572795

research-article2015
IJOXXX10.1177/0306624X15572795International Journal of Offender Therapy and Comparative CriminologyChen et al.

Article
International Journal of
Offender Therapy and
Randomized Trial of Group Comparative Criminology
1­–18
Music Therapy With Chinese © The Author(s) 2015
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DOI: 10.1177/0306624X15572795
Depression, and Self-Esteem ijo.sagepub.com

Xi-Jing Chen1, Niels Hannibal1, and Christian Gold2

Abstract
This study investigated the effects of group music therapy on improving anxiety,
depression, and self-esteem in Chinese prisoners. Two-hundred male prisoners were
randomly assigned to music therapy (n = 100) or standard care (n = 100). The music
therapy had 20 sessions of group therapy compared with standard care. Anxiety (State
and Trait Anxiety Inventory [STAI]), depression (Beck Depression Inventory [BDI]),
and self-esteem (Texas Social Behavior Inventory [TSBI], Rosenberg Self-Esteem
Inventory [RSI]) were measured by standardized scales at baseline, mid-program,
and post-program. Data were analyzed based on the intention to treat principle.
Compared with standard care, anxiety and depression in the music therapy condition
decreased significantly at mid-test and post-test; self-esteem improved significantly at
mid-test (TSBI) and at post-test (TSBI, RSI). Improvements were greater in younger
participants (STAI-Trait, RSI) and/or in those with a lower level of education (STAI-
State, STAI-Trait). Group music therapy seems to be effective in improving anxiety,
depression, and self-esteem and was shown to be most beneficial for prisoners of
younger age or with lower education level.

Keywords
group music therapy, prisoners, anxiety, depression, self-esteem

Introduction
The high prevalence of mental health problems in prisons has become a global prob-
lem (Bureau of Justice Statistics, 2006; Stewart, 2008). Imprisonment has been found

1Aalborg University, Denmark

2Uni Research, Bergen, Norway

Corresponding Author:
Xi-Jing Chen, Fu Yuan Xiao Qu 10-3-601, Da Xing district, Beijing, China 102628.
Email: xijing@hum.aau.dk

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2 International Journal of Offender Therapy and Comparative Criminology 

to negatively influence prisoners’ psychological well-being by disconnecting them

from family and the outside world (Picken, 2012). In recent decades, results from
prison surveys in China (Fu et al., 2012; Qian, 2001; Zhang, Wang, & Yang, 2007)
have shown high rates (53%-80%) of Chinese prisoners suffering from mental health
problems. In addition to other common mental health problems among prisoners, sev-
eral studies (Unver, Yuce, Bayram, & Bilgel, 2013; Værøy, 2011) found the high prev-
alence and levels of anxiety and depression in prisoners are thought to be related to
histories of domestic violence and substance abuse. Furthermore, affective problems
may increase the risks of suicide and self-harm, and influence the development of
psychosis (Hartley, Barrowclough, & Haddock, 2013; Unver et al., 2013). Moreover,
level of self-esteem seems to play a role in prisoners’ experience of anxiety and depres-
sion. Castellano and Soderstrom (1997) suggested that low self-esteem in prisoners is
often related to high anxiety and depression. This co-occurrence is likely to result in a
seriously compromised state of mental health in prisoners (Gullone, Jones, &
Cummins, 2000). The close relationship between self-esteem and emotions needs to
be taken into consideration in prisoners’ mental health treatments and correctional
programs for promoting their overall mental health well-being and correcting related
inappropriate behaviors.
The rehabilitation of offenders in correctional systems usually involves crimino-
genic and mental health domains. A variety of interventions and programs for diverse
offender populations which are typically group programs based on risk–need–respon-
sivity (RNR) principles have been applied mainly focusing on reducing the risk of
criminality, and several therapy models (e.g., cognitive behavioral therapy, family
therapy, multisystemic therapy, group counselling) have proved to be effective (Jolliffe
& Farrington, 2007; Lipsey & Cullen, 2007). The variability of the intervention effects
is linked with the types of the intervention, therapy intensity, quality of implementa-
tion, and types of offenders. However, there are some studies focusing on improving
offenders’ mental health issues, which may or may not be related to offending behav-
ior (Leigh-Hunt & Perry, 2014).
In the decades of music therapy’s application in correctional systems, various music
therapy approaches based on active music therapy (e.g., improvisation, song writing,
performing music) or receptive music therapy (e.g., music imagery, music relaxation)
have been applied to help offenders improve mental health in terms of mood states,
empathy, social relationships, connections with reality (Chambers, 2008; Compton
Dickinson & Gahir, 2013; O’Grady, 2011; Thaut, 1989). In receptive music therapy,
the client focuses on perceiving and experiencing music; in active music therapy, the
client is actively involved in the process of music creation. The distinguishing features
of these two music therapy modalities may each contribute to meet the client’s per-
sonal preference and various therapeutic needs at different therapy stages. Combining
the two modalities may therefore be advantageous.
The psychological and neurological influences of music on mental health are well
documented in the research literature (Blood & Zatorre, 2001; Lin et al., 2011). Brain
research has shown that music can elicit various emotional and physiological responses
based on the area of the brain in which it is processed (Koelsch, Fritz, Cramon, Müller,

