Priming for Flow States Through Engagement Within Music Therapy Improvisation

A Thesis Submitted to the Faculty of Drexel University by Bonnie Rose Eccles in partial fulfillment of the requirements for the degree of Master of Arts in Music Therapy and Counseling Department of Creative Arts Therapy College of Nursing and Health Professions May 2018

Acknowledgements To my thesis advisor, Paul Nolan, for your continued support, guidance, and dedication throughout this process. Your wealth of knowledge is inspiring, and I appreciate you sharing some of it with me. And to my second reader, Ali Rigby for your time, feedback, and enthusiasm.

To my practicum supervisors, Phil McMillan and Emily Bolles, for being my initial models of what a music therapist can be and providing me with an understanding of how to work with a range of populations. To my internship supervisor, Tim Honig, for your constant support and push throughout my internship process. Your drive and passion continue to inspire me, and I cannot thank you enough for encouraging me to pursue and develop my unique interests in music therapy.

To my family, for a lifetime of modeling hard work, love, and commitment.

Thank you for your constant support and guidance.

To the faculty, for your wealth of knowledge and dedication, and to my classmates, for encouraging me to step outside of my comfort zone and take risks. It has been quite the journey.

To my roommates, for our session planning brainstorms, late night jam sessions, and vocal improvisations. Thank you for keeping me grounded, reminding me to breathe, and letting me be myself. I cannot imagine this year without you.

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TABLE OF CONTENTS LIST OF FIGURES ...... v ABSTRACT ...... vi 1. INTRODUCTION ...... 1 2. LITERATURE REVIEW ...... 5 2.1 Depression...... 5 2.1.1 Lifelong Problems Associated with Depression ...... 5 2.1.2 Common Practice ...... 7 2.1.3 Positive Psychotherapy ...... 8 2.2 Flow ...... 10 2.2.1 Eight Elements of Flow ...... 11 2.2.1.2 Additional components of flow ...... 14 2.2.2 Benefits of Flow ...... 14 2.2.3 Depression and Potential Difficulties with Flow ...... 16 2.3 Priming ...... 17 2.4 Music Therapy and Depression ...... 18 2.4.1 Expressive Methods ...... 18 2.4.2 Receptive Methods...... 19 2.4.3 Resource-Oriented Approaches in Music Therapy ...... 21 2.5 Music Eliciting Flow...... 22 2.6 Music Therapy and Flow ...... 24 3. PRODUCT/REPORT ...... 27 3.1 Description of the Setting ...... 27 3.2 Method ...... 28 3.2.1 Considering the Elements of Flow ...... 29 3.2.2 Structure ...... 30 3.2.3 Anxiety Reduction/Management ...... 31 iv

3.2.4 Group Music Making ...... 32 3.2.4.1 Promoting competency ...... 33 3.2.4.2 Improvisation ...... 34 3.2.5 Verbal Processing ...... 37 3.3 Clinical Vignettes...... 39 3.3.1 Vignette 1: High Skill, High Challenge ...... 39 3.3.1.1 Active music making ...... 39 3.3.1.2 Verbal processing ...... 40 3.3.2 Vignette 2: Increased Engagement Through Grounding ...... 40 3.3.2.1 Anxiety reduction...... 40 3.3.2.2 Active music making ...... 41 3.3.2.3 Verbal processing...... 42 3.3.3 Vignette 3: Loss of Self-Consciousness ...... 42 3.3.3.1 Active music making ...... 43 3.3.3.2 Verbal processing...... 44 3.3.3.3 Personal reaction ...... 44 4. DISCUSSION ...... 46 4.1 Conclusions ...... 46 4.2 Reflection ...... 50 4.3 Suggestions ...... 52 4.3.1 Further Study ...... 52 4.3.2 Recommendations for Practice ...... 53 LIST OF REFERENCES ...... 54 APPENDIX A ...... 59

List of Figures 1. Flow Channel ...... 35 vi

Abstract Priming for Flow States Through Engagement Within Music Therapy Improvisation Bonnie Rose Eccles Paul Nolan, M.C.A.T., MT-BC, LPC

The purpose of this thesis is to develop a method to promote flow states in patients in an inpatient psychiatric hospital through group music making. Relevant literature will be reviewed to inform and provide context for the method. The reviewed literature includes an overview of everyday issues associated with depression on quality of life, common practice in the treatment of depression, an introduction to positive psychotherapy, defining characteristics of flow states, benefits of frequently reaching and sustaining flow states, common music therapy practice, music eliciting flow, and flow within the context of music therapy. With the elements of flow in mind, this method was developed to promote complete immersion during group improvisation in order to exploit the benefits of engagement in the intrinsically rewarding experience that group improvisation can be. These benefits include self-growth, a greater sense of connection with the group or to oneself, and increases in subjective well-being, while accessing individuals’ internal areas of health and strength. Additionally, I reflect on what I learned while developing and implementing the method, and how this experience has influenced who I am as a music therapist.

CHAPTER 1: INTRODUCTION

The primary purpose of this capstone thesis was to examine flow states in group music therapy sessions with hospitalized individuals with depression. A secondary purpose of this method was to help music therapists working in mental health become more aware of the experience and implications of flow states during music therapy sessions. Taking into consideration recommendations and findings from the literature on flow, positive psychotherapy and depression, and flow and music/music therapy, I developed a method for structuring a music therapy session so that it would be conducive to eliciting flow states in group members on a mood disorders (primarily depression) unit of a psychiatric hospital, using normal music therapy techniques. I also sought to structure verbal processing so as to increase participants’ awareness of their achievement of flow states and of their own cognitive and behavioral contributions towards their experience in order to give them ideas about how to use their own resources to have similar experiences outside of the music therapy session.

Flow is defined as the complete immersion in an intrinsically rewarding task and has been linked to an increase in quality of life, subjective well-being, positive experiences, and meaning (Hunter & Csikszentmihalyi, 2003; Silverman, Baker, &

MacDonald, 2016). Flow states may also aid in increasing one’s sense of connection to others, prosocial behavior, self-determination, and intrinsic motivation (Yaden, Haidt,

Hood, Vago, & Newberg, 2017). As all or most of these components may be diminished in individuals with depression, it may be of particular importance to explore how flow can be achieved with this population. 2

The creative process, including practicing and participating in music, is a well- recognized way to reach such a state (Croom, 2015). Some of the factors that aid in the facilitation of a flow state include a balance between challenge and skill, clear goals, focus on task, feelings of control, and autotelic experience (Fritz & Avsec, 2007). In a music therapy session, the therapist may be able to help create an environment that is conducive to participants moving towards or reaching flow states by carefully considering how these factors are incorporated.

Though the evidence base makes it clear that music making is a prevalent means through which people experience flow (Bernard, 2009; Fritz & Avsec, 2005; Croom,

2015), the research on music therapy and flow is limited. Literature on music therapy and flow has had a heavier focus on therapeutic songwriting thus far, suggesting that the structure of songwriting followed by the eventual performance of the song facilitates the required balance between skill and difficulty and is an autotelic experience with clear goals (Silverman, Baker, & MacDonald, 2016).

While studying flow in the songwriting process, Baker and MacDonald (2013) found that participants experienced higher rates of flow during the writing of songs than in the performance of songs, suggesting that the creative process also had a strong influence on flow. The analytical components of songwriting, however, may have less of an impact on participants reaching a flow state. As Dietrich (2004) explains, flow states require a switch from explicit to implicit systems of information processing. Since flow states temporarily suppress the analytical and meta-conscious capacities of the explicit system of information processing (Dietrich, 2004), the analytic component of clinical songwriting may be antithetical to a flow state. With these two studies in mind, 3 improvisation was used in the current method to allow for participants’ creativity to be used to its highest potential while reducing the need for the analysis and meta-cognition that may not be available to an individual in a flow state.

The objective of the proposed method was to hone in on the elements of flow that a music therapist can control in order to create the necessary conditions for clients to reach a flow state during improvisation, while presenting the benefits of flow that argue for the intrinsic value of group music making. In addition to increasing one’s sense of connection to others, prosocial behavior, self-determination, and intrinsic motivation, research on flow and other self-transcendental experiences suggests that such experiences enhance well-being which, when applied to a psychiatric population, can have positive outcomes regarding compliance, quality of life, and perhaps symptom reduction (Sin &

Lyubomirsky, 2009; Hunter & Csikszentmihalyi, 2003; Yaden et al., 2017).

Despite the limited research on music therapy and flow, it seems likely that flow is occurring in music therapy sessions around the world. Client’s often report feeling as though they were able to leave their worries behind, focus entirely on the task at hand, and feel a deeper sense of connection with themselves and to the group, all phrases that may indicate a flow experience. Music therapists may not be aware of the fact that clients are experiencing flow states, however, so the benefits of flow states have not been developed and exploited within a music therapy context. While it is not within the scope of this capstone project to explore the longer term impact of flow in group improvisation on one’s quality of life, it is my hope that this project will inspire music therapists to place a greater value and consideration on the here-and-now experience of group music 4 making while acknowledging and understanding the inherent benefits of flow in group music making. Conclusions and recommendations can be found in chapter 4.

