Music and Its Healing Effects

*Songül Mollaoğlu and Mukadder Mollaoğlu*

## **Abstract**

Music therapy, which is widely recommended for patients living with chronic problems, is actually a mind-body therapy. This therapy, which has been used clinically for more than a century, is one of the oldest treatment methods and is known to have been used in the treatment of patients in various cultures for four thousand years. Music therapy, known as simple harmonic movement, is rich in psychological and physiological effects. Used to support emotional, mental, and physical health, music therapy is an integrative art therapy method that provides a way to express feelings and experiences that cannot easily be expressed through words. Particularly in recent years, it has been observed that interest in traditional and complementary medicine in the field of health has increased worldwide. In this context, music therapy, one of the art therapy methods, attracts attention as a treatment method preferred by people among medical alternative treatment methods. In this section, the journey of music therapy from past to present and the neurophysiology of music are briefly explained and its effects on health problems are discussed in the light of findings in the literature.

**Keywords:** music therapy, healing effect of music, history of music therapy, physiology of music, integrative art therapy

## **1. Introduction**

The word musica is taken from the Greek "mousike" or "mousa". Nine fairy girls, who were considered the daughters of Zeus, the greatest god of the Greeks, were called "mousa" (mus). The ancient Greeks believed that these fairy girls were responsible for organizing the beauty and harmony of the whole world. It is accepted that the word music, which exists in almost all languages today, is derived from the root "muz" [1].

With the existence of medicine, music therapy has also existed. When we look at the use of music in medicine throughout history, it is seen that this association has always existed and continues until today. In ancient times, music was more common in belief-based use regarding the human soul. It is stated that the history of music therapy dates back to primitive tribes. According to the belief in primitive tribes, every being had its own voice and song. It was thought that the sound and song that a person would react to would be found by a sorcerer and the evil spirits inside him would be removed in this way and the cure would be cured. In addition, according to primitive tribes, diseases were caused by evil spirits and demons, and their treatment was done by a respected person called a shaman. According to mythology, Shamans would remove

evil spirits from the patient's body with rhythm and dance accompanied by music. In Christianity, church leaders used music as a treatment for mental illnesses [2, 3].

Apollo was a god believed to have played the lyre beautifully in ancient Greek mythology. He was considered the god of medicine. According to the belief in mythology, the music needed to relieve people's troubles and give them joy was performed by playing the lyre [4]. It is said that Orphee, one of Apollo's sons, played the lyre very well. In ancient Greece, mathematician and philosopher Pythagoras also played the lyre. After Pythagoras, the basic thought and moral teachings of the classical Greek music movement developed with Plato and Aristotle [4, 5].

While Aesculape used the trumpet to treat deafness, Homera is known to have used music in surgeries and demonstrated its effectiveness. Plato stated in 400 BC that music gives tolerance and comfort to the individual by affecting the depths of the soul with harmony and rhythm [6]. Egyptians used music during childbirth to reduce labor pain. In ancient Rome, Celcus and Areteus pointed out that music soothes the soul and is good for mental illnesses. It is reported that Confucius talked about the positive effects of music on people, that it calmed people and had beneficial effects on blood circulation [7].

In the late twentieth century, music therapy studies made significant progress, especially in the West. In the examinations, these studies appear as non-clinical studies as well as clinical studies. It is seen that music therapy in an experimental sense is also used in qualitative and quantitative research and is used especially to improve the physical and psychological conditions of patients during and after medical procedures [8]. Thomas Edison's invention of the phonograph in 1877 and his development of the disc recorder in 1886 were the beginning of the use of music in patient treatment in hospitals. As a result, music has been used in hospitals for therapeutic purposes since the first half of the twentieth century. The first studies were mostly conducted on anesthesia and analgesia applications. In the mid-twentieth century, researchers began to develop theories about the neurological basis of the effects of music and experimentally investigated the effects of music on physiological parameters [6, 9].

One of the first doctors who wanted to make music therapy available clinically was French neurologist Philipe Pinel. Pinel, who bases his studies on mental health on understanding people and advocates humanistic treatment methods, is known to advocate the use of music in treatment [4]. Dr. Willer Van der Wall took the first step in working on music therapy in America. In 1920, he conducted some research on music in hospitals and prisons in Pennsylvania and New York states and determined that music had positive contributions to people and had soothing and positive stimulating effects. The practice of music therapy as a profession was started during World War I. Music was used in hospitals to heal traumatic soldiers injured in war and to relieve their pain psychologically. Music therapy, which was accepted as a branch of science in America in 1977, has been used as an effective method in psychiatric diseases since the 1950s [10, 11].

The aim of music therapy studies that started in the hospital is to keep patients as involved in life as possible, to make them productive, to enable them to socialize, and to increase their adaptation to daily life. Art therapy by providing inter-institutional cooperation: It is a mental health specialty that uses the creative process in art to increase and improve the physical, mental, and emotional well-being of individuals of all ages [12].

This process, followed by music as a therapy method, has been used as an integral part of the field of music and health throughout human history. Today, music therapy, as a form of expression that helps people express their emotions and reflect their

*Music and Its Healing Effects DOI: http://dx.doi.org/10.5772/intechopen.113900*

unconscious emotions, adds meaningfulness to people's inner world. Today, music therapy has become a form of help sought for various reasons such as coping with the symptoms of chronic diseases, reducing the side effects of medications, strengthening the immune system, preventing mental depression, strengthening healthy behaviors, and preventing tension and loss of strength.

## **2. Physiology of music**

Music therapy has a history of thousands of years and today it emerges as a globally accepted field of expertise. The relationship between music and therapy goes back a long way. In fact, it is one of the oldest treatment methods. It is said that it is used in different cultures and civilizations. Music, one of the art therapy methods, appeals to the feelings and thoughts of the living being. Music has its own elements. There are expression elements such as genre, structure, rhythm, and language. For music therapy purposes, musical features such as rhythm, harmony, and melody are used [6, 13].

In the last 20–25 years, music, many studies have been conducted on its effects on neurotransmitters, hormones, cytokines, lymphocytes, vital signs, and immunoglobulins. Especially in the last decade, there has been an increasing number of studies examining the psychological and neurological effects of music on patients and the benefits of music on health [10].

Music is a unique stimulus because it causes both physiological and psychological responses in the listening individual. Music therapy, known as simple harmonic movement, is rich in psychological and physiological effects. When there is an auditory stimulus force, it is perceived as moving in a series. It begins with the compression of air molecules in the external ear canal, reaches the tympanic membrane, and finally passes through the cochlea to reach the nerves in the somatosensory region. Music stimulation leads to psychobiological improvements in this pathway. This way creates many effects on the person who listens to music (**Figure 1**) [14, 15]. Listening to music affects the autonomic nervous system and serves a healing function by causing relaxation in the organism. The first place where the sound of music is perceived is the auditory center located in the temporal lobe of the brain. Music perceived in the auditory center stimulates the thalamus, medulla, hypothalamus, midbrain, and pons [14, 16]. Music that affects different areas of the brain can reduce pain, for example, by causing the release of endorphins and enkephalin. As a result of its effect on the right hemisphere of the brain, it causes some effects on the limbic system and psychophysiological reactions occur, creating a therapeutic effect. Brain waves can be accelerated or slowed down by music, and it has an anxiolytic effect by helping to coordinate muscle tension and movements. As the pressure on neurotransmitters in the center increases, mood changes are achieved and anxiety decreases by correcting the nerves in the medulla oblongata [14–16].

As mentioned above, music creates a therapeutic effect by affecting the autonomic nervous system and neuroendocrinal activities. As it is known, the center of emotions is the limbic system. The influence of emotions on the limbic system is also related to the fact that the music reaching the body is not loud and has a normal tone and pitch. Thus, music listened to in a normal tone can transform negative emotions or disturbing emotions into positive emotions in the limbic system [17, 18]. As a result of a series of neuroendocrinological activities and autonomic processes stimulated by the effect of music in the organism, differences in emotions and physiological parameters occur in individuals. The parasympathetic nervous system takes action, slowing down and

#### **Figure 1.**

*Physiological mechanism of music therapy [14].*

improving vital signs, especially breathing, blood pressure, and pulse. On the other hand, the pituitary gland, activated by the neuroendocrinological effect, accelerates the release of endorphin. Endorphins both regulate the mood in the organism and reveal the therapeutic effect of music through its natural pain-relieving effect, thus reducing both pain and anxiety levels in those who listen to music. It also enables people to perceive difficult situations more positively [18, 19].

