The Impact of Music Relaxation on Affect and Relaxation of Stressed Female College

Students

A thesis presented to

the faculty of

the College of Fine Arts of Ohio University

In partial fulfillment

of the requirements for the degree

Master of Music

Yinglan He

May 2018

This thesis titled

The Impact of Music Relaxation on Affect and Relaxation of Stressed Female College

Students

YINGLAN HE

has been approved for

the School of Music

and the College of Fine Arts by

Kamile Geist

Associate Professor of Music

Matthew Shaftel

Dean, College of Fine Arts

ABSTRACT

HE, YINGLAN, M.M., May, 2018, Music Therapy

The Impact of Music Relaxation on Affect and Relaxation of Stressed Female College

Students

Director of Thesis: Kamile Geist

Female college students have reported experiencing higher stress levels than their male counterparts. Relaxation techniques that alleviate psychological stress by helping them reach a better mental/emotional state may be more helpful for coping with stress.

Music relaxation intervention in audio recorded forms were found to be effective for multi-faceted consequences of stress. However, effects of its live forms presented by a music therapist for alleviating psychological stress among female college students remain under-researched. This pilot study explored the impact of a live music relaxation intervention on female college students who self-reported as stressed (N = 31). The objectives of this study were to assess changes in five pre- and post-intervention states: negative affect, positive affect, contentment, relaxation responses, and observable relaxation responses. The focus of this study was to learn about qualitative differences in participants’ subjective experience with the intervention. Thus, self-reports were chosen to assess the aforementioned mental states. To provide insightful information for future investigations, the researcher also collected information about participants’ satisfaction levels and subjective experiences with the applied intervention. Results of the primary research questions indicate that benefits of the applied intervention for stressed female college students may be associated with decreasing states of negative affect, promoting relaxation, and relaxing muscle tension. Although positive affect scores dropped post- 4 intervention, the ten positive affect items contained higher arousal words, which might not be appropriate descriptors for the participants’ subjective experience with the applied intervention. Results of the secondary research questions indicate that all participants were either somewhat satisfied (19.4%) or very satisfied (80.6%) with the experience, and most participants (93.5%) expressed willingness to receive a comparable intervention in the future. Content analysis of their review of the intervention reveals that, during or after the intervention, the participants felt calm, relaxed, safe, and/or happy, free of worries/emotions, and their breathing deepened and/or muscle tension relaxed gradually.

More than half of the participants (64.6%) noticed changes in at least one musical element or in the music. Nearly half of the participants (45.2%) commented that the auditory stimuli of the experience were positive for them. Of the 17 participants who indicated the pros and cons of a present therapist, 88.2% suggested the therapist helped with the process. Future studies that consider a complete treatment cycle with a larger sample size are recommended to build a clinical foundation for the use of music relaxation interventions/music therapy for female college students who self-report as stressed. 5

DEDICATION

I dedicate this thesis to my mother, , who has been an inspiration in my life and has encouraged me in all of my pursuits with her continuous love and support.

ACKNOWLEDGEMENTS

I would like to use this opportunity to express my heart-felt gratitude to everyone who has been generously supporting me intellectually and emotionally throughout the course of this thesis project.

To my dear Dr. Kamile Geist for being very supportive and understanding throughout the process: Thank you very much for your continuous guidance and timely response to all my questions. You have been one of the best clinicians and professors I admire. Your academic guidance has been a light to help me find my way to complete this journey.

To Dr. Peggy Zoccola for supporting me to complete this thesis project and providing me with the direction to see my way through the difficult issues of this topic and helpful advice: Thank you very much for sharing your intelligence and resources!

To Professor Brent Beeson: Thank you for sharing your insights about this project and sharing your clinical experience and knowledge with me to help me improve the intervention and expand the conversation that kept me thinking about the issues that impact how we handle such problems in the daily clinical work.

To Dr. Richard Wetzel: I appreciate your critical insights on the musical components used for the intervention and the musical materials provided for the participants.

Thanks to the all professors in the music therapy department, Dr. Kamile Geist,

Dr. Laura Brown, and Professor Brent Beeson, who provided excellent education, supported me to complete the study, and granted me permission to use the music therapy clinic for this study. 7

To all clinical supervisors who I have had: Thank you for your generosity in sharing your knowledge and helping me to become a music therapist. Especially, I would like to thank my internship supervisors and the patients that I had the privilege to serve at

Park Nicollet Health Services. I gained more experience in practicing this type of music relaxation intervention during my time being a music therapy intern there.

Special thanks to my extremely helpful, kind, and intelligent friends, particularly

Kai-Jung Chen, Kathy Devecka, Yining Liu, Jinling Zhao, and Robert Neff, who have devoted their personal time to helping me with this project and offered great friendship in my college life.

To my family: Thank you for encouraging me to be a kindhearted and helpful person. I will always take your inspiring words with me.

Most importantly, I thank the female college students who spent time participating in this study to provide us with insightful information about the potential of using this music therapy intervention for this population. 8

TABLE OF CONTENTS

Page

Abstract ...... 3 Dedication ...... 5 Acknowledgements ...... 6 List of Tables ...... 11 List of Figures ...... 12 Chapter 1: Introduction ...... 13 Female College Student Stress and Coping ...... 14 Positive Emotions and Stress ...... 15 Music Therapy ...... 16 Music Relaxation and Its Application ...... 17 Live music interventions...... 17 Problem Statement ...... 18 Purpose of the Study ...... 19 Research Questions ...... 20 Limitations of the study...... 20 Definition of Terms ...... 21 Music therapy...... 21 Music therapy intervention...... 21 Music relaxation ...... 21 Emotion regulation ...... 22 Chapter 2: Literature Review ...... 23 Psychological Stress ...... 23 Stress in College Students ...... 25 Female college students...... 26 Alleviating Psychological Stress by Cultivating Positive Emotions (Contentment) .... 31 Relaxation-effective treatments for alleviating psychological stress...... 33 Influences of Music on Psychological Stress Among College Students ...... 35 Live music therapy interventions for emotion regulation...... 37 Music-based interventions for relaxation induction...... 39 Music Relaxation ...... 41 Live music relaxation...... 44 Considerations of using live music in studies...... 47 Therapeutic presence...... 48 Summary ...... 50 Chapter 3: Methods ...... 52 Participants ...... 52 Setting ...... 54 Procedure ...... 54 Instrumentation ...... 55 Subjective measures...... 55 Objective measures...... 58 9

Equipment for implementing the intervention...... 59 Intervention ...... 60 Preparation...... 61 An autogenic scan of body parts...... 63 Sedative music...... 64 Return to alert state...... 65 Data Analysis Plan ...... 66 Data completion ...... 66 Data analysis ...... 67 Chapter 4: Results ...... 71 Research Question 1: Benefits of the Live Music Relaxation Intervention ...... 71 Research question 1a: Positive affect and negative affect...... 72 Research question 1b: Serenity items from PANAS...... 73 Research question 1c: Relaxation response ...... 74 Research question 1d: Observable relaxation responses...... 75 Research Question 2: Satisfaction Level and Willingness to Revisit ...... 78 Satisfaction level ...... 78 Willingness to revisit ...... 79 Content Analysis of Experience Review ...... 80 Question 1: Impact on mind and body ...... 80 Question 2: Changes in mind, body, and auditory stimuli...... 82 Question 3: Positive and difficult parts of the experience ...... 85 The presence of the music therapist ...... 88 Chapter 5: Discussion ...... 90 Limitations of the Study ...... 95 Recommendations ...... 99 Design of the study...... 99 Measurements...... 99 Music selection ...... 100 Intervention implementation ...... 101 Reclining position ...... 103 Future inquiries ...... 103 Conclusion ...... 104 References ...... 106 Appendix A: Ohio University IRB Approval Notice ...... 124 Appendix B: Flyer for Recruiting Participants ...... 125 Appendix C: Study Description on the SONA System ...... 126 Appendix D: Ohio University Adult Consent Form with Signature ...... 127 Appendix E: Debriefing Statement ...... 129 Appendix F: Experimenter Sheet ...... 130 Appendix G: Qualtrics Survey – Positive Affect Negative Affect Scale, VAS-Relaxation, & Satisfaction Review ...... 131 Appendix H: Behavioral Relaxation Scale Score Sheet ...... 138 Appendix I: Guidelines for Relaxing Music ...... 139 Appendix J: Script for Autogenic Body Scan Relaxation ...... 142 Appendix K: Watermark ...... 143 10

Appendix L: Self-Care Strategies ...... 145 Appendix M: Experience Review—Mind, Body, and Other Thoughts ...... 146 Appendix N: Experience Review—Changes in Mind, Body, and Auditory Stimuli ..... 148 Appendix O: Experience Review—Positive and Difficult Parts of the Experience ...... 150 Appendix P: Experience Review—The Presence of the Therapist ...... 152

LIST OF TABLES

Page

Table 1. Paired t-Test for Pre- and Post-Positive Affect Scores ...... 72 Table 2. Paired t-Test for Pre- and Post-Negative Affect Scores ...... 73 Table 3. Paired t-Test for Pre- and Post-Serenity Scores ...... 74 Table 4. Paired t-Test Results for Pre- and Post-VAS—Relaxation Scores ...... 74 Table 5. Paired t-Test for Breathing Frequency ...... 76 Table 6. Paired t-Test for Percentage of Relaxed Behaviors ...... 76 Table 7. Paired t-Test Results for Percentage of Unrelaxed Behaviors ...... 77 Table 8. Satisfaction Level ...... 79 Table 9. Willingness to Receive Similar Music Relaxation Again ...... 79 Table 10. Willingness to Recommend the Experience ...... 80 Table 11. Experience Review—Mind, Body, and Other Thoughts ...... 81 Table 12. Experience Review—Changes in Mind, Body, and Auditory Stimuli ...... 83 Table 13. Experience Review—Positive and Difficult Parts of the Experience ...... 86 Table 14. Experience Review—The Presence of the Therapist ...... 89 Table 15. Data of Participant X, Y, & Z ...... 94

LIST OF FIGURES

Page

Figure 1. Example of the Musical Stimuli for Facilitating Breathing Patterns ...... 62

CHAPTER 1: INTRODUCTION

Psychological stress can be perceived and experienced by individuals in everyday life, and such stress can be positive or negative. On the one hand, psychological stress may help motivate individuals to accomplish tasks, maintain attention to tasks, or activate one's energy. On the other hand, it can be harmful to one's physical and psychological health. Whenever one perceives and experiences stress, the inner climate of the body system is altered; this body system alteration is referred to as physiological reactivity such as a release of stress hormones and the fight-or-flight response (Lupien, Maheu, Tu,

Fiocco, & Schramek, 2007; Thayer, Åhs, Fredrikson, Sollers, & Wager, 2012). In addition to the physiological activation, at the same time, the emotional response to stress, such as happiness or anxiety, is triggered (Lazarus, 1993).

When an individual experiences psychological stress, the individual’s cognitive appraisal of the encounters can mediate his or her stress responses based on the potential harms of a stressor. Then, the stress responses could cause positive or negative effects on the physical and psychological health of that individual (Lazarus, 1993). Thus, psychological stress is categorized into two types—eustress and distress (Selye, 1974).

Eustress may benefit the immune function and elicit positive emotions, while distress may dampen the immune function and evoke negative emotions (Lazarus, 1993; Selye,

1974). This thesis does not focus on eustress but on distress that college students, especially female college students, experience and the negative effects generated by this psychological stress.

Based on Lazarus's (1993) proposal that the experience of psychological stress should be discussed within an array of emotions to better understand an individual’s 14 subjective experience and coping process, in this study, three changes in affect among female college student participants were assessed. To be specific, the objective of this study was to explore the impact of a live music relaxation intervention on states of negative affect, positive affect, and relaxation among female college students who self- identified as stressed.

Female College Student Stress and Coping

According to nationwide surveys on stress among Americans, historically women and Millennials (18-32 years old) have higher levels of stress than other genders and other generations (APA, 2012, 2013, 2015, 2016, 2017). Concurring with these results about stress levels in women and young people, female college students report suffering significantly higher stress levels than their male counterparts (Abouserie, 1994; Eagan,

Stolzenberg, Ramirez, et al., 2016). Scholars pointed out that higher levels of stress in female college students may be related to their higher expectations for academic achievement, stronger sensitivity to social interactions, and greater concern about self- image and financial worries (Dixon & Kurpius, 2008; Eagan, Stolzenberg, Ramirez, et al., 2016). Even though being better at time management helps reduce academic-related stress (Misra & McKean, 2000), such students report being overwhelmed by tremendous intrapersonal and interpersonal stress (Brougham, Zail, Mendoza, & Miller, 2009; Dixon

& Kurpius, 2008; Frazier & Schauben, 1994; Mahmoud, Staten, Hall, & Lennie, 2012;

Misra & McKean, 2000). Especially, during the transition to adulthood, when female college students are experiencing more uncertainty and anxiety, the lack of social support and self-efficacy can amplify their psychological stress (Kadison & DiGeronimo, 2004). 15

Emotional suffering due to psychological stress may lead to maladaptive coping patterns, such as unhealthy lifestyles, substance use, and even suicide attempts

(Anastasiades, Kapoor, Wootten, & Lamis, 2017; Haslam, Stevens, & Haslam, 1989; Lee et al., 2013). Since college stress is so prevalent, researchers have recommended that strategies for building the internal capacity to bear stress and also promoting relaxation are helpful for alleviating stress through reaching a better mental state (Benson, 1992;

Deckro et al., 2002; Fredrickson, 2000; Klainberg, Ewing, & Ryan, 2010). In addition,

Fredrickson’s broaden-and-build theory (1998, 2004) proposed that cultivating positive emotions can strengthen one’s internal capacity, and cultivating contentment (one of the positive emotions) may help an individual reach a better mental/emotional state.

Positive Emotions and Stress

It is important to note that Fredrickson’s broaden-and-build theory about positive emotions has a different focus from Lazarus’ theory (1991) about action tendencies generated from emotions, which fits better for the discussion of negative emotions.

Fredrickson (2004) expanded and re-described the theory about positive emotions by considering the cumulative/long-term effects from the process of cultivating positive emotions (i.e., joy, interest, contentment, and love), and she indicated that, in the coping process, these effects would eventually be helpful for dealing with psychological stress.

Data in substantial studies by Fredrickson and her colleagues (Fredrickson &

Levenson, 1998; Fredrickson, 1998, 2000) have indicated that cultivating positive emotions can increase psychological resilience and one’s ability to draw on personal resources. Cultivating positive emotions can develop an essential foundation that allows an individual to overcome negative emotions, focus on positive aspects, and effectively 16 utilize social and intellectual resources when coping with stressful situations

(Fredrickson, 2000, 2004). Fredrickson (1998) outlined four positive emotions—joy, interest, contentment, and love—and suggested that contentment could help develop internal capacity, encourage self-integrity, and prepare a better mental/emotional state to cope with stressful encounters (Fredrickson, 2000).

Because cultivating contentment may “widen the array of thoughts and actions that come to mind” (Fredrickson, 2004, p. 1370), to transfer this approach to help female college students alleviate stress by reaching a better mental/emotional state in the first place is worth considering. One way contentment can be cultivated is through relaxation therapies, such as meditation and progressive muscle relaxation (Deckro et al., 2002;

Fredrickson, 2000; Klainberg et al., 2010). Music therapy is one treatment used for relaxation, which has the potential to produce contentment.

Music Therapy

By using music as a primary tool, music therapy has the potential to regulate emotions (Moore, 2013) and release tension (Davis & Thaut, 1989; Robb, 2000). Also, this treatment modality has been found to be a potent treatment for addressing multi- faceted consequences of stress, such as anxiety (Knight & Rickard, 2001), depression

(Hirokawa & Ohira, 2003), physical pain (Gutgsell et al., 2013; Rider, 1985), and the release of stress hormones (Rider, Floyd, & Kirkpatrick, 1985). For the purpose of this study, the author specifically discusses a music therapy intervention—music relaxation— which has been shown to induce relaxation and have greater effects on stress reduction

(Kibler & Rider, 1983; Pelletier, 2004; Robb, 2000). 17

Music Relaxation and Its Application

A music relaxation intervention that combines relaxing music and verbal relaxation techniques may inhibit the increase of stress, alleviate emotional suffering, and promote relaxation states (Pelletier, 2004; Robb, 2000). Researchers indicated that such interventions in recorded forms presented greater effects on inhibiting the increase of stress than listening to tape-recorded music alone or practicing verbal relaxation techniques without music (Kibler & Rider, 1983; Pelletier, 2004; Robb, 2000). Previous music-stress studies have considered recorded forms of music relaxation to address stress responses; however, the benefits of live music relaxation in the presence of a music therapist as well as other forms of music relaxation interventions are under-researched

(Smith, 2008). Despite a strong embrace by music therapy educators and clinicians for live music interventions, not much research was found to explicitly support the benefits of music relaxation intervention in live forms conducted by a music therapist for alleviating psychological stress among college students, particularly for female college students.

Live music interventions. Mainly, scholars have studied separately the benefits of live music interventions and the presence of a therapist (Bailey, 1983; Cowan, 1991;

Geller & Porges, 2014; Linnemann, Straher, & Nater, 2016). Nevertheless, live music interventions are recommended in the field of music therapy because the therapist can tailor the musical elements according to the clients’ immediate response and guide them to achieve the therapeutic outcomes. Generally, however, when music therapists refer to utilizing live music in music therapy interventions, it is assumed that a music therapist’s presence is involved to manipulate the live music (Bradt, Dileo, & Potvin, 2013). 18

Compared with the use of taped-recorded music, therapists can more flexibly adapt the musical elements of live music to entrain the clients’ current mental states and guide them to gain the most from the music relaxation experience. Apart from merits of live music, although rarely academics analyzed the effects on psychological distress among college students when live music and the therapeutic presence of a therapist are combined in music relaxation interventions, there are currently explorations for the effects of the therapist’s therapeutic presence (Geller & Porges, 2014).

Therapeutic presence. Scholars support that the presence of other people can reduce subjective stress levels when listening to music (Linnemann et al., 2016), which suggests the presence of the therapist would also facilitate the effects of stress reduction.

That the presence of a therapist can reduce stress levels is obliquely supported by study findings which indicate this therapeutic presence can help a client reduce defenses (Geller

& Porges, 2014), and this therapeutic presence combined with live music interventions can change mood states and reduce tension (Bailey, 1983). More importantly, feeling psychologically supported, which can be facilitated by the therapeutic presence of a therapist, is significant for alleviating psychological stress among female college students

(Brougham et al., 2009). Considering the potential of such intervention, especially for female college students self-reporting stress, which may not only help alleviate stress but also provide emotional support, the need for further exploration of music relaxation intervention in a live form presented by a music therapist is evident.

