascal Flatts
Doors
Aerosmith
Maroon 5
Michael Buble
Sugarland
Ann Murray
Elton John
Billy Joel
Laura Nyro
Bruce Springsteen
Hank Williams, Jr.
Elvis Presley
Jim Cullen
Aaron Copland
Beatles
Rolling Stones
George Strait
Andy Williams
Casting Crowns
Garth Brooks
Eric Clapton
Josh Groban
John Lennon
Cat Stevens (Yusef Islam)
Beatles
Kenny Chesney
Andre Bocelli
198
APPENDIX J
PARTICIPANT COMMENTS AND EXPECTATIONS FROM THE MTSG-AF

199
In addition to favorite songs and artists, participants completed a question

involving expectations for the music therapy support groups. The qualitative information
was categorized according to primary themes generated from the written feedback from
participants. The primary themes included: connection and interaction with others,
music-specific expectations, relaxation and stress reduction, cancer recovery
expectations, and uncertainty.
Expectations Involving the Music Therapy Cancer Support Group
Question: What are your expectations for the music therapy cancer support
group? What do you hope to gain or learn as part of your participation in the groups?
Connection and Interaction with Others
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Music Specific Expectations
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201
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Cancer Recovery Expectations
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Additional Comments
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202
APPENDIX K
PARTICIPANT COMMENTS FROM THE MTSG-EQ

203
Participants indicated their most enjoyable and most therapeutic parts of the
music therapy support groups. After checking the most enjoyable/therapeutic music
intervention boxes, a follow-up question asked for more specific information. The
written comments were categorized according to primary themes for each question.
Most Enjoyable Parts of the Session
Question: Why was/were the previous part(s) most enjoyable for you?
Self-Expression and Mood
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New Experiences and New Skills
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205
Therapeutic Connection with Others

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Least Enjoyable Parts of the Sessions
Question: Why was/were the previous part(s) least enjoyable for you?
Self-Consciousness and Self-Doubt
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Individual Preferences for Interventions
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206
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Continuation of Learned Techniques

Question: Do you still use any of the techniques learned in the music therapy
support groups? If yes, please describe which ones you have used since the group or
which ones you find most helpful in your life.
Greater Awareness and Appreciation
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Playing Instruments and Singing
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9)>A#)7F#*17?#(1.&#.&,#>&3->&<#
207
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Relaxation and Music Listening
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208
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Highlights and Significant Moments
Question: Please describe any highlights or significant moments you experienced
during the group.
Relationships with Group Members
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209
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Highlights Regarding Interventions
Playing Instruments
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Music-Assisted Relaxation
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9-23?&.#6'#*.-,**#:,0,:#F2(7#)#;,("##V&)7A#'23a#
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Singing and Creative Arts
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210
Suggestions for Future Groups

Positive Feedback to Therapist
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Group Size and Length of Therapy
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$" J,-&)/*#6)A,#*3-,#.&).#(1.&#)#*6)::,-#?-23/#).#:,)*.H#)::#6,69,-*#>)7#
>2661.#.2#-,?3:)-#)..,7F)7>,#41;#72.#/,-;,>.#)..,7F)7>,5H#,*/,>1)::'#1;#1.#27:'#
-37*#;2-#)#*&2-.#.16,"##G.T*#F1*>27>,-.17?#.2#&)0,#/,2/:,#>26,#)7F#?2"##
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Specific Intervention Suggestions
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211
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Recommendation of Groups to Others
Question: Would you recommend the music therapy support groups to another
person going through a similar situation? Why or why not?