Research conducted so far indicates that the effect of music on immune response and psychological and neurological diseases is due to its important effect on stress pathways. Studies on the subject have determined that there is a significant relationship, especially between music and dopamine, adrenaline, testosterone, and serotonin. These hormones, which affect the emotional state of the organism, have a positive effect on people who listen to music. Considering the relationship of these hormones with psychiatric diseases, it is known that music therapy is widely used especially in this field [6, 10]. Physiological effects of music therapy ranges from reducing psychophysiological stress, pain, anxiety, and isolation to inducing a change in behavior and altering mood. Research has shown a significant relationship between music therapy and pain and anxiety. In addition to other neurohormonal effects, music therapy has many benefits for the organism, such as reducing nausea and vomiting due to chemotherapy, reducing anxiety, and pain, improving sleep quality in people with sleep problems, and increasing the comfort of the person by distracting attention. As we mentioned before, music also has benefits in regulating pulse, respiration, body temperature, and blood pressure due to its effect on the autonomic nervous system [10, 20].

#### *Music and Its Healing Effects DOI: http://dx.doi.org/10.5772/intechopen.113900*

Thus, music therapy has been actively used in healthcare environments as a result of the stages it has gone through from past to present. With the development of modern medicine, it is now used as an alternative and complementary method to relieve the symptoms of diseases along with medical treatment. Below, the effects of music on some symptoms are discussed, using the physiological effects of music on humans.

## **3. Pain - anxiety and music**

Pain is defined by the Taxonomy Committee of the International Association for the Study of Pain as "an unwanted emotional sensation or behavioral pattern related to the individual's past experiences, originating from a specific area of the body, whether or not due to tissue damage" [21, 22]. It is thought that the positive effect of music on pain management is that it affects the autonomic nervous system and increases the release of endorphins, resulting in less pain perception. It is stated that music therapy, which has a very long history, has come to the fore again in recent years with the increasing interest in non-pharmacological methods [22, 23].

The process of neurophysiology of music and its effect on humans, the transmission of music, begins with the compression of air molecules in the external ear canal, reaches the tympanic membrane and finally passes through the cochlea and reaches the nerves in the somatosensory region. It is sent to the hearing area of the brain by nerve cells. The transmitted musical stimulus is first pushed upwards in the part of the brainstem called the lateral lemniscus. In the brainstem, music is first evaluated and analyzed. Music perceived by the temporal lobe, the hearing center, causes stimulation in the thalamus, medulla, hypothalamus, midbrain, and pons. The thalamus decides the state of music within the brain. The influence of the thalamus is important for the evaluation of musical information. The first cortex regions provide hearing and analysis is done from the temporal lobe, the thalamus receives this information, sends it to the relevant areas in the brain and the music spreads in an area. Thus, the right hemisphere works on the progression of the music, the left hemisphere makes the appropriate analysis [24, 25].

Music affects the right hemisphere of the brain, causes psychophysiological responses through the limbic system, and causes the release of enkephalin and endorphins, resulting in a decrease in the level of pain. Brain waves can be accelerated or slowed down by music, and it has an anxiolytic effect by helping to coordinate muscle tension and movements. As the pressure on neurotransmitters in the center increases, mood changes are achieved and anxiety decreases by rehabilitating the nerves in the medulla oblongata [25]. Music causes both physiological and psychological responses in the individual who listens to it. The individual is more influenced by the music of his own culture. Because they can establish healthier communication with the music of their own culture. Individuals' understanding of music varies depending on the social and cultural structure of the society they live in and the education they have received [25, 26].

Studies conducted in different clinical settings report that music therapy is an effective intervention method, especially for intensive care patients. In Elliot's study in 1994, the effects of music therapy on anxiety, pain, and muscle relaxation were examined in patients hospitalized in the coronary intensive care unit with a diagnosis of ischemic heart disease. The study revealed that music had a positive effect on these patients and increased their comfort, and the importance of music as a therapy method was emphasized [27]. A similar study was conducted by Bolwerk. In this

study, in patients with myocardial infarction in intensive care, it has been found that music is effective in reducing patients' pain and anxiety [28]. In another study, music therapy was used for the first time to reduce the pain and anxiety experienced by patients in the coronary intensive care unit and to increase the comfort of the patients [29]. Sullivan, in his study on patients hospitalized in coronary and surgical intensive care units, the patients listened to classical music, and it was determined that the patients' pain and anxiety decreased after music therapy [30]. Tse et al. in their study with experimental and control groups, investigated the effects of music therapy after nose surgery on postoperative pain, pulse, blood pressure, and analgesic use. They applied 30-minutes of music therapy to the experimental group patients intermittently for the first 24-hours after surgery and measured pain values 4 times during the intervention. As a result of the study, they showed that the pain level decreased significantly over time in the experimental group compared to the control group [31]. In their study with experimental and control groups, Allred et al. investigated the effect of music on postoperative pain. They randomly divided 56 patients who had knee replacement surgery into two groups. As a result of the study, they found that the pain averages of the patients in the experimental group decreased statistically significantly [32].

In a randomized controlled study conducted by Takmak et al. patients diagnosed with COVID-19 were listened to nature-based music, and its effect on stress, some physiological parameters, and adaptation to the prone position was evaluated. Accordingly, in the intervention group listening to music, the stress level decreased the oxygen saturation of the intervention group increased, and the time lying face down increased, compared to the control group. At the end of the study, the researchers concluded that listening to nature-based music in the prone position may reduce anxiety, increase adaptation to the prone position, and improve oxygenation and heart rate in conscious patients with hypoxemic respiratory failure [33].

In another study (2020), it was found that music therapy reduced the pain, anxiety, and depression levels of patients [13]. Music reduces muscle tension and affects the biological rhythm of individuals by causing brain waves to accelerate and slow down, affecting the parasympathetic nervous system, and increasing the release of endorphins [34, 35]. Chlan examined the effect of music on anxiety in patients receiving ventilator support and found that there was a decrease in the respiratory and pulse values of the patients in the music group [36].

## **4. Nausea-vomiting and music**

Nausea and vomiting are common due to chemotherapy. Chemotherapy-related nausea and vomiting are the most common and serious side effects caused by chemotherapeutics. This is a common symptom in those receiving chemotherapy, and patients are very afraid of developing nausea and vomiting. It is recommended that music therapy be used in conjunction with other non-pharmacological methods to prevent chemotherapy-related nausea and vomiting. When the literature is examined, it is seen that many studies on music have been conducted with patients who have undergone bone marrow transplantation or solid organ transplantation, and as a result, music therapy is effective in reducing nausea and vomiting in these patient groups [37]. In the study of Rhodes et al. which investigated the effects of music therapy and visual imagery on the severity and duration of anxiety, nausea, and vomiting, they found that it significantly reduced the severity of nausea and vomiting and the duration of

#### *Music and Its Healing Effects DOI: http://dx.doi.org/10.5772/intechopen.113900*

vomiting also decreased [38]. Ezzone et al. showed less nausea and vomiting in a group of 33 bone marrow transplant patients who received music therapy [39].

2010 yılında Madden ve ark. Müzik ve dansı birleştiren ve kemoterapi gören hastalar için haftada 60 dakika uygulanan bir sanat formu tasarladı [40]. Deney grubundaki hastalar, kontrol grubundaki hastalara göre önemli ölçüde daha az mide bulantısı bildirdiler.

In a meta-analysis study conducted by Zhong and colleagues, seven articles applying music therapy to patients receiving chemotherapy were analyzed. This study determined that music therapy significantly improved symptoms of nausea and vomiting in patients with digestive system cancer during chemotherapy [41]. In the study by Doro et al. it was found that music therapy provided bio-psychosocial well-being by reducing nausea and pain in patients who underwent autologous hematopoietic stem cell transplantation [42]. According to a randomized study conducted by Madson and Silverman in a group of 58 patients who underwent solid organ transplantation, it was found that there was less nausea and vomiting in the music therapy group [43].

A systematic review and meta-analysis were conducted by Wei and colleagues to investigate the relationship between nausea and vomiting and music therapy. Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), China Biomedical Database (CBM), China National Knowledge Infrastructure (CNKI) and WanFang were searched as databases for this study. A total of 608 studies were examined in these scanned databases. Ten randomized controlled trials met the criteria established for the study. A total of 632 patients were included in the study. The effect of music therapy applied to the patients was analyzed. The study was analyzed by comparing the effect of music therapy with the type of music, duration of listening to music, and frequency of listening to music. The results were that music therapy reduced the expected incidence and severity of nausea and vomiting [44].