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Chen et al. 3

& Friederici, 2006; Menon & Levitin, 2005). As a “language of emotion” (Juslin &
Sloboda, 2010), music not only influences people’s emotional experiences but also pro-
vides a means for people to explore and express emotions, build up relationships, and
experience autonomy, which are necessary pre-requisites for mental health improve-
ment. With respect to its application in music therapy for offenders, music may support
offenders to identify, explore, and express emotions in a positive way (Loth, 1994); it
also provides multimodal experiences, including images, sensations, and feelings to
facilitate offenders’ action-oriented forms of musical expression instead of verbal dis-
cussion (Nolan, 1983). Studies show that music therapy can be beneficial for prisoners,
especially for those with restricted ability of emotional expression caused by the prison
setting or the individual’s own limited verbal skills (Erickson & Young, 2010); as well
as for those with negative emotions and low motivation who are unable to benefit suf-
ficiently from psychotherapy (Gold, Mössler, et al., 2013; Howells, 2006).
Research has shown that music therapy is effective in improving depression
(Maratos, Gold, Wang, & Crawford, 2008), psychiatric symptoms, and psychosocial
functioning (Erkkilä et al., 2011; Ulrich, Houtmans, & Gold, 2007). Several qualitative
studies also suggested the potential benefits of music therapy for offenders (Chambers,
2008; Compton Dickinson, Odell-Miller, & Adlam, 2013; Daveson & Edwards, 2001;
Tuastad & O’Grady, 2013). Yet, only a few controlled trials have explored the effects of
music therapy on the mental health and psychosocial functioning of people in correc-
tional services, either with or without diagnosed mental disorder (Gold, Assmus, et al.,
2013; Hakvoort, Bogaerts, Thaut, & Spreen, 2013; Johnson, 1981; Thaut, 1989). Most
of these studies contained a small sample size (N = 13-50) with a low test power or no
calculation of test power. One study utilized only non-standardized measures (Thaut,
1989). For one study with a larger sample size (N = 113) and more rigorous study
design (a randomized-controlled trial, music therapy vs. standard care, analysis based
on intention to treat principle, sufficient test power), the result was inconclusive because
of the high rate of dropout (Gold, Assmus, et al., 2013). The effects of music therapy on
mental health in prisoners therefore remain unclear.

Aims of the Study

This study aimed to investigate the effects of group music therapy on reducing anxiety
and depression, and improving self-esteem in Chinese prisoners. The research ques-
tion was the following: Can music therapy contribute to the mental health improve-
ment of prisoners in terms of anxiety, depression, and self-esteem? Study hypothesis
was formulated as follows: Music therapy can alleviate anxiety and depression of
prisoners as well as improve their self-esteem.

