Running head: MUSIC AND SCHIZOPHRENIA 1

The Effect of Music on Adolescents with Schizophrenia

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Andrews University
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The Effect of Music on Adolescents with Schizophrenia

Schizophrenia is one of the most disabling mental and physical illnesses that exist among

the world today. Although it only affects 1% of the adult population in the United States, it has a

devastating effect on the life of a person, the person’s family, as well as society. Many people

who suffer with schizophrenia have a difficult time caring for themselves, holding a job, and

maintaining healthy relationships. In addition, the stigma associated with mental illness prevents

some from seeking proper treatment, which only quickens the progression of the disease.

Schizophrenic symptoms include, but are not limited to, hallucinations, thought derailment, flat

affect, social withdrawal and trouble paying attention. The onset of schizophrenia typically

occurs between ages 16-30 (National Institute of Mental Health, 2016). According to the World

Health Organization, adolescent is described roughly as the period from 10-19 years old. The

occurrence of the disease in adolescents is particularly challenging because it also happens to be

the years when they search for a sense of personal identity and independence by exploring

personal values, developing a belief system and setting goals. The occurrence of such a

deteriorating disease at such a pivotal transition in life demands research in using complementary

medicine to assist patients in improving overall health and wellbeing which may not be afforded

by the use of drug treatment alone.

The purpose of this literature review was to gather relevant information and draw

conclusions regarding the use of the group music therapy to improve the overall health and

wellbeing of adolescents who suffer from schizophrenia. In this project, health and wellbeing is

defined as “a state of complete physical, mental, and social well-being and not merely the

absence of disease or infirmity” and are the categories observed for improvement (World Health
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Organization, 1946). Thus, the question to be answered is: In schizophrenic patients, aged 10-19

years old (P), what is the effect of group music therapy in addition to standard facility care (I) as

compared to schizophrenics receiving only standard facility care (C) on the physical (reduction

in symptoms), mental (improved self-esteem) and social (positive interactions) (O) wellbeing of

the patients?

Background

Treatments for schizophrenia typically include antipsychotic medications and

psychosocial treatments. Some side effects of the medication disappear after a few days, but

others may persist, which cause patients to be noncompliant with the medication regimen. It is

imperative that doctors and individuals work together to choose the appropriate treatment plan.

Psychosocial treatments help patients deal with issues that medication can’t solve such as coping

skills, work, maintaining relationships and communication. When these are used collectively,

schizophrenics are less likely to experience relapse and hospitalizations (National Institute of

Mental Health, 2016). Holistic care is vital to the health of these individuals and thus,

nonpharmacological techniques must be pursued.

Literature Review

The literature review was conducted using the EBSCO and Google scholar online

databases. Key words used when searching the database were schizophrenia, schizophrenic,

music therapy, adolescents, mental illness, psychosis and hallucinations. The time frame for the

literature search ranged from 1999-2016. The literature review focused on music therapy and

schizophrenia and adolescents and music. The inclusion criteria consisted of (1) patients

clinically diagnosed with schizophrenia or any psychotic disorder and the use of music therapy in

treating those individuals and (2) the effect of music on adolescents. Some articles were
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excluded from this literature review because (1) access to the full article could not be retrieved

(2) not enough methodological information and (3) language barriers as some articles were not

translated to English. The two themes that emerged from the research was exploring the effect of

music on severe mental illness and exploring the effect of music on adolescents.

Exploring the Effect of Music on Severe Mental Illness

Three research articles addressed the effect of music on patients with severe mental

illness. In the first, A. De Sousa and J. De Sousa (2010) conducted a single blind randomized

controlled trial with 272 patients to explore the effect of music therapy in improving the

symptomatology of chronic schizophrenia. The subjects were between the ages of 18-60 years

with a diagnosis of schizophrenia at least three years prior to the start of the study. Music therapy

was given in daily sessions every day for 30 minutes for one month using a CD player with

speakers. Indian classical music was played with instruments such as the santoor, tabla, shehnai,

flute, sitar and violin. Following the music session, there was a reflection on the type of music.

