Eating Disorder Treatment and Meal support therapy
Anorexia nervosa (AN) is a mental illness which is characterised by intense fear of weight gain, low weight and a disturbance in the perception of body weight or shape (Phillipou, Gurvich, Castle, & Susan, 2015). Goals for treatment of AN in an inpatient setting are medically and psychologically focused. A treatment plan for admission is developed by the consumer in collaboration with their multi-disciplinary team which focuses on goals for health restoration and therapeutic treatment for long-term recovery (Hay, Touyz & Sud, 2012; Newton, 2012).
Mealtimes can be a highly distressing and anxiety provoking time for people with AN (Hage, Ro, & Moen, 2015). Eating and weight gain is often associated with feelings of fear and anxiety (Breiner, 2003; Harvey, Troop, Treasure, & Murphy, 2002). People with AN can experience psychological and physical discomfort after meals, becoming preoccupied with feelings of guilt and thoughts of purging (Leichner, Standish & Leichner, 2005). Risk to self and safety concerns are increased during this time, with some people being prone to self-harm as weight restoration occurs, intense suicidal ideation and increased compensatory behaviours (Hage et al., 2015).
Support from staff during meal times is recognised as important for decreasing meal-related distress in an inpatient setting (Clinton, Bjorck, Sohlberg, & Norring, 2004; Federici & Kaplan, 2008; Long, Wallis, Leung, & Meyer, 2012; Offord, Turner & Cooper, 2006). Although supported mealtimes are generally viewed as positive by consumers with AN (Lindstedt, Neander, Kjellin, & Gustafsson, 2015) there is little research into what specific therapeutic activities are helpful for reducing anxiety during supported post-mealtimes (Long et al., 2012).
Collaborative music therapy approaches and mental health recovery
It is well documented that music therapy can improve the quality of life and relationships of people with mental illness (Grocke, Bloch & Castle, 2009; Hayashi et al., 2002; Mossler, Chen, Heldal, & Gold, 2011). Psychodynamic, cognitive-behavioural, humanistic and ecological approaches are commonly used in music therapy work specifically with people with eating disorders (McFerran & Heiderscheit, 2016). In this study, a collaborative and resource-oriented approach to practice was used since it is congruent with the collaborative conceptualisation-based treatment approach (Newton, 2012) used in the eating disorders unit where the study was conducted. Through collaborative and resource-oriented practice, music therapy can promote autonomy during mental health recovery (Rolvsjord, 2010). Mental health recovery emphasises empowerment, collaboration, lived experience and looks beyond the limitations of ‘illness’, for health(Banfield. Barney, Griffiths, & Christenson, 2014; Slade, 2009). Recovery values the consumer’s perspective together with the skills and knowledge of mental health workers, challenging traditional understandings of power and knowledge in mental health care (Commonwealth of Australia, 2013). The relationship between music therapy practice in mental health care and the emphasis on empowerment and consumer led processes in contemporary recovery-oriented mental health practice is congruent (Baines, 2003; Procter, 2002; Rolvsjord, 2010; Solli, Rolvsjord & Borg, 2013).Like recovery-oriented practice, resource-oriented and collaborative music therapy practices promote principles of empowerment and self-determination by collaborating with consumers and focusing on their strengths and resources (Rolvsjord, 2010). Collaborating with people with eating disorders in their mental health recovery can promote feelings of empowerment and equality, which are important in inpatient eating disorder settings that may otherwise offer minimal opportunity for self-determination (Dalton, Elias & Wandersman, 2001; Fitzsimons & Fuller, 2002).
Music therapy and eating disorders
Music therapy can play an important role in the recovery from AN. Participation in music therapy offers motivation and distraction from negative thoughts and feelings around body image (Hilliard, 2001; Robarts & Sloboda, 1994; McFerran, 2005) and can foster processing of therapeutic issues in therapy settings (McFerran et al., 2006). People with AN have described a sense of renewed self confidence and empowerment through participation in music therapy (Lejonclou & Trondalen, 2009). Pavlakou’s (2009) study examining the experiences of group singing in eight people with eating disorders reported on the perceived emotional and cognitive benefits of music therapy. Participants described improved self worth and increased opportunity to distance themselves from life’s problems through participation in group music therapy. Despite these positive reports, the role of music therapy during supported meal times has received scant attention hitherto. This study aimed to address this gap by examining group music therapy during post meal support therapy amongst a group of consumers with AN in hospital.