Problem Statement

Female college students have reported experiencing emotional stress and indicated that they need more psychological care and emotional support during the 19 college experience (Brougham et al., 2009; Dixon & Kurpius, 2008; Dyson & Renk,

2006; Mahmoud et al., 2012). Support for all young people to deal with stress is still inadequate (APA, 2013), yet music therapy has been shown to be an effective treatment modality for stress reduction among college students. Indeed, a live music relaxation intervention with the presence of a therapist may be helpful for mood alternations, relaxation induction, and stress alleviation (Bailey, 1983; Geller & Porges, 2014; Smith,

2008). However, studies about such interventions are under-researched. Thus, exploration of the benefits of a live music relaxation intervention, which has the potential to alleviate psychological stress by reaching a better mental/emotional state through cultivating contentment, may be helpful for developing an effective therapy option for helping female college students self-reporting stress.

Purpose of the Study

Because the researcher is interested in observing the effectiveness of helping participants alleviate psychological stress by reaching a better mental/emotional state through a live music relaxation intervention that cultivates contentment, the purpose of this study was to examine the impact of a live music relaxation intervention on female college students who self-reported as stressed. This study specifically looked at changes of states of positive affect, negative affect, and relaxation among participants of the study. To evaluate the effects of the intervention, a self-reporting scale for measuring affect changes (Appendix G) to reflect emotional changes and a self-reporting scale for measuring the state of relaxation (Appendix G) were used. Also, secondary research questions for collecting data to reflect participants’ satisfaction level with the experience were included in this study to better understand participants’ satisfaction level with the 20 live music relaxation intervention and to provide more information for future investigators with a larger sample size.

Research Questions

RQ1: What are benefits of the live music relaxation intervention for participants?

RQ1a: Does live music relaxation intervention help improve scores for positive affect and lower scores for negative affect?

RQ1b: Does live music relaxation intervention help increase scores for contentment (i.e., at ease, relaxed, and calm)?

RQ1c: Does live music relaxation intervention help increase scores for relaxation responses?

RQ1d: Does live music relaxation intervention help improve participants’ observable relaxation responses?

RQ2: How satisfied are participants with live music relaxation intervention?

RQ2a: What is the satisfaction level of participants with this live music relaxation intervention?

RQ2b: Do participants express a willingness to receive this music relaxation intervention to help with stress alleviation in the future?

Limitations of the study. The data from this study need to be interpreted based on the context of this study, which may not be applicable to other female college students of Ohio University. Since the participants of this study are a convenient sample selected from Ohio University, the results of this study may not be suitable to be generalized for the whole population of female college students. Also, the intervention was being piloted as part of this study; therefore, opening up the study for errors which would impact the 21 validity of the data. Although self-report is suitable for this study because the intent of this study is to understand the impact of an intervention on the qualitative difference of an individual’s subjective experience, self-report is also not as reliable an indicator.

Additionally, because the student researcher did not have the resources or training to take other types of measures, the breathing frequency data were obtained through watching participants’ video-recordings, which are not reliable as the use of a physiological equipment.

Definition of Terms

Music therapy. The American Music Therapy Association has defined music therapy as “the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program” (AMTA, 2018).

Music therapy intervention. “The music therapy interventions may include music improvisation, receptive music listening, song writing, lyric discussion, music and imagery, singing, music performance, learning through music, music combined with other arts, music-assisted relaxation, music-based patient education, electronic music technology, adapted music intervention, and movement to music.” (AMTA, 2015).

Music relaxation intervention. In the realm of music therapy, music relaxation intervention is a type of intervention in which music therapists incorporate relaxation inductions into the music experience to help clients promote relaxation or alleviate stress responses (Bruscia, 2014; Grocke & Wigram, 2007). 22

Emotion regulation. Emotion regulation/affect regulation is an internal process that involves the use of certain strategies to help people alternate from undesired states to desired states within an individual’s abilities (Moore, 2013).

Chapter 2: Literature Review

The process of pursuing a college degree is stressful, and available data have revealed that female college students may experience more psychological stress during this process (Abouserie, 1994; Eagan, Stolzenberg, Ramirez, et al., 2016; Frazier &

Schauben, 1994). Although numerous music-stress studies have examined the effects of music on reducing stress among college students, this literature review focuses on stating the needs of exploring a potential music therapy intervention for alleviating stress among female college students. The main topics of this chapter include an overview of psychological stress within the array of emotions, stress and coping strategies in college students, especially in female college students. Also, this chapter discusses Fredrickson’s broaden-and-build theory (Fredrickson, 1998, 2004), which describes how using positive emotions (e.g., contentment) to counteract negative emotions. The influences of music on psychological stress and its effects on emotion regulation and relaxation induction as well as effects of music therapy interventions on emotion regulation and relaxation induction are reviewed. The application of music relaxation intervention is also presented. A summary is then provided regarding the need to expand treatment options for helping stressed female college students alleviate stress, the potential of using music relaxation for this purpose, and the need to examine benefits of music relaxation delivered in a live form.

Psychological Stress

Stress has been a topic of discussion among healthcare scientists for decades

(Chrousos & Gold, 1992). Physiological aspects of stress which focus on activation of body systems were extensively explored, and theories about emotional response to 24 psychological stress were also established (Lazarus, 1966). The concept of emotions in psychological stress stands in contrast to the physiological angle, which measures the response of physical body systems to stress. This concept centers on qualitative differences of the subjective experience with stress, which may be presented by an individual’s perception of or feelings about the external harm, threat, challenge, and/or benefit (Lazarus, 1993). Thus, Lazarus (1993) proposed to discuss psychological stress within the array of emotions. His proposal led to a more open discussion for the subjective experience of psychological stress. Anxiety, anger, guilt, sadness, and fear are emotions that human beings may have when experiencing and/or coping with psychological (di)stress (Lazarus, 1993).

When encountering stressors, one’s cognitive appraisal of external factors draws on both previous experience and personal resources and also continuously mediates the responses of the emotional region of the brain (e.g., the amygdala) (Lazarus & Folkman,

1984; Thayer et al., 2012). At the same time, the individual reacts to the situation based on the feedback from cognitive appraisal (Lazarus & Folkman, 1984). Lazarus and colleagues (Lazarus & Folkman, 1984; Lazarus, 1993) named the process of experiencing and then coping with stress the transactional model of stress and coping, defined as ongoing transactions between the individual and the environment. During this process, one may figure out a solution to the stressor(s) or one may find another angle to interpret the stressor(s). These present two main ways of coping with psychological stress: problem-focused coping and emotion-focused coping (Lazarus, 1993). Problem-focused coping involves actions to change the results caused by the stressor(s). Emotion-focused coping aims at the change in internal thoughts about the stressor(s) (Lazarus, 1993). 25

Coping strategies and the cumulative effects of psychological stress caused by acute stressors, brief naturalistic stressors (e.g., examinations), or chronic stressors may gradually affect one’s immune system and psychological well-being (Lazarus, 1993;

Segerstrom & Miller, 2004), as well as various self-destructive habits and stress-related behaviors (Dixon, Heppner, & Anderson, 1991).

According to the latest survey about stress in Americans by the American

Psychological Association (2017), results indicate that women and young people are suffering tremendous stress, and they are calling for a greater need for psychological support than other genders and other generations. Therefore, the current stressful climate may exacerbate the cumulative stress among young people, thus causing health issues.

Although other young people live with stress, college students who face different transitions and pervasive college stressors may be more likely to suffer psychological stress. A 2016 British survey cited by Peate (2017) reported that “data repeatedly demonstrates that, on average, [British] students are less happy and more anxious than non-students” (p. 377), which could be parallel to what American college students experience.

Stress in College Students

Pursuing a college degree has been identified as a highly stressful process

(Kadison & DiGeronimo, 2004; Mahmoud et al., 2012). Frequent exposure to regular examinations, presentations, and other worries, such as financial and social demands, can be challenging and stressful and cause depression (Wallace, Boynton, & Lytle, 2017), poor sleep quality (Valerio, Kim, & Sexton-Radek, 2016), and low immune function

(Glaser et al., 1987). These negative effects may result in increasing rates of physical 26 health issues and mental health issues (Beiter et al., 2015; Dixon & Kurpius, 2008).

Additionally, the Center for Collegiate Mental Health (2017) reported a continuously increasing trend of mental health visits among college students, with fifty percent more increase in 2016 compared to data on 2015. When confronting challenges, college students who are not equipped with adaptive and effective coping skills for stress management may foster unhealthy lifestyles for emotional release, which may exacerbate the existing problems (Borsari, Murphy, & Barnett, 2007; Kazemi, Dmochowski, Sun,

Grady, Nies, & Walford, 2012; Mahmoud et al., 2012).

Female college students. Because female college students hold higher aspirations in academic success, a stronger sense of considerations and empathy toward others in social life, and a higher standard of self-image, they report suffering from immense self- imposed stress (Eagan, Stolzenberg, Ramirez, et al., 2016; Misra & McKean, 2000;

Reisberg, 2000). Various stressful situations in college life may be triggers for psychological stress. For female college students, the major sources that increase self- imposed stress and lead to psychological stress are academic pressure, financial burden, and interpersonal relationships (Deasy, Coughlan, Pironom, Jourdan, & Mannix-

McNamara, 2014; Frazier & Schauben, 1994).

Sources of psychological stress in college life. Stress from academic pressure is ranked as the highest concern for female college students (Abouserie, 1994; Frazier &

Schauben, 1994). Since female college students generally enter college with higher academic grades, they tend to envision getting good grades while pursuing higher education (Eagan, Stolzenberg, Ramirez, et al., 2016). As a result, higher expectations for academic performance and aspirations in degree qualifications may easily drive them to 27 be stressed out (Abouserie, 1994; Eagan, Stolzenberg, Ramirez, et al., 2016; Misra &

McKean, 2000). In a recent survey that compiled data of self-ratings about perceived health and aspirations for academic achievement from college students between 1985 and

2015, a decreasing trend in both perceived emotional health and physical health among college students has been reported to be associated with an increasing trend in high aspirations for academic achievement (Eagan, Stolzenberg, Ramirez, et al., 2016). This report also indicates that the negative correlation appears to be more evident among female college students’ overall self-ratings. Two different studies, one of which included graduate and undergraduate students and one of which included first-year medical students, show that when regular exam testing is part of a college norm, most female college students are affected by test anxiety and thus are chronically exposed to higher risks of immunosuppression and various health problems (Chapell et al., 2005; Glaser et al., 1987).

Cost of tuition is another growing worry for college students. Although students coming from low-income families may be able to get financial aid (e.g., Pell and work- study), insufficient financial support continues to be an issue, which also is a concern for students coming from relatively well-off families (Zinshteyn, 2016). Approximately 23% of the college students owe more than 1000 dollars on their credit cards (Nelson, Lust,

Story, & Ehlinger, 2008). Under the weight of such financial debt, students appear to experience higher stress; more irregular life patterns; and more risks in weight gain, substance abuse, violence, and binge drinking (Nelson et al., 2008). A survey of

American college freshmen also displays that 65.7% of female college students reported somewhat or very worried about paying for college while only 34.3% of male college 28 students reported somewhat or very worried about paying for college (The Higher

Education Research Institute, 2017, p. 2).

Apart from academic-related stress and financial concern, social demands for interpersonal relationships are also a source of psychological stress in college.

Interpersonal stressors may include personal adaptation for socialization and relationships with parent(s), partner(s), co-workers, professors, and roommates (Bulo & Sanchez,

2014). Undesired interpersonal relationships in college may increase daily hassles, and researchers have implied that peer relationships are the most frequent predictors of emotional distress (Hokanson, Rubert, Welker, Hollander, & Hedeen, 1989; Jackson &

Finney, 2002). Students living with others and maintaining regular social contacts may be less depressed, anxious, and stressed; however, a low quality of friendship with roommates can also cause depressive symptoms (Hokanson et al., 1989; Mahmoud et al.,

2012). Studies have also predicted that the lack of emotional support and problem- solving skills may not only impede students’ academic-related success but also lead to suicidal ideation (Clum & Febbraro, 1994).

All discussed psychological stressors may have a negative impact on college students’ mental health, which may lead to depression and anxiety. However, the stressors themselves are not the main cause of the negative impact; instead, it is how college students perceive and react to the stressors (Mahmoud et al., 2012). Their abilities and ways of coping with the stressors mediate such impact on their lives (Mahmoud et al., 2012), which reflects Lazarus and Folkman’s (1984) transactional model of stress and coping (i.e., the ongoing transactions between the individual and environment/stressors).

Within the transactional model, the coping strategies—problem-focused and emotion- 29 focused coping strategies—can be categorized into two main coping mechanisms: maladaptive and adaptive (Mahmoud et al., 2012).

Maladaptive coping profiles. Emotional suffering due to stressors predicts action tendencies for coping (Lazarus, 1991). In other words, according to Lazarus, when an individual is stressed, s/he may cope with the resulting emotions by taking some action or

“acting out.” Unfortunately, several unhealthy behavioral patterns have become pervasive among college students to cope with psychological stress, such as overeating (Haslam et al., 1989), excessive partying, drinking (Borsari et al., 2007; Kazemi et al., 2012; Park,

Armeli, & Tennen, 2004), smoking (Nichter, Nichter, & Carkoglu, 2007), and self-harm

(CCMH, 2017). The initial intention of students as they engage in these behaviors may be to relieve stress, but unhealthy/maladaptive coping patterns may worsen the situation, which may turn into a vicious cycle or lethal consequence. For example, in a 2008 survey, 84,367 college students admitted that drinking alcohol damaged their relationships with others, destroyed their physical and psychological health, and altered their life routines (Nguyen, Walters, Wyatt, & DeJong, 2013). In addition, there are reports showing increases of alcohol-related injuries and deaths among college student populations. Furthermore, an analysis conducted by Valerio, Kim, and Sexton-Radek

(2016) suggested that college students living with stress and consuming alcohol or cigarettes reported lower sleep quality and worse condition of general health. Their results also indicated that 68.5 % of female college students of the 14,870-participant sample study reported suffering difficulty sleeping which affected their daytime energy and potentially degraded their academic performance. 30

When an individual fails to release psychological stress, clinical psychological symptoms like depression may arise, which leads to adverse consequences. Suicidal ideation, which ranks as the second major threat for college students’ lives, is one of the adverse consequences (Anastasiades et al., 2017; CDC, 2014; Reynolds, 2015). Nearly

1100 college students reported committing suicide each year (Wilcox, Arria, Caldeira,

Vincent, Pinchevsky, & O’Grady, 2010). Among published reports, female college students were predicted with a greater possibility of committing suicide (Brownson,

Drum, Smith, Denmark, 2011; Reynolds, 2015; Wilcox et al., 2010), and the negative emotions associated with depression may contribute to suicidal ideation (Reynolds,

2015). Since Lazarus (1991) indicated that emotions occurring in response to psychological stress can potentially direct actions, these maladaptive coping behaviors and suicidal ideation may be generated from (negative) emotions.

Adaptive coping behaviors. The other main category of coping mechanisms for coping with stress is adaptive coping (Mahmoud et al., 2012). Adaptive coping behaviors are actions that are helpful for reducing stress and have positive impact on emotional regulation and psychological well-being (Mahmoud et al., 2012). Adaptive coping behaviors include evaluation of the stressful situation, planning, engagement in social networking/support, acceptance, and positive reappraisal (Brougham et al., 2009;

Mahmoud et al., 2012). These behaviors are either problem-focused or emotion-focused, and emotion-focused coping strategies are more frequently adopted by female college students (Brougham et al., 2009).

Since psychological stress can lead to negative emotions, which may lead to maladaptive coping patterns that negatively affect female college students’ health, 31 helping this population alleviate psychological stress by reaching a better mental/emotional state in the first place may be an important part of the coping process, such as choosing adaptive coping strategies. Fredrickson (2000) implied that cultivating positive emotions like contentment may help broaden an individual’s intellectual, physical, psychological, and social resources, which may help an individual mentally prepare for the process of coping with psychological stress.

Alleviating Psychological Stress by Cultivating Positive Emotions (Contentment)

If, as Lazarus (1991) stated, “an action tendency is what makes an emotion embodied” (p. 285), or actions carry out emotions, then one way to alleviate psychological stress and avoid maladaptive coping behaviors may be to cultivate positive emotions that may counteract negative effects generated by negative emotions

(Fredrickson, 2000) and lead to adaptive coping patterns. Theoretically, the positive emotions discussed in this section is slightly different than the positive emotions (e.g., happiness and pride) discussed in Lazarus’s theory (1993). In this section, the positive emotions (i.e., joy, interest, contentment, and love) is a subset of positive emotions, which was proposed by Fredrickson (1998, 2000, 2004) to form the broaden-and build theory of positive emotions. Instead of focusing on the action tendencies (Lazarus, 1991), most time, generated from negative emotions, Fredrickson (2000) argued that by cultivating positive emotions like contentment, an individual’s internal capacity was strengthened. While negative emotions may trigger physiological actions, such as a fight- or-flight response, reduce one’s ability for critical thinking to discover other solutions to the situations, positive emotions counteract the negative effects generated by negative emotions and allow an individual to think with a clear mind and flexibly apply personal 32 resources under stressful conditions (Fredrickson, 2000, 2004). Fredrickson (1998, 2000) and Levenson (1998) referred to cultivating positive emotions as a process for

“broaden[ing] one’s momentary thought-action repertoire” (Fredrickson, 1998, p. 300).

The subset of positive emotions proposed by Fredrickson (2000) includes joy, interest, contentment, and love. Contentment is the direct focus of this study. Whilst joy and interest are not the direct focus of this study, they were also considered in this study.

Love, a combination of the three other positive emotions, is a long-term commitment developed through the process of interacting with and firming relationships with specific individuals. However, love does not apply to the structure of this study; therefore, it is excluded. Joy facilitates the urge to play physically, intellectually, socially, and artistically, which can shape one’s physical and mental resources that may be drawn on later (Fredrickson, 2000). Interest inspires or sparks people to explore and gain new knowledge or experience (Fredrickson, 2000). Contentment creates a space for self- reflection and an opportunity to communicate with one’s own psyche (Fredrickson,

2000). Because cultivating contentment has the potential to nurture a better mental/emotional state, it is worth considering how this approach might help female college students alleviate stress and reach a better mindset to cope with stress.

Relaxation therapies are one way to cultivate contentment to encourage a cognitive change (Fredrickson, 2000), which may help counteract anxious tendencies, increase one’s emotional resilience, and cultivate mindfulness (Benson et al., 1994;

Fredrickson, 2000). Although several relaxation-effective treatments or therapies, such as yoga and meditation, have been reported to be beneficial to college students (Prasad, 33

Varrey, & Sisti, 2016), there is still a need for similar research that applies specifically to female college students.

Relaxation-effective treatments for alleviating psychological stress. Relaxation

-effective treatments or therapies for cultivating contentment and buffering emotional strain include yoga, meditation, mindfulness, cognitive-behavioral therapy, biofeedback therapy, and music therapy (Bernhardsdottir, Champion, & Skärsäter, 2014; Henriques,

Keffer, Brahamson, & Horst, 2011; Prasad et al., 2016; Pelletier, 2004; Zimmaro et al.,

2016).