CHAPTER 2: LITERATURE REVIEW

Depression

Depression is one of the most common mental health problems, and is the leading source of mental health disability worldwide (Woo & Keatinge, 2016). In 2015, the

National Institute for Mental Health (NIMH) estimated that 16.1 million people above the age of 18 in the United States had experienced at least one major depressive episode in the past year (NIMH, 2015). Symptoms include depressed mood, loss of interest or pleasure, difficulty concentrating and making decisions, a mood-congruent attentional bias, negative self-evaluation, motoric changes, changes is sleep and appetite, and fatigue or decreased energy (Woo & Keatinge, 2016). For the purposes of this thesis, however, attention will primarily be given to the impact that depression has on one’s quality of life and well-being, defined by Killingsworth and Gilbert (2010) as an interplay between happiness, life satisfaction, and low levels of neuroticism.

Lifelong Problems Associated with Depression

Depression leads to reduced well-being, impairments in social functioning, and reduced social and material supports, which has an impact on a person’s quality of life in a variety of domains (Angermeyer, Holzinger, Matschinger, & Stengler-Wenzke, 2002).

Angermeyer et al. (2002) examined the six domains of quality of life assessed by the

World Health Organization Quality of Life (WHOQOL) assessment, which includes physical health, psychological domain, independence, social relationships, environment, and spirituality. Results suggested that the quality of life in people with remitted depression is higher than quality of life when depressive symptoms are present, yet lower than in individuals with no diagnosis of depression (Angermeyer et al., 2002). These 6 results were especially evident in the domains of levels of independence, spirituality/religion/personal beliefs, and physical health. Quality of life scores remained stable in patients with remitted depression after six months, suggesting that the impact of depression on quality of life persists even when the depression is in remission.

(Angermeyer et al., 2002).

Depression may have a greater impact on overall health than chronic physical diseases, further impacting one’s quality of life. In an analysis of results from the World

Health Organization’s World Health Survey, Moussavi et al. (2007) found that respondents with depression alone had lower health scores than respondents with either angina, arthritis, asthma, or diabetes alone. Additionally, health scores were lower when the depression was comorbid with a chronic disease than when an individual suffered from multiple chronic diseases but not depression. This analysis also found that the prevalence of chronic disease and depression was significantly greater than chronic disease alone (Moussavi et al., 2007).

Oftentimes, patients and psychiatrists often have differing views of what constitutes quality of life (Lambert & Naber, 2004). Patients describe quality of life with regards to standard of living and lifestyle and express a greater interest in promoting well-being versus focusing on symptom reduction (Lambert & Naber, 2004; Solli &

Rolsvjord, 2015). Psychiatrists, on the other hand, view quality of life more in terms of the illness, focusing on the absence of disability (Lambert & Naber, 2004). Many mental health facilities have been shifting towards a recovery model, however, which empowers individuals with severe mental illness to become more active agents in their recovery 7 process, creating their own personal meaning that is independent from their symptoms

(Jacob, 2015).

In addition to quality of life, depression is also associated with low levels of patient activation, or the ability to care for oneself. Though they could not determine causation within the scope of their study, Magnezi, Glasser, Shalev, Sheiber, and Reuveni

(2014) found the presence of depression to be associated with low levels of quality of life and patient activation. This suggests a possible entry point at which the cycle between these three elements may be disrupted. Magnezi et al (2014) recommend developing strategies to promote patient activation, with the hopes that an increase in patient activation will ameliorate depressive symptoms while improving quality of life.

Common Practice

Treatment for depression generally involves pharmacological interventions, short- or long-term psychotherapy, such as cognitive behavioral therapy (CBT) or interpersonal therapy, or some combination of the two with the aim of reducing or managing symptoms

(Olfson et al., 2002; Mayo Clinic Staff, 2017). In fact, Blackburn, Bishop, Glen, Whalley, and Christie (1981) found cognitive therapy, in conjunction with pharmacological treatment to be more effective than either form of treatment alone. Additionally, ongoing intervention and the regular monitoring of depressive symptoms by medical professionals, referred to by Rost, Nutting, Smith, Elliott, and Dickinson (2002) as enhanced care, has positive implications in the treatment of depression. Rost et al. (2002) found that enhanced care for individuals with depression increased remission rate and improved emotional and physical functioning. Patients receiving enhanced care were also 8 more likely to engage in a pharmacological regimen and attend mental health counseling

(Rost et al, 2002).

Positive Psychotherapy

Stemming from the field of positive psychology, a term first introduced by

Maslow in 1954, positive psychotherapy aims to ameliorate depression by targeting and enhancing what Seligman, Rashid, and Parks (2006) believe to be the three main components of happiness – positive emotion, meaning, and engagement (Srinivasan,

2002; Seligman, Rashid, & Parks, 2006). A lack of these three components may not merely be symptoms of depression, they may be part of the cause (Seligman, Rashid &

Parks, 2006). In order for the depressed individual to experience happiness, more needs to be done than relieving depressive symptoms. By building positive emotion, meaning, and engagement in therapy and through homework exercises, a client is more likely to experience “the good life”, or happiness (Duckworth, Steen, & Seligman, 2005;

Seligman, Rashid & Parks, 2006).

Positive psychotherapy may have the ability to go beyond remission of depressive symptoms, promoting recovery. Results from a meta-analysis conducted by Sin and

Lyubomirsky (2009) suggest that positive psychotherapy interventions not only increase subjective well-being in participants with depression, they may also decrease depressive symptoms. Some components of the positive psychotherapy interventions described include engagement in enjoyable activities and using one’s strengths in new ways. Woo and Keatinge (2016) also note the importance of tailoring interventions to a client’s strengths as opposed to solely improving areas of deficit. 9

Positive emotions related to the past, present, and future may counteract some of the effects of depression (Seligman, Rashid, & Parks, 2006; Duckworth, Steen, &

Seligman, 2005). Interventions in positive psychotherapy teach and encourage an individual to focus on positives, such as strengths and resources. This redirection of attention towards positives counteracts a depressive bias that many people, especially those with depression, exhibit (Seligman, Rashid, & Parks, 2006; Schrank, Browell,

Tylee, & Slade, 2014). Techniques employed in positive psychotherapy aim to reverse the tendency for people with depression to have a stronger memory for negative events by encouraging people to reflect on positive events and emotions more frequently

(Seligman, Rashid, & Parks, 2006).

Meaning has long been considered an important component of human existence.

Even before the emergence of positive psychology, existentialists such as Victor Frankl, with his logotherapy, viewed the understanding of the meaning of one’s existence to be the fundamental goal of life (Cain, 2002). Baumeister and Vohs (2005) describe meaning in life as the merging of a sense of purpose, a set of values, a sense of efficacy, and feelings of self-worth. Connection, whether it is between people, objects, or ideas, is at the core of meaning. Meaning is enhanced in positive psychotherapy by encouraging individuals to use their signature strengths to belong to something greater than oneself

(Seligman, Rashid, & Parks, 2006).

The third component of “the good life” is engagement. Seligman, Rashid, and

Parks (2006) found engagement, along with meaning, to be strongly correlated with life satisfaction. In fact, the authors believe that depression may be the result of a lack of engagement. Targeting engagement in a positive psychotherapeutic practice involves 10 enhancing signature strengths and finding ways to use them with greater frequency and intention (Seligman, Rashid, & Parks, 2006; Duckworth, Steen, & Seligman, 2005).

When an individual is fully engaged in a task or activity, they are having an optimal experience, or flow (Csikszentmihalyi 1990).

Flow

Flow, or optimal experience, is described as the “psychological state that accompanies highly engaging activities” (Seligman, Rashid, & Parks, 2006, p. 777). This concept now locates itself within the positive psychology framework, but was first introduced by Csikszentmihalyi before the field was fully formed. According to

Csikszentmihalyi (1990), flow is an active state, where an individual feels as though they are truly in control of their actions and their minds are stretched to the limit, resulting in a deep sense of enjoyment. This concept is frequently cited in the positive psychology literature as playing a major role in engagement, subsequently enhancing what is termed in the field as “the good life” (Seligman, Rashid, & Parks, 2006; Nakamura &

Csikszentmihalyi, 2005).

Flow is closely related to, and oftentimes overlaps Maslow’s concept of peak experience. Both experiences are related to optimal levels of functioning and consciousness, a loss of sense of self, clear focus and absorption, and a transformation in perception of time (Privette, 1983). As Privette explains, flow differs from peak experience in that peak experience is spontaneous and unplanned, whereas flow can often be structured and planned, as it can be sought out by engaging in an autotelic activity.

Additionally, peak experience involves superior levels of joy, which may be present in but is not a requirement for flow (Privette, 1983). 11

Eight Elements of Flow

Csikszentmihalyi (1990) describes eight elements that contribute to flow. Some, but often all, of these elements are present when an individual reaches a flow state. The first is a balance between the challenge of and skill required to carry out an action, whether it is physical or mental. The challenge of a task should stretch one’s existing skills (Nakamura & Csikszentmihalyi, 2005). If the challenge is far greater than one’s ability level, an individual will become anxious. On the other hand, if the action is too easy for an individual’s skill level, they will become bored. Under both conditions described, an optimal experience will be difficult to achieve. If the balance between the difficulty of a task and a person’s ability to perform the task are balanced, however, they are more likely to experience full engagement in that task (Csikszentmihalyi, 1990).