This study was conducted within the Body Image Treatment & Recovery Service (BETRS) Adult Eating Disorder Inpatient Program consisting of five beds co-located within the Adult Acute Psychiatric Unit, on the campus of Austin Hospital in Melbourne. The inpatient program is available for people aged 18-64 years with severe AN whose needs have not been met in a community-based treatment setting. The average age of individuals with eating disorders admitted to the BETRS inpatient program is 22 years, predominantly women. The unit uses a collaborative conceptualisation-based approach (Newton, 2012) which is consumer-centred and strengths based. The inpatient program consists of two arms: 1) a medical rescue service aimed at people with significant medical compromise secondary to their eating disorder who require urgent nutritional and health restoration; and 2) a longer term therapeutic arm for consumers who are actively seeking inpatient treatment to assist in the long term recovery from their eating disorder.
The provision of adequate nutrition for weight restoration is an integral component of the BETRS inpatient program. The therapy program includes a supported lunchtime (meal support therapy) that includes a period of post meal distress tolerance and support provided by a team member. Meals and snacks are consumed six times per day, in a group setting. The lunch component of the meal support program is delivered by a variety of different disciplines throughout the week including allied health and psychiatric nursing staff. The lunch group is delineated from the other meals and snacks by including a pre-meal, during meal and post meal support session, which is targeted on eating behaviours and distress tolerance techniques.
An embedded mixed methods design was adopted where quantitative and qualitative data were collected within a quasi-experimental design (Creswell & Plano Clark, 2011).The interest in both understanding and measuring the experience of music therapy sessions after meals suggested a mixed method approach, using different modes of self-reporting on the phenomenon.
Participants attended group music therapy after lunch twice per week for the duration of their admission. The quantitative element has been reported elsewhere (Bibb, Castle & Newton, 2015). In brief, we adopted a non-randomised pre-post design comparing music therapy with treatment as usual following mealtime. A total of 89 intervention and 84 control sessions were recorded during the 36 week data collection period. Results from an unpaired t-test analysis indicated highly statistically significant differences (p < 0.0001) between the music therapy and treatment as usual conditions. Results indicated that participation in music therapy significantly decreases post-meal related anxiety in comparison to treatment as usual (Bibb, Castle & Newton, 2015).
In the current article, we present the qualitative element of the study which explored participants’ experiences of music therapy using semi-structured interviews. Privileging participants’ experiences is congruent with the emphasis on recovery-oriented and collaborative practices in this study. Understanding participants’ experiences of music therapy after mealtime is important in gaining further knowledge of the role that music therapy can play in inpatient settings, where support after mealtime is understood as helpful for consumers but experiences of ‘what works’ during this time is not (Long et al., 2012). Upon discharge, participants attended an individual interview with the first author (Bibb) and were asked about their experience of the post-meal group music therapy. Interviews were audio recorded and transcribed. This project was approved by Human Research Ethics Committee at Austin Health (HREC/14/AUS/75).
Individuals who were admitted to the BETRS inpatient program were invited to participate in the study. A plain language statement and consent form was distributed to consumers upon their admission. Informed consent was obtained from 18 out of a potential 32 consumers, recruited over a 36 week period. Ten of these 18 also agreed to participate in the qualitative interview upon discharge from the program. The remaining eight participants either chose not to participate in a qualitative interview (2) or were discharged from hospital before the primary researcher had an opportunity to interview them (6).
Interview data were analysed using descriptive phenomenological microanalysis (McFerran & Grocke, 2007) which aimed to capture the fundamental meaning of participants’ experiences. Little is known about consumers’ experiences of music therapy during post meal-time. Thus, phenomenology was chosen in an attempt to openly explore the phenomena and develop a descriptive account of participants’ experiences (Finlay, 2011). The analysis aimed to identify common features of participants’ experiences. A five step process was adopted from Giorgi’s (1975) approach to phenomenological analysis.
The first step was to reduce each interview transcript to its essential elements by identifying key statements (McFerran & Grocke, 2007). Next, the data were classified into categories based on the explicit meaning of the experience and Structural Meaning Units (SMUs) were created. The next step entailed a long period of immersion in the interview transcripts. The data were reconstructed to capture what was meant by the participant for each point they made resulting in Emotional Meaning Units (EMUs). Then, an individual distilled essence was created for each participant in the form of a narrative. The final step of analysis involved construction of common themes through examining each essence and identifying collective features across the participants’ experiences.