In recently published research, Prasad, Varrey, and Sisti (2016) examined the effect of yoga and meditation on 27 medical students. After receiving the interventions biweekly for six weeks, scores on their Perceived Stress Scale and Self-Assessment

Survey significantly improved. The students reported that they felt more peaceful, happy, focused, and hopeful about the future. In other current research, Zimmaro and her colleagues (2016) conducted a larger size within-subject study with 85 undergraduate students (female= 59). By comparing results from two assessments that were collected one month apart, they found that the mindfulness-based stress reduction model could reduce cortisol release and increase a sense of well-being. In their 2014 study,

Bernhardsdottir, Champion, and Skärsäter provided four cognitive-behavioral group therapy sessions to 19 female college students and included a brief relaxation exercise each session. They concluded that cognitive-behavioral therapy could help the participants discover and understand their own reactions to stress, think positively through self-reflection, and regain self-confidence and control. In earlier research,

Henriques, Keffer, Brahamson, and Horst (2011) also examined the effect of a 34 biofeedback software, HeartMath, for reducing anxiety in college students. A positive effect of the 4-week computer-based biofeedback intervention on anxiety symptoms was found in the study. Although studies have reported the benefits of these integrative treatments or therapies for college students; yoga, for example, may have potential harms. Cramer, Krucoff, and Dobos (2013) reported that injuries occurred when practicing yoga without appropriate guidance, and, by 2013, at least one person died from injuries associated with yoga practice.

Another type of treatment for alleviating psychological stress is called music therapy. Music therapy is grounded in different psychotherapy approaches and clinical evidence and has the potential to benefit college students. Based on previous results (e.g.,

Knight & Rickard, 2001), even listening to music for less than 20 minutes may have positive effects on stress reduction, and female college students may be more receptive to music-based relaxation intervention relative to their male counterparts (Thaut & Davis,

1993). Indeed, music—whether recorded or live—has been integrated into other treatments for stress management. Since numerous music-stress studies have reported the positive effects of taped music programs for stress reduction (Pelletier, 2004), people may be well-aware of the benefits of music for college students or other populations.

However, it is important to clarify that music-based interventions which are practiced by other healthcare professionals, such as nurses (e.g., Hamel, 2001), fall into its own category, such as music medicine, and are not music therapy interventions. As specified by Bradt, Dileo, and Potvin (Bradt, Dileo, & Potvin, 2013; Dileo & Bradt,

2007), a way to identify the two categories is the presence of a music therapist who tailors the music based on client(s)’ individual goal(s) and builds up a therapeutic 35 relationship with the client(s). Because music therapy uses music as a primary tool, various music-based interventions manipulated by a board-certified music therapist within a therapeutic relationship may allow college students to effectively cope with emotional distress.

A variety of active and receptive music therapy interventions have been shown to be effective for ameliorating stress among college students. They include active music making (Detmer, 2015), songwriting (Ashton, 2013) and group drumming (Bae, 2011), passive listening (Knight & Rickard, 2001), group Guided Imagery and Music (Bae,

2011), music-assisted relaxation with variant verbal/musical suggestions for relaxation

(Robb, 2000), and vibrotactile stimulation with music (Standley, 1991). Noticeably, some of these studies consider how music therapy interventions help college students cope with negative effects generated from psychological stress. Nevertheless, rarely do they specifically examine whether music therapy interventions help (female) college students reach a better mental/emotional state through cultivating contentment. Yet, such a study may provide more information about how the interventions can help this population mentally alleviate stress and cope with stress in the first place.

Influences of Music on Psychological Stress Among College Students

Before further exploring a specific music therapy intervention for alleviating psychological stress by reaching a better mental/emotional state, this section first discusses the potential of music itself for ameliorating psychological stress; second, previous music therapy research results about live music therapy interventions for emotion regulation among college students; and third, different music-based interventions for relaxation induction among college students. 36

Music may help regulate psychological stress through effects created by its musical features, such as timing perception provided by rhythms or tempo, imagery shaped by harmony and dynamics, and affects grounded by different keys (Hevner, 1937;

Steblin, 2002; Thayer & Faith, 2001; Trost & Vuilleumier, 2013; Van der Zwaag,

Westerink, & Van den Broek, 2011). All these musical elements have the potential to alter undesired emotional states. Through the cochlea, the musical stimuli is converted into electrochemical messages that can be encoded by neurotransmitters in the brain, which may evoke different psychological and physiological reactions, such as alterations in valence and mood states (Trost & Vuilleumier, 2013; Van Goethem & Sloboda, 2011), prevention of the release of stress hormones (Knight & Rickard, 2001), changes in blood pressure and heart rate (Knight & Rickard, 2001), and a release of dopamine (Salimpoor,

Benovoy, Larcher, Dagher, & Zatorre, 2011). These effects of music on neuro-mechanisms have been applied for ameliorating negative emotional states and physiological arousal among young people, a population reporting to use music as a self-help strategy

(Knobloch & Zillmann, 2002; Labbé, Schmidt, Babin, & Pharr, 2007).

Scholars have studied the impact of music on emotions through neural perspectives. For example, researchers reported that the same melody accompanied by dissonant or consonant chords (harmony) could arouse negative or positive emotions respectively, and, simultaneously, activate different regions of the brain associated with that specific type of emotion (i.e., negative or positive) (Blood, Zatorre, Bermudez, &

Evans, 1999). In addition, Pallesen and colleagues (2005) found that even a single chord could activate several brain areas such as amygdala and brain stem and major chords could evoke positive emotions such as happiness and pleasure. Furthermore, Salimpoor 37 and colleagues (2011) found that listening to pleasurable music triggered a release of dopamine. These findings about the impact of music on neural substrates have provided support for the clinical use of music for emotion regulation.

Because music itself has these potential effects, researchers have used studies to examine effects of both music therapy interventions and non-music therapy interventions for helping college students alleviate psychological stress by regulating emotions

(Ashton, 2013; Detmer, 2015; Montello, 1989) and inducing relaxation (Davis, 1989;

Robb, 2000; Thaut & Davis, 1993). If, according to Fredrickson (1998, 2000), cultivating positive emotions may broaden an individual's momentary thought-action repertoire to cope with stressful situations, then music therapy interventions that help regulate emotions may also have a positive impact on broadening college students' momentary thought-action repertoire.

Live music therapy interventions for emotion regulation. Music therapy researchers have studied effects of music therapy on regulating negative emotion caused by concerns about academic performance, such as anxiety and depression (Ashton, 2013;

Detmer, 2015; Montello, 1989). Results reveal that music therapy may not only alleviate negative emotion or affect generated by psychological stress but also positively influence participants’ performance following the music interventions, which suggests the potential to broaden an individual’s momentary thought-action repertoire. For example, Montello

(1989) recruited professional musicians (from two universities and one music conservatory in New York city) to conduct a series of studies (two studies) and examined the effectiveness of group music therapy interventions (i.e., “clinical improvisation, performance, awareness techniques and verbal processing,” p. 15) for alleviating 38 performance stress and increasing performers’ musicality. In her first study, compared to the control group who did not receive any treatment, the music therapy group presented a significant reduction in anxiety and a significant increase in self-confidence after receiving 12 group music therapy sessions, which consisted of relaxation, unstructured group improvisation, verbal processing of the improvisation, and music therapy interventions. Following the same structure of the first study but with different purposes,

Montello (1989), in the second study, tested whether or not the group music therapy interventions could also help musicians become more musical under performance stress.

The results showed that the music therapy group participants reported themselves being less self-involved and less stressed while performing, and they demonstrated more musicality in their music performances than those musicians in the control groups.

Also, Detmer (2015) compared effects on performance anxiety of two 3-minute

Orff-based music interventions (i.e., “paced breathing cued by Orff bass bars” and

“active music engagement via Orff improvisation,” p. 31) by conducting an experiment right before a final musicianship assessment exam with music therapy students who signed up for the assessment. Results suggest that both interventions had significant effects on participants’ self-reported performance anxiety post-interventions, with no competitive evidence showing one outweighed the other. Further, follow-up interviews for this study revealed that during the musicianship assessment these participants presented with an improved affect (e.g., felt more calm, relaxed, and pleasant) (Detmer,

2015, p.41).

In comparison to researchers who recruited mix gender groups, Ashton (2013) examined effects of short-term group music therapy on addressing depression and anxiety 39 among 14 female college students. This author employed a variety of live music therapy interventions in the sessions, such as clinical improvisation, meditation, lyric analysis, and songwriting. Although the results did not reach significant differences, the emotional states (e.g., depression and anxiety) of the treatment group showed a tendency to improve post-treatments while the control group showed an increase in anxiety and negative affect.

Music therapy could be effective for regulating negative emotions arise from psychological stress among college students, and, in Ashton’s 2013 study, female college students recruited as single-gender participants also commented that music therapy was beneficial to them. Indeed, in her recommendations, Ashton (2013) suggested that colleges with a music therapy program could integrate music therapy into their healthcare systems to benefit female college students’ psychological well-being.

Music-based interventions for relaxation induction. The state of relaxation is an important sign of physical and psychological stress levels, and it has been measured in several music-stress studies (e.g., Robb, 2000; Thaut & Davis, 1993). The state of relaxation also appeared to be highly correlated with the state of anxiety in a study conducted by music therapists Davis and Thaut (1989).

Several music therapy researchers have examined effects of music interventions in recorded forms on inducing relaxation among college students. For example, Davis and Thaut (1989) collected state of relaxation measures before and after listening to 20 minutes of subject-preferred music across the three weeks leading up to final exams.

Although significant differences were not reported, the results suggested that the subjects’ self-rated relaxation increased consistently from pre- to post-tests. Another 40 study on affect, anxiety, and relaxation conducted by the same authors further investigated effects of listening to subject-selected music (compared to experimenter- selected music) (Thaut & Davis, 1993). This study post-scores revealed that experimenter-selected music, subject-selected music, and silence conditions significantly improved relaxation responses; however, no significant differences in relaxation emerged between conditions. Comparison between genders showed that the relaxation scores of the female college students in this study increased significantly more than that of the male students. Later, Robb (2000) examined effects of multiple relaxation techniques on college students’ self-reported anxiety and relaxation. In her study, compared with participants in silence, progressive muscle relaxation (PMR), and mere music listening groups, participants in music relaxation (music + PMR) group, although without statistical significance between groups, achieved a higher relaxation mean scores after the intervention as compared to before.

A limited number of music-stress studies with college students that included relaxation measures were found in music therapy research (e.g., Davis & Thaut, 1989;

Robb, 2000; Thaut & Davis, 1993), and the results were not statistically significant. The reasons for not reaching significant differences may be: first the researchers did not specify levels of stress during recruitment (e.g., self-identified stress) and second, the researchers used recorded forms of music interventions instead of live forms of music interventions. Since, contentment cultivated by relaxation techniques may help female college students alleviate stress by reaching a better mental/emotional state, more research on effects on relaxation induction through music therapy interventions delivered in different forms other than recorded music listening is needed. 41

Music therapy could be effective for emotion regulation and relaxation induction.

Among all music therapy interventions, music relaxation is the type of intervention that focuses on cultivating contentment, and in turn, contentment may induce relaxation and ease emotional distress (Fredrickson, 2000). In order to follow the initial intention of this study, which is to treat psychological stress by reaching a better mental/emotional state through contentment, the author decided to apply this specific intervention—music relaxation that combines relaxing music and verbal relaxation techniques—in this study to explore the benefits of a live form of music therapy intervention for female college students who self-identified as stressed.

Music Relaxation

Researchers have reported that music relaxation interventions can be helpful for stress reduction (Pelletier, 2004; Robb, 2000). According to Bruscia (2014), “In receptive experiences, the client listens to music and responds to the experience silently, verbally or in another modality” (p. 134). Categorized as one of the receptive experiences in music therapy, music relaxation may be presented in either a live form of music or a recorded form of music with the presence of a music therapist (Bruscia, 2014). Similar to other types of receptive experiences, vibration of the external auditory stimuli (i.e., musical elements and sound sources) that resonates in recipients’ minds and then entrains their bodies is valued in music relaxation interventions. Thus, selecting an appropriate musical piece(s) for the experience is pivotal for a desired outcome.

Guidelines for music selections for this type of intervention have been proposed by several music therapy researchers (e.g., Grocke & Wigram, 2007; Hooper,

2012; Robb, Nichols, Rutan, Bishop, & Parker, 1995; Tan, Yowler, Super, & Fratianne, 42

2012). The musical characteristics of effective music selections include basic musical forms (e.g., ABA, AABA), regular meter, lower pitches or gradual changes in pitches between registers, smooth melodies with linear direction, small changes in dynamics (soft to moderately loud), consonant harmony but not boring, predictable rhythm, and slow tempo around 60 beats per minute (bpm) or between 60 bpm and 80 bpm (see Appendix I for details).

Among existing guidelines (listed above) for music selections for relaxation experiences, Tan, Yowler, Super, and Fratianne’s (2012) more current research provided one of the few sets of guidelines to be evaluated as relaxing through multiple studies

(three studies). In the first study, unlike other studies, the researchers had five experienced music therapists choose 30 relaxing music selections based on their clinical experiences. In the second study, nine professional music therapists listened to the 30 selections and then rated—in 12 categories of musical elements related to inducing relaxation—their perceived relaxation degree. The study results show that, for their music selections, most of the suggested musical characteristics are congruent with the previously identified guidelines. Additionally, they found that the pitch range of the instrumental pieces among the selections centered around C5 and that “the melody of the music could be more complex compared to the rhythm in relaxation music” (Tan et al.,

2012, p. 162). In their third study, Tan and her colleagues (2012) also studied how familiarity and preference affected relaxation degree respectively. In line with previous studies, results indicated that non-musicians’ familiarity and preference to the musical pieces both had significant positive correlations with perceived relaxation degree. 43

Following the existing guidelines and suggestions for music selections, music therapy researchers have compared and experimented with different ways of implementing music relaxation interventions to promote relaxation or reduce stress arousal (Barger, 1979; Grocke & Wigram, 2007; Kibler & Rider, 1983; Robb, 2000).

Various forms for implementing the intervention include mere music listening (Knight &

Rickard, 2001), vibrotactile stimulation with music (Standley, 1991), and music in a combination of relaxation techniques (Kibler & Rider, 1983, Robb, 2000). Among these forms, a combination of music with other relaxation techniques was reported as having greater effects than mere music listening and mere relaxation techniques on decreasing psychological stress responses, such as anxiety and negative affect, and physiological stress response (Hanser, 1985; Kibler & Rider, 1983; Pelletier, 2004; Robb, 2000). For example, Kibler and Rider (1983) compared effects of mere music listening, recorded music in a combination of PMR, and PMR without music for improving skin temperature. They found that although the results between groups did not yield a significant difference in skin temperature improvement post-treatment, the music + PMR group post-treatment showed greater increases in mean scores than other groups. Similar to this study regarding the effectiveness of the intervention, Robb (2000) also indicated that the mean anxiety and relaxation scores of the music + PMR group presented a greater improvement post-treatment than other groups (i.e., silence, mere music listening, and PMR without music).

Apart from PMR, autogenic-type relaxation technique is also frequently combined in the music relaxation protocol (Grocke & Wigram, 2007). Reynold (1984) compared the effects of biofeedback, music, autogenic phrases, and a combination of music and 44 autogenic phrases for coping with stress. This researcher employed electromyography to measure arousal levels pre- and post-treatment. Reynold (1984) reported that participants in the two music groups achieved lower arousal levels, and the lowest arousal level post- treatment was presented in the music with autogenic phrases group. However, none of these studies mentioned above, in which college students were the studied subjects, reported a significant difference between condition(s) and the music relaxation condition.

The studies discussed above did not reveal a statistically significant difference in their dependent variables between groups, possibly due to a few key aspects of the research. Specifically, some of these studies (e.g., Kibler & Rider, 1983) examined the influence of the music therapy relaxation technique in group settings, and all of the researchers used previously recorded music. Playing music to participants in group settings may have affected the researchers' ability to obtain statistically significant results because the participants may have felt uncomfortable given the presence of so many other individuals. Second, the use of live music interventions manipulated by a music therapist may have benefits over recorded music. Nevertheless, not a single study was found to describe the potential benefits of such music relaxation intervention in a live form for alleviating psychological stress among college students not to mention among female college students. Thus, the value of music relaxation combining with a relaxation technique in a live form to be used for helping female college students warrants a further investigation.

Live music relaxation. To synthesize previous researchers’ definitions, live music relaxation experience is a type of receptive music therapy intervention in a live form of presentation delivered by a board-certified music therapist who administers and 45 implements the musical experience while establishing a therapeutic relationship with the client throughout the process (AMTA, 2017; Bruscia, 2014; Grocke & Wigram, 2007).

For various reasons, a study focusing on effects of live music relaxation on psychological stress among college students is not available. Only one related study conducted by Smith

(2008) for reducing anxiety among customer service specialists (healthy adults) was found. By comparing effects of verbal discussion and a live music relaxation intervention

(a combination of PMR techniques and a guitar improvisation), the author found that, after a single 15-minute session, the music group (n = 40, N = 80) presented a significant reduction in the state of the anxiety level, a significant decrease in scores for feeling tensed, and a significant increase in scores for feeling pleasant and relaxed. In contrast, when comparing the pre-scores and post-scores of the verbal discussion group, there was no significant difference in their state of anxiety levels.

In fact, unlike the research on college students’ psychological well-being where music therapy literature for live music relaxation interventions is scarce, in medical settings, variations of live music relaxation interventions have been successfully applied by music therapists to address physical stress and/or psychological stress (e.g., pain and/or anxiety). For example, on the one hand, Gutgsell and her colleagues (2013) conducted a study from September 2009 to August 2011 at a hospital in Ohio to study the impact of a single 20-minute music therapy session on pain among 198 palliative care patients (200 participants in total, but two were excluded from the study because of their incomplete data). The control group (N=99) of the study sat in their private rooms for 20 minutes, and each individual of the treatment group (N=99) received a specific music therapy intervention. The music therapy intervention of this study was very similar to the 46 music relaxation intervention described by Grocke and Wilgram (2007). The structure of the music therapy intervention consisted of breathing-focused, autogenic muscle relaxation, and live instrumental music listening to five harp pieces (one improvised on the G Mixolydian scale and four pre-composed). During the live instrumental music listening, the patient can choose whether or not to play an ocean drum along with the harp. Results showed that both the treatment group and the control group yielded a significant decline in pain perception. However, while the music therapy group achieved a significantly even greater decrease in pain and also a significant decline in functional pain, the control group did not.