The second element that contributes to a flow state is a merging of action and awareness (Csikszentmihalyi, 1990). When action and awareness are merged, a task can be carried out in a spontaneous and automatic manner, though a person’s focus is still on the task at hand. A person feels as though they are one with the task at hand, becoming completely absorbed and unable to separate themselves from the task.

Once an individual’s awareness merges with the activity with which they are engaged, the sense of self fades away (Yaden, Haidt, Hood Jr., Vago, & Newberg, 2017).

As Csikszentmihalyi (1990) described, people are consumed by thoughts of the self in everyday life in order to assess and manage perceived threats. Every time there is a potential threat, the self is brought into consciousness in order to determine the risk of the threat and how to proceed, resulting in a disruption in psychic energy. Once someone becomes so absorbed in an activity, however, they often cease to think of the self 12

(Csikszentmihalyi, 1990). As Schüler and Brunner (2009) explain, there is not enough left-over attention for one to engage in self-analysis, and any fear of failure dissipates.

Additionally, the self is less threatened when experiencing flow due to the balance between challenge and skill and the clear goals of the activity.

Clear goals and immediate feedback are also important factors that lead to flow

(Csikszentmihalyi, 1990). Establishing goals lets an individual know what their objectives in carrying out an action are, while immediate feedback either lets them know that they are on the right path, or that they need to make an adjustment in order to reach goals.

According to Csikszentmihalyi (1990), goals and feedback will look different depending on the activity. In more creative activities, goals are not always clearly defined. In these cases, it is important for the individual to develop their own goals and approach the task with intention. Additionally, feedback will be different depending on the task. For example, an absence of blood in an incision provides a surgeon with feedback, confirming that they are successful in working towards their goals. Therapists, on the other hand, look for more subtle feedback in the form of facial expressions, body language, and quality and quantity of disclosure from a client (Csikszentmihalyi, 1990).

As Csikszentmihalyi (1990) stated, feedback “creates order in consciousness, and strengthens the structure of the self” (p. 57).

The fifth element, concentration on the task at hand, allows for people experiencing flow to temporarily leave their worries behind. While many ordinary activities do not fully occupy the mind, leaving it able to wander, the structured demands that are present in activities that are conducive to eliciting flow states helps to add order 13 to the mind (Csikszentmihalyi, 1990). This order assists in minimizing interferences from outside forces, allowing for full attention and concentration to be on the activity that one is engaging in.

One of the most frequently described elements of flow is a loss of sense of time

(Csikszentmihalyi, 1990). As Nakamura and Csikszentmihalyi (2005) explain, when one’s attention is entirely taken up by the present task, the passing of time becomes distorted. The passing of time becomes dictated by the unfolding of the activity.

Generally, people report that the feeling that time passes much more quickly than the clock suggests.

A sense of control, or a lack of worry that one might lose control, is an additional element that is typically involved in flow states (Csikszentmihalyi, 1990). This sense of control aids in diminishing a fear of failure and as Csikszentmihalyi (1990) describes, allows an individual to engage in a potentially dangerous or risky task without fear for one’s safety.

The last, and perhaps most important, element of flow is that it is an autotelic experience, described by Csikszentmihalyi (1990) as something that is intrinsically rewarding and is done for no other reason than for the experience. Although anyone has the capacity to experience flow, Nakamura and Csikszentmihalyi (2005) describe an autotelic personality that people who frequently do things for their own sake often possess. A curiosity and interest for life, low self-centeredness, and persistence often leave an individual motivated by intrinsic factors.

Additional components of flow.

In addition to these eight phenomenological components of flow, there are physiological components to consider as well. Dietrich (2004) described the neural mechanisms that underlie experiences of flow, claiming that a state of hypofrontality, or reduced activity of the prefrontal cortex, must be present in order for a flow state to occur. When a task is carried out with reduced prefrontal cortex activity, the execution of the task is automatic and unconscious. Dietrich (2004) refers to this type of information processing as the implicit system of information processing. The more implicit a task is, the more likely it is to evoke a flow state (Dietrich, 2004).

Benefits of Flow

Various studies have found a relationship between flow and motivation. Because of the intrinsic reward involved in flow states, people often experience motivation to return to such a state (Schüler & Brunner, 2009). In a study examining the impact of flow on runners training for a marathon, Schüler and Brunner (2009) found that the experience of flow while training increased future running motivation. Additionally, Kowal and

Fortier (1999) found intrinsic and self-determined extrinsic motivation to be strong predicters of the experience of flow. Thus, once an individual experiences flow, their motivation to return to that activity and reach a flow state again is increased, which may in turn enhance their ability to reach such a state.

There are numerous studies that convey the importance of absorption in a task or activity for the benefit of subjective well-being. A study by Killingsworth and Gilbert

(2010) found that people were happier when they were focused on the task at hand and their minds were not wandering. At random moments of the day an iPhone app prompted 15 participants to answer questions related to whether or not their minds were wandering, where they were wandering to, and their current levels of happiness. Results suggested that people’s minds frequently wander, regardless of what they are doing. Findings also suggested that people were less happy when their minds were wandering compared to when they were not wandering. This was true even when the activities that participants were engaging in were rated as being unenjoyable. A similar study by Hunter and

Csikszentmihalyi (2003) found that there is a positive correlation between the experience of interest and well-being by comparing groups of chronically interested and chronically bored students. Experiences of flow in the work place are also linked to greater job satisfaction, thus increasing overall well-being (Ilies et al, 2017).

Flow also has implications for one’s sense of self. In a study examining the presence and impact of flow in therapeutic songwriting, Baker and MacDonald (2013) found flow to be positively correlated with ownership, satisfaction, achievement, identity, and sense of self during the creation of songs that were personally meaningful. Though the causation was not determined in Baker and MacDonald’s (2013) study,

Csikszentmihalyi (1990) theorized that though the sense of self tends to be lost during the flow experience, an individual emerges from a flow experience with a stronger sense of self.

Though activities that elicit flow states are generally autotelic, self-growth is often a result of flow states over time. Because experiencing flow has positive implications for one’s well-being and motivation, people continue to return to the activities where they once experienced flow (Nakamura & Csikszentmihalyi, 2005). However, the balance between the challenge of an activity and one’s ability to meet that challenge is bound to 16 shift due to an increasing level of skill related to the task. As Nakamura and

Csikszentmihalyi (2005) explain, an individual will progressively seek out more challenging tasks in order to reach the balance between challenge and ability that is conducive to the individual experiencing flow. This, in turn, expands a person’s goals and interests while allowing for growth of existing skills (Nakamura & Csikszentmihalyi,

2005).

Depression and Potential Difficulties with Flow

Characteristics associated with depression may make it more difficult for the depressed individual to reach and sustain flow states. Ullén et al. (2012) found that trait neuroticism, described by McCrae and Costa (1987) as comprising of negative affect, worry, insecurity, self-consciousness, and temperamentality, to be negatively associated with flow states. The presence of negative affect may negatively influence the enjoyment component of flow, while emotional and cognitive instability may increase the potential for a lapse in the attention that is required to reach flow states. Amotivation and an external locus of control may also impact a person with high levels of neuroticism’s ability to reach flow states (Ullén et al., 2012). Zinbarg et al. (2016) found that the presence of neuroticism may be a predictor of depression, so the assumption can be drawn that depression may play a similar role on flow as does neuroticism.

The lack of motivation that individuals with depression often experience may also have negative implications for experiencing flow states (Marazziti, Consoli, Picchetti,

Carlini, & Faravelli, 2010; Kowal & Fortier, 1999). In a study on the motivational determinants of flow, Kowal and Fortier (1999) found amotivation to have negative 17 implications for flow. Specifically, amotivation was strongly and negatively associated with the challenge/skill balance component of flow.

Priming

In psychology, priming refers to the influence that exposure to a stimulus has on a response to a later stimulus, suggesting that previously received information can aid in the processing of new information (Borgeat, O'Connor, Amado, & St-Pierre-Delorme,

2013). When priming processes are used intentionally in psychotherapy, they may have an influence on patients’ goal achievement (Borgeat, et al., 2013; Zidani et al., 2017).

Borgeat et al. (2013) found that preconscious priming, in conjunction with behavior therapy, in participants with social phobia resulted in increased positive self-statements or thoughts, and fewer negative thoughts related to social interactions. Additionally, Zidani et al. (2017) found that by making alternative cognitions more readily available to participants with residual symptoms of social anxiety disorder and generalized anxiety disorder, preconscious priming helped to facilitate cognitive change in conjunction with cognitive behavioral therapy.

Steps of preconscious priming in both studies included an explanation of the rationale for the method to the participants, exploring and clearly defining personal goals, writing clear sentences describing cognitions and attitudes that the participants hoped to make their own, and the reading and recording of sentences by an experimenter, masked by relaxing music. Participants were instructed to listen to their personalized recordings at least twice daily as a relaxation exercise (Borgeat et al., 2013; Zidani et al., 2017).

