Integrating effect of art- and music-therapy on depression in adolescents
Mansooreh Rahmani1, BahramBakhtiari Saeed1*, Mojtaba Aghili2
1Department of Psychology, Gorgan Branch, Islamic Azad University, Gorgan, Iran
2Department of Psychology, Gorgan Payame Noor University, Gorgan, Iran
*Corresponding author:
Abstract:
The present paper reports an investigation on integrating effect of art and music therapy in order to ameliorate depression in adolescents. Due to potential side effects of variety of anti-depressant medications on clients, especially children and adolescent, a great deal of attention has been paid to positive effects of non-pharmaceutical interventions to reduce symptoms of depression. A controlled clinical trial was performed with a sample of 24 depressed adolescents. The Beck Depression Inventory (BDI) and the Children’s Depression Inventory (CDI) were adopted for selection and assessment purposes. The adolescents were randomly assigned to two groups, i.e. control (n = 12) who received no intervention in the course of the study and music and art therapy (n = 12) who received seven 2-h sessions of art and music therapy. Art-therapy was performed by using painting tasks.Music therapy sessions were performed simultaneously with art therapy.The subjects were exposed to three music themes, i.e. exhilarating, sad, and strengthening. The results revealed that integrating art and music therapy could significantly decrease depression in the adolescents.
Keywords: Adolescents, Art therapy, Depression, Music therapy.
Introduction
Adolescence is an important shifting stage from puberty to adulthood. Adolescents are prone to variety of physical and mental risks. One of the most important risks in adolescence is depression which might severely affect adolescents and hinder them from any potential achievement (Monteiro et al., 2015).Depression is considered a common, debilitating, burdensome, and chronic mental health problem. Furthermore, it is regarded as a developmental phenomenon (Hankin, 2015).Adolescent development is accompanied by the appearance of a population-wide rise in susceptibility to depression that is continued in adulthood (Davey et al., 2008). Depression in adolescence has been widely examined in several investigations (e.g. McPhieRawana, 2015;Hankin, 2015; Monteiro et al., 2015; Dierker et al., 2015; Hamilton et al., 2014; Monshouwer et al., 2012; Verbeek et al., 2012).
Depression might have variety of consequences such as unhappy temper, reduced concentrationor desire in most actions, being too thin or overweight, insomniaor hypersomnia, anxiety, exhaustion,feelings of worthlessness, and even thoughts of death or suicide (Dere-Meyer et al., 2011). Such consequences might be more severe in adolescents who are passing through one of their most important and sensitive stages of their lives.
Art therapy has been claimed to be effective to cure depression (Preskorn et al., 2004). For one thing, it may provide a basis for a depressed person to express his/her depression safely (Branch, 1992). Art therapy is considered a soft way by which a depressed person can release his/her aggression without having to engage in any verbal communication (Harnden et al. 2004). Art therapy is also beneficial to strengthen the relationship between the client and treatment team (Dere-Meyer et al., 2011).
Music therapy can be defined as the intended use of music to attain therapeuticresults. Music therapy is frequentlypresentedvia group and individual programs after a processof referral and assessment (Castillo-Pérez et al., 2010). Music therapy arouses cognitive functions,acts on anxiety, depressive phases and aggressiveness and therefore,considerably improves attitude, communication and independence (Guétin et al., 2009).Maratos et al. (2008) claimed that music therapy is accepted by people suffering from depression and it can improve mood in them. Raglio et al. (2012) believe that a music therapy intervention should occur in a therapeutic setting and be directed by trained music-therapists. Effect of music therapy on depression and several depression-related disorders have been evaluated (ShiraniBidabadiMehryar, 2015; Zhou et al., 2015; Schwantes et al., 2014; EsfandiariMansouri, 2014;Verrusio et al., 2014; Lu et al., 2013; Romito et al., 2013; Castillo-Pérez et al., 2010).
To the best of our knowledge, no research has been performed yet on integrating effect of music therapy and art therapy on depression of adolescents. Therefore, the present study was formulated in order to assess such effect on adolescents.