On the other hand, Crawford, Hogan, and Silverman (2013) focused on psychological effects of a single 20-30 minute music therapy session and conducted a study with 38 inpatients who were either solid organ transplant donors or recipients at a mid-western teaching hospital. These researchers found a significant difference between experimental and control groups. The music therapy group (N=24) achieved a more favorable improvement than the control group in relaxation, stress, and mood. It should be noted that although researchers granted the patients control over selections of music therapy interventions (i.e., either patient-preferred live music listening or a harmonica tutorial lesson), only one participant chose to have the harmonica tutorial lesson.

Music therapists have applied music relaxation/music listening intervention in a live form during clinical practice for various medical populations (e.g., Crawford, Hogan,

& Silverman, 2013; Gutgsell et al., 2013), and the results of related studies have supported its effectiveness for alleviating negative effects generated from stress. If, as 47 previous studies suggested, the efficacy of live music relaxation was evident among medical populations, then live music relaxation may also be helpful for alleviating psychological stress among female college students. Nevertheless, there is a real dearth of studies focusing on how music relaxation in a live form can have a positive impact on alleviating negative effects of stress among female college students.

Considerations of using live music in studies. It is understandable that researchers tend to use recorded music for four reasons: first the consistency of the study, second, stability of the musical elements throughout the sessions (e.g., when the music conditions were provided by more than one therapist, interpretations of the music may be different), third, possibilities to generalize musical prescriptions, and fourth, absence of the standardized guidelines for implementing live music relaxation for stress. These are true, and the studies conducted with recorded music seem to have positive psychological effects; however, recorded music may not be able to replace the merits of live music for stress reduction in many ways. When compared with tape-recorded music, a music therapist can more easily adapt musical elements of the live music for client’s current mental and physiological states. This idea is more along the lines of Altshuler’s concept about the use of iso-principle to change a client’s mood or emotion (Davis, 2003). With the use of live music, a therapist and client may be more likely to achieve a receptive communication at a deeper level through the live form of music presentation and the human interaction (Bailey, 1983). This is especially relevant because the application of live music therapy interventions in the field of music therapy also presumes the presence of a music therapist (Bradt et al., 2013). In addition, the properties of carefully selected instruments may help promote the grounding feeling held by the music therapist 48 and thus enhance the client’s acoustic experience. Furthermore, for stress alleviation, when testing effects of music relaxation on receptive interactivity between a music therapist and a client, employing live music-based intervention may enlarge the possibilities. This is also an important consideration when providing live music therapy.

Therapeutic presence. In accordance with the definition of music therapy from the American Music Therapy Association, the music therapy provision contains two indispensable components: the "clinical and evidence-based use of music interventions” and the “therapeutic relationship” established with a client by a board-certified music therapist (AMTA, 2017). While the effectiveness of various music interventions was frequently studied in music-stress research with college students, the importance of human interaction was frequently not reported in those studies. In contrast, studies with medical populations emphasized more about the therapeutic relationship during treatment provisions (e.g., Bailey, 1983; Cowan, 1991; Robb et al., 1995; Potvin, Bradt, &

Kesslick, 2015). Bailey (1983) was one of the scholars who reported the importance of human interaction between clients and therapists when she compared effects of live music and recorded music on mood states among 50 cancer patients at the Memorial

Sloan-Kettering Cancer Center. Results of her study showed significant differences in mean scores for tension and vigor between groups, with patients in the live music group indicating less tension and more vigor post-live music interventions. Several participants who listened to taped-music even commented that they would prefer the presence of the therapist playing music for them to the taped-music recorded by the therapist. Such results and comments indirectly support the benefits of having a present therapist during music therapy sessions. 49

The presence of others can help reduce subjective stress and stress response

(Linnemann et al., 2016), which, in a way, supports that a present therapist may produce similar effects and facilitate therapeutic outcomes. Geller and Porges (2014) have also proposed that the therapeutic presence of the therapist is one of the contributing factors for the therapy process because the therapeutic presence of the therapist can improve a sense of safety, openness, and self-exploration. When the client perceives the actual presence of the therapist and experiences a sense of safety created by the therapist's interaction, he or she may benefit more from the therapy.

Porges’ polyvagal theory, which helps connect the benefits of the therapeutic presence with neurophysiological mechanisms, indicates that an individual’s sense of safety or danger affects the autonomic function through activities of the vagus nerve.

Thus, based on his theory, there is a physical linkage between the neuro regulation of the autonomic nervous system (ANS) and the neuro regulation of the muscles of the face and head (Porges, 2011, para. 248). Therefore, if, according to the polyvagal theory, the therapeutic presence of the therapist may reduce one’s defenses and since a sense of safety between people is bidirectional during social engagement, how a therapist presents himself/herself may affect the client’s sense of safety and danger which may then affect the clients’ neuro regulations of the ANS and the muscles of the face and head (Geller &

Porges, 2014). In other words, an individual’s social engagement through facial expressions, eye contact, emotional expressions, and control of voice quality, which actively involve the muscles of the face and head, may reflect their degree of subjective safety; and the therapist’s presence may have an impact on the client’s subjective safety.

To construct a sense of safety and the therapeutic presence, Geller and Porges (2014) 50 offered several suggestions for therapists: a warm and prosodic voice, “soft eye contact,” an “open body posture,” and a “receptive and accepting stance” (p. 184). These suggestions are quite similar to several key points of receptive methods in music therapy stated by Grocke and Wigram (2007) and based on other scholars. However, since the music therapist may implement the intervention in different positions (e.g., playing the piano), some of the suggestions may need to be adapted depending on the settings and the therapeutic goals.

Because investigators theoretically and empirically credited that the therapeutic presence of a therapist helped reduce defenses (Geller & Porges, 2014) and reported that the combination of the therapeutic presence and live music interventions regulated mood states and reduced tension (Bailey, 1983), music relaxation in a live form of presentation may have the potential to alleviate psychological stress among female college students.

However, based on the fact that most of the music-stress studies with college students employed recorded music and were conducted without the presence of a music therapist, the need to further investigate the merits of this intervention in a live form guided by a music therapist is evident.

Summary

Female college students have been identified as a highly-stressed population

(Brougham et al., 2009; Reisberg, 2000). The accumulation of psychological stress may lead to unhealthy/maladaptive behavioral patterns, which may damage their health and well-being (Anastasiades et al., 2017; Haslam et al., 1989; Lee et al., 2013). The use of relaxation-based treatments for alleviating stress and cultivating a better mental/emotional state may be beneficial to female college students’ psychological well- 51 being (Deckro et al., 2002; Klainberg et al., 2010). Music relaxation intervention is an effective intervention for relaxation induction; therefore, it may help this population alleviate psychological stress by reaching a better mental/emotional state through cultivating contentment. Although live music relaxation intervention consisting of live music and the presence of the music therapist may promote relaxation and improve emotional states, not many music-stress studies with college students focused on the value of music relaxation intervention in live forms with the presence of a music therapist.

Thus, the purpose of this study is to understand whether live music relaxation with the presence of a music therapist helps stressed female college students reach a better mental/emotional state through cultivating contentment. Because Lazarus (1993) acknowledges that a better way to learn an individual's subjective experience of stress is to take the individual's emotional changes into consideration, the researcher observed changes of affect among female college student participants to learn the impact of this intervention. More specifically, this study examined the effectiveness of the live music relaxation intervention by observing whether or not it changed states of negative affect and positive affect through promoting relaxation among the participants. The knowledge learned from this study may help describe the benefits of such music therapy intervention in a live form and also the benefits of the therapeutic presence of a music therapist, provide a potential therapy option to ameliorate psychological distress among female college students, and prepare for future studies with a larger sample size. 52

Chapter 3: Methods

The methodology for this study was approved by an Institutional Review Board of

Ohio University (see Appendix A). Following informed consent, participants (N = 31) completed pre- and post-tests to assess affect change and relaxation change before and after participating in a music relaxation experience provided by the researcher, which was video-recorded. Data collection included participants’ states of affect and relaxation, scores of relaxed behaviors rated by the researcher through watching video-recordings, and participants’ satisfaction level as well as participant comments concerning the experience. For data analysis, quantitative data that reflected state of affect, relaxation change, and observable relaxation response were analyzed through comparing mean scores of pre- and post-intervention. Also, the basic descriptive statistics such as mean and standard deviation were reported. The qualitative data—participants’ review comments—were coded by the researcher based on recurrent thematic materials.

Participants

Thirty-one female college students from a public university participated in this study. Selection criteria for participants required that they must (a) be 18-25 year-old female college students in non-music majors; (b) understand and speak fluent English; (c) self-identify as stressed; (d) have no hearing impairments; and (e) be in general good health without a history of a severe somatic psychiatric disease or clinically diagnosed mental disorders.

Although the available data showed that female college students experience higher stress levels than male college students (Eagan, Stolzenberg, Ramirez, et al., 2016;

Frazier & Schauben, 1994), not many music therapy studies focusing on the needs of 53 female college students (Ashton, 2013) were found. Thus, the researcher chose to focus on how live music relaxation could help stressed female college students. This study also excluded students in music majors to avoid the possibility that musicians might analyze musical components instead of relaxing during the experience. The researcher decided to recruit participants who understand and speak English because, during the intervention, the majority of time was used to instruct the participants to slowly follow verbal suggestions step by step in order to relax different parts of their bodies. Female college students who self-identified as stressed were selected for this study since previous studies with college students (e.g., Ashton, 2013; Thaut & Davis, 1993; & Robb, 2000), which did not specify the severity of stress, did not find statistically significant results. The intervention used in this study was primarily an auditory experience. Therefore, this study also recruited female college students without hearing impairments because If the participants had hearing impairments, hearing aid devices, or cochlear implants, their auditory perception of this experience may have been distorted. In addition, students with mental health disorders were not included in this study since the design of this study was to help stressed female college students and not to treat individuals with mental health disorders such as post-traumatic stress disorders.

Recruitment procedures included advertising the study (see Appendix B), pre- screening potential candidates, and finalizing eligible participants. Eligible participants signed up for the study and scheduled an appointment through a university experiment sign-up system (see Appendix C). Participants received one hour of research credit for showing up for the study during their scheduled time. 54

A total of 37 participants signed up for the study through the psychology enrollment system, and 32 of them showed up for the study during scheduled time. One of the participants decided not to participate in the study because she did not want to be video-recorded, which did not affect her to get the one hour of research credit. Thirty-one participants (83.8%) showed up for the study, signed the consent form after learning details of the study, and agreed to be video-recorded during the intervention process.

Setting

The study took place in a music therapy clinic located in a school of music at a public university. The clinic consisted of three separate but adjacent rooms, rooms A and

B, both brightly lit, were used for the study. The room C between the rooms A and B was used for distributing materials. All participants completed the paperwork (e.g., consent form) and self-reports in room A before and after the intervention, and they received the intervention in room B.

Procedure

Each of the 31 participants scheduled an individual session through the psychology enrollment system. They came to the music therapy clinic at their scheduled times and experienced the same general procedure, which consisted of four sections and a debriefing process (see Appendix F).

The first section consisted of a brief tour of the clinic, an introduction to the experiment including purpose and general structure of the process, and the completion of the informed consent form (see Appendix D). For the second section, through Qualtrics, a software used for creating online surveys, the participants completed the designed self- reports in room A by themselves (Qualtrics, 2017) (see Appendix G). After completing 55 the pre-intervention self-reports, the participants were escorted to the third section in room B to receive the intervention guided by a music therapist (the primary researcher).

Upon completing the intervention, the primary researcher initiated the fourth section by inviting the participants to return to room A, and then, the research assistant escorted them to room A and left them to complete the post-intervention self-reports and also a brief experience review (see Appendix G).

During the debriefing process, the participants were provided with at least five minutes to ask questions. All participants received a printed copy of the debriefing statement (Appendix E) and a handout (see Appendix L) with suggestions of music- related resources for self-care. In addition, each participant received one hour of psychology research credit for their participation.

Instrumentation

Within the current study, a visual analogue scale to indicate state of relaxation, a self-report to reveal affect states, and a brief experience review including a satisfaction rating scale were used. All self-reports and the brief experience review were completed online through Qualtrics. Before filling out the self-reports, each participant rated their comfort levels for completing a self-report online. For collecting objective data, an adapted version of the Behavioral Relaxation Scale score sheet (Appendix H) was also employed in this thesis.

Subjective measures. An electronic version of a 10-cm line visual analogue scale for assessing relaxation response (VAS-R) (see Appendix G) was employed. This scale in a paper form was used by several music therapy researchers (e.g., Thaut & Davis, 1993;

Robb, 2000). On a 0 cm to 10 cm scale, with 0 cm being labeled completely unrelaxed 56 and 10 cm being labeled completely relaxed, the VAS-R was measured in millimeters in this study.

In addition to the VAS-R, to indicate states of affect in this study, an extended version of the Positive Affect Negative Affect Scale (PANAS; Watson & Clark, 1988,

1994), which included three serenity items, was also used. The PANAS was suggested to be reliable to reflect major aspects of one’s emotional experience, and it showed a great consistency with one’s internal reaction (Watson & Clark, 1994). According to Watson and Clark (1994), the Cronbach’s coefficient alpha for positive affect ranges from .83 to .90 (p. 5); the alpha for negative affect ranges from .85 to .90 (p. 5), and the alpha for serenity ranges from .74 to .79 (p. 12). In the same study, various forms of the PANAS were validated using a large sample of college students (e.g., Watson & Clark, 1994), which was also the population the current study used as a category for participants. Even though the researcher was not aware of any music therapy study that adopted

Fredrickson’s theory and, at the same time, used the PANAS as a measure (Ashton,

2013), the researcher used the PANAS in this study to gauge the impact of the live music relaxation intervention on female college students’ mental states through observing the changes in their affect.

In this study, the primary researcher borrowed Fredrickson’s theory as a basis for the use of music relaxation intervention to help stressed female college students alleviate stress through cultivating contentment. Fredrickson (2004) emphasized that by cultivating positive emotions (joy, interest, contentment, and love), an individual may gradually develop his/her personal resources. Then, when coping with various situations, the accumulation of these personal resources would result in a cumulative effect that 57

“broaden[s] one’s momentary thought-action repertoire (Fredrickson, 1998, p. 300)” to deal with those situations. Thus, it appears that transferrable or overt outcomes generated by positive emotions—such as participants’ actions or performance on tasks after a treatment process—should be collected to verify the effectiveness of the treatment

(Fredrickson, 2004).

Nevertheless, building on her previous studies, Fredrickson (2004) stated that the empirical evidence related to positive affect and negative affect is the “initial empirical footing for the hypothesis” (p. 1370) concerning the ability of positive emotions

(contentment, joy, interest, and love) to broaden one’s momentary thought-action repertoire. Fredrickson (2004) found that positive affect improved attention span and encouraged an individual to flexibly and creatively apply personal/diverse resources to stressful situations, and negative affect reduced one’s ability to be attentive and perform cognitive functions. These findings influenced this researcher to examine whether or not, through cultivating contentment, the live music relaxation has an impact on the changes in positive affect and negative affect among stressed female college student participants.

These changes might reflect improvement (or not) in their emotional/mental states, which might also have an impact on their mental preparation for coping with stress. Thus, the

PANAS was selected to use in this study.

The 20 PANAS items were categorized as positive affect (PA) or negative affect

(NA) as outlined by Watson and Clark (1988, 1994). PA incudes active, alert, attentive, determined, enthusiastic, excited, inspired, interested, proud, and strong. NA includes afraid, ashamed, distressed, guilty, sad, irritable, jittery, nervous, scared, and upset. Three serenity items from the extended version of the PANAS (Watson & Clark, 1994) were 58 also included in this study. They are calm, relaxed, and at ease. The participants rated each of the items to indicate their states of affect on a 1 (very slightly or not at all) to 5

(extremely) ordinal scale. Scores of the subscales (PA, NA, and serenity) were then computed separately to reflect participants’ states of positive affect, negative affect, and serenity. The lowest PA or NA score would be 10, and the highest PA or NA score would be 50. The lowest serenity score would be 3, and the highest serenity score would be 15.

In addition, the participants also completed a brief experience review that includes a satisfaction rating scale (an ordinal scale) and three open-ended questions (see

Appendix G). The three open-ended questions were asked to learn about the impact of the intervention on the participants’ mind and body; to learn about the participants’ awareness of changes in mind, body, and auditory stimuli during or after the experience; and to learn about the limitations and strengths of the protocol through the participants’ experience.

Objective measures. This study employed an adapted version of the Behavioral

Relaxation Scale (BRS) score sheet (Appendix H), which was developed by Poppen

(1998). Data were gathered to compare the observable relaxation behaviors (participants’ muscle tension) during the first 45 seconds of the intervention to during the last 45 seconds before returning to the alert state. A variation of this score sheet was also utilized by Scheufele (2000) to measure participants’ relaxation levels when comparing the effects of progressive relaxation techniques to classical music. The original version of the

BRS method states that the process of scoring uses one minute as a unit to assess 10 items (i.e., breathing, quiet, body, head, eyes, mouth, throat, shoulders, hands, and feet).

The one minute is divided into three parts: 30 seconds for counting breathing rate, 15 59 seconds for observing the relaxation states of the other nine targeted behaviors, and 15 seconds for documenting the data on the score sheet. The observation period can be designed based on the needs of the study.

For this study, one minute was selected as the observation period for comparing pre- and post-intervention relaxation behaviors. Because the process of the current study was video-taped, the 15 seconds for inputting data was not included when trimming the video clips for the coding process. Thus, the first 45 seconds of the intervention was selected to assess the participants’ pre-intervention relaxation behaviors, and the last 45 seconds before the return to alert state was also selected to assess the participants’ post- intervention relaxation behaviors. The researcher also employed the same method and scoring instructions from the original version the BRS method.

However, rather than assessing 10 items, the primary researcher selected five observable items suitable for the design of this study. The selected five items were: breathing, quiet, body, eyes, and shoulders. The other five items were excluded for two reasons: first, the sitting posture of the participants in the current study (upright seated posture) was different than the example given from the original version (reclined sitting posture); and second, the instructions for the excluded items were either unclear enough or too strict to be applied to the current study.

Equipment for implementing the intervention. Considering the music therapist’s experience in piano, a piano available in the music therapy clinic was used during the experiment. A piano bench for the therapist and a comfortable chair for the participant were set up in the room. A blanket was available within reachable distance in case the participants felt cold during the treatment. A metronome was used during the 60 intervention for providing tempo reference to the therapist, and the metronome was placed on the left key block of the piano, which was invisible to the participants. Cameras were set up to record the participants’ responses to the intervention for obtaining the observational data.

Intervention

The music relaxation intervention used in this study was selected and altered based on suggestions from previous studies and the primary researcher’s clinical evidence. This live music relaxation intervention lasted for approximately 12 minutes.