There were two data collection methods. The first was a structured interview to obtain

demographic and clinical data. The second was the Positive and Negative Symptom Scale for

Schizophrenia, which provides scores in nine clinical domains: positive syndrome, negative

syndrome, depression, anergia, thought disturbance, activation, paranoid belligerence and

general psychopathology. At the end of 1 month, there were significant differences in certain

areas of the PANSS scores. Scores on the anergia, activation, and depression subscales showed

significant differences with a p<0.0001, while scores on the positive and negative syndromes

differed significantly with a p<0.005. The researchers found that after one month of group music

therapy, there were improvements in the areas of anergia, activation, depression, and positive

and negative syndromes. These results show that music therapy can be used as an adjunct to
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standard care in the management of chronic schizophrenia. The authors recommended that

further studies address the role of long term therapy, as well as the role of various types of music

along with singing and interactive music therapy.

Hayashi, Tanabe, Nakagawa, Noguchi, Iwata, Koubuchi, Watanabe, Okui, Takagi,

Sugita, Horiuchi, Sasaki, and & Koike (2010) focused on the effect of group music therapy on

inpatients with chronic psychoses. There were a total of 66 patients, taken from two wards in the

hospital. The music therapy consisted of 15 1-hr per week sessions. The objective of the therapy

was to facilitate enjoyment in listening and performing music, as well as interpersonal

communications through musical activities. The measurements used for data collection was the

Positive and Negative Syndrome Scale (PANSS) and the Quality of Life (QLS) scale. To inquire

about the subject’s subjective musical experience in ward life, the authors devised a self-report

scale for assessing musical experiences: one for music listening experience and the other for

ward chorus activity which was carried out independently of the studied musical therapy. The

ward nursing staff also rated the therapy group using a 5-point, 10-item scale for assessing the

ward-life activity every 2 months during the study period.

Repeated measures ANOVA for the PANSS subscales revealed a significant advantage

of the musical therapy sessions for the symptoms. Individual PANSS items that showed

significant advantage of the musical sessions were emotional withdrawal, poor rapport and

passive apathetic social withdrawal (p<0.05). For the QLS total score, the repeated measures

ANOVA gave a significant finding of an interaction of group and time for the QLS total score

(p<0.05). Individual items that showed a significant interaction of group and time were less

socially withdrawal (p<0.01) and empathy toward other people (p<0.05). All the PANSS and

QLS items that gave positive finding appeared to be related to interpersonal activities. A
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significant finding of the repeated measures ANOVA for music experience scales was an

interaction of group and time for the chorus activity scale (p<0.05), which also suggested an

advantage of the therapy. Overall, the authors found that the music therapy sessions showed a

significant advantage in terms of improvement of the negative symptoms and a QOL measure:

some signs of activation of personal relations, and increased subjective sense of participation in

chorus activity. Authors’ recommendations to this study include having a blind, random

assignment of subjects to each group. Second, the assessors should be blind to the treatment

condition of the subjects. Thirdly, there was no dummy treatment for the waiting group and a

result, the effect of simply having meetings could not be distinguished from the advantage of the

therapy group found in the study. Lastly, the subjects of the study should be more representative

of the population.