Participants attended two one-hour group music therapy sessions each week, directly after lunch. The group was facilitated by the first author (Bibb) who is a Registered Music Therapist (RMT). The sessions were part of the compulsory group therapy program and had a fluctuating attendance, between two to five participants dependent on admission numbers. All consumers who were admitted to the unit agreed to participate in the group, though the level of engagement was dependent on the energy and mental state of consumers at the time. The sessions aimed to offer participants a distraction from post-meal related stress and offer opportunity to practice distress tolerance through music. Participants were encouraged to engage in singing, listening to songs, talking about songs, sharing songs and writing songs together. A resource-oriented approach to practice was adopted (Rolsvjord, 2010) which focusedon the strengths and resources of participants. Participants were invited to collaborate together on the process of each session.
Ten participants attended an individual semi-structured interview upon discharge from the inpatient program. A distilled essence of each participant’s experience of music therapy is depicted in Appendix A in the form of a narrative. Each participant is referred to by a pseudonym. A number of unique features are apparent in these descriptions and the tone of each participant has been captured by using their own words. Each sentence represents a discrete Emotional Meaning Unit (EMU) or ‘theme’ from the participants interview excerpts. During the analysis process, interview data was reconstructed to capture the ‘true meaning’ of participants’ statements. Each EMU is a theme which captures what was meant by the participant. The titles of the EMUs remain in the participants’ own words. Commonalities between the participants’ experiences are then discussed.
Three main themes emerged from the interviews depicting participants’ experience of group music therapy. In the following section direct quotes from participants are represented using quotation marks.
Taking your mind off the meal. All ten participants described music therapy as a means of distraction from the meal they had just eaten. Anne and Irene described this “as taking your mind off the meal”while Rosie stated, “it’s easier to get distracted from the uncomfortable feeling after meals.” Leah described this as “a good distraction from the experience of having eaten.” Participants also referred to being distracted specifically from challenging thoughts and feelings. Lauren described this as “a way to distract from other things and worries”while Ellen articulated the importance of having a distraction during this time saying, “having something to focus on and distract you is important cos(sic) you can get stuck in your own head.
Getting a break from anxiety. Nine participants referred to music therapy as relaxing. Ellen related music therapy sessions to a “circuit breaker” explaining, “you get a break from [the] anxiety for that time, and you feel lighter at the end.” Several participants described music therapy as “helping [them] to relax” while others described it as providing them with an opportunity to “just chill out.” Lauren made reference to the group environment and how this influenced her own feelings, stating, “when other people feel relaxed, the whole atmosphere and whole room relaxes.
A chance to get to know others. Five participants described appreciating the opportunity to get to know other people with AN through the music therapy sessions. For two participants, this was in relation to music influencing their openness with others. Leah described this as being“easier with music cos it just kind of opens up your heart straight away and it’s really helpful to engage with other people.”While Jacqui said, “music therapy forces you to interact, share and find out about other people in the group, and that’s a good thing.” Leah also likened sharing her favourite song with the other group members as saying, “here’s a piece of me I want to share with you.” She described this as “a bit scary” initially but the shared listening of the song made her feel more “connected to the group.” Getting to know others in the group was described by some participants as occurring through hearing other peoples’ music preferences. For example, Ellen reported being surprised at her co-patients’ preferred music choices and that “realis[ing] they connected to something which was the same” was a positive experience. Ellen described this as, “getting to know other people through their music choices.”
In the following section direct quotes from participants are represented using quotation marks.
An opportunity for the expression of identity
Music therapy acted as a non-threatening and familiar activity for consumers in an inpatient setting with frequent supervision and medical intervention (Bibb, Castle & Newton, 2015; Fitzsimons & Fuller, 2002; Hense, McFerran & McGorry, 2014). Hospitalised patients with AN often report feeling constantly watched by staff around meal times (Long et al., 2011). They report meal times as disempowering and a loss of identity is experienced, with the removal of choice and the rehearsed nature of structured meal times (Long et al., 2011). Emma articulated this in relation to her experience of music therapy and what being ‘un-watched’ meant to her, stating, “in music therapy I didn’t feel like I was being watched or anything so I could just sort of relax and really listen to the music.”