The structure of the intervention consisted of (a) a brief preparation with musical cues to facilitate the breathing patterns, (b) an autogenic scan of body parts (see Appendix K) with verbal and musical cues, (c) a piece of relaxing music Watermark by Enya (see

Appendix J), and (d) a return to alert state. To better help the participants cultivate a sense of safety, the music therapist (the primary researcher) referenced the suggestions proposed by Geller and Porges (2014). Geller and Porges suggested that the therapist could use a warm and prosodic voice, “soft eye contact,” an “open body posture,” and a

“receptive and accepting stance” (p. 184) to cultivate the therapeutic presence. Although some of the suggestions were not applicable for the situation of this study, such as sitting position, the therapist adjusted her approach according to the desired outcomes (Grocke

& Wilgram, 2007).

A music therapy technique named iso-principle (Davis, 2003) was applied throughout the intervention. Applying iso-principle during treatment process meant that a music therapist entrained the individual’s internal patterns through first manipulating musical elements to pace the individual’s current states then regulating it to a desirable 61 level (Davis, 2003). This technique was concluded by Maximilian Altshuler, a music therapist who worked with psychiatric patients, and it was originally named iso-moodic principle for its application for modifying psychiatric patients’ mood states (Davis,

2003). Although the technique has been presented differently for different populations in the realm of music therapy, the core concept of iso-principle remains as: achieving goals through connecting the client’s internal patterns (emotion or behavior) with the musical stimuli (Davis, 2003; Heidersheit & Madson, 2015). Here, the researcher used this technique to reflect and then regulate the participants’ relaxed behaviors mainly through adjusting the auditory stimuli (i.e., musical elements and the researcher’s voice).

Preparation. The therapist checked in with the participant to see if she was comfortable with the process of the study when meeting with her in the room B, and the therapist invited the participant to sit down. After the participant indicated that she was sitting comfortably in the chair (e.g., not presenting any overt uncomfortable signs in facial or body gestures, and not verbally expressing discomfort), the therapist invited the participant to either close eyes or found a focal point in the room. Then, the therapist started delivering relaxation induction by providing verbal suggestions and playing the F major and A minor chords alternately with simple melody consisting of quarter notes and half notes (musical elements from Watermark) to ground the experience with musical support. The therapist adjusted delivery rate of instructions by closely observing the participant’s responses, such as breathing patterns and any overt behaviors. When asking the participant to be aware of her breathing, the therapist played the music to match the participant’s breathing patterns in 5/4 meter (5/4 meter means: a quarter note as one beat, and each measure contains five beats). 62

According to previous data, the rhythm of deep breathing in healthy women is

1:1.40 (inhalation : exhalation) and their respiration rate is 14 (Ragnarsdóttir &

Kristinsdottir, 2006), which was also adopted by Detmer (2015) in his study. To calculate based on these data, the duration for inhalation and exhalation is 1.783 seconds and 2.497 seconds (corrected to three decimals places) at a speed of 60 beats per minute (bpm), which required complex rhythmic patterns to match the equation. Therefore, the researcher adopted the idea but simplifying the musical elements while best supporting the participant's breathing by using a 5/4 meter. Two beats for inhalation and three beats for exhalation, which was approximately equivalent to a 1:1.50 respiration rate and relative to the suggested ratio—1:1.40. Also, for better simulating the breathing movement and pattern, an ascending melodic line was played with a slight crescendo during inhalation, and a descending melodic line was played with a slight decrescendo during exhalation (see Figure 1). The therapist closely observed the participants’ breathing pattern and changed the tempo of the music accordingly.

Figure 1. Example of the Musical Stimuli for Facilitating Breathing Patterns

Based on the therapist’s own discretion and the participant's response, the therapist gradually adjusted the tempo of the music to invite the participant to deepen her breathing by slowing down the tempo. A metronome was used during the experience, 63 and the metronome was set to 65 beats per minute (bpm) as a tempo reference during the entire experience, which, according to Agelink et al. (2001), was within the range of resting heart rate (e.g., 76.7 ± 13.5) in healthy women age 17 – 25 years. Only the researcher could see the metronome, so the researcher made the metronome silent but visible to the researcher.

An autogenic scan of body parts. The therapist started providing verbal suggestions for autogenic training body scan while musically transitioning the meter to

3/4 (3/4 meter means: a quarter note as one beat, and each measure contains three beats), which was the meter used in the piece Watermark. The therapist proceeded with the chord progression from Watermark while improvising a smooth and water-like melody consistently. At this time, therapist spoke over the music so as to give relaxation suggestions for the body scan. Or, the therapist adjusted the layers of the auditory stimuli

(music and voice) by controlling volumes of her voice and/or by switching between piano pedals (from left to right: una corda pedal, sostenuto pedal, and sustaining pedal). The therapist conveyed the relaxation suggestions in monotone with a slight smile on her face, which were suggested by Grocke and Wilgram (2007). Also, the therapist adjusted the script, the delivery rate of the body scan, and the musical elements based on the participant's response during the experience. To define therapist’ adjustments for verbal relaxation suggestions, it referred to times when the therapist paused or waited to match the participant’s response. To define therapist’s adjustment for musical components during the body scan, it meant that the therapist stretched the melody lines, added measures when needed, changed the volume/dynamics, and played ascending or descending melodic lines to attune the participant’s response or match the scripts. For 64 example, when the participant was invited to become aware of the muscles of her face... her jaw, across the nose, the muscles of her eyes and behind her eyes, the forehead, to the top of her head... (see Appendix K), the direction of the sensation was upward. To match the verbal suggestions and better direct the participant, the therapist played an ascending melodic line to provide auditory prompts to the participant.

Sedative music. After completing the body scan process, the therapist verbally prompted the participant to become aware of the music. Then, the therapist played the musical piece Watermark to enhance the relaxation states. The piece was adapted to optimize the relaxation experience. The therapist did not provide any verbal suggestions during the music, and the therapist adapted the length of the music and the musical components by observing the participant’s response.

Music selection—Watermark. A piano version of Watermark (see Appendix J), composed by Enya, was selected for this intervention. Grocke and Wilgram (2007) and

Khalfa and her colleagues (2003) have reported the use of several musical pieces by Enya for relaxation or stress reduction. This version was selected because of its musical attributes. The musical elements of this arrangement are generally congruent with the previous guidelines for relaxing music (see Appendix I). The piece is built up of three 8- measure periods (last phrase of the piece extends one more measure), which form an

||:A:|| B ||:A':|| structure with a regular triple meter—3/4. The repetitive melodies might gradually increase participants’ familiarity to the piece, which thus could help increase perceived relaxation degree (Tan et al., 2012). This piece is in the key of F major, which is attached to a sense of gaiety mixed with "joy," “sober” "contemplative," "peace," and

"hope" (p. 169 – 178). Within the F melodic major scale, pitch range of the melody is 65 from E4 to G5, and the pitch range of the accompaniment is from C2 to F4. The melody is carried forward by step-wise musical notes or successive notes of a chord played in either ascending or descending direction. Underneath the melody is the accompaniment played in arpeggio style with regular and flowing rhythm. The repetitive and regular rhythmic patterns and the graceful melodic lines of the piece create peace and serenity.

For this study, instead of using client-preferred and familiar music, the researcher decided to select a piece based on characteristics of relaxing music suggested by music therapy researchers (i.e., Grocke & Wigram, 2007; Hooper, 2012; Robb et al., 1995; Tan et al., 2012). Because this researcher attempted to understand the impact of a music relaxation intervention in a live form of presentation, selecting a proper piece to use throughout the study helped reduce the difference in the implementation process.

Return to alert state. Before resuming verbal suggestions to prompt the closing of the experience, the therapist transitioned the melody back to a pitch range between A3 and A4. Then, the therapist gently resumed the verbal suggestions and invited the participant to return to alert state, and at the same time, the therapist reduced the harmonic complexity by simply alternating between F major chord and A minor chord to indicate that the experience was coming to an end. The reason of keeping the musical components simple and repetitive at the end of the session was that, for this study, the researcher hoped to help the participant cultivate contentment during the intervention and reserve the relaxation sensation after the intervention. The music was ended with decrescendo and retardando, which indicated that the music faded away. The experience was concluded both musically and verbally. The therapist maintained soft eye gaze and 66 smiled to the participant. After the experience, the participant was escorted back to the room A to complete the self-reports.

Data Analysis Plan

All participants rated their comfort levels of completing a self-report online before filling out the study questionnaires. Seven participants (22.6%) and 24 participants

(77.4%) rated “4 – somewhat agree” and “5 – strongly agree,” respectively, for the statement “I feel that completing a self-report online is easy for me.”

Data completion. All participants completed the PANAS (including the three serenity items), the VAS-R, the satisfaction evaluation/scale, and the brief experience review through Qualtrics online, and they completed 100% of all items on each scale and in the review survey. The researcher did not change any grammatical mistakes for the written answers, but the researcher cleared some of the typo mistakes. For example, “the voice oft he therapist” was changed to “the voice of the therapist.” Respondent comments can be found in Appendices M, N, O, and P.

For data from the video-recordings, all participants (N = 31) agreed to be video- recorded when signing the consent form, and they were also empowered to terminate the experiment whenever they felt uncomfortable. No participant terminated the experiment in this study. However, because of equipment error, video-recordings of three participants were incomplete or not available; thus, 28 instead of 31 video-recordings were available for the study. Fifty-six video clips were trimmed from the 28 video-recordings for the coding process and were rated in a random order, and the raw data were re-organized afterward for data analysis. 67

Data analysis. To answer research question 1, the researcher summarized answers of RQ1a, RQ1b, RQ1c, and RQ1d, which reflect the benefits of the live music relaxation intervention for the 31 female college students who self-identified as stressed.

For research question 1a, which concerns the states of positive affect and negative affect, the PA scores and the NA scores were reported and analyzed following appropriate statistical tests. The descriptive data such as mean scores and standard deviation and results from the paired-samples t-tests were reported.

For research question 1b and 1c, to observe whether or not the live music relaxation intervention helped improve the state of contentment/serenity and relaxation response through self-reports, the researcher conducted paired-samples t-tests to examine the statistical difference in pre- and post-serenity scores and the statistical difference in pre- and post-VAS scores. The results of the paired-samples t-tests were reported.

For research question 1d, the five targeted behaviors (breathing, quiet, body, eyes, and shoulders) were rated from the first 45 seconds of the intervention and the last

45 seconds before returning to alert state respectively. Before rating the targeted behaviors, the researcher implemented three steps to avoid experimenter bias for rating the targeted behaviors. First, the researcher cut two 45-second video clips for each participant from the 28 video-recordings and categorized them into two groups: the first

45-second video clips and the last 45-second video clips. The first 45-second video clips were trimmed from the first 45 seconds of the intervention, and the last 45-second video clips were trimmed from the last 45 seconds before returning to alert state, which was the last stage of the intervention. Second, when 56 45-second video clips were produced, the researcher labeled them with video codes. Third, the researcher imported the video codes 68 into Excel and randomized the order of the video clips. In this way, the researcher would rate the video clips in a random order without knowing if she was watching the first 45- second video clips or the last 45-second video clips.

During the coding process, video codes without any identity tags of the participants were used. The researcher analyzed the breathing behaviors separately from the other four targeted behaviors (i.e., quiet, body, eyes, and shoulders). The data of breathing frequency were taken from the first 30 seconds of the 45-second video clips, and the relaxation states for the other four relaxed behaviors were observed from the rest of the 15 seconds of the 45-second video clips.

The breathing frequency was counted by the researcher through watching the first

30 seconds of the 45-second video clips. The data were documented on the Excel document for analysis. After obtaining data for breathing frequency, the researcher reorganized the data by putting data from the first 45-second video clip and data from the last 45-second video clip together for the same participant by following the video codes and participant code. Next, the researcher conducted a paired-samples t-test to compare participants’ breathing frequency from the first 45 seconds of the intervention to their breathing frequency from the last 45 seconds before returning to the alert state.

For the other four targeted relaxed behaviors, the researcher rated the behaviors

“relaxed” or “unrelaxed” following instructions from the Behavioral Relaxation Scale score sheet (Poppen, 1998) (see Appendix H). Then, the researcher calculated the percentages of the targeted behaviors following the instructions. The statistical difference in percentages of the relaxed behaviors and the statistical difference in percentages of the unrelaxed behaviors were analyzed by conducting a paired-samples t-test. 69

After all results for RQ1a, RQ1b, RQ1c, and RQ1d were reported, the answer to the primary research question—research question 1—was summarized. The researcher reported the results for research question 1 by describing the benefits of the live music relaxation intervention learned from the RQ1a, RQ1b, RQ1c, and RQ1d. In addition to the benefits of the intervention, the researcher also analyzed the data collected for the secondary research questions in order to better understand participants’ satisfaction level and subjective experience with the intervention and to provide more information for future studies with a larger sample size.

For research question 2, the researcher reported participants’ ratings on the satisfaction level scale, their willingness to receive similar music relaxation again in the future, and their willingness to recommend this kind of experience to a female college student friend. Also, the researcher identified and analyzed the participant comments in response to three open-ended questions, using the three open-ended questions as a directory. First, the researcher skimmed through the participant responses for each question to identify the patterns of the comments. Then, the researcher divided the participants’ comments into sentences and classified the sentences into different categories based on their meanings within contexts. Sentences with repetitive meanings from the same participants was excluded. Next, based on commonalities within participant comments, the researcher assembled the responses into themes. The same sentence from a participant’s comments could be used in multiple categories, but it would not be assigned to the same theme more than one time. Thus, how many sentences/comments within a theme referred to how many participants expressing thoughts related to that theme. Participants’ comments were analyzed and presented in 70

Appendices M, N, O, and P. Also, the percentage of the participants’ comments for each theme was reported in Tables 13, 14, and 15.

Based on the participants' written comments in response to the three open-ended questions, the researcher made a related discovery. Although there was no research question directly related to the presence of a therapist, the researcher found that 17 out of the 31 participants commented on the influence of the present therapist. Though the intervention was approximately a 12-minute interaction and a one-time visit, the impact of the presence of a music therapist on the live music relaxation may be revealed from the participants’ comments. Thus, statements related to the presence of the therapist were compiled and analyzed in the following manner. The researcher reviewed the respondent comments for each participant and sorted out statements related to pros and cons of the present therapist (see Appendix P for details). This time, the same participants’ statements would not be included in multiple categories. To be specific, each related statement was categorized into one of the three categorizes, which are “pros”, “cons”, or

“pros and cons”. The researcher reported the data in Table 16.

Chapter 4: Results

The purpose of this study was to examine the impact of the live music relaxation intervention guided by a music therapist on female college students who self-identified as stressed. Each of the 31 participants was asked to complete the PANAS (Watson &

Clark, 1988, 1994) for measuring her state of affect and the VAS-R (Thaut & Davis,

1993; Robb, 2000) for rating her state of relaxation pre- and post-intervention. The process of each individual receiving the intervention was video-recorded for further analysis using the BRS (Poppen, 1998). Also, each participant completed a brief experience review including a satisfaction evaluation to reflect her satisfaction level with the experience.

Research Question 1: Benefits of the Live Music Relaxation Intervention

The first research question states as follows: What are benefits of the live music relaxation intervention for participants? To answer this question based on the focus of this study, which was to examine whether or not the intervention helps stressed female college students reach a better mental/emotional state, four research questions (RQ1a,

RQ1b, RQ1c, and RQ1d) were generated. All subjective data from self-reports and objective data from video-recordings were analyzed and summarized to answer the four research questions: (RQ1a) Does live music relaxation intervention help improve scores for positive affect and lower scores for negative affect?; (RQ1b) Does live music relaxation intervention help improve scores for contentment (i.e., at ease, relaxed, and calm)?; (RQ1c) Does live music relaxation intervention help increase scores for relaxation responses?; (RQ1d) Does live music relaxation intervention help improve participants’ observable relaxation responses? 72

Research question 1a: Positive affect and negative affect. Ten positive affect items and ten negative affect items to assess participants’ states of affect pre- and post- intervention were analyzed for answering RQ1a. Because the participants rated on a 1

(very slightly or not at all) to 5 (extremely) ordinal scale, the lowest PA or NA score would be 10, and the highest PA or NA score would be 50.

Pre- and post-intervention positive affect scores. To answer the RQ1a, scores of the 10 PA items for each participant were summed up to reveal the impact of the intervention on positive affect.

A paired-samples t-test was conducted to compare the pre-PA scores to post-PA scores (see Table 1). Results show that mean PA score differed before receiving the music relaxation intervention (M = 27.23, SD = 5.38) as compared to after receiving the music relaxation intervention (M = 22.48, SD = 6.62) at the .05 level of significance

(95% CI [2.63, 6.85], p < .001). On average, the PA scores were about 4.75 points lower after participants received the intervention. This means that the PA scores were significantly reduced after exposure to the intervention.

Table 1 Paired t-Test for Pre- and Post-Positive Affect Scores Pre-PA Post-PA 95% CI for P Mean ± SD Range Mean ± SD Range N Mean Difference Value 27.23 ± 5.38 18 – 40 22.48 ± 6.62 13 – 42 31 2.63 6.85 .000 *p < .05, two-tailed. *p < .01, two-tailed.

Pre- and post-intervention negative affect scores. Scores of the 10 NA items were also summed up for each participant to reveal the impact of the intervention on the participants’ state of negative affect. 73

The researcher also conducted a paired-samples t-test to compare the pre-NA scores with the post-NA scores. Results in Table 2 show that mean NA score differed before receiving the music relaxation intervention (M = 17.71, SD = 5.93) as compared to after receiving the music relaxation intervention (M = 11.87, SD = 3.64) at the .05 level of significance (95% CI [4.38, 7.3], p < .001). On average, the NA scores were about

5.84 points lower after participants received the intervention. This means that the NA scores significantly improved after exposure to the intervention.

Table 2 Paired t-Test for Pre- and Post-Negative Affect Scores Pre-NA Post-NA 95% CI for P Mean ± SD Range Mean ± SD Range N Mean Difference Value 17.71 ± 5.93 11 – 38 11.87 ± 3.64 10 – 27 31 4.38 7.3 .000 *p < .05, two-tailed. *p < .01, two-tailed.

Research question 1b: Serenity items from PANAS. The serenity scores were calculated for each participant. A participant’s lowest serenity score could be 3, and her highest serenity score could be 15. As presented in Table 3, the range of serenity scores increased from 3-12 to 7-15 post-intervention.

A paired-samples t-test was also conducted to examine the statistical difference in state of serenity pre- and post-intervention. Results in Table 3 show that mean serenity score differed before receiving the music relaxation intervention (M = 7.19, SD = 2.26) as compared to after receiving the music relaxation intervention (M = 12.9, SD =1.89) at the .05 level of significance (95% CI [-6.55, -4.87], p < .001). On average, serenity scores were about 5.71 points higher after participants received the intervention. Thus, 74 participants’ serenity scores significantly increased after exposure to the live music relaxation intervention.

Table 3 Paired t-Test for Pre- and Post-Serenity Scores Pre-Serenity Post-Serenity 95% CI for P Mean ± SD Range Mean ± SD Range N Mean Difference Value 7.19 ± 2.26 3 – 12 12.9 ± 1.89 7 – 15 31 -6.55 -4.87 .000 *p < .05, two-tailed. *p < .01, two-tailed.