The third study completed by Grocke, Bloch, Castle, Thompson, Newton, Stewart, &

Gold (2014) focused on the effect of group music therapy for severe mental illness. There were a

total of 99 participants divided into two cohorts-one randomized and one non-randomized. This

study was a randomized controlled trial crossover design, within an embedded-experimental

mixed methods approach. Participants were randomized to either: 1) group music therapy (GMT)

and standard care, followed by SC alone or to 2) SC alone, followed by GMT and SC. Group

music therapy was conducted over 13 weeks with 1 hr weekly sessions. It consisted of singing

familiar songs, writing original songs and preparation for recording the original songs in a

professional studio. The quantitative methods included self-reported surveys that measured

quality of life, social support, self-esteem, spirituality and global severity of illness. The

qualitative measures were focus group interviews and song lyrics. The authors found that GMT

had a positive impact on quality of life (p=0.019) as well as spirituality (p=0.026). There was
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also moderate effects of GMT for self-esteem and global severity of illness. Qualitative results

found five themes from the focus group, one of which support the current research question. It

included “feelings of achievement and accomplishment, improved self-esteem and confidence,

opportunities for creative self-expression, inspired learning and growth, and motivation to attend

the weekly group (p. 150).” Authors found that music therapy could be beneficial to those who

struggle with mental illness. The improvement in the quality of life after GMT showed that

music can provide an avenue for socialization, motivation to attend the group sessions,

appreciation of others, all of which can lead to a reduction in social isolation. It was also

concluded that GMT may enhance the quality of life and spirituality of persons with severe

mental illness. Authors’ recommendations to this study include group music therapy where songs

can be written and then immediately provided for the group members to listen to in the future

weeks and months. In addition, trying to reduce as many factors as possible that would prevent

the outpatient subjects from attending the group sessions.

Exploring the Effect of Music in Adolescents

In the study completed by Saarikallio and Erkkila (2007), the purpose was to examine

the phenomenon of mood regulation and music in eight adolescents. The participants listened to

music in their natural setting and data was then collected through interviews and analyzing of

follow-up forms. Each participant was asked to fill out a follow-up form each time they engaged

in a musical activity. Music had an effect both subjectively and physiologically. Musical

activities seemed to regulate three elements of subjective experiences: valence, intensity and

clarity. It affected valence by strengthening positive feelings and helping to move away from

negative feelings. Music also affected the intensity of the current mood that they were in. It

typically increased the intensity. Music also helped to give clarity to their feelings, giving them

the ability to understand their feelings. As it pertains to physiological processes, music increased
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energy levels and uplifted their spirits. Overall, music offered the adolescents a medium in which

to increase and restore well-being and it made their emotional lives more varied and colorful. For

further studies, the authors recommended observing another age group, as well as adolescents

beyond Finland in order to strengthen and refine the developed theory. In addition, this theory

development lays the foundation for further empirical testing. For example, a clinical,

randomized trial involving the effect of preferred music on adolescent behavior should be

completed in order to test the theory.

Schwartz (2003) performed a non-experimental study and studied 175 adolescents from

Junior and Senior High School, ages ranging from 12-19, to explore the relationship between

music preferences and a variety of emotional, social, and developmental needs in adolescents.

The main purpose of performing this study was to identify and contrast personality

characteristics in addition to developmental issues in three groups of adolescent music listeners:

(a) those who preferred light music, (b) those who preferred heavy music, and (c) those who had

no strong preference for either heavy or light music, also known as being “eclectic”. To

commence this study, no intervention was given, however, questionnaires were administered to

adolescents in groups of 15 to 24 during their regularly scheduled class times for the duration of

approximately 40 minutes. The questionnaire measured music preference, how much they

enjoyed music, developmental issues and behaviors that correlated. The Million Adolescent

Personality Inventory (MAPI), which consisted of twenty scales showed that adolescents who

preferred heavy music were: tough- minded, assertive, and impulsive (Forceful scale p <.01,

Impulse Control Scale p < .01). Adolescents who preferred light music were: overly responsible,

rule-conscious, and concerned of being accepted with peers (Respectful scale p < .01, Peer

Security scale < .05). Interestingly enough, adolescents who were more eclectic in their music
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were appeared to be better adjusted with no significant issues with regards to self or others.

Authors concluded each of these three categories has a unique and distinct profile of personality

dimensions and developmental issues which in turn can help in getting to know the background

of adolescents. Authors recommended performing a randomized controlled trial, a wider variety

of music preferences, and using more than one posttest in the case of effects occurring later on

after the experiment.