Participating in music therapy during post meal time may have provided participants in this study with an opportunity for choice, self expression and identity formation at a time when they felt most vulnerable (Lindstedt et al., 2015). A good example of this is when Leah likened sharing a song with the other group members as saying “here’s a piece of me I want to share with you.” Indeed, musical preferences reflect the public representation of who we are (McFerran, 2010). This is described by Even Ruud as the ‘performance of identity’ (Ruud, 1997, p.3). Sharing a song with fellow consumers took great courage on Leah’s part, but also allowed her to communicate something of herself and her identity with the group.
A distress tolerance technique
AN is associated with dysphoria and emotion and distress avoidance (Wildes, Ringham & Marcus, 2010). Consumers report that the illness feeds their desire to avoid and control their emotions (Corstorphine, Mountford, Tomlinson, Waller, & Meyer, 2007; Gale et al., 2006; Smeijsters, 2012). People with AN often report feeling emotionally ‘numb’ (Schmidt & Treasure, 2006). Leah describes this ‘numbness’ in relation to the role music played for her during music therapy sessions, stating, “with anorexia, you numb your feelings so much, you forget how to feel, but music helps to thaw that part of you.”Participating in music therapy after meals allowed consumers to not only tolerate, but to also transform the feelings of distress, so that music engagement acted as a new coping strategy for their long-term recovery (Smeijsters, 2012). Music therapy thus serves as a useful distress tolerance technique where the therapy transpires during the music rather than during discussion following the music (McFerran, 2010). The experience of musical process during music therapy isthe therapy (Aigen, 2005). This supports the potential for music therapy to act as a therapeutic treatment for people with AN not just during post meal support times, but at other times during their recovery.
Learning coping skills for long-term recovery
Participating in music therapy during inpatient admissions can provide patients with a new coping tool for meal times at home. Thus, patients have previously reported learning coping strategies during inpatient admissions which they then implemented upon discharge (Gutierrez & Camarena, 2015). Ellen described learning the role that music can have on her mood during her inpatient admission and the importance of intentional music use, stating:
“…even just how many songs can affect you, like I knew it affects you but how much it really can influence your mood. When I was in here I didn’t really listen to music, but after I got into music therapy a bit, then I started listening to music to help calm me down. I’ve never done that before, even when I’ve been at home.”
Effectively managing anxiety during an inpatient admission can promote music use at home as a healthy coping strategy. Some participants in the current study did report their intention to use music to cope with anxiety upon returning home. Leah stated, “listening to a song myself after a meal, I’ll continue to do that”, while Irene described how she had previously used music at home stating, “I do use it for anxiety or if I’m feeling in various crappy moods. It kinda(sic) helps me zone out and go away from whatever is making me feel crap.”Others like Anne dismissed the possibility of using music at home stating, “at home you don’t have time just to sit down and relax.”
Although 18 participants from the quantitative part of the study initially agreed to participate in qualitative interviews, data was only collected from ten participants. Six of the remaining participants were discharged before they were interviewed despite being eager to contribute. Additional ethics approval to interview participants after discharge to the community as well as increased communication between the primary researcher and the treatment team regarding discharge planning may have increased the number of participants who contributed to the study. The two participants who chose not to participate in a qualitative interview may have also added to the diversity of experiences, which were mainly positive.
Music therapy for the treatment of AN is underfunded in adult mental health services in Australia. Through the qualitative element of this study, we begin to understand the importance of participants’ experiences of group music therapy after meals. Three common themes were derived from ten participants’ individual accounts: taking your mind off the meal, getting a break from anxiety and a chance to get to know others
This is important knowledge for inpatient eating disorder programs, in which it is known that support after mealtime is helpful for consumers but experiences of ‘what works’ for them during this time, were not (Long et al., 2012). Participation in music therapy can ‘work’ for consumers by offering them an alternate distress tolerance technique for meal-related anxiety. This can be translated into their ongoing recovery plan upon discharge from the inpatient program (Gutierrez & Camarena, 2015). Existing music therapy research has explored participants’ experiences of music therapy sessions during their recovery from AN (Hilliard, 2001; Robarts & Sloboda, 1994; McFerran, 2005; Lejonclou & Trondalen, 2009; Pavlakou, 2009). Post meal-time is described by individuals as disempowering, and a time of heightened distress and anxiety (Long et al., 2012). It is essential that we consider the role music therapy can play in supporting consumers with AN during this time.