Connection with Others in Similar Circumstances
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Helpfulness of Music Therapy Interventions
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212
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Therapeutic Benefits of Music
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213
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Additional Comments
Enjoyment, Appreciation, and Thankfulness
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Future Planning Considerations
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)6#17#2.&,-#*2>1):#?-23/*#)7F#.&,'#&,:/#6,"#
O" G#83*.#(1*&#1.#>23:F#:)*.#:27?,-"#
P" \2.#63>&#'23#>)7#F2#(1.&#.&1*#29*.)>:,#.&).#G#A72(#2;#W#.&,#.(2#2.&,-#>23/:,*#
.&).#(,-,#.-3:'#>27*1F,-17?#821717?#(,-,#-,)::'#*1>A#F3-17?#.-,).6,7.*#)7F#
.&3*#9,>)6,#37)9:,#.2#)..,7F"#
214
!" S1*.,717?#)7F#.):A17?#.2#.&,#(26,7#17#.&1*#>:)**#6)F,#6,#)F61.#.2#6'*,:;#
.&).#G#&)0,#/3*&,F#6'#>)7>,-#;,)-#.2#.&,#F)-A#/)-.#2;#6'#617F#17*.,)F#2;#
:,..17?#?2#2;#1."#
Facilitator-Directed Comments
L" ^)>1:1.).2-#()*#/-26/.#)7F#&)F#?22F#;2::2(#.&-23?&#(1.&#)**1?76,7.#
/1>A3/*#)7F#;3:;1::6,7.#2;#,K/,>.).127*"#
O" [99,'#F1F#)#;17,#829#-37717?#.&,#*,**127*H#2;;,-17?#:2.*#2;#2/.127*H#:1*.,717?#.2#
.&,#/)-.1>1/)7.*H#)7F#/:)7717?#,0,-'.&17?#(,::"##
P" `23#)-,#(27F,-;3:#).#(&).#'23#F2H#A,,/#3/#.&,#?22F#(2-Aa#
!" N22F#:3>A#(1.&#'23-#J&D"##S,.#3*#A72(#1;#'23#7,,F#)7'#;3-.&,-#&,:/"#V&)7A*a#
Confidential Information Regarding Health
Two participants included specific personal information in comments on the
follow-up questionnaire, which are not included in this appendix in order to maintain
anonymity and confidentiality.
215
APPENDIX L
GROUP MATERIALS
216
Group Guidelines
You are encouraged to openly express your personal experiences, thoughts,

and feelings, and can expect to do so without criticism or judgment.
In order to create a safe environment for everyone to feel comfortable

sharing concerns and emotions, please be respectful of differences of
opinion.
Please interact with group members and feel free to share as much or as little
as you feel comfortable, keeping in mind that you get out of group what you
put into it.
Please be respectful of privacy and confidentiality, and do not share group

members’ names or things said or done in the group with others. “What
happens in group, stays in group.”
Please allow all group members to participate, and avoid interrupting others
when they are talking.
This group is not about judging your talents, but about freeing your creative
spirit. Support others in the group through your whole-hearted participation,
even though you may be nervous at first.
Please make sure to attend every group and be on time, out of respect for
others in the group.
Please avoid eating, drinking, or talking on your cell phone while in the
group, unless medically necessary.
*Adapted from The University of Iowa Hospitals and Clinics Group

Guidelines for Behavioral Health. Used with Permission, 2010-2011.
217
218
219
220
221
222
Songwriting
Songwriting is not just for the professional musician. Songwriting is a

unique tool for expression of thoughts and feelings, and anyone may write a
song. The key is to remain nonjudgmental and try different types of
songwriting in order to find the one that seems to suite you best. Remember,
there is no right or wrong in your approach to songwriting. You are a
unique and wonderful individual, and your song, like your life, will be
different than that of anyone else. Free your mind and try one of these
songwriting techniques for yourself.
There are three major types of songwriting: 1) fill-in-the-blank, 2)

piggybacking, and 3) original songwriting.
Fill-in-the-blank songwriting allows a person to pick a favorite song, fill in

the blanks to personalize the song, and decide how to play it. The melody
and some of the words of the song stay the same, but we fill in key words to
add our own meaning. Listen to the example.
Piggybacking a song means the melody stays the same, but the we change
all the words to the song. The words do not have to rhyme, and you may
decide to start with the words first and pick a melody to go along with them,
or you could decide to pick a favorite song first and then make the words fit
into the melody. Listen to this example.
Original songwriting means the words and melody used in the song are
unique and written by the songwriter. Songwriters might use their own life
experiences or memories as ideas for writing songs. Listen to this example.
Now we will try one of these techniques as a group!
For more information, please contact:

Abbey Dvorak, MA, ABD, MT-BC
Clinical Specialist-Music Therapy
Department of Rehabilitation Therapies
Office: (319) 356-4718
abbey-dvorak@uiowa.edu
223
Creative Arts and Music: The Mandala
Music paired with creative art allows our expression of thoughts and feelings in a
unique and individualized way. Many patients report an increased sense of power,
freedom, release, healing, meaning, balance, and/or identity from participating in a
creative arts approach. Music may provide a soothing or stimulative background,
depending on the music you choose. One type of visual creative art is the mandala.
What is a mandala?
• U)7F):)#1*#)#Z)7*A-1.#(2-F#.&).#6,)7*#*)>-,F#>1->:,#2-#(&,,:"###
Why circles?
• @1->:,*#)-,#;237F#17#-,:1?127H#7).3-,H#)-.H#)7F#.16,"#
• @1->:,*#*'692:1d,#371.'H#>27.1731.'H#)7F#.&,#>1->:,#2;#:1;,"#
• @1->:,*#)-,#>-2**W>3:.3-):]#,0,-'#>3:.3-,#3*,*#.&,#*'692:#2;#)#>1->:,###
• `237?#>&1:F-,7#9,?17#)-.(2-A#(1.&#>1->:,*]#?10,#'23-*,:;#/,-61**127##
to be child-like
• V&,#*.-3>.3-,#2;#)#>1->:,#?10,*#'23#)#/:)>,#.2#*.)-.#17*.,)F#2;#)#9:)7A#/)?,#
Benefits of Mandala
• G7>-,)*,#23-#*,:;W)()-,7,**#
• J,-*27):#;2-6#2;#,K/-,**127#
• %)'#2;#;17F17?#;2>3*#
• c23-7):17?#.22:#
Tibetan and Native American cultures make circle art in sand that eventually blows away.
The point of the art is the process, not the end product.
Mandala Creation
• N).&,-#'23-#6).,-1):*#)7F#&)0,#.&,6#-,)F'#4/)/,-#)7F#F-)(17?#3.,7*1:*5#
• X,?17#9'#>,7.,-17?#'23-*,:;#4:1*.,717?#.2#63*1>H#-,:)K).127#.,>&71E3,*H#'2?)5#
• %&,7#'23#)-,#-,)F'H#9,?17#.2#;1::#.&,#>1->:,#(1.&#>2:2-#)7F#F,*1?7#
• %&,7#;171*&,FH#.1.:,#'23-#6)7F):)#)7F#(-1.,#)#;,(#(2-F*#)923.#1."#
Variations
• V-'#F1;;,-,7.#6,F136*#4>2:2-,F#/,7>1:*H#/)*.,:*H#21:*H#>-)'27*H#,.>"5#)7F#
F1;;,-,7.#>2:2-*#2;#/)/,-#
• V-'#(1.&#F1;;,-,7.#.'/,*#2;#63*1>#2-#(1.&23.#63*1>"#
*Adapted and published with permission from Barbara Reuer and MusicWorx, 2011.
224
Reflection
By Mark Taylor
Peaceful q = 65
" !! % % % %
mf
% % % % % % % % %% % % % % % % &
Voice
!
Flow - ing wa - ter gen - tly flow - ing ri - ver Find - ing a path to the de - ep blue sea.
" !! # # # #
$ ! && && && && && && && &&

Orff
5
mf
" % % %% % % % %% %%% &
% % %% % % %
Voice
%
!
Calm and si - lent gen - ty flow - ing ri - ver Yo - ur re - fle cti - on I - will be.
" # # # #
$ && & & & & & & &

Orff
& & & & & & &
9
mf
" % ' % ' % % & % %
Voice
% % & % % &
!
Pea - ce - ful and still wi - nd where you will Gen - tle rain may fall
" # # # # #
$ && & & & & & & & & &
Orff
& & & & & & & & &
Copyright @ 1993 by Jenson Publications

International Copyright Secured All Rights Reserved Used by Permission
225
2
14
! $ $ $ $ $ $ $ $ $
$ $ $ $ $ $ % $ $
Voice
$
!
on - yo - ur lone - ly shores sun and moon and stars shi - ne fo - r - ev - er more
! " " "
# %% %% %% %% %% %%
Orff
17
mp
! $ $
& &
Voice
$ $ % $ $ %
!
Pea - ce - ful and still wi - nd where you will
! " " " "
# %% %% %% %% %% %% %% %%
Orff
21
p
! $ $
& &
Voice
$ $ % $ $ %
!
Pea - ce - ful and still wi - nd where you will.
! " " " "
# %% % % % % % % %
Orff
% % % % % % %
*”Reflection” was based on an initial transcription and session idea by

Joey Walker, MA, MT-BC
226
Affirmation BLues Adapted by Abbey Dvorak

Used with permission by Barbara Reuer
q = 125 E7
#### ! Swing
" % & ( )' ' ' ' ' ' )' ' ' ' '
! ' ' ' * ' ' '
I am a po -wer - ful, po - si - tive, worth -while hu -man being - ah -
5 A7 E7
# ##
"# * & ( )' ' ' ' ' ' )' ' ' ' '
' ' ' * ' ' '
- I am a po -wer - ful, po - si - tive, worth -while hu -man being - ah -
9 B7 A7 E7
##
"##* & ( ' ' ' ' ' ' )' ' ' ' '
' ' ' +
- I am a po - wer - ful, po - si - tive, worth -while hu - man being -
13
# ##
"# $ $ $ $
17
##
"## $ $ $ $
21
##
"## $ $ $ $
25
# ##
"# $ $ $ $
29
# ##
"# $ $ $ $
227
APPENDIX M
LETTERS OF PERMISSION TO CONDUCT RESEARCH

