**4. Discussion**

*Weight Management*

**Figure 2.**

**Table 3.**

*Coded references by group.*

**200**

piece of music. One patient describes a particularly sad event in their life that was tied to an artist, saying, "that would be with Frank Sinatra's song, that was played at my Granddad's funeral. So, again if I feel like I need to cry and let it all out… Ten out of ten it would make those tears fall." Music seems to elicit an emotive reaction

**Coded theme group Number of coded references Percentages of all coded references**

Music therapy 18 8.7 Preference 64 30.9 Positives 52 25.1 Negatives 21 10.1 Neutrals 6 3 Beliefs 46 22.2

Music Therapy was discussed totaling 18 references throughout both focus groups (**Figure 2**). Patients were asked for their thoughts on music therapy, if music therapy can be helpful through their recovery process, as well as if they would be interested in attending a music therapy session. None of the patients had any experience with music therapy but all six of the patients unanimously agreed that

There were nine references during the focus groups about the benefits of music therapy. One patient stated "I know it's brilliant. And I know it could help me sort through a lot of issues," while another stated its uses in a group setting with others undergoing treatment for their eating disorder, saying "…a lot of girls I was in daycare with, music was definitely a thing that we did a lot. So, I think that sort of being able to mingle with other people through the recovery process too, I think would be really, really helpful." Overall, patients all seemed to have a strong

they would be interested in attending a music therapy session.

based on the participants life experience.

*Distribution of the frequency of themes coded from both focus group.*

In this study, we conducted a software-assisted qualitative study exploring people with AN's attitudes toward music, music therapy, and the uses of music throughout their life, treatment and recovery. The results of the study point to a promising potential for the varied uses of music throughout the recovery process for eating disorders. Patients were questioned in focus groups concerning the uses of music in their day to day life and as a therapeutic strategy. Responses were analyzed with NVivo 12 qualitative software for recurring themes throughout the discussions.

The most prevalent theme throughout the focus groups involved positive expressions and positive memory associations related to music. This theme occurred in ~25% of the data and totaled 52/207 of all of the coded themes (**Table 3**). This suggests patients have pleasant feelings about music and associate good things that have happened in their lives along with musical experiences. The importance of music was the second most common theme accounting for 24 references throughout the focus groups (**Figure 2**). Patients described the effect music had on their day to day life, with regulating emotions and providing an outlet of peace through their recovery process, suggesting that it was the study participants' opinion that music could be used to improve their mental state throughout their recovery.

Negative feelings and negative memories associated with music accounted for only ~10% of all of the references from both focus groups (**Table 3**). Patients discussed how music they dislike can make them feel low in mood and also described negative memories linked to a certain genre or song. This suggests music can influence mood not only positively but negatively as well.

The final main result concerns the potential uses of music as a therapeutic adjunct to their treatment. When asked about music therapy, 6/6 patients stated they were interested in attending a music therapy session; in addition, all patients expressed that they see benefit in using music therapy as an adjunct to their current treatment for their eating disorder. This suggests music could be helpful for patients in the treatment of AN.

In previous studies on the use of music in eating disorder treatment, researchers found that patients with AN managed to eat more when listening to classical piano music and had a significant reduction in postprandial anxiety when participating and music therapy; listening to a violin concerto by Mozart induced the recall of autobiographical memories in patients with BN and reduced body width estimation [7–9, 18–20]. These previous findings align with the results of our current research as patients described that when listening to their favorite music, they generally feel happier and more positive. In addition, patients expressed their interest in attending music therapy citing the potential benefits it could have in their own life specifically with their treatment of their AN.

In other studies, however, negative symptoms presented when patients watched music videos. More specifically, researchers found that watching music videos was associated with an increase in body dissatisfaction [21], and sexually objectifying videos were associated with increased perception of body size in young women with suffering from low self-esteem [22]. In our study, we found that patients who listened to music outside their usual preference or that they did not like, as a result, had negative emotional reactions (i.e. crying, dissociation). This aligns with the previous findings suggesting that while music not only can produce positive side effects, it can also produce negatives as well [7].

Our study has several limitations. The number of participants (N = 6) was small. All study participants suffered from AN. Due to the small sample size, we could not differentiate between the subtypes of AN (restricting vs. binge eating/purging), length of illness duration and their stage of recovery. Our sample was ethnically homogeneous with only white Caucasian participants, and all patients were female. Thus, the results are not generalizable to other ethnic groups or males. From our perspective, the lack of generalizability is a main problem of research in the area of music therapy for people with eating disorders, and specifically AN. Even though there is plenty of case studies (for a comprehensive review and further literature see [23]), randomized controlled trials (RCT) are scarce [7].

AN is one of several eating disorders. As we have explained in the introduction, eating disorders are not distinct entities, but should rather be seen as symptom clusters within a spectrum of serious problems related to body image disturbance, disordered eating and their physical and psychosocial consequences. Therefore, it might be worth investigating, whether our findings can be reproduced and confirmed in people with BN, BED, ARFID or other eating disorders.

Taken together, our analysis shows that people with AN connect music mainly with positive emotions and memories. Therefore, music may be used more frequently and more extensively in psychological therapies as a tool to modulate emotions. As patients would welcome music therapy as an adjunct treatment option during inpatient or outpatient treatment, therapist might think about including music therapy into their overall treatment concept. However, quantitative research in bigger patient samples and RCTs will be necessary to verify these results.