Music Therapy and Depression

A variety of music therapy methods, from expressive to receptive techniques, are employed in music therapy sessions with people with depression. In a Cochrane Review seeking to examine the impact of music therapy on symptoms of depression, Maratos,

Gold, Wang, and Crawford (2008) found that music therapy was associated with improvements of mood. The low dropout rates throughout the studies reviewed suggest that music therapy is a well-tolerated form of treatment (Maratos et al., 2008). Grocke

(2009) also found that music therapy helped motivate people, who may otherwise have difficulty maintaining attendance, to attend treatment groups.

Expressive Methods

Expressive methods of music therapy typically involve the use of instruments or singing in improvisation, song recreation, or song composition. In working with individuals with depression, improvisation may be used to promote self-expression, mobilize affect, enhance interpersonal connections, and work through internal struggles

(Jackson, 2012). Erkkilä et al. (2011) describe the value of images, metaphors, thoughts, expressive qualities, and emotional content that may emerge from an improvisational music making experience. After the improvisation elicits these components, they are processed verbally with the therapist (Erkkilä et al., 2011).

Instrumental recreations of pre-composed music can be beneficial in drawing depressed individuals out of their typically withdrawn state (Jackson, 2012). Creating music together as a group may promote interpersonal connections, group cohesion, and present-centered focus while working towards a clear goal that is the recreation of a song.

Jackson (2012) describes instrumental recreation as being a less threatening method of 19 active music making than improvisation is, as it does not require self-disclosure or self- exploration. For this reason, instrumental recreation may be beneficial in the initial stages of music therapy, when self-disclosure and exploration may be too overwhelming

(Jackson, 2012).

Songwriting, like improvisation, is an expressive method of music therapy that is used to promote self-expression, communication, self-exploration, and empowerment

(Jackson, 2012; Rolvsjord, 2005). Grocke (2009) also found that group songwriting gave clients a sense of belonging, while working to a shared goal. Various degrees of structure can be placed on the songwriting process, depending on the client’s needs. Clients who are experiencing a psychiatric crisis may need a high amount of structure which can be implemented in the form of a fill-in-the-blank activity, substituting their own words in section of precomposed songs (Jackson, 2012). A song parody offers slightly less structure, with clients rewriting the words to a familiar song, while keeping the framework of the melody and harmony (Baker & Wigram, 2005). Freely composed songs involve the least amount of structure, with clients creating their own words and music, with the support of the music therapist.

Receptive Methods

In receptive methods of music therapy, “the client is a recipient of the music experience, as distinct from being an active music maker” (Grocke & Wigram, 2007, p.

16). The client may still be active in the therapeutic process, but therapeutic change does not occur through the music making process, as it may in improvisation or songwriting.

As depression and anxiety disorders are frequently comorbid (Woo & Keatinge,

2016; Jackson, 2012), music relaxation and stress reduction are beneficial methods to use 20 with this population. The goals associated with these methods include a release of tension and anxiety while helping the client reconnect to their body and enhance well-being

(Jackson, 2012). Grocke and Wigram (2007) describe relaxation as a skill, as opposed to something that happens to a person, suggesting that although this is a receptive method of music therapy, the client is still an active agent in the process.

Song discussion involves listening to precomposed songs, using the lyrics as a springboard for discussion (Jackson, 2012; Grocke & Wigram, 2007). Clients are encouraged to self-reflect while listening to the song, and have the opportunity to practice the communication of thoughts and feelings during the discussion phase. Through this process, clients are able to increase self-awareness, self-expression, and engage in reminiscing (Jackson, 2012). This method also allows clients to distance themselves from difficult emotions if necessary, while still maintaining contact with them. As Grocke and

Wigram (2007) describe, clients are able to discuss and express difficult emotions by projecting them onto the artist, lyrics, or song.

Expressive and receptive methods both have unique benefits. In a randomized control trial, Erkkilä et al. (2011) found that individuals with depression were able to musically express what they could not express verbally through improvisation. Active music making seemed to be important to the participants, as it was viewed as a meaningful way to deal with the issues related to depression. The psychodynamically informed approach of improvisation was found to improve symptoms of depression and anxiety (Erkkilä, 2011).

Resource-Oriented Approaches in Music Therapy

Resource-oriented music therapy is an approach that involves the nurturing of strengths, resources, and potentials, while encouraging equal collaboration between therapist and client (Rolvsjord, 2010). Similar to positive psychology, a resource-oriented approach to music therapy assumes that resources are connected to the prevention of mental illness, acting as a buffer against distress in stressful situations. Additionally, both positive psychology and resource-oriented music therapy focus on using strengths and resources to enhance positive emotions, with less of a focus on decreasing symptoms related to mental illness (Seligman, Rashid, & Parks, 2006; Rolvsjord, 2010).

In resource-oriented music therapy, music itself is seen as a health resource, and music therapists are encouraged to acknowledge and nurture health responses to music

(Rolvsjord, 2010). A recent phenomenological study on the experience of music therapy for people with psychosis found that participants saw music therapy sessions as a place to explore their strengths and valued music therapy for its enjoyment factor (Solli &

Rolsvjord, 2015). In addition to clients being able to explore their own strengths in music therapy, involvement in music therapy may also allow for music therapists to view the client in terms of strength and health, as opposed to illness (Nicholson, 2015)

In a phenomenological account, patients with psychosis viewed music therapy as being unrelated to their illness (Solli & Rolsvjord, 2015). In fact, it was seen as a break from treatment, despite the fact that therapeutic goals were still achieved. Participants also stated that music therapy positively impacted both intrapersonal and interpersonal connections, increased well-being, and facilitated symptom relief. Solli and Rolsvjord

(2015) found that in addition to symptom relief, patients with psychosis were able to 22 distance themselves from their everyday struggle in music therapy sessions. One patient described “thinking less and less about the difficult things (p. 73)”.

The collaborative therapeutic relationship taken in a resource-oriented approach may be beneficial in increasing a patient’s sense of belonging, relatedness, and identity.

Solli, Rolvsjord, and Borg (2013) synthesized qualitative accounts of mental health service users’ experiences in music therapy, and found strong themes of togetherness and identity in the service users’ reports. Individuals participating in music therapy also reported experiences of respect, mutuality, and worthiness in the therapeutic relationship

(Solli, Rolvsjord, & Borg, 2013). Solli (2008) also found that the collaborative therapeutic relationship between him and an individual with psychosis was the major vehicle for growth, while encouraging the client to explore his strengths

Music Eliciting Flow

Music is frequently cited as an activity during which one experiences a flow state.

In his seminal writing on flow, Csikszentmihalyi (1990) describes the role that music plays in organizing consciousness if the listener is fully attending to the auditory information. Citing ancient myths, Csikszentmihalyi (1990) emphasizes the importance of music participation on social order, psychic order, overall quality of life.

Riggs (2007) proposed a model of higher music education that shifts from an authoritarian style of teaching to a method of teaching that involves focusing on the

“whole” student, guiding them towards optimal experience through the creative process.

The author suggests that a shift in focus from product to process in studio music lessons, while focusing on students’ unique strengths and needs, may lead to flow. This may in turn enhance students’ motivation to continue practicing and performing (Riggs, 2007). 23

Fritz and Avsec (2007) note that the anxiety experienced in solo performances may have a negative impact on the ability to achieve a flow state. In fact, Skutnick-

Henley (2005) found that 62 percent of flow experiences occurred in nonperformance situations. Orchestral and choir performances, however, may provide better opportunities for participants to reach a flow state, as responsibility is dispersed in group performances, thus decreasing anxiety (Fritz & Avsec, 2007). Musicians also reported feeling as though they are one with the ensemble when performing with a group, increasing feelings of well-being and satisfaction (Skutnick-Henley, 2005).

Closely related to Csikszentmihalyi’s (1990) eight elements of flow described earlier, Skutnick-Henley (2005) found five predictors of proneness to flow among ninety classical musicians. These predictors included self-confidence and trust in self while playing, the desire to feel and express emotions through music, having goals related to the experience, the ability to sustain focus on the music, and the ability to play without self-criticism. Csikszentmihalyi (1990) also describes various degrees of listening skills required to appropriately match the challenge of analyzing music, stating that as an individual’s analytic listening skills are strengthened, their likelihood of enjoying music and experiencing flow while listening increases greatly.

While it is important for a musician’s ability to be well suited to handle the challenge presented, experiences of flow are not necessarily directly correlated to a musician’s level of performance. Rather, a musician’s skill level compared to those in the same environment might have a greater influence on flow and motivation. O’Neill (1999) compared the amount of time spent in flow states of high achieving musicians at a music school, moderate achieving students at a music school, and musicians at a non-specialist 24 school. Results indicated that the high achieving musicians at the specialist school and musicians at the non-specialist school spent a significantly greater amount of time in flow states while playing music than did the moderate achieving musicians at the specialist school, perhaps due to the moderate achieving students’ perceptions of peer competitiveness (O’Neill, 1999).