In another study by Pozhhan and colleagues, sixty patients were equally randomized into experimental (music therapy group) and control (routine care group) groups. About 148 instrumental, recreational, and religious records were transmitted through headphones connected to an MP3 player. The intervention consisted of five 25-minute sessions supervised by trained nurses to provide the patient's favorite music, volume, and timing regulation. A 0–10 visual analog scale (VAS) and a 4-point Likert scale were used to measure the severity of nausea. Frequencies were also asked and recorded. Study endpoints were determined before, during, and after chemotherapy (8-hours, 16-hours, and 24-hours). The statistical tests performed were found to be statistically significant in favor of the music therapy group in terms of the median of nausea frequency, vomiting frequency, nausea severity, and vomiting severity between the music therapy and control groups. Music therapy reduced the frequency and severity of nausea and vomiting in the intervention group receiving chemotherapy compared to the control group. As a result, the authors suggested that music therapy should be included in the recovery process after chemotherapy in women with breast cancer [45].

Many chronic health problems arise with aging. One of these, high blood pressure, can cause serious complications if not controlled. In addition to pharmacological treatment, non-pharmacological treatment is also widely used in hypertensive patients. The effect of music on the autonomic nervous system is reflected in a positive effect on blood pressure, as discussed before. For this reason, in addition to pharmacological treatment, music therapy can be used by taking advantage of the mechanism of music affecting the neurohormonal and autonomic systems.

Lorber and Divjak investigated the relationships between blood pressure and music therapy. This study was a random controlled study on elderly people in nursing homes. In the study, they aimed to reveal whether listening to music affects blood pressure, heart rate, and anxiety in the elderly. Thirty elderly individuals were randomly included in the experimental group and 30 elderly individuals were in the control group. Music therapy was applied to the experimental group. The experimental group that received music therapy was compared with the control group. As a result of the comparison, there were significant decreases in heart rate, systolic blood pressure, and anxiety in the elderly individuals in the experimental group. Thus, researchers said that as a result of this study, music therapy can be used as an alternative treatment method. Moreover, the fact that it is cheap, does not cause any harm to the person, and is safe are stated as important reasons for the preferability of this method [46].

Cao and Zhang conducted a meta-analysis study to evaluate the effects of adjuvant music therapy in hypertension patients and to shed light on the clinical management of hypertension. A total of 20 randomized controlled studies were included in the study. In these studies, it was determined that music therapy was applied to 1154 patients. The analysis of the study showed that music therapy lowered blood pressure, a vital sign. It was also found to have positive effects on both systolic and diastolic blood pressure. Similarly, music therapy reduced heart rate in this study [47].

Loomba and his colleagues investigated how music therapy affects blood pressure in their study "Effects of music on systolic blood pressure, diastolic blood pressure, and heart rate: a meta-analysis" in 2012. They compared the group that received music therapy and the group that did not. In this comparison, diastolic blood pressure was found to be significantly lower in patients in the music therapy group. Similarly, heart rate decreased in patients who received music therapy compared to patients who did not receive music therapy [48].

Alammar and colleagues wanted to examine the relationship between music therapy and heart rate in adults. For this purpose, they searched six databases (PsycInfo, MEDLINE, PubMed, CINAHL, and Cochrane Library). In this meta-analysis study, there were 194 studies on the subject from six databases. They included 12 studies from these studies. The data of 1.118 adult patients who took part in the studies accepted for the study were included. The patients had different medical diagnoses. At the end of the analysis of the study, it was determined that the heart rate of the patients in the experimental group (who received music therapy) decreased compared to the patients in the control group (who did not receive music therapy) [49].

## **5. Substance abuse and music therapy**

Many studies indicate that one of the unique interventions that can cure drug addicts is music therapy. From past to present, music therapy has been applied variably as primary and secondary health care for people with alcohol, tobacco, and other drug addictions. The data obtained in studies conducted in the field of music therapy suggest that music can play a critical role in multifaceted research. Music can be used to motivate and engage patients with substance addiction, to reveal emotions and positive mood changes, and to reduce stress and anxiety. The purpose of music therapy in substance addiction is to save the person from substance addiction, to

#### *Music and Its Healing Effects DOI: http://dx.doi.org/10.5772/intechopen.113900*

encourage the change of existing behaviors that harm the individual or society, and to raise awareness of the basic bio-psycho-social factors that contribute to substance use problems [50]. In a study conducted by W. S. Mathis, he states that music therapy in drug addicts has a potential esthetic input that can prevent the increase of dopamine in the brain regions affected by drug use and reduce substance craving. In an experiment he conducted with Han, Mathis applied music therapy to a group with substance addiction and made another group listen to white noise. They observed that there was a decrease in the desire to use substances in the group that listened to music [51]. In a similar study, three different treatment methods were applied to the group with substance addiction to reduce drug cravings. To one of these groups, only music was administered, to the other, a desire-reducing drug was administered, and to another group, both were administered. As a result, data were obtained that the desire for substances decreased in the group that listened only to music [52].

In a 2008 study, Dingle and colleagues investigated the effect of music therapy on substance abusers' participation in group cognitive behavioral therapy. They sought to answer the question of whether music therapy enables drug addicts to participate in cognitive behavioral therapy groups. This study was conducted in a private hospital. A total of 24 people, 14 women and 10 men, participated in the research. A total of 24 surveys applied to a sample aged between 17 and 52 were analyzed. The aim was to include patients in cognitive behavioral therapy administered in groups at the hospital where the study was conducted. For this purpose, music therapy was applied to substance addicts for 7 weeks. At the end of the sessions, how many substance addicts participated in music therapy and their perceptions were examined. As a result of the review, it was seen that 75% of substance abusers participated in cognitive behavioral therapy for 7 weeks. During the sessions, it was determined that substance addicts participated in the cognitive behavioral therapy group with pleasure and their motivation increased. They received an average score of 4.3 out of 5. About 46% stated that they saw themselves as part of the group thanks to music therapy. About 83% said they would attend other music therapy sessions in the future. They said that in the future, music therapy would improve the sense of belonging to the group. In addition, this study determined that music therapy is effective in all substance use. It was also determined that it could be applied to all age groups and that music therapy increased participation and motivation in all age groups in the cognitive behavioral therapy group [53].

Another study was conducted at a smoking cessation clinic. Of the smokers who applied to the outpatient clinic, 53 were in the study group and 61 were in the control group. Thus, a total of 114 people were included in the study. While art therapy was applied to the study group, health education was given to the control group. Thus, some parameters were examined in two groups. Symptom checklist score, blood lipid level, and high-density lipoprotein cholesterol were evaluated along with smoking duration. In addition, serum total cholesterol amount according to smoking duration and lung function according to smoking duration were also examined.

Low-density lipoprotein cholesterol decreased statistically significantly in both the study group and the control group. Symptom control scores of the study group were compared with the control group. According to this comparison, scores decreased in both groups. However, the scores of the study group were lower than the control group and were found to be statistically significant. High-density lipoprotein cholesterol was examined in the control group and the study group. Although smoking durations were different, it was determined that the highdensity lipoprotein cholesterol level in the study group was increased compared to

the control group. It was also determined that the smoking rate decreased in the art therapy group. Additionally, lung function tests were compared in both groups in this study, and both smoking cessation and smoking cessation rates decreased after the intervention. Moreover, it was determined that lung capacity improved significantly in the study group [54].

## **6. Sleep quality and music**

In order for music to be perceived, sound waves must first reach the ear. A series of steps then begins that convert these sound waves into electrical signals in the brain. Eventually, the brain interprets these sounds and a triggering effect is created for a series of changes to occur in the organism. One of the daily life activities that music affects the brain is sleep. Music affects regulating cortisol levels and stress hormones in people. This effect increases the comfort of people by ensuring quality sleep. In addition, by triggering the release of dopamine, music makes the person feel good before going to bed and helps manage pain, which is a factor that negatively affects sleep. People react both physically and psychologically to musical activity. These responses to music have significant effects on reducing not only acute pain but also chronic pain. Another effect of music on sleep improvement is related to the autonomic nervous system. Music increases sleep quality and improves sleep by relaxing the autonomic nervous system, which automatically controls many systems such as the nervous system. It is known that listening to music has significant effects on the autonomic nervous system. The autonomic nervous system, which regulates breathing, heart rate, and blood pressure, has a healing effect on these functions with the influence of music.