Material and Methods

Participants
We planned to include 192 adult male inmates in one prison in Beijing, China (see the
full protocol for this study; Chen, Hannibal, Xu, & Gold, 2013). Inclusion criteria

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4 International Journal of Offender Therapy and Comparative Criminology 

were as follows: (a) anxiety score ≥ 49 on the State and Trait Anxiety Inventory (STAI:
STAI-State or STAI-Trait [Chinese version]; that is, 1 SD above the population mean,
representing mild anxiety; Spielberger, Gorsuch, & Lushene, 1970; Wang, Wang, &
Ma, 1999; Zheng, Shu, Zhang, & Huang, 1993); or (b) depression score ≥ 14 on the
Beck Depression Inventory (BDI [Chinese version]; that is, mild depression; Wang et
al., 1999), see section “Outcome Measures” for more details on these instruments; and
(c) a remaining prison term ≥ 6 months from the date of recruitment. Exclusion criteria
were as follows: (a) a diagnosed severe physical disease or a psychotic disorder, (b) an
intelligence quotient ≤ 69 (mild intellectual disability), or (c) unable to understand the
questionnaires (as reported by the participant).
A psychological counsellor gave the study recruitment information to prisoners
using posters and announcements from the prison’s psychological education and coun-
selling department. The psychological counsellor conducted measurements for all par-
ticipants. More details of the flow of participants are provided in Figure 1.
The Human Research Ethics Board of Aalborg University approved this study on
March 20, 2012. In the absence of research ethics committee in the Chinese correc-
tional system, there was no access to an ethical assessment from this prison. However,
this study received an official administrative approval from the psychological educa-
tion and counselling department in this prison after the evaluation of their expert com-
mittee. All participants signed an informed consent form to participate in the study.
They were informed that they would be randomly allocated to take part in music ther-
apy; people who were not chosen into music therapy group would receive group psy-
chotherapy or music therapy after the study was completed. There were no incentives
provided for participants and no consequences for not participating. The trial was reg-
istered (NCT01633125).
A power calculation was conducted to determine test power. Assuming a medium
effect size, we calculated that the planned sample size of 192 participants (24 groups
with 8 participants each, up to 1 dropout per group) would have 87% power in a two-
tailed t test, or slightly less if some clustering occurred (Chen et al., 2013).

Randomization
All eligible participants were individually randomized to two groups of equal size.
One researcher (C.G.) who had no direct contact with the participants conducted a
computer-generated randomization and kept this list concealed until a decision was
made about inclusion.

Assessment
The assessments were conducted before randomization (pre-test), after 10 sessions
(mid-test), and after 20 sessions (post-test; see Figure. 1). The pre-test assessment
score was also used to screen for eligibility.
All assessments were self-reports. Participants delivered them to a psychologi-
cal counsellor with extensive experience with prisoners, who was masked to the

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Chen et al. 5

Assessed for eligibility

(N = 263)

Excluded (n = 63)
Not meeting inclusion criteria (n = 63)

Randomized (n = 200)

Allocated to group music therapy Allocated to standard care only (n = 100)

(n = 100)
Received 10 sessions (n = 97)
Received 6-8 sessions (n = 3)

Drop out Drop out

Transferred to another prison (n = 3) Transferred to another prison (n = 2)
Illness (n = 1)

Mid-test (after 10 sessions)

Continue music therapy (n = 97) Continue standard care (n = 97)

Received 20 sessions (n = 72)
Received 15-19 sessions (n = 21)

Drop out Drop out

Transferred to another prison (n = 2) Transferred to another prison (n = 4)
Reduced sentences (n = 2) Lack of motivation (n = 1)
Illness (n = 1)

Post-test (after 20 sessions)

Included in final analysis (n = 93) Included in final analysis (n = 91)

Figure 1.  Participants flowchart.

assignment of the participants and had to report if any instance of broken masking
occurred. Participants in both groups were tested in the same room on the same
day.

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6 International Journal of Offender Therapy and Comparative Criminology 