Research question 1c: Relaxation response. Data collected from the VAS-R ratings to reflect the participants’ level of relaxation were analyzed. As can be seen in

Table 4, on a 0-10 cm scale, with 0 cm referring completely unrelaxed and 10 cm referring completely relaxed, no participant rated 0 indicating completely unrelaxed pre- and post-intervention. Results of the paired-samples t-test showed that mean VAS score differed before receiving the music relaxation intervention (M = 4.79, SD =1.62) as compared to after receiving the music relaxation intervention (M = 7.75, SD = 2.31) at the .05 level of significance (95% CI [-3.89, -2.02], p < .001). On average, the VAS scores were about 2.96 points higher after participants received the intervention. In other words, participants’ VAS scores increased significantly post-intervention.

Table 4 Paired t-Test Results for Pre- and Post-VAS—Relaxation Scores Pre-VAS Post-VAS 95% CI for P Mean ± SD Range Mean ± SD Range N Mean Difference Value 4.79 ± 1.62 2.3 – 9.2 7.75 ± 2.31 1 – 10 31 -3.89 -2.02 .000 *p < .05, two-tailed. *p < .01, two-tailed. 75

Research question 1d: Observable relaxation responses. The scores of the five relaxed behaviors taken from the first 45 seconds of the intervention (the first 45-second video clips) and the last 45 seconds before returning to alert state (the last 45-second video clips) were compared to examine participants’ observable relaxation responses pre- and post-intervention. In this study, the researcher analyzed the breathing behavior separately from the other four targeted behaviors. Due to an equipment error, three participants’ video-recordings were excluded. When importing data into IBM SPSS

Statistics 24, the researcher included the missing data and replaced them with -3. To simplify the names in tables and in the paper, data from the first 45-second video clips were labeled “first 45 secs”, and data from the last 45-second video clips were labeled

“last 45 secs.” For example, relaxed (first 45 secs), unrelaxed (last 45 secs), and breathing frequency (first 45 secs).

Breathing frequency. Breathing frequency referred to how many breaths the participant inhaled over the course of 30 seconds. A paired-samples t-test was also conducted to test the statistical difference in breathing frequency between the first 45 seconds of the intervention and the last 45 seconds before returning to alert state. Table 5 shows that the mean breathing frequency differed during the first 45 seconds of intervention (M = 9.14, SD = 1.69) as compared to during the last 45 seconds before returning to alert state (M = 8.29, SD = 1.96) at the .05 level of significance (95% CI [.04,

1.68], p = .042). On average, breathing frequency was around 1 inhale-exhale cycle less after participants received the intervention. This suggests that participants’ breathing deepened after exposure to the live music relaxation intervention.

Table 5 Paired t-Test for Breathing Frequency Breathing Frequency Breathing Frequency 95% CI for (First 45 Secs) (Last 45 Secs) N Mean M ± SD Range M ± SD Range (Missing) Difference P Value 28 9.14 ± 1.69 6 – 14 8.29 ± 1.96 5 –12 .04 1.68 .042 (-3) *p < .05, two-tailed. **p < .01, two-tailed.

Observable relaxed behaviors. The four targeted behaviors—quiet, body, eyes, and shoulders—were rated “relaxed” or “unrelaxed” within a 15-second observation from participants’ 45-second video clips. Paired-samples t-tests were conducted to compare percentages of relaxed behaviors during the first 45 seconds of the intervention and the last 45 seconds before returning to alert state, and also to compare percentages of unrelaxed behaviors during the first 45 seconds of the intervention and the last 45 seconds before returning to alert state.

Table 6 shows that the mean percentage of relaxed behaviors differed during the first 45 seconds of intervention (M = 82%, SD = 22%) compared to during the last 45 seconds before returning to alert state (M = 94%, SD = 13%) at the .05 level of significance (95% CI [-18%, -5%], p < .05). On average, percentage of relaxed behaviors increased by about 12% after participants received the intervention.

Table 6 Paired t-Test for Percentage of Relaxed Behaviors Percentage of Relaxed Behaviors Percentage of Relaxed 95% CI for (First 45 Secs) Behaviors (Last 45 Secs) Mean P M ± SD Range M ± SD Range N Difference Value 82% ± 22% 25% – 100% 94% ± 13% 50% – 100% 28 -18% -5% .001 *p < .05, two-tailed. **p < .01, two-tailed.

As can been seen in Table 7, the mean percentage of unrelaxed behaviors differed during the first 45 seconds of intervention (M = 18%, SD = 22%) compared to during the last 45 seconds before returning to alert state (M = 6%, SD = 13%) at the .05 level of significance (95% CI [5%, 18%], p < .05). On average, the percentage of unrelaxed behaviors decreased by about 12% less after participants received the intervention.

Because Poppen (1998) stated that the percentages of the relaxed and unrelaxed behaviors indicate the participant’s current muscle tension, the results of this study imply that the participants’ muscle tension relaxed after exposure to the intervention.

Table 7 Paired t-Test Results for Percentage of Unrelaxed Behaviors Percentage of Unrelaxed Behaviors Percentage of Unrelaxed 95% CI for (First 45 Secs) Behaviors (Last 45 Secs) Mean P M ± SD Range M ± SD Range N Difference Value 18% ± 22% 0% – 75% 6% ± 13% 0% – 50% 28 5% 18% .001 (-3) *p < .05, two-tailed. **p < .01, two-tailed.

All paired-samples t-tests regarding the changes of observable relaxation response yielded a significant difference (p < .05). Thus, the results of the observable relaxation responses (breathing frequency and the four other targeted behaviors) were consistent with results from the participants’ self-reports (three serenity items and the VAS-R).

Results addressing the RQ1a, RQ1b, RQ1c, and RQ1d provide possible answers to the research question 1: What are benefits of the live music relaxation intervention for participants? Results of this study presented that NA scores and percentages of unrelaxed behaviors significantly decreased, and serenity scores, VAS scores, and percentages of 78 relaxed behaviors significantly increased post-intervention. These results suggest that benefits of the live music relaxation intervention for female college students who self- reported as stressed may be related to decreasing states of negative affect, promoting relaxation, and relaxing muscle tension.

Research Question 2: Satisfaction Level and Willingness to Revisit

The second research question states the following: How satisfied are participants with live music relaxation intervention? To answer this question, the researcher analyzed the participants’ self-reported satisfaction level and their experience review.

Satisfaction level. No participant rated 1, 2, or 3 indicating that they were very dissatisfied, somewhat dissatisfied, and neither satisfied nor dissatisfied with the experience. The majority of the participants (80.6%) rated 5 indicating that they were very satisfied with the experience, and the rest of the participants (19.4%) rated 4 indicating that they were somewhat satisfied with the experience. The mean score of the satisfaction level was 4.81.

Table 8 Satisfaction Level Mean ± SD N (Range) 4.81 ± 4 Satisfaction Level 31 (4 – 5)

Frequency Percent 1 0 0 2 0 0 Satisfaction Level 3 0 0 (N = 31) 4 6 19.4 5 25 80.6 Total 31 100.0 Notes. “1” means very dissatisfied, “2” means somewhat dissatisfied, “3” means neither satisfied not dissatisfied, “4” means somewhat satisfied, and “5” means very satisfied.

Willingness to revisit. In addition to the satisfaction level scale, 29 participants

(93.5%) also indicated that they would consider receiving similar music relaxation again in the future (see Table 9). However, two participants (6.5%) indicated that they would not consider receiving similar music relaxation again in the future. Nevertheless, all participants indicated on the survey that they would recommend this kind of experience to a female college student friend (see Table 10).

Table 9 Willingness to Receive Similar Music Relaxation Again Frequency Percent 1—Yes, I Will 29 93.5 2—No, I Won’t 2 6.5 Total 31 100.0 Note. Original question is “Will you consider receiving similar music relaxation again in the future?”

Table 10 Willingness to Recommend the Experience Frequency Percent 1—Yes, I Will 31 100.0 2—No, I Won’t 0 0 Total 31 100.0 Note. Original question is “Will you recommend this kind of experience to a female college student friend?”

Content Analysis of Experience Review

The researcher used three open-ended questions as a directory to analyze and present the participants’ review. The three questions are: (Q1) How did you feel during the music body scan experience? You can talk about your emotions, body awareness, and feelings in your body? Or, any other thoughts that come to mind.; (Q2) Did you notice any changes during or after the experience, such as the music, the voice of the therapist, or your own responses?; (Q3) What about this experience felt positive for you? Was there any part of the experience that was difficult for you?

Question 1: Impact on mind and body. Based on the content, the researcher identified and organized the participants’ statements into four categories: “mind and body," “mind,” “body," and “others” (see Appendix M for details). Following this categorization, the researcher, then, analyzed and concluded that the statements represented a similar theme or pattern. For both their minds and bodies, the experience may have effects on helping the participant(s) (a) feel connected with mind and body and

(b) sleep. For their minds, the experience may have effects on (c) clearing and relaxing mind/thoughts; (d) developing spiritual resources; (e) alleviating mental stress; (f) stimulating imagination; and (g) feeling calm, relaxed, safe, or happy. For their bodies, the experience may have an effect on (h) deepening respiration or relaxing muscle 81 tension and (i) enhancing body sensation. The researcher calculated the frequency of respondents' comments and their percentages for each theme (see Table 11).

Table 11 Experience Review—Mind, Body, and Other Thoughts Categories Themes Percentage Mind and (a) Feeling connected with mind and body 3.2% (1) Body (b) Sleeping 12.9% (4) (c) Clearing and relaxing mind/thoughts 12.9% (4) (d) Developing spiritual resources 6.5% (2) Mind (e) Alleviating mental stress 32.3% (10) (f) Stimulating imagination 3.2% (1) (g) Feeling calm, relaxed, safe, or happy 77.4% (24) (h) Deepening respiration or relaxing muscle tension 51.6% (16) Body (i) Enhancing body sensation 9.7% (3) Feeling connected with mind and body Previous experience. Other 16.1% (5) Motivated to try similar interventions. Favor for the piano and the music. Notes. Number in parenthesis represents the number of participants whose review emerging the same/similar themes. The percentage = N divided by 31 (the total number of participants who wrote the statements)

As shown in Table 11, after the intervention, the majority of the participants

(77.4%) expressed that they felt calm, relaxed, safe, or happy. Four of them stated feeling very tense, nervous, or anxious at the beginning of the experience, but they felt relaxed, calm, or happy as the intervention progressed. Because the four participants indicated that their feelings turned to positive (relaxed, calm, or happy), the researcher still categorized their data under theme (g) feeling calm, relaxed, safe, or happy. More than half of the participants (51.6%) stated that their breathing deepened or muscle tension relaxed gradually. Almost one third of the participants (32.3%) indicated that the experience helped them alleviate mental stress. 82

In addition to those comments related to body or mind, the participants also expressed other thoughts about the experience. The researcher put comments not belonging to either “mind” category or “body” category under “other” category. Two participants stated that this experience reminded them of previous experiences in yoga classes or therapy sessions. One participant stated that she felt motivated to try music relaxation daily or weekly. Also, two participants expressed a preference for the sound of a piano and the music.

Question 2: Changes in mind, body, and auditory stimuli. To learn about the participants’ awareness of changes in mind, body, and auditory stimuli during or after the experience, based on the changes that the participants noticed, the researcher identified and categorized the respondent comments to the second question into three groups: mind, body, and auditory stimuli (see Appendix N for details). The researcher analyzed the data and compiled them into five themes: (a) changes in feelings; (b) changes in thoughts; (c) changes in breathing, muscles, or parts of the body; (d) musical elements; and (e) voice of the therapist (see Table 12).

Table 12 Experience Review—Changes in Mind, Body, and Auditory Stimuli Categories Themes Percentage (a) Changes in feelings 29% (9) Mind (b) Changes in thoughts 3.2% (1) (c) Changes in breathing, muscles, or parts of the Body 25.8% (8) body Changes Described one musical 22.6% element (7) Described two musical 12.9% elements (4) 58.1% (18) Described three musical 3.2% (d) elements (1) Musical 19.4% Auditory elements Described the music (6) Stimuli No changes 3.2% (1) Described changed musical elements and unchanged musical 6.5% (2) elements (e) Voice Changes 6.5% (2) of the No changes 32.3% (10) therapist Notes. Number in parenthesis represents the number of participants whose review emerging the same/similar themes. The percentage = N divided by 31 (the total number of participants who wrote the statements)

Changes in feelings and thoughts. As shown in Table 12, nine participants (29%) stated that they noticed changes in their feelings, and one participant (3.2%) noticed changes in her thoughts. Among the nine participants who expressed changes in feelings, one participant felt that she was in a better mood after the intervention, and one participant recognized that her feelings/emotions changed from being tense and nervous to being more relaxed. Seven out of those nine participants felt less nervous, stressed, and more relaxed, calm (see Appendix N). The one participant who noticed a change in her thoughts indicated that initially she had "a lot" on her mind "like tests and projects," but

"towards the end" she "wasn't thinking or worried about anything." 84

Changes in breathing, muscles, or parts of the body. Eight participants (25.8%) noticed changes in their bodies. One of the eight participants indicated that her breathing changed with the music. Another participant stated that her muscles became more and more relaxed. Also, a participant noticed that a specific part of her body (shoulders) became relaxed. The other five participants noticed that their bodies became more relaxed as the session progressed, but they did not elaborate on the details.

Musical elements. The researcher sorted out all of the participants’ comments based on whether or not they noticed a change of the musical elements, as well as how many musical elements and what musical elements they referred to in the comments.

Eighteen participants (58.1%) indicated changes in musical elements or the music while one participants (3.2%) indicated no changes in musical elements or the music. Two participants (6.5%) noticed musical elements (e.g., tempo and melody) that were changed and musical elements (e.g., rhythm and base line) that were unchanged. Changes in musical elements that at least one participant identified and described included tempo, melody, pitch, dynamics, tone/timber, and harmony. Twenty participants (64.6%), including the two participants (6.5%) describing both changed and unchanged musical elements, pointed out or described a change in at least one musical element or in the music. Six of them (19.4%) noticed that the music was changed throughout the experience, or that the music was tailored to reflect or match their body responses (e.g., breathing patterns) along with the scripts, but they did not mention a specific musical element. Musical elements that at least one participant indicated were unchanged are tone, rhythm, and the bass line. 85

Tone was the only element mentioned as “stayed consisted” by one participant and as “get a deeper tone” by the other participant. Normally, tone is referred as the sound of an instrument, quality of the sound, or musical interval (semitones). Within the context of this experiment, the two participants might indicate either the sound of an instrument or quality of the sound. To better present the two participants’ thoughts, the researcher tried to elaborate the part of their statements that may cause confusion (see original comments in Appendix N). The researcher interpreted the statement “The music would get a deeper tone and louder during some parts of the experiences” as the participant noticed the quality of the sound got deeper. For the other statement “The tone of the therapist and the piano stayed consisted throughout the session,” the researcher interpreted it as the sound of the therapist and the piano did not change, or the quality of sound of the therapist and the piano did not change. Thus, although the two participants used the same musical term—tone, they could refer to the same subject or different subject.

Voice of the therapist. Two participants (6.5%) indicated that they noticed the voice of the therapist changed or became softer while 10 participants (32.3%) stated that they did not notice a change in the therapist’s voice. Of the 10 participants, four participants described the therapist’s voice as “extremely soft and calming,” “pretty calm,” “extremely soothing,” and “soothing and kind.” Several participants also indicated that the therapist’s voice “helped a lot in the calming effect of the experiment.”

Question 3: Positive and difficult parts of the experience. In order to understand the parts of the experience that were positive and/or difficult for the participants, the researcher analyzed the respondent comments from the third open-ended 86 question and categorized them into “positive parts” or “difficult parts” (see Appendix O for details). Themes that emerged from the statements about positive parts include (a) mind: feelings, states, and stressful thoughts; (b) body; (c) experience; and (d) auditory experience. Themes that emerged from the statements about difficult parts include (e) mind: thoughts and/or feelings; and (f) body. Nearly half of the participants (48.4%) stated that they did not have difficulty partaking in the intervention, and they included or did not include specific comments about positive parts of their experiences (see Table

13).

Table 13 Experience Review—Positive and Difficult Parts of the Experience Categories Themes Percentage Changes in feelings or 19.4% (6) states (a) Mind 45.2% (14) Alleviation of mental 25.8% (8) Positive stress Parts (b) Body 16.1% (5) (c) Experience 3.2% (1) (d) Auditory stimuli 45.2% (14) Racing thoughts 12.9% (4) (e) Mind Thoughts and feelings 6.5% (2) 25.8% (8) Novelty 6.5% (2) Difficult Adjustable as the 50% (4) Parts session progressed (f) Body 16.1% (5) Adjustable as the 40% (2) session progressed No Difficulty (with or without details about positive parts) 48.4% (15) Notes. Number in parenthesis represents the number of participants whose review emerging the same/similar themes. The percentage = N divided by 31 (the total number of participants who wrote the statements)

Even though 45.2% of the participants indicated that the experience had positive effects on their minds in terms of feelings and thoughts, 25.8% of the participants acknowledged that they found it difficult to relax their minds during the experience. On the one hand, the participants who reported positive effects on their minds stated that the experience helped them feel better and more relaxed and calm, and it also provided them space to analyze themselves and to be with themselves without worries. The positive effects described by the participants appeared to help them reach a better mental/emotional state, which was the intention of this study. On the other hand, eight participants (25.8%) who found it difficult to relax their minds stated that they had too much on their minds, were not used to relaxing themselves, could not be focused, became emotional (sad), or felt “nerve racking” when listening to music without lyrics. Some of them also stated that they had a hard time in adapting themselves to the new environment and the new people. Of these eight participants, four of them (50%) indicated that they overcame the difficult parts as the session progressed.

An equal number (five) of the participants (16.1%) described the positive effects of the experience on their bodies and their difficulties in relaxing their bodies. The participants who described the positive effects indicated that the experience helped relax their muscles and bodies. In contrast, the participants who described their difficulties in fully relaxing their bodies stated that they could not relax certain body parts (e.g., shoulders), were always tense, wanted to move certain body parts (e.g., hands), or would like to lie down. Of those five participants who mentioned having difficulty relaxing their bodies, two of them (40%) expressed that they felt at ease or relaxed as the session progressed. 88

One participant typed three words “Positive for me” for this question without giving any details. Additionally, 14 participants (45.2%) stated that the auditory stimuli were among the parts that felt positive for them. They described that the music was

“calming,” “positive,” “upbringing,” “inspiring,” “uplifting,” “comforting,” and also the therapist’s voice was “positive and relaxing,” “calming,” “reassuring,” and “soothing.”

Four participants also expressed their preference for the sound of the piano, and one of them stated, “[l]istening to the calming sounds of the piano seemed to make my mind more at ease and the sounds seemed to have created mental images, such as outdoor scenery.”