This research was financially supported by the Austin Medical Research Foundation (AMRF). The authors would like to thank the consumers who generously contributed to this study.
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Appendix A. Individual distilled essence for each participant (pseudonyms used)
Emma: Engaging and listening to music was nice, choosing the songs was nice too. It’s something else to listen to apart from what’s in your head. I didn’t feel like I was being watched so I was able to relax a bit more.
Anne: It’s helped me a fair bit. It certainly lowered my distress levels. And it’s a good place to just be mindful. It was nice to be able to lay back and go somewhere else. It took your mind off the meal you’d just eaten. Everyone finds their own little space in that room, their own sacred corner. You can zone out in your area and not worry about anyone else. They were nice soft songs and hearing songs you can relate to makes it easier to reflect. It’s nice to have something planned, you didn’t have to worry about thinking of something to distract you, just keep the mind busy. But at home you just don’t have time to sit down and relax.
Sally: Music therapy was helpful in reducing my level of anxiety. There’s something about music that relaxes me, just that distraction thing. There were other people there to choose songs, not just me. The intimacy of the live music, it’s kind of more real.
Irene: I find it a much nicer way to spend post meal. I guess it was relaxing, it just takes your mind off post meal. Doing something else with my hands while I’m in music group kind of helps as well. Also, listening to music at home helps me zone out and go away from whatever is making me feel crap.
Rosie: I enjoy the music played in the moment, it itself is its own power, stronger than other things. It gives us a chance to share some of our feelings or thoughts together and attend to the same activity at the same time. Sharing songs gives the chance for others to experience what works for them. It gives you reminders of good memories and leads your thoughts somewhere you’d prefer to go. The tune of the songs give you a feeling of flowing, like it’s consistent. It’s helpful to reduce the anxiety and makes me feel relaxed. It’s easier to get distracted from and reduces the uncomfortable feeling after meals.
Leah: In music therapy, I’m talking about feelings that are really quite vulnerable and deep. I think it builds your self esteem up, if you start to allow yourself to talk about that stuff it’s like you’re willing to believe that you’re worth hearing about. It’s easier with music cos(sic) it just kind of opens up your heart straight away and it’s really helpful to engage with other people. When you’re in a group with music therapy, you learn more about other people. Sharing a song is like kind of saying ‘here’s a piece of me I want to share with you’. It’s also just a good distraction from the experience of having eaten. With anorexia, you numb your feelings so much, you forget how to feel, but music helps to thaw that part of you. The music evokes emotions so you can express your own feelings. It stirs up different emotions in you, the anxiety isn’t stuck. You might hear a song and you feel the same as what that person wrote in that song, it resonates with you. And with music, you’re saying how you’re feeling right there and then. We just want to hide away and disappear so bringing us out, it’s a good thing. Some days though it would feel really challenging, it just felt harder but it was also still really important. Journey-ing(sic) through the music therapy, accepting what you can contribute at that time and having contact with the therapist was how I could get through that challenging time. It’s not a laboring experience like listening to music on your own. Listening to a song myself after a meal, I’ll continue to do that.
Penny: Having some kind of music therapy can be helpful I think. It was something nice to relax to after lunch and I suppose there was a bit of distraction. It was good to have other people in the group to choose songs too.
Ellen: It felt useful to have something prearranged that couldn’t be changed regardless of how we were feeling. The individual tension that each person is feeling kind of dissipates as people start to interact with the music. And it’s intriguing, getting to know other people through their music choices. The session is like a circuit breaker, you get a break from the anxiety for that time, and you feel lighter at the end. Having something to focus on and distract you is important cos(sic) you can get stuck in your own head. Having flexibility and choice in the session felt important too. I learnt that using music intentionally can really influence your mood. I will keep using music at home.
Jacqui: It was a good distraction, I could just relax and chill out. It also forces you to interact, share and find out about other people in the group, and that’s a good thing. It takes a lot of energy for us after a bigger meal, it’s the best time to be distracted but also when you’re most tired.
Lauren: Music therapy is a way to distract from other things and worries. Overall I found it very helpful and pleasant. It is especially helpful when I like the music. When other people feel relaxed, the whole atmosphere and whole room relaxes. Learning what others listen to and being exposed to it is like an experiment.