Outcome Measures
Anxiety was measured by the STAI. This measure consists of two similar subscales:
STAI-State and STAI-Trait. Each scale encompasses 20 items measuring state anxiety
or trait anxiety, respectively. Respondents are asked to rate themselves on each item on
the basis of a 4-point Likert-type scale (1 = not at all, 4 = very much so [STAI-State];
1 = almost never, 4 = almost always [STAI-Trait]). The STAI does not have a pre-
defined cutoff. A higher score indicates a higher level of anxiety. Cronbach’s alpha
was computed to examine the internal consistency of the STAI. It showed a high level
of internal consistency with alpha coefficients of .849 and .848 for the two subscales
separately.
Depression was measured by the BDI and self-esteem was measured by the
Rosenberg Self-Esteem Inventory (RSI [Chinese version]; Wang et al., 1999) and
Texas Social Behavior Inventory (TSBI [Chinese version]; Wang et al., 1999). The
BDI consists of a 21-question multiple-choice self-report scale. A higher score implies
a higher level of depression. The cutoffs are as follows: 0 to 13: minimal depression;
14 to 19: mild depression; 20 to 28: moderate depression; and 29 to 63: severe depres-
sion (Beck, Steer, & Brown, 1996). Cronbach’s alpha coefficient for the BDI was .893.
The RSI is a 10-item Likert-type scale used to assess global self-esteem. The answers
are on 4-point scales (0 = strongly disagree, 3 = strongly agree). A higher score indi-
cates a higher level of self-esteem. Scores below 15 suggest low self-esteem. The
TSBI consists of a 5-point Likert-type scale with 32 items measuring social self-
esteem in terms of perceived competence and confidence in social situations (1 = not
at all true of me, 5 = very true of me). A higher score indicates a higher level of self-
esteem. Cronbach’s alpha coefficients were .609 and .794 for the RSI and TSBI
respectively. Coefficient alpha is influenced by the number of items, item correlations,
and dimensionality (Cortina, 1993). Given the various characteristics of four measures
and their corresponding standards, all measures showed an acceptable to high level of
internal consistency. All scales in the Chinese version have been validated with
Chinese people (Wang et al., 1999).

Interventions
Standard care.  The control group received standard care but no music therapy during
the study. Standard care in this prison included medical care, monthly mandatory men-
tal health education, and psychological/psychotherapeutic care on a volunteer basis.
The contents of mental health lessons contained trainings of mental health knowledge
and behavioral coping skills, and each lesson lasted for 50 minutes. The psychologi-
cal/psychotherapeutic care was provided by a counsellor for the participants who
required an individual consultation. Beside these, the prison routine management for
all prisoners included four hours of mandatory labor at every working day and manda-
tory education and exams. Of all the participants who received either standard care or
treatment, only four participants received one to four extra sessions of individual psy-
chological consultations during the study.

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Chen et al. 7

Group music therapy.  Participants randomized to music therapy received 20 sessions of

group music therapy twice weekly. Each session lasted for 90 minutes. The choice of
intensity and duration for the intervention were based on the therapist’s clinical experi-
ence, prison management, and the inmates’ average length of sentence, as well as
previous findings on dose–effect relationship in music therapy (Gold, Solli, Krüger, &
Lie, 2009). A more detailed discussion about the intervention choices is provided in
the study protocol (Chen et al., 2013).
The intervention took place in an activity room in the prison. The equipment for
music therapy included one stereo, one electronic piano, two guitars, one set of hand
glockenspiel, and percussion instruments such as African drums, cymbals, tambou-
rines, and xylophones. During therapy, a prison guard sat in the room outside the
group circle to ensure the music therapist’s safety.
Three music therapy methods—music and imagery, improvisation, and song writ-
ing—were introduced to the group in the first three sessions. The following is a brief
introduction of the three methods.
Music and imagery is a method adapted from the Bonny Method of Guided Imagery
and Music (BMGIM; Paik-Maier, 2010). It was introduced in the first session. In the
prelude, the therapist gathered clients’ information and helped group members to find
a common issue (i.e., emotion, self-exploration, family) through discussion or arts
experience (i.e., improvisation, dance movement, painting). Then, the therapist
selected one music piece that matched the clients’ current state and issue to induct their
music imagery journey. After a short time (approximately 5 min) of imagery experi-
ence, the clients were asked to express their imagery through painting while listening
to the same music repetitively. In the postlude, the therapists and group members
explored the imagery and feelings together through discussion or arts activities.
Improvisation, also referred to as clinical improvisation, is “the use of musical
improvisation in an environment of trust and support established to meet the needs of
clients” (Wigram, 2004, p. 37). In the second session, group musical improvisation
activities including vocal and/or instrumental improvisation in solo, duet, dialogue,
trio, or group were introduced. The members experienced free improvisation with no
structure or thematic improvisation based on their capability and needs.
Song writing is a method where the music therapist writes “songs for and with cli-
ents to address various therapeutic goals” (Baker & Wigram, 2005, p. 13). Structured
and/or unstructured song writing techniques were applied in the third session, such as
replacing blanked keywords with new lyrics in a pre-composed song, replacing whole
lyrics for a song, creating new melody for the existing lyrics, or creating a new melody
and lyrics.
Each session after the first three introductory sessions started with a discussion
about thoughts, feelings, personal issues, or incidents in prison. Then group members
and the therapist together selected one method described above to continue the thera-
peutic process.
The researchers developed a music therapy protocol for this study. This protocol
lists several common group topics (e.g., friendship, trust, empathy, family, interper-
sonal conflict, emotional problems) and describes several music therapy activities