The presence of the music therapist. As stated, the application of live music relaxation interventions considers the presence of a music therapist who responds and communicates with the clients actively through the live form of music presentation and the human interaction. Data in Table 12 show that 64.6% of the participants noticed a change in the live music accordingly to their responses, which indirectly reflected that the music therapist did change the musical elements following the participants’ responses. To construct a sense of safety and the therapeutic presence when delivering the intervention, the researcher who was also the music therapist in this study adhered to the suggestions stated in previous studies: a warm voice with monotone quality (Grocke & Wilgram,

2007), “soft eye contact,” (Geller & Porges, 2014, p. 184) an “open body posture,”

(Geller & Porges, 2014, p. 184) and a “receptive and accepting stance” (Geller & Porges,

2014, p. 184). The researcher reviewed the respondent comments again to extract statements related to the therapist and unfold the pros and cons of the presence of the therapist in this study in Table 14. 89

Table 14 Experience Review—The Presence of the Therapist Categories Percentage Pros 88.2% (15) Cons 5.9% (1) Pros and Cons 5.9% (1) Total 100% (17) Notes. Number in parenthesis represents the number of participants whose review belongs to the categories. The percentage = N divided by 17 (the total number of participants who wrote related statements)

Of the 31 participants, 17 participants (54.8%) mentioned how the therapist seemed to help with the process or impede the process through answering the three open- ended questions. Due to the limitation of the three open-ended questions, the related comments were limited to the therapist’s voice, the existence of the therapist, and the adjustment that therapist made for the verbal suggestions and the musical elements. Of the 17 participants, 88.2%% of them indicated that the quality of therapist’s voice, her existence, and the adjustment she made for the auditory stimuli seemed to help with the process. Several participants also commented that “The researcher and the researcher assistant’s voice were both really soothing and calm, it made me feel very comfortable being here...” and “It seemed like I was more relaxed by her voice...” However, one participant (5.9%) stated that she felt the situation where she sat in a room with a lady playing the piano telling her to relax her body was “a little strange” to her. Also, another participant (5.9%) indicated that although the therapist provided the verbal prompts along with the music timely, which helped with the process, she felt difficult being relaxed at a new environment with new people—the therapist and the research assistant—in the beginning of the experience.

Chapter 5: Discussion

The results of this study showed that the impact of the live music relaxation intervention on stressed female college students may improve state of negative affect

(NA), promote relaxation, and relax muscle tension. Statistical tests for all dependent variables (positive affect, negative affect, VAS—relaxation, serenity items, relaxation behaviors, and breathing frequency) yielded a significant difference pre- versus post- intervention. Although the positive affect significantly reduced post-intervention, which was contradictory to the hypothesis, the significant decrease of negative affect level might still be helpful for addressing perceived stress among the participants because

Watson and colleagues (1994) found that “perceived stress was strongly correlated with within-subject fluctuations in Negative Affect but not Positive Affect” (p. 19). Thus, from the results of this study, it is reasonable to speculate that the live music relaxation intervention helped stressed female college students through cultivating contentment (a positive emotion).

The results of the participants’ satisfaction level also revealed that all participants were somewhat satisfied or very satisfied with the intervention. Most of the participants

(93.5%) would consider receiving similar music relaxation again in the future, and 100% of the participants indicated that they would recommend this kind of experience to a female college student friend. Results from the qualitative data were, in general, consistent with the results from the quantitative data. Emerging themes of participants’ experience review stated that this type of intervention might help relax muscle tension, deepen respiration, clear the mind, create space to feel the reaction of the body and the mind, and alter negative affect. Several participants stated that when they reflected on 91 personal matters that usually bothered them, they felt less discomfort or realized that it would be okay. In addition, the respondent comments indicated that the participants noticed the changes of the musical elements adjusted by the therapist, stated that the changes appeared to be in sync with their responses, and implied that the changes of the live music seemed to be helpful throughout the process. Therefore, participant comments reflected that the live music relaxation intervention had a positive impact on helping stressed female college students through cultivating contentment.

However, the statistical results of the paired-samples t-test for the PA scores indicated that this live music relaxation intervention did not improve the state of positive affect. Instead, the PA scores significantly decreased post-intervention. Although contentment (one of the positive emotions) was the direct focus of the study and not the

10 positive affect items, it was interesting to learn that when an individual was in a very calm and relaxed state and reports experiencing much less negative affect, the individual, at the same time, could also experience less positive affect. No studies that used both music relaxation as an intervention and the PANAS as an instrument can be referenced to explain this phenomenon. Since the intervention was designed to cultivate contentment during the intervention and preserve the relaxation sensation after the intervention, it was possible that the participants were less active, alert, attentive, determined, enthusiastic, excited, and interested because they were still in a relaxed state when completing the

PANAS, which was also indicated by the serenity scores. In addition, the 10 positive affect items on the PANAS are high-arousal words; however, the intention of the intervention was to reduce arousal and preserve contentment. Considering the intervention protocol and the desired outcomes, the results of PA seemed reasonable. 92

Another possibility should be considered is that, before exposure to the intervention, a reason that the participants’ PA scores were high might be because they were interested in learning about the intervention. If a comparison group was recruited, a comparable data set would allow us to see whether perhaps PA scores would not drop as much following the music intervention relative to a control condition.

In a similar study conducted by Smith (2008), although she did not include measurements for affect and relaxation, Smith reported that participants felt more pleasant after exposure to a live music relaxation intervention (music + PMR) compared to pre-intervention. Also, in current study, even though pleasant was not one of the positive affect items assessed here, there were participants stating in their experience review that they were “happy” or found themselves “smiling” during or after the experience. Therefore, different positive mood descriptors, which are happy and possibly joyful, that reflect the participants’ state of positive affect are observed from the participants’ written comments for this study.

Because of the length of this study, the long-term effect of this intervention on the state of positive affect was not examined. Thus, while this intervention cultivated contentment (one of the positive emotions) that appeared to help counteract negative affect in a one-time visit, the long-term effect of this intervention on positive affect or even other variables remained uncertain due to the limitation of the study.

For the VAS scores, while paired t-test revealed that the VAS scores increased significantly post-intervention, the researcher found that there were three participants rated their state of relaxation lower post-intervention. When comparing their scores on the VAS scores with the three serenity items, which were two similar measurements for 93 assessing the state of relaxation and the state of serenity, the researcher noticed that their scores for the VAS and for the three serenity items were inconsistent (see Table 27).

While both participant X and Z rated their VAS scores lower post-intervention, which means that they felt less relaxed, they rated higher scores for the three serenity items indicating that they felt more calm, relaxed and at ease post-intervention. Participant Y rated her VAS scores lower, but on the scale of the three serenity items, she indicated that she felt more at ease and felt not much change in being calm and relaxed post- intervention. Although the three participants rated their state of relaxation lower on the

VAS post-intervention, they indicated that their state of serenity remained the same or increased through rating the three serenity items (i.e., calm, relaxed, and at ease). All participants completed the VAS before the PANAS. As higher VAS scores indicate higher levels of perceived relaxation, the three participants indicated that they perceived lower levels of relaxation post-intervention, which is different than what they indicated through the three serenity items. From the experience review, they also stated that the experience helped them relaxed and was positive for them. It was unsure if the three participants changed their mind when rating the serenity items; if they suddenly felt more relaxed when rating the serenity; or if they misunderstood the instructions for rating the

VAS. Even though the visual analogue scale for measuring relaxation was able to reflect more subtle effects than the Likert scale for measuring the three serenity items (Allen,

Kennedy, Cryan, Dinan, & Clarke, 2014), the results did not seem possible to be contradictory.

Table 15 Data of Participant X, Y, & Z Participant X Participant Y Participant Z Pre- Post- Pre- Post- Pre- Post- 4 5 4 4 3 4 calm calm calm calm calm calm Pre- Post- Pre- Post- Pre- Post- 4 5 4 4 1 4 relaxed relaxed relaxed relaxed relaxed relaxed Pre-at Post-at Pre-at Post-at Pre-at Post-at 4 5 4 5 2 3 ease ease ease ease ease ease

Pre- Post- Pre- Post- Pre- Post- 5 1 4.3 1 9.2 5.8 VAS VAS VAS VAS VAS VAS

Another fact emerging from this study was that during the process of reaching a relaxed state, such music relaxation experience could also elicit a variety of emotions like sad feelings in different individuals. When answering the question regarding positive parts and difficult parts of the experience, one participant wrote, “Most of the experience was positive for me, I needed a break from the past month I have endured, but the portion of being alone with music without any lyrics was a little nerve racking because I was trying not to let my mind wander on to things that I have been stressed about...” Another participant wrote, “The only part that was difficult was clearing my head and the emotional response I had to the music because it was so beautifully played, it was bringing up emotionally sad feelings for me personally.” The portion of listening to the music without lyrics accidentally reminded them of their worries or sad memories, yet these same two participants also stated on their comments that the autogenic body scan helped them relax and perhaps shift toward emotional balance. While the music portion was designed to enhance the contentment effect, it apparently caused an adverse effect on the two participants. Music could help regulate emotions, and music could also stir up a wide range of emotions. It was possible that the music elicited emotions more easily 95 when an individual was in a calm and relaxed state—her internal defenses reduced— which could also provide access to one’s psyche. Similar phenomenon also emerged from the patients’ quotes from another study conducted by Potvin, Bradt, and Kesslick (2015).

Normally, in a therapeutic setting, the music therapist would help the client address any issues arise from the relaxation experience during the verbal processing, which was a step after returning to an alert state (Grocke & Wilgram, 2007). However, like other similar research studies (e.g., Gutgsell et al., 2013), the verbal processing was not included in the research setting of this study.

From the participants’ comments, the researcher also noticed that of the 31 participants, one participant (3.2%) created images herself to help with the process during the experience. On the experience review, she stated that “While listening to the piano, my mind would envision pictures correlating to the tone of the music. This also made me more relaxed and also happy.” and “Listening to the sounds of the calming piano seemed to make my mind seem more at ease and create images, such as outdoor scenery.” Even though the live music relaxation intervention of this study was not designed for visual imagery, it was not uncommon that participants would use visual imagery (self- generated) technique to relax or enhance the effect of the experience. This was also described by other music therapy researchers (e.g., Thaut & Davis, 1993; Robb, 2000). In a study, Robb (2000) found that 67% of the participants in the mere music group (n=15) utilizing visual imagery (self-generated) technique to relax.

Limitations of the Study

Although the present study presents preliminary evidence for the benefits of a live music relaxation in the presence of a therapist on stressed female colleges, it is important 96 to consider the limitations within this study. First, sample size of this study is relatively small although it is a pilot study. The results from this study may not be applicable to other female college students who self-identified as stressed. Second, the timeframe of the session and the length of the study were relatively short for a therapist to build rapport with the participants, although in medical settings, a music therapy session could be as short as 20 minutes or could be a one-time encounter. Still, the duration of the study and the length of this study somehow limited the opportunities for the therapist to build rapport with the participants. Even though the therapist tried her best to construct a safe environment for the participants, there was still one participant indicating experiencing difficulties being in a new environment with new people. If the length of the session and the study extended, participants’ discomfort being in a new environment with new people may abate, and the participants may benefit more from the experience and may feel more supported psychologically. Thus, the results of this study may be affected by negative factors such as anxiety, nervousness, and novelty due to the one-time short encounter.

Also, the researcher would gain a deeper insight in the impact of contentment cultivated by the live music relaxation in a longitudinal angle if the length of the study lasted for a complete treatment. With that said, the researcher expects that if this program were to be implemented more widely, most participants might find themselves in similar situations.

Therefore, these experiences may be generalizable.

Third, this study is a single group, pre- and post-test design. Although the data of this study may be used as reference for future studies with experimental research design with a larger sample size or with repeated measures design with a longer period, this study did not consider a comparison group. That is, the effects of the examined 97 intervention cannot be compared with other conditions such as no treatment/intervention or different types of treatments/interventions. Also, it was a one-time visit study, effects of the examined intervention on the same subjects cannot be compared over time, from a longitudinal angle, which would be more suitable for observing its effects for cultivating contentment. Without a comparison group formed by random allocation, the design of this study opens the results for errors due to history of therapy experiences and musical exposure and regression effects (Marsden & Torgerson, 2012). In addition, because the researcher did not recruit a comparison group like previous researchers did (e.g., Robb,

2000), although results of this study yield a significant difference in state of negative affect and relaxation responses, whether the live music relaxation intervention is more effective than the recorded form of the intervention still needs further exploration.

Fourth, measurements used in this study may not be as reliable as physiological measures. It is acceptable to use self-reports to assess the participants’ affect change and relaxation response for this study, because the intent of this study was to focus on the qualitative difference of an individual’s subjective experience. However, social desirability bias is inevitable for self-reports. Even though the researcher rearranged the order of the PANAS, arranged to have the participants indicate their state of relaxation repeatedly through rating both the serenity items and the VAS, and avoided asking questions directly related to the intervention and the therapist, there may be some bias in their responses. Nevertheless, adding physiological measures may help provide a more objective view for the impact of the intervention on stressed female college students and a comparable data set with the subjective data.

In the current study, for gaining objective data, the Behavioral Relaxation Scale 98

(BRS) score sheet (Poppen, 1998) was employed because a physiological device was not accessible. When following the method described by Poppen (1998), the researcher found that the observable breathing patterns were not as accurate as data shown on a physiological device. When a participant moved their body parts (e.g., head, lips, or hands), the breath from that second could not be observed. Thus, future studies with a similar situation may need to consider adapting the scoring method of the BRS according to the research settings by adding physiological measurements to obtain the breathing rate. Also, as suggested by Williamson, Porges, Lamb, and Porges (2015) that slow and deep respiration and elongated exhalation may help activate the parasympathetic nervous system, including physiological devices to measure breathing rate throughout the intervention may provide an insight on whether or not the intervention helps increase the activities of the parasympathetic nervous system (to increase the HRV indices).

In addition, the PA subscale of the PANAS may not be an appropriate scale for this study. Although the PA scores were significantly reduced after the exposure of the intervention, the participant comments showed that they felt happy, were smiling, and that they felt the experience was positive for them. The conflicting findings of the study may be attributed to the fact that many of the PA subscale items could be capturing elements of arousal as well as positive affect. Given that the intention of this study was to help the participants cultivate contentment instead of arousal, the intervention might have made the participants less aroused, which led to the decreases in PA scores. As such, future research may consider using a different measure of positive affect. 99

Recommendations

More music therapy research studies about using live music-based intervention to help female college students are needed to establish a foundation for the use of music therapy in a college program. Based on findings from previous research studies, as well as the present study, the researcher concluded several points for future scholars who may be interested in a similar topic of study.

Design of the study. Future studies examining the effects of a live music relaxation intervention within a treatment cycle are preferred because contentment is cultivated over time. With a longer timeframe for the treatment process, the therapist would be more likely to develop a therapeutic relationship with the participants and provide them psychological support. Additionally, a comparison group should be included to compare effects of the live music relaxation intervention with other treatments conditions and/or a no treatment control condition. If possible, adding a pre- screen to determine the participants’ baseline stress levels before finalizing eligible participants may provide more information about the effectiveness of the intervention for stress severity. It is also not unusual for some music therapy researchers to include stress induction test(s) when examining an intervention (e.g., Barger, 1979; Hirokawa & Ohira,

2003; Khalfa, Bella, Roy, Peretz, & Lupien, 2003; Knight & Rickard, 2001; Thoma,

Marca, Brönnimann, Finkel, Ehlert, & Nater, 2013). However, even though stress induction could be helpful for determining stress severity, future researchers should decide whether or not to include it based on the purpose of their studies.

Measurements. Apart from self-reports, physiological measures should be considered in the future studies. Stress hormones (adrenal cortisol and catecholamines) 100 and heart rate variability (HRV) have been considered as relevant markers for measuring stress levels (Allen et al., 2014) and have been included in some music-stress research

(Khalfa et al., 2003; Knight & Rickard, 2001; Thoma et al., 2013; Wang, Dong, & Li,

2014). If future researchers share the same interest as the present investigation

(examining the effect of live music relaxation intervention on regulating emotions and stress levels), HRV may be a novel marker for measuring both emotional states and stress levels because HRV indices can indirectly reflect the cardiac vagus nerve that mediates the interactivity between the brain and the heart (Thayer et al., 2012). The vagal tone, which may be hard to be directly measured, is closely related to responses to acute stress and emotional expression; thus, its indirect indicator—HRV may help provide valuable information about the homeostasis of the autonomic nervous system and emotional states under stress (Beauchaine, 2015; Bunford, Evans, Zoccola, Owens, Flory, & Spiel, 2017;

Porges, 2011; Quintana, Guastella, Outhred, Hickie, & Kemp, 2012; Thayer et al., 2012).

Also, HRV may imply the functioning level of the prefrontal cortex (PFC), which continuously appraises situations and mediates the response of the amygdala based on memory and previous experience to inhibit emotional behaviors or reactions (Hänsel & von Känel, 2008; Thayer et al., 2012). Therefore, future researchers may consider measuring HRV as an additional predictor to learn if the process of cultivating contentment using live music relaxation has an impact on stress levels and emotional states.

Music selection. The use of client-preferred music has been recommended by previous music therapy researchers (Robb, 2000; Tan et al., 2012). Tan and her colleagues (2012) have recommended that preference for and familiarity to the music 101 being played are important factors to include when selecting a musical piece for relaxation. However, in a research setting, participant-selected music may create potential confounding variables, and the music selected by the participant may induce effects that contradict to the purpose of the study. For example, the musical components of the participant-selected music could induce excitement, even when the purpose of the study is to induce contentment. A solution may be selecting suitable musical pieces/songs within the participants’ favorite genre. Indeed, Walworth (2003) reported no differences between self-selected ‘genre’ and self-selected ‘song’ in terms of reducing anxiety. It is uncertain if the effects would be different on helping stressed female college students, but anxiety is also one of the negative emotions. Selecting music within the participants’ favorite genre may not only increase the participants’ familiarity to the song but also provide the therapist with opportunities to select appropriate pieces that the participants also prefer.

Intervention implementation. Although whether or not live music relaxation had a positive impact on the results of the current study needs further investigation due to the lack of a comparison group, this researcher would like to share several basic rules that she adhered to when implementing the applied intervention. These rules are:

(a) Choosing musical pieces following the existing guidelines for relaxing music.

(b) Familiarizing herself with the musical elements of the pieces, which includes analyzing the structure of the pieces and the harmonic structure.

(d) Avoiding constantly direct eye-contact. 102

(e) Being aware of the participants’ responses (in this way, the researcher changed the music according to the participants' responses she noticed).

(f) Preparing enough time for the return to alert state.

Also, future researchers should consider the desired outcomes when adjusting musical elements during this process, which is also suggested by Robb (2000). For example, the design of this study is to cultivate contentment; therefore, the therapist purposely faded the music and the verbal prompts to end the experience. If the purpose of the study was to help the participants reenergize and be prepared for the next task in life, the therapist could modify the musical elements differently during the stage of returning to alert state.