Asynchronous music listening may also increase the intensity or the likelihood for an individual to experience flow while engaging in another activity, especially sports. In a study by Pates, Karageorghis, Fryer, and Maynard (2003), collegiate athletes reported enhanced flow and improved athletic performance after listening to music. Participants indicated that their performance felt more automatic, they experienced an increase in sense of control and a decrease in self-consciousness, and their focus was entirely committed to the athletic task. A similar study that examined the impact of asynchronous imagery, music listening, or both on flow during athletic performance found that music listening combined with an imagery script that aimed to enhance confidence in one’s performance was the greatest indicator of flow (Pain, Harwood, & Anderson, 2011).

When assessed separately, the music listening condition was more likely to elicit flow than the imagery condition.

Music Therapy and Flow

Peer relationships and the relationship between the therapist and client are likely influenced by flow (Silverman, Baker, & MacDonald, 2016). Jointly engaging in an intrinsically motivating, rewarding, and joyful activity may play a role in strengthening bonds between humans. Research conducted by Nicholson (2015) found that the peak experiences of music therapists strengthened the connection that therapists experienced 25 between themselves and clients. Therapists were able to connect to clients “on a more fundamental human level (p. 67)”. These findings are consistent with the view that it may be beneficial for the therapist to take the role of fellow musician to focus on the interpersonal and intermusicial relationship as a means for therapeutic change (Solli,

2008).

The experience of flow may also have positive implications for the creation of meaning in therapeutic songwriting. In a study with college students and retirees, Baker and MacDonald (2013) found a higher sense of satisfaction, ownership, achievement, identity, and sense of self following songwriting to be associated with greater experiences of flow during songwriting. Though causation was not established, the more connection an individual felt with their song, the more powerful the report of flow. Additionally,

Silverman et al. (2016) found that while flow and meaningfulness during songwriting interventions were positively correlated, the experience of flow was more predictive of positive treatment outcomes than meaningfulness alone.

Results from a study by Baker and MacDonald (2013) that examined flow during various songwriting conditions suggested that therapeutic songwriting with non- musicians may lead to greater flow experiences than the eventual performance of the song does. Baker and MacDonald (2013) hypothesized that this may be due in part to the supportive therapeutic relationships present in the songwriting experiences, which allowed for a sense of connection, feelings of relaxation, and judgement-free interactions.

Another reason why reports of flow may have been higher in the song writing phase than in the performance phase is that participants had more room to be creative during the songwriting portion of the music therapy intervention (Baker & MacDonald, 2013). 26

Additionally, the anxiety that may accompany musical performance, which has negative implications for flow, was not a factor in the therapeutic song writing experience. The study also provides evidence that one does not need to be a musician in order to experience flow during a musically creative experience (Baker & MacDonald, 2013).

Qualitative case studies and phenomenological accounts of patients’ experiences in music therapy have not explicitly stated that flow states are occurring, but they have suggested that some of the elements of flow are present in music therapy, thus resulting in a motivating, engaging, and rewarding experience. In a meta-synthesis on patients’ experiences in music therapy, Solli, Rolvsjord, and Borg (2013) highlighted four main themes that arose from interviews with the patients: having a good time, being together, feeling, and being someone. Music therapy allowed for patients to increase active participation and gain a sense of agency over their recovery process. Rolvsjord (2014) also found exerting control and engagement across contexts to be themes that arose in interviews with patients about their experiences in music therapy. Patients’ engagement in music therapy sessions motivated them to seek similar experiences outside of the therapy room, often resulting in the purchasing of an instrument or the intentional use of music listening at home. Though the term flow was not used, intrinsically rewarding experiences, a strengthened sense of self, feelings of connection, active participation, a sense of control, and engagement are all concepts linked to flow previously in this literature review.

CHAPTER 3: PRODUCT/REPORT

Description of the Setting The proposed method was developed within the context of an inpatient psychiatric hospital. Units in this particular hospital are generally split up by diagnosis.

Though components of the method were implemented on all units, I targeted the method towards the mood disorder unit. Individuals assigned to this unit are experiencing a psychiatric emergency, typically related to depression, suicidal ideation (SI), and/or a recent suicide attempt. Broad treatment goals, determined by psychiatrists, social workers, nurses, recovery specialists, and creative art therapists generally involve stabilization, decreases in depressive symptoms and SI, identification of triggers for depression and SI, and the development of skills for coping with these triggers.

Though flow is not mentioned anywhere in patients’ treatment goals, music therapy or otherwise during their stay at the hospital, the literature on flow states suggest that flow may be a means to reach some of the specified goals. While literature on flow focuses on enhancement of health as opposed to reduction of illness, enhancement of healthy qualities, resources, or strengths of an individual are often associated with symptom reduction. For example, studies described in the preceding literature review suggested that the experience of flow states enhance an individual’s well-being, which may imply that depressive symptoms partially or fully subsided. The intrinsic motivation associated with flow may also motivate patients to continue to attend music therapy groups, thus increasing compliance with their treatment plan. Additionally, the experience of total immersion in and concentration on a task allows an individual to leave their worries behind so, a patient’s ability to reach and recognize flow states can be seen 28 as a resource to be used as a skill for coping with thoughts related to depression and anxiety, which is in line with the goals on patients’ treatment plans.

Music therapy is situated within the expressive therapies department at this hospital, a term that in this case is synonymous with creative arts therapies. One expressive therapy group occurs daily on this unit, though the modality rotates unevenly between music therapy, art therapy, and dance/movement therapy. Expressive therapy sessions are one hour long, and attendance is encouraged but not required. Depending on the size of the unit, the group size ranges from around 8-25 participants. It is an open group, and though participants are encouraged to remain in the group room for the duration of the session, individuals are often called to take medication or to talk with their doctor or social worker during group, resulting in frequent interruptions. Patient turnover on this unit is high, so the lifespan of each group is typically one session.

The proposed method was developed in a group setting for a variety of reasons.

First, music therapy sessions most commonly occur in group format in inpatient psychiatric settings, so it seems most practical to consider the group context. There are also many interpersonal benefits that result from the group experience, including Yalom’s

(2005) eleven therapeutic factors. Additionally, any sense of responsibility to create something aesthetically pleasing may be dispersed in group settings, thus decreasing anxiety, which is important, as anxiety can prohibit flow states (Fritz & Avsec, 2007;

Csikszentmihalyi, 1990).

Method

The current section provides a narrative account of the current form of the method, beginning with general considerations made while conceptualizing the method. 29

Some components of the method, such as structure and anxiety management, are considered throughout the duration of the music therapy session, so the many ways in which they are incorporated into the method are described towards the start of this section. This method is intended to be flexible, as each client presents with a unique set of resources and needs. The clinical vignettes in the following section will illustrate such adjustments to my approach in working with clients with varying needs.

Considering the Elements of Flow

This method was developed with Csikszentmihalyi’s (1990) eight elements of flow in mind. While some of the elements are more a result of the other elements and overall experience, for example, merging of action and awareness or a loss of sense of time, some elements are better able to be controlled for. As Privette (1983) explained, flow can be structured and planned, though the experience cannot be guaranteed in a music therapy session. Elements of flow that a music therapist may have greater control over include balance between the challenge and skill required to carry out the action, clear goals and immediate feedback, while appropriate levels of structure may help to encourage concentration on the task at hand. These three latter elements were considered in the development of the active method and will be described in context within the description of the method, while all elements of flow were considered in the observational method. Findings from studies on music and flow were also taken into consideration.

An additional element of flow that may be taken into consideration is the autotelic experience, or engaging in an activity for no other reason than for the intrinsically rewarding experience. This is a complicated component within the context of a music 30 therapy session, as participants both have little say in their decision to attend music therapy and are likely expecting to get something out the therapy that is more than the experience itself. Additionally, hospital personnel want to see that extra-musical goals are being reached in music therapy, suggesting that the therapeutic process as an autotelic experience is antithetical to goals of mental health professionals. The underlying philosophy of this thesis, however, is that being fully engaged in an intrinsically rewarding experience can have a positive impact on one’s quality of life. This increase in quality of life may not only result in symptom reduction, but may also increase happiness, which is not implied when the sole focus of treatment is symptom reduction.

Structure

Structure is important for several reasons and is listed at the beginning of the method as it was considered in all components of the method. There is an inherent sense of safety in structure, which can help to reduce anxiety among participants and allow for some predictability within the session. Additionally, structure can aid in the development of clear goals and understanding of immediate feedback, which is one of

Csikszentmihalyi’s (1990) eight elements of flow. Structure may also have an impact on balancing the difficulty of the task with participants’ skill level, another important element of flow.

Structure is seen in many aspects of a music therapy session. There is structure in the session’s beginning, middle, and end, available instrument choices provide structure, facilitating musical elements such as rhythm, harmonic progression, and tempo provide structure, and the questions or comments posed for verbal processing can alter the level of structure. All of these forms of structure were considered when developing the present 31 method, with the aim of providing enough structure to reduce anxiety and enhance safety, convey clear goals and provide immediate feedback, and balance challenge with skill level. Too much structure, however, could limit participants in their creative expression, so a careful balance must be established. The exact amount of structure provided will need to be based on the music therapist’s assessment of the group.