A study was conducted by Kavurmacı et al. on university students. In this study, pretest and posttest were applied and a control group was used. An answer was sought to the question of whether music therapy affects students' sleep quality. In the study, students who received a total score of 5 or more according to the Pittsburgh Sleep Quality Index (PUQI), who did not have any neurological/psychiatric disorders, who did not have a hearing problem, who did not receive any medical treatment, and who volunteered to participate in the study were included in the study. In this study, after randomization was achieved, students in the experimental group were allowed to listen to music for 1 hour a day *via* a music player. The MPM music player was asked to keep the music volume below 70% from students. The control group was not allowed to listen to music or any other intervention. Both groups continued their normal routines, including sleep. No other intervention was made to either the experimental or control groups regarding sleep habits. Before the intervention, the Pittsburgh Sleep Quality Index was applied to both groups, and baseline values were determined. Then, after the music treatment was given to the experimental group, the Pittsburgh Sleep Quality Index was applied again as a final test. When these measurements were compared, the post-test scores showed that sleep quality was improved in the Experimental Group compared to the Control Group. This value was statistically significant. Music therapy, one of the non-pharmacological treatment approaches for solving sleep problems, has been recommended as a non-pharmacological method that can be used in all areas of health, as a painless, safe, and economical treatment method without any side effects [55].

Another study examining the relationship between music therapy and sleep quality was conducted on elderly people. For this purpose, elderly people living in nursing

## *Music and Its Healing Effects DOI: http://dx.doi.org/10.5772/intechopen.113900*

homes were examined. The method of the study was pretest-posttest single group quasi-experimental. In the first stage, sleep quality was determined with a scale and the baseline value was obtained. Then, the elderly listened to music before going to bed at night, and their sleep quality was measured again as a final test. As a result, it was determined in the study that music therapy applied to the elderly before going to bed improved their sleep quality and they slept more comfortably [56].

## **7. Conclusion**

It is known that the art of music has existed since primitive societies and has an important place in human life. Because people have expressed their joy, sadness, and love through the art of music in every period of their lives. Among the fine arts, music is the area where emotions are best expressed and have the highest social impact. Music, a phenomenon that has been going on since the existence of humanity, is inherently empowering, cathartic, and healing. For this reason, it seems that the use of music as a therapy method dates back to prehistoric times and a wide variety of cultures. Thus, music has played an active role in the belief systems of many civilizations and has been used to treat diseases. Literature review shows that music therapy is widely used in health fields with increasing interest due to its relaxing effect on the symptoms of chronic diseases. As a result of the neurophysiological physiological effects of music therapy in this literature study, it has been determined that music is an important complementary medicine method that reduces heart rate and blood pressure, provides relaxation, changes the patient's perception of pain, diverts attention, reduces nausea due to chemotherapy, and improves the quality of life in patients and healthy individuals. Music therapy, which has the potential to improve symptomatic treatment and quality of life measures, is necessary and important to be used routinely alongside medical treatment, especially in clinical areas.

## **Author details**

Songül Mollaoğlu1 and Mukadder Mollaoğlu<sup>2</sup> \*

1 Faculty of Education, Department of Fine Arts, Sivas Cumhuriyet University, Sivas, Turkey

2 Faculty of Health Sciences, Sivas Cumhuriyet University, Sivas, Turkey

\*Address all correspondence to: mukaddermollaoglu@hotmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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## **Chapter 6**

## A Case of Music and Choral Painting in Online Arts Therapies

*Irina Katz-Mazilu*

## **Abstract**

This chapter presents an art and music online art therapy process with a 19 years old young woman during the lockdown period of the COVID-19 pandemic in 2021. The EFAT-European Federation of Art Therapy implemented social actions offering free online art therapy by some of its members to anyone experiencing difficulties at this time. The author volunteered to offer eight free art therapy sessions in individual settings in 2021 to 10 clients. The chapter describes the therapeutic process that successfully helped the client solve issues resulting from social isolation and other personal and familial aspects. The art therapy process combined art and music in each session with writing, recording, and finally, sharing. The therapeutic methodology, relationship and creativity are presented in their specific and original context. The chapter discusses the advantages and limits of the online methodology and some clinical and ethical questions and refers to other research in the field. While more research is needed on the synergy between different media, this case proves the efficiency of online arts therapies. The originality of this case is to cross music and art – as asked by a very gifted client. The healing power of the therapy is reinforced by crossing the two media and the two partners' creativity: client's and therapist's.

**Keywords:** music, art, online art therapy, synaesthesia, creativity, therapeutic relationship

## **1. Introduction**

Early 2021, Margherita is a 19 years young woman studying contemporary literature at the university of the city, where she lives with her parents.

The year before, she had a difficult time: "her father left the home to join a new partner, her mother, already fragile, was unhappy, destabilised and clinging on her (daughter…) Margherita has still a good relationship with her father but this event was a shock as she didn't expect it, nobody knew about the parallel life of the father. Moreover, she has had a hard time to be a teenager, to become a woman, she was searching…."

Margherita lives in Italy, the first European country to be strongly impacted by the COVID-19 pandemic. With the first – and strict – lockdown, she finds herself brutally isolated. She keeps living with her mother, studying online, separated from her friends. She gets anxious, depressed, lost.

In these siderating times, between 2020 and 2021, the EFAT-European Federation of Art Therapy – offers support to its members personally and professionally. Working groups, seminars and meetings help keep in touch, belong to a community and maintain professional development. First social action will be implemented between early January and the end of March 2021, offering eight free online art therapy sessions to anyone experiencing psychological difficulties with the pandemic. Each art therapist is free to organise the process (duration and frequency of the eight offered sessions, methods and materials, individual or group workshops, etc.) but has to sign a specific contract established by the EFAT. The characteristics of online art therapy have to be thoroughly explained to clients, and their consentment asked if any further use of their art therapy work is previewed. At the end of the social action, the participating art therapists are asked to deliver a short report. Group supervision is offered by experienced colleagues [1].

I am a volunteer for this action, able to work in French, English and Romanian. Starting from early 2021, I have had the opportunity to offer individual online art therapy to up to 10 clients from several European countries: France, Italy, Slovakia, and Ukraine. But, at this time, online art therapy is a challenge for me as I never practised it before. I feel insecure… Moreover, the lockdown echoes my own locked-in experience in my native country, Ceausescu's Romania, where I lived my young years in an open-sky prison… Through EFAT, I can benefit from four supervision sessions which are very helpful.

## **2. The arts therapy setting and process**

Margherita gets in touch with me in this frame, and we have eight art therapy sessions online in English. She has to find some place in the small apartment where she lives with her mother offering confidentiality and intimacy – sometimes the kitchen, or a glory hole where I can see the vacuum cleaner, etc.

I require Margherita's consentment to take pictures of her work and record the sessions to allow her to view herself in action. She agrees with this method often used in drama therapy and dance therapy. Mirroring oneself is a plus offered in online work.

Margherita is a brilliant and very gifted young woman. Before COVID, she already had experienced painting, music, theatre and dance, and she is writing poems…her wish is to be a multimedia artist exploring the synergy of crossed arts' possibilities. But for now, she feels locked and blocked: is her creativity lost? Behind this anxious self-questioning, I can feel the importance of the family background, her emotional and sexual difficulties, and the struggle to evolve to maturity and adult identity.

Building our therapeutic relationship and acknowledging how to collaborate in online art therapy are the objectives of the first two sessions. They are dense, rich and inspiring. Margherita likes painting with music and asks me if I agree. Yes, of course…she chooses either classical or jazz music, according to her feelings of the day. Soon I suggest painting with her hands, on the floor on big sheets of paper, with liquid materials, gouaches and ink. Her body dances while painting in music.

The third session carried by one of Beethoven's symphonies, Margherita paints with her hands, immersed in painting, her long hair diving into the paper, and finally, *A Case of Music and Choral Painting in Online Arts Therapies DOI: http://dx.doi.org/10.5772/intechopen.109989*

**Figure 1.** *Painting hands.*

**Figure 2.** *Hand and brush.*

she kisses her painting. In fusion with materials, soul and body in a sensual movement, she *feels,* she is living, she exists… (**Figures 1**–**4**).

After this third session, she sends me paintings and poems. Her creativity is released (**Figure 5**)

**Figure 3.** *Painting movement.*

**Figure 4.** *Margherita with blue lips.*

*A Case of Music and Choral Painting in Online Arts Therapies DOI: http://dx.doi.org/10.5772/intechopen.109989*

**Figure 5.** *Dancing figure.*

> *"and these tired shadows for you today cradle your hands scratch high on the ground and shake my lonely steps there's a world for you where it's always spring you living in colours without asking anything in return these days are sharpened by men, but I have a place for you in my pockets. tomorrow morning I'll dress up my twenties but tonight I am eternal I don't dwell because I don't ressemble"*

Margherita Fabbri, January 29, 2021, translated from Italian/French by herself.

In the fourth session, Margherita chooses the Heroical Symphony by Beethoven. In her glory room, the vacuum cleaner is like a big musical instrument, and she is her own orchestra director… (**Figures 6**–**8**).

The fifth session is dedicated to layers painting. Colours and writing follow, recover and transform each other… (**Figures 9** and **10**).