Gold, Wigram, and Voracek (2007) performed a quasi-experimental Study on 136

adolescents recruited from outpatient care and special education centers to compare changes over

time in clients receiving music therapy versus those on waiting lists. The purpose of this study

was to determine if individual music therapy as is provided in outpatient services would be an

effective treatment for adolescents with psychopathology, as well as examining its effects. For

the duration of 25 weeks, one 45-min session per week was given to the experimental group

consisting of the music intervention, while the control group was put on the waiting list. To

assess levels of capabilities, or competencies, from social competence even to achievement, the

German version of the Child Behavior checklist (CBCL) scale was used, while quality of life

was measured with the Munich Health-Related Quality of Life Questionnaire for children

(KINDL). Medical conditions were present in 73 of the 136 participants, with associated

psychosocial conditions in 88. There were four outcome variables being tested for both groups:

symptoms, competencies, quality of life (parent), and quality of life (self). Results found that the

intervention group showed a medium effect significant improvement on two outcomes: the

CBCL parent rating of symptoms with p <.001, as well as the KINDL parent ratings of quality

life with showed a p-value of .09. Authors concluded that although music therapy was shown to

be a good treatment for children and adolescent with mental disorders, its overall effect to be
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implemented into clinical practice is still uncertain. The study was only able to conclude an

effect in just a fraction of the clients, namely those who didn’t present with any comorbidities.

Researchers recommended using clients with lesser comorbidities or further research on the

effectiveness of interventions for comorbid clients.

Rucsanda (2015) performed an experimental study with fifty adolescent students from High

School to determine if listening to various music genres influence positive or negative emotions

in adolescents. Adolescents in the control group received a questionnaire with a focus on music

preferences in young people, the amount of time spent listening to it, why they listen to the genre

they do and what their emotion is at the time they are listening to it. Over the course of 4 days,

the adolescents in the experimental sample group received the music intervention and listened to

4 different genres of music, one per day as was scheduled. On completion, they would then

indicate their emotional state before and after on a piece of paper, categorized into two

categories: positive emotions and negative emotions. During the listening activity, the

adolescents were then asked to write down any feelings that might have been triggered by the

music through the usage of adjectives, verbal expressions, drawings etc.

When it came to reaching a correlation between music and emotional state, authors

noticed: when adolescents felt cheerful 37% listen to pop music, when adolescents feel

enthusiastic 41% listen to pop music, when adolescents feel sad 33% listen to rock music, when

adolescents feel melancholic 34% listen to pop music, and when adolescents feel angry 42%

listen to heavy metal. Authors concluded that the modern music helps to create a foundation for

socialization, communication and self-reflection in adolescents. Music plays an important role in

their lives, and has the capability of influencing their development when it comes to self-concept

and socialization amongst their peers. Authors recommended expanding the repertoire of music
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to promote a more representative approach by using a larger number of participants, possibly

some from more foreign areas, and performing a randomized controlled trial to help prevent

biases in students.

Hendricks, Robinson, Bradley, and Davis (1999) performed an experimental study where

19 adolescents from Junior High School where studied to determine the efficacy of music

techniques in adolescents who exhibited symptoms of depression. The efficacy of these

techniques were measured with a pretest and posttest of the Beck Depression Scale. Participants

were first randomly assigned to either the experimental group with the music techniques over 8

weeks, or the control group with no music techniques, but cognitive behavioral group activities

dealing with self-concept. It was discovered that the treatment group’s score was more

significant on the posttest. The t test including the variance of the group means was found to be

significant at the .05 level with p= .0195. Not only did depression decrease in the treatment

group, there was also a 6-month follow-up showing a great decrease in depression with

participants admitting to continual usage of the music techniques in-group counseling

Because the finding was so significant, authors concluded with an emphasis on paying

attention to the environment of adolescents and their context. It is important to understand some

of their beliefs and values in hopes of fostering a relationship of trust. Authors then mentioned

the necessity of counselors and employees actively listening to youth in order for their needs to

be met. At times this may require going against the tide of tradition, but is necessary to reshape

our approach towards adolescents. Though music techniques have been found to be of help in

adolescents with depression, it is not the “gold standard” for all and counselors must always

consider what will be best for the adolescent. Authors recommended that there should be a larger
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sample size, a more structured curriculum, and a variety of techniques used instead of only music

to be considerate of the needs of other individuals.