Anxiety Reduction/Management

Anxiety is commonly comorbid with or a clinical feature of depression (APA,

2013) Additionally, an anxiety response can be triggered whenever someone tries something new or unfamiliar, as music therapy often is. Anxiety is antithetical to flow, as it contradicts Csikszentmihalyi’s (1990) description of concentration on the task at hand, which involves leaving all worries behind. For this reason, anxiety management is considered throughout the session, as discussed when considering the structure of the session. In this method, the structure of the session, as well as transparency from the therapist in being upfront about what is to come of the session, provides the foundation for anxiety management.

There are also ways in which the music therapist can support patients in managing any anxiety, such as music assisted relaxation techniques. In the proposed method, a short music assisted breathing exercise is used to aid clients in reducing anxiety by promoting a here-and-now focus, bringing awareness to one’s breath and body, and controlling the rate of breathing. Additionally, this more active form of relaxation is beneficial for patients who may be experiencing agitation, tension in their bodies, or worry and rumination (Jackson, 2012). 32

This phase of the method begins with the music therapist providing a description to group members of what to expect from the phase, and the reason behind engaging in the relaxation exercise. This can jumpstart the anxiety management process by making the unknown known, while following Csikszentmihalyi’s (1990) suggestion that the presence of clear goals assists an individual in reaching and maintaining a flow state. The music therapist then encourages group members to find a comfortable position in their chairs. The option of closing one’s eyes or maintaining a soft gaze is often given in such exercises, but for the purpose of this method and the goals that are targeted in the session, the music therapist should encourage clients to maintain a soft gaze, to decrease the likelihood of falling asleep. With the aid of live musical accompaniment with an ambiguous tonal center, the music therapist encourages group members to focus on their natural breath, noticing the rise and fall that the breath creates in the belly, placing a hand on the belly if comfortable. The music therapist should be engaging in continuous assessment of the group throughout this phase. If group members’ breathing appears to be too rapid or shallow, the music therapist can direct the in- and out-breath for a few cycles to help slow down and regulate breathing. Providing directives, such as “imagine sending your breath all the way down to your feet” can also encourage clients to deepen their breathing, while giving them something to focus their minds on with the hopes of decreasing worry and rumination.

Group Music Making

The following discussion provides an overview of active music making portion of the session, with special attention given to the way in which instruments are set out, 33 giving participants less structured and more structured opportunities to gain proficiency on and comfort with their chosen instruments, and structuring the improvisation.

Promoting competency.

Related to the balance between the difficulty of the task and the participant’s skill level is a sense of competency with the instruments. Many individuals become anxious upon realizing that they are going to be encouraged to play an instrument, especially those who have never played an instrument or those who have previously had unsuccessful experiences playing instruments. Their perceived lack of ability to meet the demands of the task result in anxiety, which is not conducive to experiencing flow.

Therefore, the music therapist must attempt to put participants at ease.

Giving a demonstration of how to play each instrument as it is offered as an option to play provides the client with an initial understanding of how to approach the instrument. It also allows for participants who are less familiar with the instruments to make a more informed decision when selecting their instruments. Once instruments are selected, a short, specified amount of time given to participants to allow them to experiment on their instruments gives them a low-pressure practice opportunity, while retaining some structure in the form of a time limit.

If additional skill development is required for participants to feel comfortable with their instruments and to balance skill with challenge, a simple call and response exercise can be used as a warm-up. The music therapist plays a series of four beat rhythms with increasing complexity, while participants repeat each one. This serves multiple purposes related to skill development. First, it gives participants an extra opportunity to develop a sense of competency with the technical aspects of playing their 34 chosen instrument. Second, participants can get ideas about rhythms to play during improvisation by listening to the suggestions from the music therapist. Third, it encourages participants to begin listening to the musical contributions of others, which may springboard musical interactions and increased engagement later on in the session.

Improvisation.

This is the phase in the music therapy session during which it is intended that an individual is most likely to reach a flow state. Before beginning the music making, it is important to provide clear instructions for group members, even if they are simple, while being transparent about the purpose of the experience. For example, before facilitating an improvisation, the music therapist may state “We will be improvising, or spontaneously creating music, for this portion of the session. People tend to have a variety of experiences while improvising, such as feeling a sense of connection with the group, temporarily forgetting about worries as they are so focused on the music, or a sense of fulfillment. I will begin with a chord progression on the guitar. Come in on your instrument once you get a sense of how to fit in with the group’s music.” These clear and concise instructions are in line with Csikszentmihalyi’s (1990) suggestion that clear goals and immediate feedback help a person to reach a flow state. The description of the purpose of the improvisation may also serve as a primer to enhance the likelihood of group members reaching a flow state.

Immediate feedback, though subjective in this instance, is implicitly present in any music making experience. The patient receives feedback on their playing in the form of their aesthetic experience. Even if a patient has no formal training in music, most people in American culture have had enough exposure to music that they have 35 established views of what sounds “good” or “bad.” This involves self-awareness and a desire for social acceptability. If a group member notices that their music does not fit in with the group’s music, with sustained awareness, they are likely to change their playing so that it does begin to fit in. If the group member does not respond to auditory feedback on their own, the music therapist can suggest a rhythm for the group member to try. This can also aid in finding the right balance between the group member’s skill level and the difficulty of the task.

As in the music-assisted relaxation phase of the session, the music therapist should be engaging in continuous assessment of the group during improvisation in order to determine whether or not the structure should be altered to meet clients’ needs. If group members seem to be zoning out or disengaging, the demands of the task may be too low compared to their skill level. In this case, the music therapist should decrease their overall level of structure or provide an opportunity for such group members to engage in something more difficult. Examples include encouraging group members to play different, more complex rhythms or to try a different instrument. On the other side of the spectrum, if participants present with uncharacteristic anxiety, they may not have or think that they have the proper level of skill to meet the demands of the task. In this case, the music therapist should increase musical structure, perhaps by playing simple rhythms that are easy for group members to fit in with, facilitating group singing, or by suggesting a specific rhythm to a group member who is demonstrating greater difficulty with the task than other group members. Figure 3.1 provides a depiction of the appropriate challenge and skill balance for flow states. 36

Figure 3.1. Flow channel created by balance between challenge and skill. (Csikszentmihalyi 1990, Flow:

The psychology of optimal experience.)

Situating an improvisation within a simple, familiar song may meet the needs of certain groups for a few reasons. First, songs provide an additional level of structure. The chorus, verse, and melody can serve as extra scaffolding for the improvisation. This additional structure is not always needed, however, so again, continuous assessment of the group is necessary. An improvisation within the framework of a song may also enhance the engagement of group members who are more motivated by singing and may help to reorient individuals who may have zoned out or were otherwise unable to experience flow, providing them with a new ground from which to engage.

Using a song also allows group members to adjust the difficulty of the task to fit their needs. While it is likely that simply playing an instrument with varying degrees of complexity provides an appropriate challenge/skill balance, group members can choose to sing while playing if they need to increase the difficulty of the task. Similarly, group members can choose to focus solely on singing during the vocal parts of the song, which may better suit their needs, depending on the individual. 37

It is recommended to use a song that all group members are likely to know, so as to not change the difficulty level of the task by adding in an unfamiliar component. This eliminates the need to pass out lyric sheets for people who are motivated by singing, which could be a distraction or added challenge if they also choose to play an instrument.

Playing an instrument while singing can be difficult but adding in reading makes the task even more difficult. It is also recommended that the instrumental sections be extended beyond the length in the original song, to allow time for individuals to become engaged, explore their creativity, and express themselves.

Verbal Processing

Though an individual may not still be experiencing the flow that was reached during group music making during verbal processing or may not be able to immediately discern whether or not they achieved flow, discussion about the experience is still important. Verbal processing serves many purposes, including increasing the patient’s awareness of their own thoughts, feelings, and observations and cueing the therapist in to the client’s internal experience and their perception of their musical experience (Nolan,

2005). In discussion of the music making, group members may become more aware of their contributions to the experience and the impact that it had on them. In this method, attention is given to words that may describe experiences of flow, bringing patients’ awareness to their own contributions to their experience, and encouraging patients to view the ability to reach a flow state through involvement in music as a resource that they can use to cope with daily life outside of the hospital.

In verbal processing, it is beneficial to leave the initial prompt (if any is needed) as open ended as possible to allow for group members to share a wide range of thoughts, 38 feelings, or reactions related to the experience. For the purposes of this method and the importance of bringing clients’ awareness to their own contributions to any potential experience of flow, I narrow in on targeting any experiences of flow fairly early on in verbal processing. I have found that the question, “What did you notice about your thoughts?” targets experiences of flow in verbal processing.

Some clues that a client experienced flow during music making include descriptions of racing thoughts subsiding, leaving their worries behind, not thinking about anything other than the music, and feeling as though they were one with the music and/or the group. Appendix A includes a list of statements that suggest that flow states were reached. While flow does not imply any emotional quality, people often report positive feelings following flow, such as euphoria or a sense of relief.