Subjects and methods
Subjects (n= 24) selected for the present study were all 15 year-old girls belonging to high schools in Gorgan, a city located in the north of Iran. Approval for study was achieved from Gorgan Education Office. The questionnaires used in the study were also approved by Research Department of Education Head Office of Golestan Province, Iran.The Beck Depression Inventory (BDI) and Children’s Depression Inventory (CDI) were used to find depressed students in 10 high schools and finally, 24 depressed students were found. Permission were taken from the students’ parents and they were asked to sign consent forms for their children to participate in the study. The students were randomly assigned to two groups (n= 12), i.e. control and experimental. It was assured that all the subjects were not suffering from any other neurological problem and they were not taking any other psychological treatment since any other treatment might cause disturbance in the process of the study. The tools adopted in the study were all anonymous and any information regarding the identity of the subjectswas kept confidential.
The experimental group received music therapy and art therapy simultaneously while the control group didn’t receive any treatment in order to check the potential influence of the therapies used in the study. Depression levels of the respondents in both groups were evaluated by using theBeck Depression Inventory (BDI) and the Children’s Depression Inventory (CDI) before and after the treatment.
The questionnaires
The Beck Depression Inventory (BDI)is a 21-question multiple-choice self-report inventory, one of the most widely used instruments for measuring the severity of depression. The questionnaire consists of items which are related to symptoms of depression including hopelessness and irritability, cognitions like guilt or feelings of being punished, in addition to physical symptoms like fatigue, weight loss, and lack of interest in sex (Beck, 1972).
The Children’s Depression Inventory (CDI) is a psychological testwhich evaluates the extents of symptoms associated with depression in children and adolescents. The CDI is aself-rated and symptom-oriented 27-item scale which is grouped into five major factor areas. Clients rate themselves according to their feelings and thoughts and each statement is rated from 0-2 (Kovacs, 1992).
Art therapy
Art-therapy was performed by using painting tasks. Painting was considered because it provides a basis for the subjects to express their feelings without worrying about any sudden reaction by audiences. The tools provided for the subjects for painting consisted of crayons, colored pencils, water color, and papers. The subjects in experimental group were painting 2 hours in seven sessions. While painting, they were also listening to music.
Music therapy
Music therapy sessions were performed simultaneously with art-therapy. While the music tracks were playing, the therapist made sure there was no noise or stressor. There were seven 2-h sessions altogether. The subjects were exposed to three music themes, i.e. exhilarating, sad, and strengthening. Exhilarating theme consisted of rhythmic music with rather fast beat in order to induce happiness without too much excitement. Sad theme was tragic and magnificent inducing sympathy and relief. Strengthening theme included heavy and hard beats stimulating positive and pleasant feelings and a sense of arousal and excitement. The music tracks were selected by a counselor with over 10 year experience of working with depressed adolescents.
Data analysis
A Cronbach’s Alpha test was run in order to determine reliability of the questionnaires. In order to find out whether parametric or nonparametric tests should be used to evaluate the data, normality of the data was evaluated by using Kolmogorov-Smirnov Test. To understand whether there were statistically significant (p<0.05) differences within the groups before and after the intervention, independent t-test was adopted. All operations were performed in SPSS Software (version 22).
Results
The results obtained from the Cronbach’s Alpha Test indicated that both the questionnaires were reliable since the alpha for BDI and CDI were found to be 0.787 and 0.712, respectively. Validity of the tools had also been approved by asking the ideas of experienced experts in the area of children and adolescents psychology. All the samples had normal distributions and therefore, we used independent t-test as a parametric test.
Table 1 shows that there is no major change in depression of the adolescents as reported through BDI from pretest to posttest in control group. However, in the experimental group, the scores from pretest to posttest decrease considerably. Furthermore, according to Table 2, there is not any significant difference between the CDI scores of pretest and posttest in control group (p>0.05); however, a significant decrease was observed from pretest to posttest in art and music therapy group (p<0.05). These findings illustrate that incorporated use of art and music therapy helped lessen depression among the participants of the experimental group.