228
229
230
231
Clinical Trials Development, Support, and Monitoring

200 Hawkins Drive
C621 GH (office), 5970 JPP (mailing)
319-353-7846 Tel
319-356-0471 Fax
www.uihealthcare.com
July 28, 2008
Abbey Dvorak, MA, MT-BC

Music Therapy
1701B JPP
Re: PRMC: 05-08-01-36; IRB: 200804781; NCT: TBD
Dear Ms. Dvorak:
The Protocol Review and Monitoring Committee reviewed and approved your protocol entitled,
“Music Therapy Support Groups for Individuals Diagnosed with Cancer and Their Families,” on
July 24, 2008.
Thank you for responding to the committee’s first review; the current version of your protocol
represents a considerable improvement over the earlier submission.
Sincerely,
Edwin J.R. van Beek, M.D., PhD, Med FRCR

Acting Chair, Protocol Review and Monitoring Committee
PRMC Notice: When a response to the PRMC review is required, please do so electronically to gary-rick@uiowa.edu and
meggan-fisher@uiowa.edu
232
Description of Department of Nursing Personnel Involvement

Music Therapy Support Groups for Individuals Diagnosed with Cancer and Their Families
Primary Investigator: Abbey Dvorak, MA, MT-BC
Clinical Services Areas to be Used: Holden Comprehensive Cancer Center, including the Cancer
Clinic, Radiation Oncology, and Breast Health Clinics
1. Specify the activity requested of Department of Nursing personnel contributing to the

research protocol (i.e. data collection, recruitment of subjects, communication with research
personnel, monitoring of patients).
Department of Nursing personnel will assist in recruitment of subjects and communicate

with the primary investigator. Potential subjects will be informed as to the existence of the
research study by staff, posters, news releases, advertisements, and presentations. As indicated in
the attached “Participant Recruitment Checklist for Team Members,” nursing personnel will
contact the primary investigator if a patient meets the eligibility criteria. If the PI is unavailable
within five minutes, nursing personnel will provide the patient with the IRB approved small
poster and/or the PI’s contact information, but will not answer questions or participate further in
the process.
2. Describe plan for educating Department of Nursing personnel about the research study and
the activity they are expected to perform (e.g. monitoring for adverse effects of medications).
The primary investigator will present the study information during a designated meeting
time on the respective units. The IRB approved PowerPoint presentation will include the
PowerPoint handout and the Participant Recruitment Checklist for Team Members, which will
assist nurses in identifying potential participants. In addition, an email will be sent to the nurse
managers in each area who will forward the email to all nursing staff. The expected activity for
nursing personnel is to identify potential participants, provide them with the poster/contact
information, and refer them to the primary investigator. No other activities are expected from
nursing personnel.
3. Identify Department of Nursing supplies and equipment that will be required to complete this
research study.
No Department of Nursing supplies or equipment will be required to compete this study.
Attachments:
1. Staff Email Re: Music Therapy Cancer Support Groups
2. PowerPoint Presentation for Nursing Personnel
3. Participant Recruitment Checklist for Team Members
Protocol – Please see PRMC approved protocol

233
234
235
APPENDIX N
LETTERS OF PERMISSION FOR GROUP MATERIALS

236
237
238
239
APPENDIX O
LETTERS OF PERMISSION FOR MEASUREMENT FORMS

240

241
State Trait Anxiety Inventory (STAI)

242
Functional Assessment of Cancer Therapy – General Form (FACT-G)

243
244
Personal Resource Questionnaire 85-Part 2 (PRQ85-Part 2)
September 29, 2008
Abbey Dvorak
200 Hawkins Drive, 0733 JPP
Iowa City, IA 52242
Dear Abbey,
Thank you for requesting the PRQ 85. Any changes to question stems or answer sets
must be approved in advance. Translation of the PRQ into other languages is acceptable
and encouraged. A copy of the translated version of the PRQ should be sent to us.
If you have not already done so, please send us a brief abstract of your proposed study,
the population that you plan to sample in your research, and which version of the PRQ
you intend to use. We will include this information in our database. If you are a student
please send us the name of your university and the name of your advisor. If you do, in
fact, use the PRQ for data collection in your study, we ask that you send us an abstract of
your findings, PRQ results, and conclusions whenever they are available.
Should you have any questions or need clarification, kindly write or e-mail
cweinert@montana.edu. We will try to respond in a timely manner. Our web site is
www.montana.edu/cweinert.
Thank you for your interest in the PRQ. We hope that this tool will help you in your
research.
Sincerely,
Clarann Weinert, SC,PhD,RN,FAAN