Summary of Findings

The findings from this literature review support the use of music therapy in the treatment

of schizophrenic adolescents. It can be used as an adjunct therapy to standard care in order to

improve physical, mental and social well-being. As it pertains to physical health, group music

therapy gave an improvement in the both the positive and negative syndromes and energy levels.

The reduction of symptoms can help individuals in having a better quality of life as they attempt

to live a normal life. The mental health of schizophrenics also saw an improvement with the use

of group music therapy. There was an increase in self-esteem as they explored personal

creativity and learned new songs as a group, which also assisted with building social

connections. As a matter of fact, the findings of the study completed by Hayashi et.al (2005),

revealed that the positive findings in the scales used were all related to interpersonal activities.

There is a therapeutic benefit in being with a group who understands the challenges of living

with a severe mental illness.

Music also tends to have an influence on adolescents. It was found that music had an

outstandingly strong effect on mood improvement as long as the musical activity was self-

selected. It made the adolescents feel better and change their mood in a positive direction. The

reflective mental work caused by some songs and lyrics provided the adolescents with a deeper

understanding of their unsettling thoughts and improved their knowledge. To determine how

music effected the mood regulation in adolescents, various experimental designs were used and

showed that music acts as an outlet to release feelings such as frustration, happiness, and

sadness. Listening to peaceful or cheerful music when feelings of anger or sadness were present
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for instance, aided in the manifestation of a peaceful and tranquil atmosphere among the youth.

This intervention was also found to aid in building a foundation in socialization amongst peers,

communication, and self-reflection. Of the three music categories in one of our studies, the one

found to be the most emotionally beneficial was light music. Authors noted that light music was

especially helpful in transitioning to being more independent and expressive adults. Overall,

those who responded better towards the music intervention were generally adolescents with

lesser comorbidities.

Conclusion

The use of music therapy in the treatment of mental illness is not unfamiliar to the realm

of research. According to Nizamie and Tikka (2014), there are benefits in using music as part of

the therapeutic environment such as “positive alteration in mood and emotional states, improving

concentration and attention span, developing coping and relaxation skills, exploring self-esteem

and personal insight, enhancing awareness of self and environment and improving social

interactions (“Music Therapy, para. 8).”  In addition, studies have noted a connection between

music preferences and emotional development in adolescents. Adolescents have used music

effectively and successfully in diverting themselves from stress, worries and disturbances

(Saarikallio & Erkkila, 2007). Overall, an intervention such as this would be best performed in

adolescents presenting with little to no comorbidities, and should consist of a wider realm of

music for participants to choose from. Further research should be explored in a more systematic

way to expand knowledge before implementation should occur, as well as planning effectively to

minimize controllable barriers. The use of music therapy in schizophrenic adolescents is an area

of research that holds much light and promise in improving the physical, mental and social

wellbeing of those who fight a battle against darkness and despair.

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References

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Gold, C., Wigram, T., Voracek, M. (2007). Effectiveness of music therapy for children and

adolescents with psychopathology: A quasi-experimental study. Psychotherapy

Research, 17(3), 292- 300.             

Grocke, D., Bloch, S., Castle, D., Thompson, G., Newton, R., Stewart S., & Gold, C. (2014).

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Hayashi, N., Tanabe, Y., Nakagawa, S., Noguchi, M., Iwata C., Koubuchi, Y.,…Koike I. (2002).

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