For the sixth session, I propose painting with "real life" raw material: coffee grounds, egg yolk, beetle juice…and mixing the techniques: painting, writing, collage, splitting, holes, etc. This brings her even closer to her body-mind subjective reality. She experiences jubilation with these warming familiar materials, with the freedom to transform them, with the vivacity of her body, with the sensual synergy of the visual, phonic and tactile elements (**Figures 11** and **12**).

She is diving into this original magma. Her defences are lowering; she escapes the omnipresence of intellectual interpretations, esthetically regressing to the age of the free handling of visual and sound stimulations by a toddler1 *.* She feels secure in my presence. At the end of each session, we share our impressions and thoughts, coming back to the *here and now.* The regression is contained by the art therapist. Finally, from the original magma, a new structure is coming to life…

She also shows me some of her artwork before the start of art therapy. We discuss the evolutive trends and perspectives. She keeps working on it between our sessions, sending images and poems. A kind of new-born artistic complicity is happening... (**Figures 13**–**15**).

#### **Figure 6.** *Finger painting.*

<sup>1</sup> The *aesthetic regression* is a concept introduced by Rita Simon as a symetrical concept of regression in psychotherapy [2].

**Figure 7.** *Painting with the back of the hands.*

**Figure 8.** *Margherita like an orchestra director.*

**Figure 9.** *Margherita showing her painting.*

**Figure 10.** *The red finger paint.*

*A Case of Music and Choral Painting in Online Arts Therapies DOI: http://dx.doi.org/10.5772/intechopen.109989*

**Figure 11.** *Painting with coffee.*

**Figure 12.** *Painting with eggs.*

**Figure 14.** *Painting with a square piece of paper.*

Her paintings are now fluid and light. She figures the frame is a protective and mild container.

The seventh session is caressing and tender… (**Figures 16** and **17**).

The eighth and last session is a crowning choral moment of our collaboration. I propose to create simultaneously, each one behind her computer, on the theme of togetherness in spite of the physical distance. We are listening to the same music and painting simultaneously, and the sound is carrying us and bringing us physically and emotionally closer. We feel connected. We show our art and share our feelings. The synergy of image and sound creates a powerful and nourishing stance for both of us. Beyond our therapeutic relationship, we feel belonging to the human community, and we are two human beings, two women, and two artists (**Figure 18**/Irina, **Figure 19**/Margherita).

*A Case of Music and Choral Painting in Online Arts Therapies DOI: http://dx.doi.org/10.5772/intechopen.109989*

**Figure 15.** *Yellow painting with black spots.*

**Figure 16.** *Tracing with fingers.*

At the very end of our sessions, Margherita showed me a self-portrait she had drawn before her art therapy process. Compared to her actual creative outburst, the change is obvious. This transformation spreads to her relationships with her parents, friends and colleagues. Soon the lockdown will end, and even if the pandemic is not yet over, she feels much stronger to face the challenges to come (**Figures 20** and **21**).

**Figure 17.** *Smiling Margherita with her painting.*

**Figure 18.** *Simultaneous painting - Irina.*

*A Case of Music and Choral Painting in Online Arts Therapies DOI: http://dx.doi.org/10.5772/intechopen.109989*

**Figure 19.** *Simultaneous painting - Margherita.*

**Figure 20.** *Self-portrait before the art therapy process.*

**Figure 21.** *Fluid painting in brown and white at the end of the art therapy process.*

## **3. Second time**

Two years later, Margherita lives in Paris, studying theatre at the Sorbonne University. She starts a new series of art therapy workshops, in my studio, in real life. We were both surprised when we first met: she is much taller than I imagined her online, and my studio is much smaller than she imagined it… This makes us laugh and comment, at which point the virtual reality is biaised…but maybe not more than our subjective perception of the reality? We explore new issues about her evolution, research, travel, expatriation and broadening her life horizon. Each time again, she chooses a musical piece to combine with visual traces. She feels a powerful echoing between the two media in her body and mind. The whole of her being is diving into action and creation (**Figure 22**).

Meanwhile, in 2022, Margherita also published a collection of poems titled "Anime Fradicie" ("Soaking Souls") in Italian.

With respect to the reglementation on the patient's protection, when I decided to write this article, I asked Margherita's informed consent for publishing images of her art therapy work and portraits of herself, as well as for giving some information about her personal and familial difficulties. I also asked her if she wanted to be published anonymously or with her full name. After some reflection, Margherita decided to testify openly and wrote these lines:

"Since when I met Irina and we begun our therapeutical path, I've been feeling the unveiling of something, someone in me, who's not left me since then. A Me in me who's the truest answer to my being. The reason of my consent to using every material without censorship is deeply radicated in this: if there's someone I would want as an expression of me, it is that Me." Margherita Fabbri, January 2023.

*A Case of Music and Choral Painting in Online Arts Therapies DOI: http://dx.doi.org/10.5772/intechopen.109989*

**Figure 22.** *White and yellow painting with writing.*

## **4. Discussion**

Online art therapy at 2000 km distance: did this context facilitate or limit the efficiency of the art therapy? We discussed it without deciding definitively if yes or no, or none of the two…Working with Margherita in this way – and in English – did not damage the quality of our collaboration. It was the only possible strategy at that time of isolation and social distancing – and it proved to be helpful.

One of the advantages of online art therapy is that it lets us free of masks – which obviously is a precious aspect. Also, it allows recording and taking photos/screenshots during the process without disturbing or interfering with the patient's concentration, making it possible to restitute these recorded traces to the patient and discuss each step of the art therapeutic and creative process in detail. Also, for some clients, the physical distance might facilitate contact and relationship.

It would be interesting to check and develop the existing research for a better understanding of the synergy of image and sound in the art therapeutic context by the use of recent possibilities of neuropsychiatry and other medical sciences. The concept of *synaesthesia* helps to understand how the complementarity and the crossed use of our senses can enhance our creativity as well as the healing power of art and art therapy [3].

Nevertheless, if digital technology offers many possibilities, the therapeutic relationship is prevalent in any technical context. Much research has been realised since the COVID-19 pandemic on the pertinence of online tools and methodologies in arts therapies [4].

Several articles have been published between 2020 and 2022 by Emmanuelle Césari and others in *The Canadian Art Therapy Association Online, Magazine* [5–8]. Most interesting is the concept of the "présence modifiée du corps"/"modified body presence" (trad.IKM). The discussion corroborates my own perceptions and analysis of the specific link to the body in virtual settings. We must learn to take advantage of digital techniques and understand their limits.

The specific ethical issues of the confidentiality, privacy, realisation, and the conservation of art therapy products, the sharing with pairs and medical partners, etc., have been the object of a careful elaboration by the EFAT's Ethics Committee and resulted in a Guide for online art therapy destinated to the members of the Federation [1].

## **5. Conclusion**

The use of digital methods in art and music therapy proved to be efficient in the case presented and might be extended to other clinical situations such as loneliness, isolation at home, hospitalisation in a sterile environment, social or school phobia, addiction to virtual games, geographical or social distancing… – when the patients are in a transitory or long-lasting impossibility to join a care centre or a private arts therapist's studio. Music and art are easy to use in a digital context, with simple materials and just a mobile, an Ipad or a computer, in most circumstances. Some existing creative apps might also be helpful for clients who manage digital techniques. Of course, as soon – and if – possible, meeting in real professional life is important because it allows connecting the other's presence by subtle phenomena that virtual techniques and reality cannot offer.

