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(Title of the Thesis)* LOW-INTENSITY COGNITIVE BEHAVIOURAL THERAPY-BASED MUSIC GROUPS FOR THE TREATMENT OF MILD TO MODERATE SYMPTOMS OF MENTAL ILLNESS by Christopher Gordon Trimmer A thesis submitted to the Graduate Program in Neuroscience Studies in conformity with the requirements for the degree of Doctor of Philosophy Queen’s University Kingston, Ontario, Canada (June 2020) Copyright © Christopher Gordon Trimmer, 2020 This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License (CC BY-NC-SA 4.0) Abstract The costs of mental illness - economic, social, and human - are immense. However, the demand for evidence-based non-pharmaceutical therapies appears to exceed the availability of these services, and when therapy is available, sustained client engagement can remain a prominent issue. Cognitive behavioural therapy (CBT) has been well-established as an effective form of psychotherapy in the treatment of mental illness. Low-intensity CBT evolved from standard CBT to address availability concerns while maintaining effectiveness, but issues of engagement remain. Music has the potential to be a popular and effective new medium for low- intensity CBT because of the positive emotional connection people have with it, the potential ease of adaptation to a low-intensity therapy format, and its non-verbal nature. The purpose of this project was to develop, and assess the feasibility of, two low-intensity CBT-based music group protocols, CBT-Music (Study 1, Chapter 2; for symptoms of depression and anxiety) and CBTp-Music (Study 2, Chapter 3; for symptoms of psychosis), for individuals in community mental health care. A randomised controlled trial (RCT - Study 1) and a pre-post trial (Study 2) were used. Measures of therapeutic acceptability (i.e. recruitment, attendance, & client feedback) and clinical effectiveness (i.e. symptomology & disability) were gathered in both studies. Development and provision of a standard CBT-based group protocol utilising music as a delivery medium was successful, as was recruitment from community mental health services. In both studies, there were high attendance rates and overall positive response from participants that showed acceptability of the group protocol. In Study 1, there was a significant decrease in measures of disability following treatment (compared to a control group), though there was no significant effect of symptom reduction. In Study 2, there was also a significant decrease in ii measures of disability following treatment, plus a significant reduction in the severity of delusional symptoms of psychosis. There have been no previous trials of a low-intensity CBT-based music group for mild- to-moderate symptoms of mental illness. The advantage of a CBT-based music group may be its potential for reaching a more comprehensive range of the general population, including individuals unsure about engagement with therapy. A CBT-based music group may help individuals with mild-to-moderate emotional and mental health difficulties, but also those at high risk of developing mental health problems. iii Co-Authorship & Publication Statement of Co-Authorship I declare that this dissertation incorporates material that results from joint research and authorship. For each of the studies presented in this dissertation, the key ideas, primary contributions, experimental designs, data analysis, interpretation, and writing were the primary responsibility of the author. My co-authors shared their valuable perspectives and expertise throughout the process of publication. Study data was primarily collected by myself, or it was collected under my supervision by my co-authors (Richard Tyo & Claire McKenna). Richard Tyo made essential contributions to the development of the CBT-Music protocol (Chapter 2), including the composition of two songs. Jennifer Pikard contributed substantively in reviewing and refining the logic and form of the manuscript for Chapter 2. All co-authors understood that this work was to form part of my dissertation, and they have consented to its inclusion here. All research was conducted under the supervision of Dr. Farooq Naeem. Declaration of Previous Publication This dissertation contains three published manuscripts. Chapter 2 is an amalgamation of two published papers - a report to highlight the innovation and development of the CBT-Music protocol and a research article featuring data collected from a randomized control trial for the CBT-Music (for symptoms of depression and anxiety) intervention. Citation information is listed on the first page of Chapters 2 and 3. Previously published material included within this dissertation complies with the terms of author agreements for Canadian Periodical for Community Studies Inc. (Chapter 2), Cambridge University Press (Chapter 2), and Springer Nature (Chapter 3). iv Acknowledgements To my supervisor, Dr. Farooq Naeem, I would like to offer my sincere gratitude for taking me on as a graduate student, broadening my capacity as a researcher, and providing unlimited support in the past five years. Your encouragement and trust throughout this process has mattered the most to me through many life changes. It has been an honour to work under your guidance. Thank you to my advisory committee members - Dr. Julia Brook, Dr. Muhammad Ayub, Dr. Al Ferguson and Meg McQueen - for their patience, support, and valued contributions throughout the dissertation process. A special thank you to all the individuals who participated in my studies and the case managers who provided logistical help, support, and words of encouragement. I am grateful for the financial support I received in the form of an Ontario Graduate Scholarship and the Latham Family Award. My special thanks to my initial collaborator, Richard Tyo, and to my colleagues and managers at AMHS who provided significant support as I began my PhD journey. I dedicate this dissertation to my wife, Laura, who made so many adjustments, big and small, to support me during this journey. There are few words to describe how thankful I am for your love, support, and motivation. I am also grateful for the love and support from my family & friends. This includes my daughter Carmen, who kept me grounded and inspired, and to my mom and sister, who never stopped believing that I could find the finish line. v Table of Contents Abstract ..........................................................................................................................................................ii Co-Authorship & Publication ....................................................................................................................... iv Acknowledgements ........................................................................................................................................ v List of Figures ..............................................................................................................................................vii List of Tables ............................................................................................................................................. viii Chapter 1 General Introduction ..................................................................................................................... 1 Chapter 2 Low-Intensity Cognitive Behavioural Therapy-Based Music Group (CBT-Music) for the Treatment of Symptoms of Anxiety and Depression: A Feasibility Study ................................................. 23 Chapter 3 CBTp-Music: A feasibility study of a low-intensity Cognitive Behavioural Therapy music group for individuals with symptoms of psychosis ..................................................................................... 56 Chapter 4 Conclusions & General Discussion ............................................................................................. 82 Appendix A CBT-Music/CBTp-Music Facilitator Instructions .................................................................. 91 Appendix B Additional CBT-Music/CBTp-Music Songs ......................................................................... 122 Appendix C General Research Ethics Board Approval ............................................................................. 127 vi List of Figures Figure 1. ‘The Less You Do’. A song about behavioural activation …………………………...…….... 45 Figure 2. ‘Your (Fast) Beatin’ Heart’. A song about the connection between negative thoughts, emotions, and physical reactions………………………………………….………………………...…… 46 Figure 3. Consort flow diagram of the CBT-Music study………………………………………………..47 Figure 4. ‘Challenge the Harmful Ones’. A song about challenging negative thoughts and unbelievable beliefs……………………………………………..……………………………………………………….75 Figure 5. ‘Breath of Gold’. A song about dealing with stress and the benefits of deep breathing……....76 Figure 6. ‘People are Strange’. A song about experiencing symptoms of psychosis……..……………122 Figure 7. ‘You Might Know How it Feels’. A song about the stigma and normalization of mental illness…………………………………………………………………………………………………….123 Figure 8. ‘Eight Days a Week (of Problem Solving)’. A song about the successful steps to problem solving……………………………………………………………………………………………………124 Figure 9. ‘Bad Moon Rising’. A song about negative beliefs and paranoia….….………...……………125 Figure 10. ‘I Heard the Other Voice of Mine’. A song about hearing voices due to symptoms of psychosis…………………………………………………………………………………………………126 vii List of Tables Table 1: An example of a ‘musical’ thought record…………...………………………..………48
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