Application of Music Psychotherapy to Social Phobia: Evaluation Study Based on a Mixed Methods Design

Abstract

The state-of-the-arts concerning the etiology and the current treatment options for social phobia are reported.

We present an evaluation study of music psychotherapy, proposed in combination with cognitive restructuring techniques, with N=10 adult patients suffering from social phobia.

The methodology of evaluation is based on a psychometric scale (SVF 78), projective tests (Rotter’s Sentences Blank and TAT) and a semi-structured self-evaluation form. Original rating scales were constructed for the projective tests, allowing passing from qualitative analysis to the use of inferential and multidimensional non parametric statistical procedures.

The results of the study show a positive evolution on coping strategies with stress and anxiety, self-esteem, autonomy, playfulness and creativity in social situations. For some of the participants the defensive functioning is enhanced and a longer treatment period would be necessary for them.

The results are discussed in the light of the assumption, coming out of former research projects, that the action of music psychotherapy could be linked to the structural organization of personality.

Keywords: Cognitive restructuring; Coping strategies; Integrated quantitative and qualitative research methodology; Music psychotherapy; Optimal scaling; Self-esteem; Social phobia

Introduction

In the context of a multi-annual research project exploring the efficiency of arts therapies and arts psychotherapies with several subgroups of psychiatric patients, we present an exploratory follow-up study with people suffering from social phobia. The research project comprehended methodological research (especially adaptations of existing non parametric statistical procedures for small samples and non-metric data and development of original rating scales for projective and expressive tests) with action research [1,2].

In the context of a multi-annual research project exploring the efficiency of arts therapies and arts psychotherapies with several subgroups of psychiatric patients, we present an exploratory follow-up study with people suffering from social phobia. The research project comprehended methodological research (especially adaptations of existing non parametric statistical procedures for small samples and non-metric data and development of original rating scales for projective and expressive tests) with action research [1,2].

For most authors, social phobia is identical with social anxiety [8,9]. Some publications underline the enhanced embarrassment and paralysing self-consciousness in social phobia, leading to greater distress and a higher risk for depression and self-medication by alcohol or drug abuse [10].

The roots of social phobia go back to our first interpersonal experiences [11,12,3] and for some authors it is an expression of a precocious attachment disorder [13,14]. For others, it is linked to the performance and emulation based ideology of our Western society [15].

Let us stress that, according to the levels of personality organization distinguished by structural psychopathology [16], social phobia can appear with any type of structural organization, be it neurotic, borderline or psychotic.

Psychosocial treatment options: Theoretical and methodological considerations

Besides the psychopharmacological interventions, social anxiety is currently treated with Cognitive Behavioural Therapy (CBT), eventually combined with the learning and practicing of social skills [17-19], or by Internet-based self-help interventions [20].

CBT is based on the assumption that anxiety is a learned emotional response, maintained and triggered when confronted with certain environmental stimuli. This conditioning can spread at comparable, but decreasingly precise situations generalising the fears and multiplying the painful experiences [21]. Thus, the cognitive approach refers to the existence of dysfunctional thought patterns whose acquisition and reinforcement would give a negative representation of the situations considered as being menacing [22].

On the other hand, several methods of arts therapies proved to be efficient with emotional problems [23,24]. Arts therapies based on pictorial expression can have beneficial effects at the level of selfesteem, of the sense of well-being and of resilience with anxious patients [25,26]. Narrative techniques seem also promising, especially with children [27].

Specific evaluation studies of music therapy with social phobia could not be identified.

Former publications showed the liberating power of musical improvisation with anxious and inhibited patients. Austin [28] rests upon the theory of attachment [13] in order to develop her theoretical concepts about the effect of duo improvisation or of free associative singing. According to the author, this experience allows recovering the links between words and emotions. Those links have been destroyed during traumatic experiences going back to the second or third year of one’s life. Stige [29] who uses a constructivist approach describes an anxious and dysphonic patient’s music psychotherapy. For him, music becomes either a means of relaxation or a means of triggering emotionally charged memories. The author discusses the comparative importance of these two components and concludes that music is mainly a means of feeling alive, i.e. of recovering the vitality affects.

The presently evaluated intervention with people suffering from social phobia combined musical and literary production with verbal techniques derived from CBT. Music therapy can be part of the process of cognitive behavioral therapy by acting simultaneously on the emotions, on cognition and on the behavior. The cognitive distortions can be addressed through the stories written by clients to the plates of the Thematic Apperception Test [30] or while listening to music [31]. The consequent verbalization is based on the symbols created by the clients themselves and allows speaking about the figures created in the stories instead of using the first or second person. This indirect approach is less intrusive, especially for persons who have suffered from repeated traumatic events since childhood.

Therapeutic objectives based on the acquisition of mental health and not on the disappearance of symptoms are perfectly adapted to the treatment of people suffering from emotional disorders. In the case of social phobia the main aim is focused on the resolution of an existential problem: remaining oneself and finding the right distance in front of others [32].

Material and Methods

General objectives

The research questions are focussed on the exploration of changes appearing between the pre-test and post-test situation (comparative approach), as well as on the investigation of the latent dimensions underlying the manifest changes (multidimensional approach).

Based on the study of literature and on previous personal studies concerning the application of arts therapies and arts psychotherapies with other subgroups of suffering of developmental , clinical or psychosocial problems, we expected a positive evolution on the following dimensions:

• Efficiency of coping strategies with stress and anxiety
• Self-esteem
• Ease of communication
• Autonomy
• Playfulness and creativity in social situations

The general hypotheses were operationalized through psychometric and projective categories.

Methodology of treatment

The cognitive behavioural approach (techniques of cognitive restructuring) was completed by active music therapy (vocal and instrumental improvisation) and by the writing of stories under musical induction [31]. They consist of free literary expression while listening to music, without proposal of a theme, and are followed by verbal elaboration in the group.

While active music therapy was focused on the release of tensions and on the development of assertiveness in front of others, the literary expression aimed at favouring the imaginary and symbolic elaboration of the past and the resolution of fundamental existential problems.

The combination of musical and literary expression with CBT was tested in other parts of our research project and proved to be efficient [1].

The clients assisted to weekly group sessions during 3 months.

Evaluation tools

The evaluation was based on an integrated quantitative and qualitative methodology, combining a psychometric scale, (the SVF- 78 [33]), projective tests (Rotter’s Sentences Blank [34]; the Thematic Apperception Test [30]), and a semi-structured self-evaluation questionnaire.

For the Rotter test and the TAT, we constructed original rating scales allowing passing from qualitative analysis to quantification and the use of inferential and multidimensional non parametric statistical procedures [35,36].

This kind of methodology aims at taking in account the objective and subjective perspectives and provides a great number of data per person (person centred research).

Description of the sample

The sample comprehends 10 participants treated in the outpatient setting of a general hospital. They were divided into two subgroups for reasons of personal convenience (temporal restrictions linked to their professional obligations).

The inclusion criteria corresponded to the categorical definition of social phobia (according to the DSM).

Sub-group is composed of 4 persons, 2 men and 2 women.

Mean age: 37, 5;       SD: 6, 6

Sub-group b is composed of 6 persons, all men

Mean age: 36, 33; SD: 11, 39

Results

In the presentation of results, we will underline especially the changes in coping strategies and defence mechanisms between pretest and post-test.

Pre-test / Post-test comparison

At the SVF 78
Statistical comparison (N = 10)
The negative strategies (escape, pondering, resignation and selfaccusation) have diminished between pre-test and post-test.
(Table 1)