## **Author details**

Irina Katz-Mazilu Centre Popincourt, Paris, France

\*Address all correspondence to: irina.katzmazilu@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **References**

[1] EFAT–European Federation of Art Therapy. Available from: www. arttherapyfederation.eu

[2] Simon R. Symbolic Images in Art as Therapy. New York: Taylor & Francis Ltd.; 1997

[3] Synaesthesia. 2022. Available from: https://www.bbc.com/culture/ article/20221102-synaesthesia-thesuperpower-behind-great-art

[4] Zubala A, Kenell L, Hackett S. Art therapy in the digital world: An integrative review of current practice and future directions. Frontiers in Psychology. 2021. Available from: https:// www.frontiersin.org/articles/10.3389/ fpsyg.2021.600070/full

[5] Cesari E, Barberi C. Visioconsultation: art-thérapie en miroir. In: The Canadian Art Therapy Association Online, Magazine. Vol. 5, Issue 2. Envisage, Spring 2022; 2022 [Online]

[6] Cesari E, Clain M. D'écran à écran: un nouveau cadre art-thérapeutique. In: The Canadian Art Therapy Association Online, Magazine. Vol. 5, Issue 1. Envisage, Winter 2022; 2022. [Online]. Available from: https://www. canadianarttherapy.org/envisage/ envisage-winter-2022-cesari-clain

[7] Cesari E, Gerard S. Un atelier e-artthérapeutique avec un processus de faire créatif contre l'anxiété due à la COVID-19. In: The Canadian Art Therapy Association Online, Magazine*.* Vol. 3, Issue 3. Envisage 3.3 Fall 2020; 2022 [Online]

[8] Cesari E, Gerard S. Un atelier e-art-thérapeutique avec un processus de faire créatif contre l'anxiété due à

la COVID-19. In: The Canadian Art Therapy Association Online, Magazine. Vol. 3, Issue 3. Envisage 3.3 Fall 2020; 2020. [Online]. Avaialble from: https:// www.canadianarttherapy.org/envisage/ envisage-fall2020-cesari-grard

## **Chapter 7**

## Relaxing Music in the Dental Waiting Room Has Paradoxical Effects on Dental Anxiety in Patients with High Cognitive and Social Anxiety Sensitivity

*Emma E. Truffyn, Colin B. Pridy, Margo C. Watt, Amanda Hill and Sherry H. Stewart*

## **Abstract**

We sought to determine the efficacy of a music intervention in decreasing state anxiety and dental-related anxiety among patients awaiting dental clinic services, particularly those with high AS-physical concerns (i.e., fear of adverse physical consequences of arousal sensations). Forty-six dental patients between the ages of 20 and 78 years (61% female) participated in the intervention. While awaiting dental procedures, patients completed the Anxiety Sensitivity Index-3 and were exposed to music selected by experts to be either relaxing (*n* = 24) or neutral (*n* = 22). During the exposure period, participants completed the State-Trait Anxiety Inventory-State Form-6, and the Dental Anxiety Scale-4 as outcome variables. Contrary to predictions, participants exposed to relaxing (vs. neutral) music did not report lower levels of dental or state anxiety. Paradoxically, participants in the *relaxing* music condition showed a significant positive correlation between AS-cognitive concerns (e.g., fear of losing control) and AS-social concerns (e.g., fear of public embarrassment) with dental anxiety. Dental clinics should be more intentional in their selection of music in the waiting room, as patients with high AS-cognitive and/or high AS-social concerns may experience a paradoxical increase in dental anxiety from music intended to be relaxing.

**Keywords:** anxiety, dental anxiety, fears, anxiety sensitivity, music interventions

## **1. Introduction**

Many people fear dental care: the prevalence of clinically significant (i.e., high) dental anxiety is ~15.0–24.3% [1–3]. About 3.7% of the population meets the diagnostic criteria for the most severe form of dental anxiety, namely dental phobia. Avoidance caused by dental anxiety, including phobic-level fears, can lead to dental erosion and

decay, periodontal disease, and tooth loss [4]. Poor oral health has been linked to heart and respiratory diseases, diabetes, and oral-related cancers, as well as to major mental disorders such as anxiety, depression, obsessive-compulsive disorder, and eating disorders [4–7]. Indeed, high dental anxiety increases the risk for other phobias, depression, mood disorders, and other psychiatric disorders and symptoms [7].

Unlike other Blood-Injection-Injury (BII) phobias, dental phobia is marked by intense anxiety at the sight and sound of dental equipment and the dental treatment setting as opposed to the sight of blood and/or needles [8, 9]. Individuals with high dental anxiety focus attention on perceived dental threats (e.g., dental pain) and feared dental stimuli (e.g., sight of drill or dentist) [9, 10]. Dental anxiety is related to anxiety sensitivity (AS)—the specific fear of arousal-related sensations due to beliefs that anxiety-related sensations signify harmful consequences [11]. Examples of such beliefs include: a racing heart rate portending a heart attack (AS-physical concerns); dizziness signifying loss of control or "going crazy" (AS-cognitive concerns); and/or trembling eliciting social humiliation (AS-social concerns). AS is linked to, but distinct from, both state (i.e., transitory) and trait anxiety (i.e., dispositional anxiety-proneness) [12]. In a sample of military workers (88% male), AS predicted dental fears but not more general BII fears [13]. Although AS-physical (vs. cognitive or social) concerns have been found to uniquely predict pain-related anxiety [14], no studies have examined relations of AS components to dental anxiety and phobic-level fears, specifically.

Good rapport with patients, allowing them to express their fears, and talking them through procedures can reduce low to moderate dental anxiety [15–19]. High dental anxiety may require more intensive intervention. Cognitive-Behavioral Therapy (CBT) is highly effective [17] but requires specific training and dedicated treatment sessions [18]. More easily administered options, such as music interventions, may be preferable for dental clinics. Focusing on pre-operative music interventions, Thoma et al. [20] found that patients who listened to music (relaxing music) vs. those who did not (i.e., silence) had lower state anxiety prior to dental hygiene treatment. A meta-analysis conducted by van der Weijden et al. [21] examined the effects of playing background music specifically during dental treatment. Results showed that listening to music during dental treatment reduced state anxiety more than treatment-as-usual and that background music provided a small reduction in dental anxiety [19, 21]. Classical music and non-classical relaxing music demonstrated the strongest effects on anxiety. More recently, a study with two meta-analyses of 104 music interventions (coded separately for physiological and psychological stress-related outcomes) revealed significant beneficial effects of music as compared to control groups. Results showed a significant small-to-medium effect of music intervention on physiological outcomes (e.g., blood pressure, heart rate; d = .380) and a medium effect on psychological outcomes (e.g., state anxiety, nervousness, feelings of worry; d = .545) across various settings (e.g., mental health settings, medical settings) [22]. No significant moderating effects of intervention characteristics were found but a trend for music tempo (p = .064) indicated that music with a slow tempo (60–80 bpm) yielded somewhat larger effects than music with a faster or unspecified tempo.

To date, studies have examined the effects of music on state anxiety in the dental context, with few directly examining the effect of music on dental anxiety specifically. Furthermore, AS and its components have not been investigated as individual difference factors that might moderate susceptibility to the anxiolytic (i.e., anxiety-reducing) effects of music. Moreover, studies have been inconsistent in defining type (e.g., relaxing; neutral) and intention (e.g., distraction vs. anxiolysis) of intervention music. Norr [23] found exposure to classical music (control condition) reduced AS-cognitive

*Relaxing Music in the Dental Waiting Room Has Paradoxical Effects on Dental Anxiety… DOI: http://dx.doi.org/10.5772/intechopen.113288*

concerns more than a psychological treatment (i.e., exposure to feared dissociative symptoms; active condition). It was concluded that classical music might be relaxing and, therefore, an effective state anxiety-reducing intervention for those with high AS. Accordingly, the present study explored the efficacy of an in-situ music intervention in reducing general state anxiety and specific dental anxiety among patients awaiting dental procedures. We also explored, for the first time, the potential effects of AS components (physical, cognitive, and social concerns) in moderating the hypothesized anxiety-reducing effects of music. Patients were pseudo-randomly exposed to music intended to be either relaxing or neutral, and completed validated measures of state anxiety and dental anxiety as outcomes, and of AS as a moderator of intervention effects.

Two hypotheses were proffered: (H1) Music condition would impact both state and dental anxiety, such that levels would be lower in participants exposed to relaxing (vs. neutral) music; and (H2) Music condition effects would be moderated by AS-physical concerns, with AS physical concerns positively correlating with state and dental anxiety more strongly in the neutral (vs. relaxing) music condition, due to the dampening effects of the relaxing music on state and dental anxiety, particularly among those with high AS physical concerns.

## **2. Method**

#### **2.1 Participants**

Recruitment took place at a dental clinic in northeastern Nova Scotia. Of 57 dental clinic patients invited to participate, eight declined and 49 gave consent (86% recruitment). Three cases were removed due to incomplete answers (>20% missing data) for a final sample of 46 patients [*M* (*SD*)age = 47.44 (15.49), range 20–78 years, 2.2% of unknown age; 89.1% White; 30.4% completed university]. Of the total sample of N = 46: 61.9% reported visiting a dentist about every 6 months; 4.8% visited once a year; 19% visited once every 2 years or less frequently; and 14.3% visited once every 5 years or less frequently. No intellectual, physical, or other mental health conditions were screened for given the scope of the study. Twenty-four (52.2%) were exposed to *relaxing* music and twenty-two (47.8%) were exposed to *neutral* music. **Table 1** includes descriptive statistics and Pearson Product Moment correlations. Betweengroup *t*-tests and chi-square analyses confirmed the two music conditions did not differ significantly in age, sex, visits to dental clinic (every 6 months vs. less frequently), or levels of the three AS components.