Table 1
Scores on adolescent report of depression (BDI).
Control group (n = 12) / Art and music therapy group (n = 12)Pretest / Posttest / Pretest / Posttest
41
41
39
35
37
35
43
41
43
41
44
38 / 40
38
44
34
44
36
49
41
41
54
45
32 / 35
37
41
37
46
47
38
45
47
43
45
39 / 22
21
26
24
14
22
30
24
21
29
22
24
Mean Scores / 39.83 / 41.50 / 41.67 / 23.25
Table 2
Independent samples t-test on the Beck Depression Inventory (BDI)
Measures / Mean difference / Std. error / t / Df / Sig. (1-tailed)Control
Pretest-posttest / -1.667 / 2.005 / -0.831 / 22 / 0.415
Art and music therapy
Pretest-posttest / 18.417 / 1.734 / 10.621 / 22 / 0.000
As shown by the results in Table 3, the same trend with BDI results can be detected in the case of CDI. Again, the scores from pretest to posttest in control group had no major change while in the art and music therapy group, the participants’ scores decreased. Moreover, there was no significant difference between the scores of participants in control groups from pretest to posttest (p>0.05) while a significant difference was found in the scores of the participants in art and music therapy group from pretest to posttest (p<0.05) (Table 4). It again shed light on the considerable effect of incorporation of art and music therapy in order to reduce depression levels in adolescents.
Table 3
Scores on adolescent report of depression (CDI).
Control group (n = 12) / Art and music therapy group (n = 12)Pretest / Posttest / Pretest / Posttest
27
32
24
31
27
27
34
29
33
26
30
33 / 29
26
28
32
29
40
22
35
34
39
37
28 / 29
33
27
29
33
22
43
29
29
27
27
34 / 26
27
27
28
24
28
31
15
28
22
22
26
Mean Scores / 39.83 / 41.50 / 41.67 / 23.25
Table 4
Independent samples t-test on the Children’s Depression Inventory (CDI)
Measures / Mean difference / Std. error / t / Df / Sig. (1-tailed)Control
Pretest-posttest / -2.167 / 1.846 / -1.174 / 22 / 0.253
Art and music therapy
Pretest-posttest / 4.833 / 1.923 / 2.513 / 22 / 0.020
Fig. 1 depicts seven paintings representing each single session. The first painting is a crying face of a woman and a burning candle with falling melted wax as if they are tears of the candle. There is a great sorrow in the eyes of the woman and the form of the lips is in a way that it reflects a great sense of indifference which can be a consequence of a big grief.
The second painting shows a girl with long black hair dressed in a red gown through which her body is also recognizable. It shows a land with seemingly yellow grass and either a blue sky or blue sea with a beautiful sun in the middle. The red grass might point to a degree of depression in which the adolescent has considered herself in but there is also a sign of hope for her to reach the blue sky or sea and the beautiful sun.
In the third painting, there is no person but a view of sea and the beach with some rocks. It seems like there is no major sign of depression in this picture but it still induces a feeling of indifference and the fact that there are not enough reasons to be happy.
The fourth painting depicts the face of a girl. Unlike the first painting, there are no tears on the face of the girl and there is no burning candles. The girl looks confident and she is looking at somewhere very assertively. There is barely a sign of boredom or irritation. The way she is looking induces a feeling of hope and purposefulness. Her hair is tidy and she seems to pay a lot of attention to her appearance. Unless from a very pessimistic point of view, the girl’s face indicates positive emotions.
In the fifth painting, two trees can be seen, one very upright and fresh and another with falling leaves. The beautiful sun and blue clouds give a happy sensation to the audience as does the fresh tree. However, there is a sign of disappointment as the leaves are falling off another tree.