As Csikszentmihalyi (1990) describes, optimal experience, or flow, is not something that happens to an individual. It is not a passive or receptive state, but a state that requires an exertion of energy and effort. When individuals experience flow in a music therapy group, they often attribute the experience to the group’s music, failing to recognize their own contributions to their state of consciousness. In the verbal processing phase of the method, it is important for the music therapist to aid group members in realizing their contributions to their experience. Once an individual is aware of the type of effort and energy that they put forth to achieve a flow state, they can use this ability as a resource to aid them in improving their quality of life, whether it is through music or other intrinsically motivating activities.

Clinical Vignettes

Vignette 1: High Skill, High Challenge

This session occurred early on in the development of the proposed method, and did not include a relaxation exercise at the start of group, though anxiety management was still considered throughout the session. The session began with a musical check-in that turned in to a group improvisation, followed by another improvisation and creative writing. Reports of flow-like experiences occurred after the improvisations.

Active music making.

After doing a more traditional, verbal check-in, I asked group members to reflect on the word or phrase that they used to check in, and to choose an instrument on which that they could capture some part of that feeling. We then did a musical check-in, with each group member musically portraying the word that they used to initially check in.

After each person shared their short phrase or rhythm, we put them all together – I started the group with a simple, repetitive rhythm on a buffalo drum in order to ground and help organize the group’s music. Then, going around the circle, I gave each individual a cue to join in one at a time, encouraging them to begin playing once the rest of the group’s music was cohesive. The improvisation ended shortly after all group members were playing. Verbal processing of the experience followed.

The next improvisation began with a rhythm initiated by an experienced drummer. This particular group member chose to play four frame drums of varying sizes set out in front of him like marching tenors, demonstrating active and self-initiated involvement in making sure that the difficulty of the task matched his skill level. As a drummer with his specific skill set, he knew that he needed to increase the challenge of 40 the task in order to avoid boredom. After this group member began with his rhythm, I came in with a rhythm to support his. I encouraged other group members to come in as they felt comfortable. The improvisation continued on with minimal intervening by myself as the music therapist, as group members’ skills were such that they needed only a moderate level of support.

Verbal processing.

After the first improvisation, the experienced drummer reported feeling connected to the group and being able to focus his mind entirely on the music and his playing, shutting out any worries or anxious thoughts. Many other group members reported having generally positive experiences during this improvisation.

One group member reflected on the transcendental nature of the arts in response to the second improvisation and expressed frustration with the fact that there is a lack of connection in today’s society. The drummer in the group again described being able to focus his mind entirely on the music, and was motivated to return to making music.

Vignette 2: Increased Engagement Through Grounding

Anxiety reduction.

This was the first session during which I implemented the relaxation exercise before the active music making phase. After check-in, group began with a music-assisted relaxation, where I played a simple chord progression with no leading tones (C – F/C) on guitar while guiding group members through a breathing exercise that lasted about five minutes. The breathing exercise should not last too long, as the goal is not to induce sleep or such a deep state of relaxation that participation in improvisation is inhibited. Many individuals reported increased relaxation at the end of this exercise. 41

Active music making.

After setting out the instruments, giving a brief demonstration of how to play each one, I encouraged each group member to choose an instrument, even if they did not think that they would play it. Group members then spent about one minute experimenting with their instruments while I checked in with and offered to bring instruments to group members who had not gotten up to choose an instrument. Then, I went through a series of about ten rhythms for group members to repeat in a call and response style warm-up.

To begin the improvisation, I played a simple chord progression on guitar (I-IV-I-

V-IV-I). This is only one example of a chord progression that provides a familiar sense of structure and containment. The feel was mellow, yet upbeat. I then asked participants to join in the music as they got a sense of what they were going to play to fit in with the group’s music. We improvised for five minutes or so, and group members experimented with different ways of playing. Some people tried a few different rhythms, while a couple of people decided to trade instruments. Once the groove settled, I told the group that I was going to add in words, and that they were welcome to sing along if they would like, or they could focus on playing their instruments. As I began singing Bob Marley’s

“Three Little Birds,” group members appeared to momentarily turn their attention to my singing and to the words of the song. Many group members returned to playing their instruments, while some people chose to sing along. One woman who typically presented with flat affect demonstrated an increased range of expression while singing along, as well as a decrease in responses to internal stimuli. After singing through a verse and a chorus of the song, the focus shifted back to improvisation. 42

At one point in a later improvisation, I asked one half of the group to play at a time, with the aims of reorienting group members, giving quieter instruments the opportunity to be heard, and encouraging group members to increase their awareness of the other instruments in the room.

Verbal processing.

To begin verbal processing, I asked “What did you notice about yourself during that experience?” One woman, likely primed by the content of the song, expressed that she was able to forget about some of the things that had her worried. Another woman said that focusing on the rhythms that other people were playing helped to reduce her anxiety.

One man stated that he was able to focus entirely on the group’s music and his own playing. I asked him what helped him to be able to give all his attention to the music, and he stated that the grounding that he felt as a result of the breathing exercise helped him to increase his engagement in the music. After the latter improvisation described above, the same man stated that at this point in the session he became more aware of the musical contributions of other group members.

Vignette 3: Loss of Self-Consciousness

Observing flow was not a main focus of mine during this session, and the guided relaxation was not implemented, but one group member in particular had a significant experience of flow during musical improvisation. He described a loss of self- consciousness in a way that I had not heard described before, so I decided that it would be important to include this vignette, despite not implementing the initial relaxation step of the method. 43

To begin this group, I asked the check-in question, “what do you hope to get out of group.” Group members generally have meaningful and authentic answers to this question, such as increased relaxation, improved mood, or the opportunity to express themselves. The group member who reported the strongest experience of flow related his goal for group directly to music. He described wanted to explore and strengthen his connection with music. This intention that he set for himself at the start of group seemed to serve as a primer for engagement and experiencing flow throughout group.

Active music making.

I set out the instruments, giving a brief demonstration of how to play each as described previously in this chapter, and asked group members to choose instruments. To warm-up, I played a series of simple, repetitive rhythms and asked group members to join in with the same rhythm once they caught on. I used this altered version of a call and response warm-up because it was taking group members a bit longer to organize their playing and figure out how to play the rhythms I was playing. As we went through this exercise, group members’ technique on their instruments, as well as their rhythmic discrimination improved.

Next, we played and sang through “Man in the Mirror.” I left a couple of sections open for improvisation, each lasting about three minutes. Group members spontaneously chose to either sing or play an instrument, with about half of the group singing and half playing instruments. The group member whose experience of flow seemed to be the most significant played a djembe, and he stated that he had taken a few djembe lessons over ten years ago. After this song recreation/improvisation, we moved to verbal processing of the experience and lyric discussion. Group members then engaged in creative writing 44 surrounding the themes of what they see in the mirror, personal identity, and making changes. We ended group with a short improvisation that was fairly upbeat, at a moderate tempo and in a major key, followed by a check-out guided by the prompt, “use one word or short phrase to summarize your experience in group today.”

Verbal processing.

This section will focus primarily on the responses from the individual who most strongly described experiencing flow, who I will refer to in this section as “Participant

A.” All group members were engaged in verbal processing, but most responses were related to past experiences and how they connected with the song, with less of a focus on their “here and now” experience.

In the initial processing after the song recreation/improvisation, Participant A stated that he felt careless while playing, and described being able to focus on and put effort into what he was playing, without worrying about what the actual result was.

Participant A also spoke of his strengths at a time when many other group members spoke about challenges and weaknesses. In the closing check-out, Participant A used the phrase “creative spontaneity” to summarize his experience in group.

Personal reaction.

Participant A’s description of being careless, yet careful and intentional about his playing without worrying about the result suggested to me that he had experienced the merging of action and awareness, described in the literature review, resulting in not having enough attention left over to engage in self-analysis. This was likely facilitated by the appropriate balance of his level of ability to the demands of the task. Participant A also received immediate feedback, an important component in reaching and sustaining 45 flow, in multiple forms. He had his own auditory feedback, influenced by a lifetime of listening to music. Additionally, I as the therapist gave him positive feedback, as I was genuinely interested in what he was playing, and encouraged him to bring his rhythms out.

I found it interesting that Participant A was the group member who discussed his strengths with the greatest conviction and also appeared to have the strongest experience of flow. Flow and optimal experience are ideas housed within the field of positive psychotherapy, which also focuses on using and building upon people’s strengths and resources to access health. I cannot help but wonder if and how this patient’s quick access to his strengths were related to his ability to quickly reach and sustain a flow state.

CHAPTER 4: DISCUSSION

This chapter will include a summary of conclusions that I have made over the course of the development and implementation of this project. The conclusions will be followed by a personal reflection, including what the process was like for me and how what I learned in the process is now influencing my clinical practice and theoretical orientation. Finally, recommendations for future research and considerations for practice will be made.

Conclusions

Literature reviewed in chapter 2 suggested that individuals with depression may have greater difficulty reaching and sustaining flow due to amotivation, negative affect, external locus of control, and emotional and cognitive instability (Kowal & Fortier, 1999;

Ullén et al., 2012; Marazziti et al., 2010). Despite these previous findings, I found through my informal observation that if the appropriate conditions were created, individuals with depression frequently reported that they were able to experience flow during group improvisation. This suggests that individuals were able to access internal resources and healthy aspects of their core being in order to reach and sustain flow, which may lead to a strengthened sense of self, as Csikszentmihalyi (1990) theorized is a result of flow.