#### **2.2 Measures**

#### *2.2.1 Demographic information*

Data collected included participant age, sex, ethnicity, education, and frequency of dental clinic visits.

#### *2.2.2 Anxiety Sensitivity Index 3 (ASI-3)*

The ASI-3 [24] is an 18-item self-report questionnaire that uses a 5-point Likert scale ranging from 0 ('very little') to 4 ('very much'). It has three subscales: AS-physical concerns (i.e., fear that physical sensations portend adverse physical consequences such


*Note. AS-P = Anxiety Sensitivity Index-3 (ASI-3) physical concerns; AS-C = ASI-3 cognitive concerns; AS-S = ASI-3 social concerns; DAS = Dental Anxiety Scale; STAI-S-6 = State-Trait Anxiety Inventory (State Scale only). M = Mean; SD = Standard deviation.*

#### **Table 1.**

*Descriptive statistics and between-group test statistics.*

as heart attack or death), AS-cognitive concerns (i.e., fear that cognitive sensations signal dyscontrol), and AS-social concerns (i.e., fear that observable anxiety sensations will have adverse social consequences). Cronbach's alphas in the present study ranged from acceptable to good (.77 for AS-physical and AS-social to 0.81 for global AS).

## *2.2.3 State-Trait Anxiety Inventory-State Form-6 (STAI-S-6)*

The STAI-S-6 [25] is a 6-item self-report measure of state anxiety derived from the 20-item Spielberger State-Trait Anxiety Inventory-State subscale (STAI-S) [25, 26]. It is scored on a 4-point Likert scale ranging from 1 ('not at all') to 4 ('very much'). Total scores can range from 6 to 24; higher scores (>12) indicate greater state anxiety [25]. The STAI-6 has demonstrated good internal consistency (Cronbach's alpha = 0.82 [25]; 0.84 in the current study) and showed concurrent validity with the 20-item full form and 14-item short form of the STAI-S [25].

## *2.2.4 Dental Anxiety Scale-4 (DAS-4)*

The DAS-4 [27] measures anxiety specific to dental health. It is a four-item, selfreport questionnaire to which participants respond on a 5-point Likert scale ranging from 1 ('Relaxed') to 5 ('So Anxious'). The sum of the item scores yields a total score that can range from 4 to 20. The DAS-4 has demonstrated good construct and content validity, internal consistency, and test-retest reliability (Cronbach's alpha = 0.82; 0.89 in the current study) [27].

## **2.3 Procedure**

Data collection occurred across five consecutive workdays (see **Figure 1**). Assignment to music condition was achieved by playing 'relaxing' vs. 'neutral' stimuli (detailed in **Table 2**) in the clinic waiting room on alternating days as patients arrived for their scheduled appointments. To best investigate the effects of the music intervention in the real-world context, few controls were implemented. The order of presentation of

*Relaxing Music in the Dental Waiting Room Has Paradoxical Effects on Dental Anxiety… DOI: http://dx.doi.org/10.5772/intechopen.113288*

**Figure 1.** *Music condition design.*

the 'relaxing' vs. 'neutral' stimuli conditions were pre-determined; the assignment of the first day as relaxing or neutral was determined arbitrarily. Participants were pseudo-randomly assigned to one of two conditions depending on when their appointment occurred. To match music condition sample sizes as closely as possible, on day 5 the 'relaxing' playlist was administered in the morning and the 'neutral' playlist in the afternoon. Patients were exposed to music stimuli upon arrival for approximately 5 minutes, then were checked in and invited to participate in the study. Willing participants provided informed consent and completed the study measures immediately following exposure to the music stimuli. No incentive was provided for participating. Music stimuli were selected based on a previous study of contrasts in structure between music used for arousal reduction vs. arousal induction [28]. In that study, 160 music selections were analyzed by three expert raters (all musical composers with doctorates) to obtain a single Relaxing/Energizing Index (REI) score for each selection. Each REI score was an average of six equally weighted musical property measurements, each comprised of the mean of three expert ratings. Intra-class correlations (ICCs) were used to assess interrater reliability (IRR) for each musical property measurement. IRR was fair for Rhythmic Definition (ICC = 0.551), good for Metric Accentuation (ICC = 0.719) and Textural Complexity (ICC = 0.670), and excellent for Relaxing vs. Energizing (ICC = 0.875), Intensity (ICC = 0.862), and Tempo (ICC = 0.822) [29]. These REI scores were used to rank the 160 music selections from those predicted to be most arousal reducing (i.e., relaxing) to most arousal inducing (i.e., energizing). For the present study, the 31 lowestranked selections (i.e., those with the greatest preponderance of anxiolytic musical structures) comprised the 'relaxing' music playlist (MRelaxing (SD) = 3.32 (0.58)) and the 27 selections closest to the median ranking comprised the 'neutral' music playlist (MNeutral (SD) = 4.94 (0.23); see **Table 2**). The difference in REI scores between the two conditions was statistically significant (t (40.33) = 14.19, p < .001; Cohen's d = .46 (medium effect size)). [Levene's test was significant, F = 17.62, p < .001, so the independent samples t-test was conducted with equal variances not assumed.] Each music condition playlist was loaded onto a Micro SD card and played through a speaker in the dental waiting room. The playlist for each condition was played in a continuous loop and was not restarted prior to each participant. As an awareness check, participants were asked post-treatment whether they had noticed the music; if yes, they were asked to classify the music as relaxing or neutral.

## **2.4 Data analytic strategy**

We (a) tested between-group (relaxing vs. neutral) differences in demographic variables, global AS, and AS dimensions to ensure equivalence between groups; (b) examined H1 through between-group *t*-tests on state anxiety and dental anxiety;


*Relaxing Music in the Dental Waiting Room Has Paradoxical Effects on Dental Anxiety… DOI: http://dx.doi.org/10.5772/intechopen.113288*


*Notes. REI = Relaxing/Energizing Index (REI); scores were a composite of six musical property ratings. Scales and anchors were as follows: Intensity, from 1 ('Very Gentle/Soft') to 7 ('Very Aggressive/Loud'); Metric Accentuation, from 1 ('Very Light') to 7 ('Very Well Marked'); Relaxing vs. Energizing, from 1 ('Very Relaxing') to 7 ('Very Energizing'); Rhythmic Definition, from 1 ('Very Vague') to 7 ('Very Salient/Prominent'); Tempo, from 1 ('Very Slow') to 7 ('Very Fast'); Textural Complexity, from 1 ('Very Simple') to 7 ('Very Complex').*

#### **Table 2.**

*Music stimuli listed by music condition*

and (c) examined H2 through one-tailed correlations between AS dimension scores and both dental anxiety and state anxiety in each music condition. Comparisons of correlation magnitude across groups, using *z-*tests, were planned a priori. Given that directional predictions had been made a priori, H2 was evaluated using one-tailed tests. We also explored participants' awareness of the presence of the music and of the music condition to which they had been assigned through between-group chi square tests on the proportions who reported being aware of the music and, of those, the proportions who reported having heard "relaxing" vs. "neutral sounding" music.

## **3. Results**

#### **3.1 Hypothesis testing and correlational analyses**

Hypothesis 1 was not supported: no significant between-group (relaxing vs. neutral music) differences in state anxiety or dental anxiety were found. Hypothesis 2 also was not supported: AS-physical concerns were unrelated to state anxiety and dental anxiety in both music conditions. By contrast, dental anxiety was unexpectedly significantly positively correlated with both AS-cognitive and AS-social concerns in the *relaxing* condition but not in the neutral condition (see **Table 3**). Due to the null


*Note. AS-P = Anxiety Sensitivity Index-3 (ASI-3) physical concerns; AS-C = ASI-3 cognitive concerns; AS-S = ASI-3 social concerns; DAS = Dental Anxiety Scale; STAI-S-6 = State-Trait Anxiety Inventory (State Scale only).\* p < .05 (one-tailed).*

*\*\*p < .01 (one-tailed).*

*\*\*\*p < .001 (one-tailed).*

#### **Table 3.**

*Pearson Product Moment correlations, split by music condition (relaxing vs. neutral).*

results in the neutral condition, the comparisons of correlation magnitudes across music conditions that had been planned a priori were not undertaken.

#### **3.2 Awareness check**

Of participants who acknowledged having noticed the music (21/24 [87.5%] and 18/22 [81.8%] in the relaxing and neutral conditions, respectively), the majority classified the music they heard as "relaxing" vs. "neutral sounding" (15/21 [71.4%] and 13/18 [72.2%] in the relaxing and neutral conditions, respectively). Neither of these between-group differences were statistically significant. This null result for a between-group difference did not change when we compared the proportion of those in each condition who reported having heard music that was "relaxing" vs. "neutral sounding/not noticed" (i.e., using the number in each condition as the denominator: 15/24 (62.5%) vs. 13/22 (59.0%) in the relaxing and neutral conditions, respectively).