The sixth painting is a plant stand with beautiful green leaves and visible roots. The roots can indicate the firmness of the plant and green leaves induce a feeling of dignity and prosperity. The small buds at the tip of some branches also indicate hope of growth and revitalization. It seems like the painter had a good feeling while painting this plant stand.
The culmination of happiness and livelihood can be seen in the seventh painting. There are beautiful green tress and birds flying in the beautiful sky with marvelous sun and glorious clouds. The green lawn is so inspiring and the overall scene can be a spot of choice for everyone who wants joy and bliss. Needless to say, there is no sign of depression, anxiety, or boredom in this painting.
Session 1 /
Session 2
Session 3 /
Session 4
Session 5 /
Session 6
Session 7
Fig.1.Paintings of seven art and music therapy sessions.
It is evident that the participants in the art and music therapy group showed signs of hope and recovery from depression as the painting they presented in the last sessions were happier and less depressed that those painted in the first few sessions.
Discussion
The results obtained from the present study revealed that depression among adolescents can be alleviated by incorporation of art and music therapies. The results from the control group also implied that depression might exacerbate with time as some participants suffered from higher level of depression in the posttest.
Brillantes-Evangelista (2013) believes that although visual arts can lead a person to release his/her life in the form of, say, a painting, gain higher level of awareness cognition about him/herself, and get to know what kinds of conflicts he/she is suffering from, subjective therapeutic changes cannot be achieved solely through visual arts. However, in the present study, consolidation of art therapy with music therapy could significantly lessen depression level among the adolescents.
One of the most important features of the art therapy adopted in the present study is that it was performed in a group context where the participants felt containment and they could also communicate with their mates. This definitely brings them a sense of mutuality and can be considered as one of the most important factors to reduce the level of depression (Gatta et al., 2014), especially among adolescents who are shifting into their different role-playing state in society as more sociable members.
Another very important implication of the present study is that non-pharmaceutical interventions can also be applied in order to alleviate adverse effects of depression. Of course, the present study did not compare the effect of art and music therapy and pharmaceutical interventions on the depression level. However, in a study by Castillo-Pérez et al. (2010), it was revealed that the subjects in the music-therapy group had less depressive symptoms than those in the psychotherapy group. Nevertheless, the authors suggested that non-pharmaceutical interventions would best suit for those suffering from low and medium levels of depression.
One of the distinguishing properties of the present study is incorporated use of art and music therapy to cure depression in adolescents. However, other combinations are also possible. For instance, Kim et al. (2014) evaluated theeffectsofgrouparttherapyalong withbreathmeditationonthesubjective ameliorationofdepression andanxiety symptoms inadolescents. They found that group art therapy has a better effect on improving the well-being of the adolescents when combined with breath meditation. This study had opened an avenue toward the higher effects of combinations of different psychotherapy methods. However, it seems more rational to combine interventions which are more popular and easier to teach to potential therapists. As music is almost always popular among adolescents, it would be easier to make use of music therapy, instead of breath meditation, combined with art therapy for depressed adolescents.
Art therapy is a wide concept per se and may include variety of artistic activities from painting to sculpture. In some studies, variety of artistic activities were used in a single intervention as art therapy. However, it seems the most popular type of art therapy in literature was painting (Gantt and Tabone, 1998;Diaz, 2009 as cited in Dere-Meyer et al., 2011;Brillantes-Evangelista, 2013; Kim et al., 2014; Gatta et al., 2014; Petruta-Maria, 2015, among others). However, it seems that different types of art therapy, and even different types of, say, painting, might have various psychological and mental influence. Therefore, we preferred to make use of only one of type of art therapy (i.e. painting). Nonetheless, it seems very interesting area of research to investigate effects of different kinds of art therapy in isolation and combination.
There were some limitations concerning the present study. The first limitation is related to limited number of participants; however, as it seems cumbersome to work this type of subjects, the results obtained here may be considered valuable. Another limitation, which can be somehow attributed to the limited number of participants, is the lack of separate art therapy and music therapy groups in order to compare the effect of each single therapy with each other and with the ones obtained from incorporating both therapies.