A focus on enhancing strengths, as was part of the focus of this method, does not imply that any issues underlying clients’ presenting complaints will not eventually be addressed. While accessing internal strength and health, combined with interactions with external resources, participants’ experiences of flow may inherently reduce symptoms.

This phenomenon may also leave an individual better equipped to confront their 47 challenges. In viewing this concept in terms of flow, this is likely both in terms of perceived ability and actual ability, as results from previous studies suggested that experiences of flow can enhance one’s sense of self, as well as promote self-growth

(Baker & MacDonald, 2013; Csikszentmihalyi, 1990; Nakamura & Csikszentmihalyi,

2005).

Though this project was initially intended to focus on concerns related to depression, the scope eventually widened for logistical and clinical reasons. After initially implementing the method on the mood disorders unit, I began considering and implementing elements of the method on the addictions unit as well. This was both due to the fact that I work with the addictions unit more frequently than the mood disorder unit, and I saw strong evidence for promoting flow through group improvisation with this specific population. Despite moving away from the mood disorder unit, many of the individuals on the addictions unit have a dual diagnosis with depression.

Individuals seeking treatment for substance use may have needs that are similar to those of individuals with depression, yet nuanced. Areas of need often include depression, anxiety, hopelessness, isolation, shame, and trauma. There may be complex feelings of loss in individuals with substance use disorder, whether it is the loss of a loved one due to overdose, the loss of their previous lifestyle and identity, or loss due to the need to break ties with friends or family or are still using substances. Individuals in treatment for substance use may also have difficulty finding the motivation to stay or fully engage in treatment. Activities that used to bring them joy may no longer, especially during initial withdrawal and detoxification. 48

The areas of need described above not only make a case for group music therapy, but they also made me realize how valuable repeatedly reaching flow states would be for this population. First, I began to conceptualize eliciting flow as being beneficial with this population as it would potentially be an intrinsically rewarding experience without the use of substances. For many individuals that I see on the substance use units, it has been so long since they have had an enjoyable or rewarding experience while sober that they seem to lack a sense of how to engage in activities other than substance use in a way that may bring them joy. While musical improvisation may not be the activity that they choose to engage in outside of the hospital, they now know that they are able to have a rewarding experience without the use of substances.

Connection was another area that I saw as important when working with this population. Murphy (2012) explained that many people who struggle with addiction have difficulty connecting with anything outside of themselves. This is also an area that can be targeted by promoting flow states. As Yaden et al. (2017) described, there is a relational component of self-transcendent experiences such as flow, which results in an increase in a sense of connection, typically to other people but also potentially to oneself or to something greater than oneself. Group members often reported feeling more connected with the group or feeling as though they were one with the group.

The individuals with whom I have worked who are struggling with substance use often report that they do not have a sense of who they are without the use of substances.

This uncertainty in identity seems to be especially true for individuals who began using substances at an early age and never had a chance to explore and form a sober identity.

Music making in general provides an opportunity for authentic expression and self- 49 reflection. From the lenses of resource-oriented and positive psychology approaches, participants are also encouraged and have the opportunity to tap into their inner resources and build upon their strengths in music therapy. Additionally, Csikszentmihalyi (1990) suggested that flow states may promote and expanded and strengthened sense of self.

A lack of motivation to stay in and engage with treatment can also be a barrier to recovery for individuals with substance use disorder. Cravings may still be strong, withdrawal can be painful, and individuals may no longer find pleasure in once what brought them joy due to anhedonia. Musical engagement and the access to something aesthetically meaningful can be strong motivators for many people, though the experience of flow in music making may be an even more powerful motivating force.

After deep engagement in musical improvisation, group members are often disappointed that group is over and we need to put away the instruments, but they are eager and motivated to attend the next music therapy group. Once an individual experiences flow during a given activity, they have a desire to return to the activity in order to have another engaging and meaningful experience. This appeared to be true even for individuals who were initially resistant to playing instruments, which has strong implications for treatment compliance.

Although an experience does not need to have certain aesthetic qualities for an individual to reach and sustain flow, I think that flow and aesthetics are inherently linked at times. People are naturally drawn to and engaged in that which is aesthetically pleasing and meaningful to them. In the music making process, people strive to continually achieve higher standards of aesthetics and experiences of beauty. After a certain amount of practice, an individual’s skill level will eventually match, then will be greater than the 50 level of challenge that the task poses. In terms of flow, boredom will occur if a person’s ability level is too great for the challenge of the task. Thus, an individual will continue to seek out greater challenge in order to find the right match for their ability level in order to experience flow. Continually seeking out the next step in music making also has implications for aesthetics.

Reflection

I think that this method is especially beneficial in the inpatient psychiatric setting.

The short-term nature of this setting is not conducive to personality change or the resolution of psychological conflicts, as may be the goal in long-term outpatient therapy.

Nevertheless, this method leaves room for insight and self-reflection, while also benefiting individuals who are currently only able to engage in music therapy at an activity level, a level of music therapy during which gaining insight is not essential to treatment. Even when engaging at an activity level, individuals who seemed to enter flow reported feeling at ease, with decreased anxiety, a strong sense of connection to the group, and increased motivation to attend the next music therapy group.

When I first started my internship, my idealist self was troubled by the realization that the patients we see in the inpatient psychiatric setting are often not going to be

“recovered” before discharge. I was worried about what type of impact I would be able to make, often only seeing patients once or twice. I also was initially concerned that this method would not be meaningful, being that the focus is not directly on insight and change. Through the process of developing and implementing the method and learning more about patients’ experiences in music therapy from the patients themselves, I have come to have a different, simpler view of what is or can be meaningful in therapy. While 51 there may be greater end goals in a person’s treatment, I see that how a person engages in the process can be as important and meaningful as reaching the ultimate goal. I also have a greater understanding of the therapeutic value of engagement in group music making in and of itself.

While this method was primarily developed and implemented through resource- oriented and positive psychotherapy lenses, I think that it is important to be aware of the intersubjective field created between patients, the therapist, and the music. Group dynamics will always be in play, regardless of the theoretical framework from which the therapist is operating. When music is added into the equation, the music is more than a product of patients’ self-expression, but a virtual space where these expressions are interacting and personal and interpersonal meaning is being created.

The biggest challenge in the implementation of the method was the lack of closed groups at my internship site. Patients are able to leave and enter the group room at their own accord, and doctors and social workers often pull people from group for brief meetings or assessments. While I could not enforce a closed group policy, I did encourage patients who were already in the group room to remain in group unless they had an emergency, and I encouraged patients who were in the hallway to join group before it started. I also openly acknowledged at the start of group that there may be people coming in and out but encouraged group members to try to stay focused on the music, despite interruptions.

Suggestions

Further study.

While the benefits of flow that were examined in previous literature have therapeutic implications, I think that it would be valuable to examine the unique impact that experiencing flow in a therapy setting might have. I am specifically curious about how flow states may or may not impact the therapeutic relationship and intersubjective space, especially if both the patient and therapist are experiencing flow.

I also am interested in other methods of observing flow. For this project, I focused on participants’ self-reports of their experience in improvisation to assess whether or not they may have been in a flow state. Questionnaires that measure flow after the fact also exist, but this project has left me wondering if there is a way to observe and assess for a flow state in the moment, such as through physical observation or through in the moment musical analysis.

While the method in this thesis may clue participants in to the fact that they are able to experience flow, a beneficial further development of the method may be to include a psychoeducation component that helps clients to reach flow in their everyday lives. After this method is implemented in a session or in multiple sessions, participants may have a greater understanding of ways that they can use music to reach flow states, but this is limited in that music, especially improvisational music making, may not always be accessible to individuals in their everyday lives. Additionally, expanding participants’ understanding of how they can reach flow in their lives can help them to reengage in activities that may have once brought them joy, but no longer due to physiological and psychological changes brought about by their substance use. 53

Recommendations for practice.

No part of this method is new or innovative. I used techniques that are standard practice in music therapy. However, the way in which I structured and conceptualized my music therapy groups is not something that is not often directly addressed in the literature. Based on what I learned in the development of this method, I encourage music therapists to very intentionally consider how they structure their sessions, in order to promote engagement and increase the likelihood that group members will reach flow states. Elements to consider, as discussed in chapters 2 and 3, include anxiety reduction and management, a balance between the challenge of the task and each person’s ability level, and clear goals and immediate feedback. If the proper conditions and priming are worked towards with the support, structure, and guidance of the music therapist, flow is likely to occur during group improvisation, allowing for much of the therapeutic work to occur in the music itself.

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Appendix A – Phrases Suggesting Various Elements of Flow “My mind was only on the music.” – Concentration on the task at hand “I was able to leave my worries/anxiety behind.” – Concentration on the task at hand “I was distracted from my negative thoughts.” – Concentration on the task at hand “I was one with the music.” – Merging of action and awareness “I was in the zone.” – Concentration on the task at hand “I felt careless, yet careful about what I was playing.” – Decrease in self-consciousness “Was that really 20 minutes? It felt like no time at all.” – Loss of sense of time