## **4. Discussion**

It was expected that patients exposed to music intended to be relaxing (vs. neutral) would report lower state and dental anxiety while awaiting dental treatment. Surprisingly, music condition had no effect on state or dental anxiety, in contrast to previous studies [19, 30]. AS is known to amplify dental anxiety [31]; therefore, it had also been predicted that the magnitude of relations between AS-physical concerns and state/dental anxiety, while awaiting a dental procedure, would be largest in the 'neutral' music condition and dampened (or decoupled) in the 'relaxing' music condition. Instead, AS-*cognitive* and AS-*social* concerns were associated with increased dental anxiety in the *relaxing* rather than in the neutral condition. It appears that for patients with elevated AS-cognitive and AS-social concerns, hearing music judged by experts to be relaxing while awaiting dental treatment may be countertherapeutic.

#### *Relaxing Music in the Dental Waiting Room Has Paradoxical Effects on Dental Anxiety… DOI: http://dx.doi.org/10.5772/intechopen.113288*

These unexpected findings may reflect a phenomenon known as "relaxation induced anxiety" in the dental context—a paradoxical effect whereby physiological, behavioral, and cognitive aspects of anxiety are enhanced via relaxation techniques [32]. Our findings suggest that dental anxiety may be exacerbated by listening to ostensibly "relaxing" music while awaiting treatment among patients who fear losing control (high AS-cognitive concerns) or public humiliation (high AS-social concerns) when anxious. The anticipatory nature of fearful thoughts associated with dental anxiety may have contributed to their specific paradoxical increase in dental (vs. general state) anxiety when hearing music intended to be relaxing in the waiting room prior to dental treatment. Furthermore, fears of losing control and being viewed negatively by others may cause increased dental anxiety as these patients begin to relax and "let go" while immersed in relaxing music as they await a feared treatment in a public space. Indeed, high AS has been found to be associated with fear of the loss of vigilance that can occur during states of meditative relaxation [33].

Despite differing arousal-reducing potential between music conditions as previously judged by expert raters [28], most participants in both the 'neutral' and 'relaxing' conditions classified the stimuli they heard as "relaxing". This could reflect differing music perception in expert vs. casual music listeners, a failed manipulation underlying the lack of a differential effect of music condition on state and dental anxiety, or an insufficiently sensitive manipulation check. Importantly, however, the differing correlations with AS dimensions between conditions suggests the two types of music stimuli did indeed produce differential effects that were dependent on levels of two specific AS components. One explanation for this paradoxical finding involves differences between emotion perception and emotion induction in response to music. These are known to be distinct processes and are therefore not always congruent [34, 35]. The majority of participants in each music condition may have classified both 'neutral' and 'relaxing' music stimuli as 'relaxing' based on their *explicit* (or conscious, effortful) perception of musical content, despite differing *implicit* (or automatic) effects between music conditions on the magnitude of the association between AS-cognitive/AS-social concerns and dental anxiety levels.

Music neutral in the tension–relaxation dimension of affect [36] (upon which the Relaxing/Energizing Index (REI) is based [28]) may be needed to maximally benefit dental anxiety reduction in those with high AS cognitive or social concerns. Norr [23] attributed the reduction in fear in his control condition to relaxation (an oblique reference to tension–relaxation) induced by music. Thus, it may be that Norr's classical music playlist (comprised of selections previously found to induce mood of neutral affective *valence*) was also appropriately neutral in the *tension-relaxation* dimension of affect. This may have produced Norr's anxiolytic effects, in line with the results of the neutral (vs. relaxing) condition in the current study. One possible explanation of the anxiolytic effects among high AS cognitive/social concern participants in the neutral vs. relaxing music condition could be distraction—which paves the way for anxiolysis. While relaxing music, like neutral music, would have a distracting effect, relaxing music might also have a counter-therapeutic paradoxical anxiety enhancement effect in those prone to relaxation-induced anxiety, making neutral music a better choice for distraction and hence dental anxiety reduction in these patients in the dental waiting room. Thus, our results highlight two potential processes at play: (1) relaxing music may paradoxically increase dental anxiety in those with high AS social or cognitive concerns; and/or (2) neutral music could be sufficient to distract and hence reduce dental anxiety in patients with high AS social or cognitive concerns.

## **5. Limitations and future research**

Several limitations should be acknowledged. First, caution must be taken in interpreting these results as—apart from ensuring that the two music conditions did not differ significantly on several potentially important confounding variables—few controls were exerted in this study, to ensure the findings were generalizable to the naturalistic dental treatment context. Second, as music stimuli were drawn from a previous study [28] conducted with undergraduate students, the current music selections may have been perceived and responded to differently by the somewhat older participants in the current study. The relaxing and neutral music playlists were based on perceived arousal-reducing and/or arousal-increasing properties as rated by experts. However, these stimuli have yet to be experimentally validated [37] as capable of inducing their hypothesized changes in emotional arousal. It is possible that the neutral and relaxing playlists may not have been sufficiently contrasting to have had the anticipated main effects on dental and state anxiety. Playlists focused on a smaller number of the most arousal-reducing/most 'neutral' selections might have achieved greater contrast. Moreover, it is possible that the exposure duration of approximately 5 minutes was insufficient to induce the expected effects on dental and state anxiety. Indeed, previous studies have used exposure times lasting 15–30 minutes [36, 38]. Finally, it was not possible to determine whether both or neither music condition(s) led to reductions in dental and/or state anxiety. Feasibility constraints inherent to our real-world dental office setting precluded establishment of a premusical induction baseline. Future studies incorporating a no-music control group, pre-and post-assessments of state and dental anxiety, and ruling out other potentially confounding variables (e.g., mood disorders, use of other distraction techniques) are warranted.

## **6. Implications for group therapy**

Being more intentional in selecting background music for therapeutic purposes has implications for various settings, including group therapy. Music intended to promote relaxation could induce anxiety in clients inclined to maintain vigilance (like those with high levels of AS cognitive or social concerns). Let's imagine that a well-intentioned facilitator chooses "relaxing" (vs. neutral) music with the intention of alleviating the anxiety commonly experienced by members of a newly formed group. In approaching group therapy, it is not unusual for clients to be somewhat guarded -- wary of group therapy processes, feelings of vulnerability, and of oversharing with unfamiliar facilitator(s) and other group members. Selecting "relaxing" music, however, could have the paradoxical effect of increasing these clients' anxiety and, thereby, impede the development of group cohesiveness. If the group was designed to explore mindfulness, the "relaxing" music could undermine clients' early efforts to become observers of their thoughts and emotions, to let them come and go, to practice self-compassion, etc. all of which require letting one's guard down (i.e., reducing vigilance). On the other hand, "relaxing" music might be more appropriate in later group therapy sessions when the therapeutic alliance among group members has been established and clients' self-perceived need to maintain vigilance has diminished. Early group therapy sessions might be better served by music that is more "neutral" (neither activating nor deactivating) or by no music at all.

*Relaxing Music in the Dental Waiting Room Has Paradoxical Effects on Dental Anxiety… DOI: http://dx.doi.org/10.5772/intechopen.113288*

## **7. Conclusion**

Many dental clinics use music to relax patients and/or provide distraction from fear-inducing sounds (e.g., dental drills). Results of the present study, however, belie the assumption that the presence of music rated as relaxing by experts will effectively relax patients while awaiting dental treatment. Up to 20% of dental patients are at heightened risk of treatment avoidance due to high AS [22]. The current results suggest that a more intentional (vs. random, i.e., relying on radio or internet playlists) approach to the selection of "neutral" music (i.e., neither extremely arousal-inducing nor arousal-reducing) may best achieve the goals of reduced dental anxiety and preventing future avoidance of dental care among high AS patients.

## **Acknowledgements**

The authors would like to acknowledge the contributions of dental hygienist Michelle Duchovni, clinical staff, and our dental patient participants. Dr. Brad Stark, Dr. Fiona Ryan, and Dr. Colin Pridy completed music analyses [28], with additional assistance from Dr. Christopher Lively. Financial support was provided to the first author by the Nova Scotia Health Research Foundation. The last author is supported through a Tier 1 Canada Research Chair in Addictions and Mental Health.

## **Conflict of interest**

The authors declare no conflict of interest.

## **Author details**

Emma E. Truffyn1 , Colin B. Pridy2 , Margo C. Watt3 , Amanda Hill4 and Sherry H. Stewart<sup>2</sup> \*


\*Address all correspondence to: sherry.h.stewart@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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## **Chapter 8**