In addition, a verbal processing step or an opportunity to express internal thoughts through various modalities should be added to the protocol. Respondent comments of the current study revealed that most of the participants were stressed out and were worried about current life issues. One of the participants also stated that she recalled her mother’s recent death during the experience, which made her sad. An opportunity for the participants to process internal thoughts at the end of the experience may be helpful for emotional catharsis. As music relaxation experience can bring an individual into a calm and relaxed state where the individual may have more access to his or her subconsciousness, which may evoke or unfold a wide range of emotions, creating a safe container for the individual to process the feelings seems appropriate to add as a closure for the experience. This step could be presented in different modalities such as verbal processing, mandala, or sandplay. However, when the therapist incorporates other modalities into the protocol, the therapist should be mindful of his or her own 103 competency and make sure to select and implement a technique within his or her scope of practice. Within the scope of music therapy practice, a music therapist may help a client process his or her unsolved issues or emotions through music making such as improvisation and songwriting.

Reclining position. Allowing the participants to lie down during the experience may optimize the effects of the treatment. One participant of this study stated that she would be more comfortable if she could lie down, and another participant mentioned that she had difficulty relaxing her shoulders during the experience. If the participants could lie down in a comfortable recliner chair, they might be able to rely their back and shoulders against the chair, which would make them feel more comfortable and enjoyable.

Future inquiries. This researcher is interested in further exploring the impact of a present therapist on the therapeutic process. If the HRV indices or other physiological parameters can help indicate a receptive interactivity between the therapist and the participant through indicating the changes of stress levels and emotional states, this researcher has these follow-up questions: Would the stress levels and emotional states of the therapist or of the participant be affected by each other throughout the process?

Would this receptive interactivity help with the process or impede the process? Would it help improve the results, worsen the results, or have no influence on the therapeutic outcomes?

Another interest of this researcher is related to the effects of adjusting melodic phrases on breathing patterns. The intervention of the current study included four stages.

During the third stage of listening to the musical piece—Watermark, the therapist 104 adjusted the melodic phrases based on the participants’ responses—such as facial expression, body posture, and breathing patterns—to facilitate the relaxation effects of the experience which was to help regulate participants’ states of affect to a desirable level. However, this study did not include a research question and an analysis regarding how the melodic phrases of the sedative music could affect the participants’ breathing patterns specifically. It would be worth exploring how the musical adjustments (e.g., melodic phrases) made by a music therapist could affect the participants’ breathing patterns. This may also reflect Porges and colleagues’ suggestion regarding the benefits of deeper breathing for increasing parasympathetic tone (Williamson, Porges, Lamb, &

Porges, 2015) and help investigate whether or not the adjustments for melodic phrases can help activate the parasympathetic nervous system through deepening respiration.

Conclusion

Results of this study implied that although there was a lack of a comparison group, to some extent, the live music relaxation intervention might help the participants of this study reach a better mental/emotional state through cultivating contentment.

However, the results may not be generalized to other stressed female college students.

Future studies are called for to establish a clinical foundation for making music therapy available for stressed female college students, and scholars should consider the limitations and recommendations from this study and recruit a larger sample size of participants to implement a study using an experimental design.

As one of the few music therapy studies focusing on benefits of live music and the presence of a music therapist, this study provides preliminary evidence to support the benefits of live music relaxation for female college students who self-identified as 105 stressed. The results also indicate that the protocol was effective for cultivating contentment and it can be replicated in future studies with a similar focus. Although music therapy researchers rarely study this population, qualitative data from this study revealed that the female college student participants were suffering from psychological stress due to academic pressure and other life crises. It is necessary to find more healthcare options for stressed female college students to ameliorate mental stress in the first place. Because this study indicated that music therapy interventions such as live music relaxation may fit this need, evidence for the clinical use of music therapy to help stressed female college students needs to be established.

Since during the debriefing discussion, several participants also expressed to the researcher that if there was a regular session, they would like to receive the intervention for dealing with stress. Thus, if there is a music therapy program in a university, it may be worth considering helping stressed female college students by providing them access to the music therapy clinic on campus. This would not only provide stressed female college students with one more option for alleviating psychological stress but also provide more opportunities for establishing the clinical foundation for the use of music therapy among stressed female college students.

106

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Appendix A: Ohio University IRB Approval Notice

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Appendix B: Flyer for Recruiting Participants

+ »

NEED RESEARCH CREDIT FOR PSYCHOLOGY CLASS?

Female College Non-Music Major Student Participants Needed for Live Music Listening Study

Are you a female non-music major college student? Are you aged from 18 to 25 years? Do you feel stressed-out? Do you understand and speak fluent English? Do you have no hearing problems? Are you generally in good health?

If you said yes to all of these questions, you may benefit from participating in a Music Therapy graduate thesis study. If you participate in this study, you can receive one (1) hour of research credit for your psychology class.

If you are interested in participating in this study, please find the study by searching its name “Impact of A Live Music Relaxation Intervention on Stress Among Female College Students” and sign up through the Psychology Experiment Sign-up System (http://psychpool- ohio.sona-systems.com). This study is only available for students who have access to the psychology experiment sigh-up system.

*If you have any questions about the study, you may contact the research at [email protected]. Also, you may contact the researcher’s faculty advisor, Kamile Geist, PhD, [email protected] or the Ohio University Office of Research Compliance, [email protected] or 740-593-0664.

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Appendix C: Study Description on the SONA System

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Appendix D: Ohio University Adult Consent Form with Signature

Title of Research: Impact of a Live Music Relaxation Intervention on Stress Among Female College Students

Researchers: Yinglan He

You are being asked to participate in research. For you to be able to decide whether you want to participate in this project, you should understand what the project is about, as well as the possible risks and benefits in order to make an informed decision. This process is known as informed consent. This form describes the purpose, procedures, possible benefits, and risks. It also explains how your personal information will be used and protected. Once you have read this form and your questions about the study are answered, you will be asked to sign it. This will allow your participation in this study. You should receive a copy of this document to take with you.

Explanation of Study This study is being done to understand the impact of a live music-listening protocol on stressed female college students’ well-being.

If you agree to participate, you will be asked to fill in questionnaires about your state of relaxation and affect. Also, you will receive an approximately 12-minute music therapy intervention. The entire process will be video-recorded.

You should not participate in this study if you have a hearing impairment or have a history of a severe somatic psychiatric disease or clinically diagnosed mental disorder, such as PTSD.

Your participation in the study will last for no more than an hour.

Risks and Discomforts Risks or discomforts that you might experience are very mild, which may be caused by filling in self-reports and sitting in front of a camera.

Benefits This study is important to science/society because it may help advocate the benefits of music therapy for alleviating stress among female college students. The study may provide female college students an option to relieve stress.

Individually, you may benefit from this experience, which may improve your well- being. Moreover, you may have a better understanding about how music therapy can promote relaxation and alleviate stress.

Confidentiality and Records All information will be kept confidential by removing personal identifiers and by keeping the data and video-recordings in a secure location on a password protected 128

flash drive. Only the primary researcher and the research assistant will have access to this information. Additionally, those data with identifiers will be kept only for coding data and granting research credit. All of the data will be destroyed after the closure of the study, which may be before October 2020.

Additionally, while every effort will be made to keep your study-related information confidential, there may be circumstances where this information must be shared with: * Federal agencies, for example the Office of Human Research Protections, whose responsibility is to protect human subjects in research; * Representatives of Ohio University (OU), including the Institutional Review Board, a committee that oversees the research at OU;

Compensation As compensation for your time/effort, you will receive one hour of research credit awarded through the Psychology SONA enrollment. . Contact Information If you have any questions regarding this study, please contact Yinglan He at 740-818- 6813 or at [email protected]. You may also contact the researcher’s faculty advisor, Kamile Geist, PhD, at 740-593-4249 or [email protected]

If you have any questions regarding your rights as a research participant, please contact Dr. Chris Hayhow, Director of Research Compliance, Ohio University, (740)593-0664 or [email protected].

By signing below, you are agreeing that: • you have read this consent form (or it has been read to you) and have been given the opportunity to ask questions and have them answered; • you have been informed of potential risks and they have been explained to your satisfaction; • you understand Ohio University has no funds set aside for any injuries you might receive as a result of participating in this study; • you are 18 years of age or older; • your participation in this research is completely voluntary; • you may leave the study at any time; if you decide to stop participating in the study, there will be no penalty to you and you will not lose any benefits to which you are otherwise entitled.

Signature Date

Printed Name Version Date: [10/11/17] 129

Appendix E: Debriefing Statement

Thank you for participating in the Live Music Listening study. You were told that this study investigated the impact of a live music therapy intervention on female college students’ sense of well-being. While it’s true that we were interested in your sense of well-being, we were actually interested in how this live music relaxation intervention may reduce your psychological stress by regulating your emotions and improving your state of relaxation. You were told this cover story to prevent any biased responding on the part of the participant.

All of the participants received the same type of live music relaxation intervention, experienced the same procedures during the experiment, and completed the same types of self-reports.

We hypothesized that the live music relaxation intervention guided by a music therapist would help lower your negative emotion, improve your positive emotion, and promote your relaxation.

Please make sure to not discuss the hypotheses or procedures of this with any other person who may elect to participate, because knowledge of the study’s hypotheses may bias their responses. If you have any questions about the study, feel free to contact Yinglan He ([email protected]).

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Appendix F: Experimenter Sheet

Experimenter: ______Date: ______Time:______

Participant’s ID: ______

Part I Introduction & Consent (~5-10 mins) Actual Time ______Start video-recording for breathing baseline Then, describe study, confirm eligibility and consent ______Turn off the camera

Part II: Pre-intervention self-reports – PANAS & VAS-R (~5 mins) Actual Time ______Issue the self-reports to participant ______Return when signaled by participant

Part III: Music Intervention Time (~12 mins) Actual Time ______Start video-recording ______Finish the intervention and turn off the camera

Part IV: Post-intervention self-reports – PANAS, Satisfaction Rating Scale + Experience Review (~10 mins) Actual Time

______Issue the self-reports to participant ______Return when signaled by participant

Part V: Conclusion (~ 5 mins) Debriefing

Notes

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Appendix G: Qualtrics Survey – Positive Affect Negative Affect Scale,

VAS-Relaxation, & Satisfaction Review

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133

134

135

136

137

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Appendix H: Behavioral Relaxation Scale Score Sheet

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Appendix I: Guidelines for Relaxing Music

Referencing from the existing techniques, approaches (e.g., passive listening, and various music-assisted relaxation techniques) and related studies for stress reduction, characteristics of musical elements for stress reduction and/or relaxation may be concluded in the followings (Grocke & Wigram, 2007; Hooper, 2012; Robb et al., 1995; Steblin, 2002; Tan et al., 2012; Pelletier, 2004).

*Please note that the listed components may not be suitable for music imagery experience. Characteristics of Musical Elements for Stress Reduction/Relaxation Form ABA, AABA, and A-A-B-B Regular meter provides regular and predictable accents, which can affirm Meter the stability of the structure by steady moves Some researchers suggested that for relaxation purposes and to decrease brain waves, lower pitches should be predominantly used (Robb et al., 1995; Saperston, 1993). In contrast, some (Nakajima, Tanaka, Mima, & Pitch Izumi, 2016) indicated that high-frequency components of music were more effective for stress reduction than low-frequency components. Also, Tan and her colleagues (2012) reported that pitches of the relaxing instrumental pieces in their study “centered around C5.” Smooth or water-like. Continuous without sudden change. Linear direction without wide intervals between pitches are preferred. Little Melody embellishment. Predictable without too many accents and dramatic expressions. Dynamics Soft to moderately loud range Consonant and predictable without abrupt changes. Suitable for the Harmony melodic line and not boring. Traditional cadence for the end of the piece (e.g., authentic cadence) Thick or thin consistently. Smooth transition or alteration if additional Texture instrument part(s) is added or faded. Predictable. Limitations in syncopation (stretch the units and make it not Rhythm percussion-like, if there is syncopation in the piece) Stable with gradual changes toward desired direction. It could sometimes be slower than 60 beats per minute, but it should not be faster than the Tempo range of a normal heart rate. According to Hart (2015), the resting heart rate range of participants who aged 17-25 years is between 75 to 80 beats per minute. Considerations of key were rarely discussed in the music-stress studies, but pieces in major modes are highly recommended by therapists (Tan et al., 2012). The 30 relaxation music selections evaluated by Tan and her colleagues (2012) were written in C, D, or G major. The researcher of this Key thesis compiled the characteristics of the keys from related literature. There are controversies throughout the musicological history about the key affects, especially in the eighteenth and early nineteenth centuries (Steblin, 2002). Many composers and musicologists studied the keys and 140

attached them with different characteristics as stimuli of emotional arousal (Steblin, 2002). Observing from Steblin’s collections of descriptions and quotes of the keys from the predecessors, the researcher attempted to classify and rank the keys from high energy to low energy. Keys endorsed by positive feelings include: C major (“grandeur,” “purity,” “simplicity,” completeness, and “triumph”) D major (“joy,” “victory,” “uplifting” and “lively” qualities) A major (“devotion,” “joy,” God, “brilliance,” “warmth,” and “innocent love”) F# major (“triumph over difficulty,” “victory,” “less brilliancy”) F major (“church,” “gaiety mixed with gravity,” “dead calm,” “joy but sober than C major” “contemplative,” “peace,” and “energy”) Bb major (“joy,” “tragic” character, “twilight,” “love, charm, and grace,” “less noble than C major and more pathetic than F major,” “dignity”) G major (“tenderness,” “sweetness,” “pleasing tone,” “indifference,” “serenity,” and “recklessness”)

Keys were described as creating negative moods include: Eb minor (horror, “difficulty in performance,” “anxiety,” and “ghost”) Bb minor (mourn, “preparation for suicide,” and “deep feelings of pain,”) F# minor (“great distress” from love, “melancholy,” “a little hardness,” and “tragic” character) B minor (“lonely,” “it can touch heart,” “sweetness,” “black” and “gloomy” character, “biting, dry, and savage,” “closely related to f# minor” and “calm resignation,”) F minor (“complaints,” “tenderness,” “sadness,” “grief,” and “deep depression”) C minor (“gloomy” and “pathetic” character, “extremely lamenting feelings” from love, and “longing and gentle lament”) Ab major (“grave,” “splendid majesty,” “dark feelings,” and “dull but noble” qualities) A minor (“serious subjects,” “sorrow,” “grief,” “tenderness,” and “patience”), Db major (“unusual,” “awful dark,” “grief,” and “majesty”) G minor (“sadness,” nobility, “meek and passive” qualities, “apathy,” “cannot be directly characterized,” and “sulkiness”)

Keys with mixed feelings from the descriptions are considered as keys conveying neutral feelings here: Eb major (“hard”, “night”, hero, God, “the most ambiguous key,” and “devotion”) B major (“harsh and plaintive” feelings, “harsh but more piercing than E [major],” “wild passion--jealousy, anger and despair,” “the most glaring color” as E major, “brilliancy,” and “overexcitement”) 141

E major (“quarrelsome,” “hopelessness,” “noisy shouts of joy,” “brightness,” and “brilliancy”) D minor (gravity, sweetness and tenderness, gentle sorrow and pain, and “melancholy womanliness”) E minor (“tenderness,” “innocent sound of love,” “lament of sympathy,” incomplete fulfillment” and “slightly commonplace”)

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Appendix J: Script for Autogenic Body Scan Relaxation

As you continue to breathe deeply, become aware of the muscles of your feet…relax those muscles, so that your feet feels relaxed…Become aware of the muscles of your legs… relax those muscles, so that your legs are relaxed…Become aware of the muscles through your hips and pelvis and through to the lower back… relax those muscles, so that this part of your body is relaxed… Become aware of the muscles of your stomach… relax those muscles, so that your stomach is relaxed……Become aware of the muscles in your diaphragm and chest…relax those muscles, so that your chest is relaxed….. Become aware of the muscles of your shoulders, across the shoulders and the back of the shoulders… relax those muscles, so that your shoulders are relaxed…… Become aware of the muscles of your arms through to your hands, and fingers and thumbs… relax those muscles, so that your arms and hands are relaxed... Become aware again of the muscles of your shoulders and, moving up now into the neck and throat… relax those muscles, so that your neck is relaxed…Become aware of the muscles of the face… the jaw, across the nose, the muscles of your eyes and behind your eyes, the forehead, to the top of your head…relax those muscles, so that your face is relaxed… Your body is fully and deeply relaxed… and now become aware of the music and let yourself sink into the music…(therapist played Watermark).

References: Grocke, D. E., & Wigram, T. (2007). Receptive methods in music therapy: Techniques and clinical applications for music therapy clinicians, educators, and students. London ; Philadelphia : Jessica Kingsley Publishers

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Appendix K: Watermark

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Appendix L: Self-Care Strategies

Free Applications for Relaxation: • With verbal suggestions Aura Calm: Meditation • Only music Relax Melodies

Potential Repertoire for Self-care (Grocke & Wilgram, 2007; Pelletier, 2004) *Please note: effects of listening music as self-help strategies could be different from music therapy. Music selections used in music therapy session are carefully selected by a board-certified music therapist based on individualized goals. • Classical Music Prelude to an Afternoon of a Faun (composed by Debussy) Air on a G String Morning Mood (composed by Edvard Grieg) Moon on the Ruined Castle (performed by James Galway) New World Symphony (composed by Antonin Dvorak) • Non-classical Selections Watermark—tracks 1, 3, 6 and 8 (composed and performed by Enya) Shepherd Moon—tracks 3, 6, 9 and 10 (composed and performed by Enya) Peace of Mind (performed by John McLaughlin) Deep Breakfast (composed and performed by Ray Lynch) Fragrances of a Dream (composed and performed by Daniel Kobialka) Timeless Motion (composed and performed by Daniel Kobialka) A Child’s Gift of Lullabies (performed by Tanya Goodman) • Environmental Sounds Early Morning in the Rainforest (composed by Ken Davies)

Studies also showed that preferred music selections can help reduce stress, so feel free to follow your own preference and pick up songs your like outside of the suggestions from this handout!

References: Pelletier, C. L. (2004). The effect of music on decreasing arousal due to stress: A meta- analysis. Journal of Music Therapy, 41(3), 192-214. doi: 10.1093/jmt/41.3.192 Grocke, D. E., & Wigram, T. (2007). Receptive methods in music therapy: Techniques and clinical applications for music therapy clinicians, educators, and students. London ; Philadelphia : Jessica Kingsley Publishers

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Appendix M: Experience Review—Mind, Body, and Other Thoughts

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Appendix N: Experience Review—Changes in Mind, Body, and Auditory Stimuli

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Appendix O: Experience Review—Positive and Difficult Parts of the Experience

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Appendix P: Experience Review—The Presence of the Therapist

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