Professor #
#
#
# # # # # # # # # #
#
245
!
!
PERMISSION TO USE THE PERSONAL RESOURCE

QUESTIONNAIRE
PERMISSION TO USE THE PRQ85 and PRQ2000
IS GRANTED TO: Abbey Dvorak
THE PRQ85 IS A TWO PART INSTRUMENT. EITHER PART -1 OR PART -2 OR

BOTH PARTS MAY BE ADMINISTERED. HOWEVER, NO PART OF PRQ85 OR
PRQ2000 MAY BE MODIFIED WITHOUT CONSULTATION WITH THE
AUTHORS.
________________________________
Clarann Weinert, SC,PhD,RN,FAAN DATE: September 29, 2008
246
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MUSIC THERAPY SUPPORT GROUPS FOR CANCER PATIENTS AND

Thesis Supervisor: Professor Kate Gfeller

questionnaires were analyzed using five individual repeated measures analysis of

and significantly improved quality of life in four of six sessions.

Abstract Approved: ____________________________________

A thesis submitted in partial fulfillment

Thesis Supervisor: Professor Kate Gfeller

All rights reserved

INFORMATION TO ALL USERS

This is to certify that the Ph.D. thesis of

Abbey Lynn Dvorak

has been approved by the Examining Committee

Thesis Committee: __________________________________

I would also like to dedicate this dissertation to my family.

Music expresses that which cannot be put

Where words fail, music speaks.

My dissertation committee members are amazing people, and I would like to

provided referral guidance; Jane Hershberger provided expertise in participant

questionnaires were analyzed using five individual repeated measures analysis of

and significantly improved quality of life in four of six sessions.

APPENDIX H MTSG GROUP PROTOCOL AND INTERVENTION

6. Patient Current and Past Cancer Treatments by Treatment Group (n=24)...............86

Anyone may develop cancer, depending on external (tobacco, radiation,

Biopsychosocial Model of Health and Illness

to circumstances in which they perceive a discrepancy between the demands of a stressor

by changing the environment, expanding resources, or reducing demands of the stressful

Oncology, defines distress as a “multifactorial unpleasant emotional experience of a

anxiety, sadness, alienation, helplessness, loss of socialization, and increased marital

treatment disappointments, complications of therapy, and progressive illness (Lorenz &

Family members can create a positive emotional climate to help patients

quality of life is a subjective viewpoint of overall well-being, and may be based on

physical, psychological, social, economic, and political environments (Revicki et al.,

inherent physical, psychological, and social components of music to improve therapeutic

society, provide aesthetic enjoyment, and provide entertainment (Merriam, 1964).

Disturbance Score on the Profile of Mood States (POMS).

an increase of scores on pre- and post-Music Therapy Support Group Numerical

or psychological process that is activated following threat

Social Support The structure and function of resources and relationships

Stress A circumstance in which a perceived discrepancy exists

thereby providing a measurable relief in symptoms (Olofsson & Fossum, 2009).

described in the following section.

Music Listening: Nursing Studies

selected music delivered via a sound system.

Good, Stanton-Hicks, Grass, Anderson, Lai, Roykulcharoen, and Adler (2001)

significant difference in response between patient-selected and researcher-selected music

In summary, extant research supports the use of music in pain management

The field of psychoneuroimmunology studies the interaction of psychological,

with a significant increase in interleukin-1 in one experimental group after an immediate

(GIM) on mood and cortisol. The experimental group demonstrated a significant

Research in Clinical Music Therapy

Nausea and Fatigue

exhaustion, inactivity, and an inability to complete daily tasks (“Fighting Cancer

Boldt (1996) studied the effects of music therapy on motivation, well-being,

As noted earlier, psychological processes can influence physical functioning, including

Music affects psychological experiences through modulation of attention

relaxation techniques had a significant impact on decreasing undesirable arousal due to

conditions such as imagery or visualization techniques. For example, Goodwin (2004)

to guided imagery with relaxation music or a relaxation music-only group. Depression,

interventions can be inexpensive and easily utilized in a busy hospital environment,

Results indicated significant improvement in fear, anxiety, fatigue, relaxation, and

As indicated, both receptive and interactive music therapy interventions may

A response to stressful circumstances is not only influenced by cognitive

Depression/Dejection and Fatigue/Inertia; scores were maintained at the six-week follow-