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8 International Journal of Offender Therapy and Comparative Criminology 

under each topic. Each activity description includes therapeutic objectives, instru-
ments and equipments, procedures of implementation, and possible topics for discus-
sion. The activities are structured or unstructured, and a variety of music imagery,
improvisation, and song writing techniques are utilized. The full manual is available
from the authors and will be published separately.
The therapist (X.J.C.) received biweekly supervision with her clinical supervisor to
ensure the quality of the therapy and to reflect on relevant issues for her own safety.
The group members were encouraged to keep a diary during the study. However, only
one participant shared it with the therapist.

Statistical Analyses
Statistical analyses were conducted with SPSS version 17.0 and R version 2.15.0. All
statistical tests were two-tailed at the 5% significant level. After randomization, the
data of all participants were included for analysis, regardless of whether they stopped
the therapy early (intention to treat principle). Before the statistical analyses, all
dependent variables were examined for normal distribution. All dependent variables
were normally distributed, and therefore parametric procedures were used for data
analysis. Because the level of missing data was below 5%, no strategy was used to
analyze them. Descriptive analyses were conducted for demographic information,
anxiety, depression, and self-esteem to assess baseline comparability of both groups.
Effects of music therapy were analyzed using t tests for independent samples. This is
a simple but valid approach to analysis of adequately randomized-controlled studies
because groups are compared directly to each other and baseline variables are assumed
to be balanced (Gold, 2015; Moher et al., 2010). We also performed repeated-mea-
sures ANOVAs as an overall test and examined interaction effects between time and
group (using Wilk’s lambda). In addition, two types of sensitivity analyses were con-
ducted: (a) linear mixed-effects (LME) models taking into account potential clustering
by department and batch as a random effect, using endpoint scores as above and (b) the
same LMEs but using change from baseline. Furthermore, LMEs were also calculated
to identify potential predictors of change, including age, years of education, crime
type, and criminal record. The models included both main effects and interaction
effects with treatment group, but only the interaction effects were of interest and are
reported. In contrast to the study protocol (Chen et al., 2013), concomitant psychologi-
cal interventions were not controlled for in the analyses, because only very few partici-
pants applied for psychological treatments.

Results
Baseline Characteristics
Of 263 male applicants who took part in the study in four batches from April 2012 to
April 2013, a total of 200 (76%) participants were found eligible after the screening
(Figure 1). They were randomized to two groups of equal size. Four batches of

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Chen et al. 9

participants from different units, with 43 to 62 people in each batch, were enrolled and
completed the intervention sequentially. Participants from one batch had no contact
with other batches. In the music therapy group, 12 therapy groups were formed with
each one consisting of 8 to 10 people. Participants’ age ranged from 18 to 57 (M =
35.5, SD = 9.95). They had 8 years of education on average (SD = 2.61). In all, 116
participants (58%) had more than 6 years of education and only 8 (4%) had more than
12 years of education. Half of the sample was currently imprisoned for the first time.
The great majority (80%) were convicted for acts of physical injury or theft. The aver-
age sentence length was 13.02 months (SD = 2.02). No specific risk assessment was
conducted. The groups were balanced on all variables at baseline, indicating success-
ful randomization. The baseline comparison of demographic and clinical characteris-
tics of participants in music therapy and standard care is provided in Table 1.

Characteristics of Music Therapy

Of 240 sessions, improvisation was applied in 107 sessions (44.6%), music imagery in
90 (37.5%), and song writing in 43 (17.9%). In the music therapy group, 72% partici-
pants received 20 sessions of therapy, and 97% participants had more than 10 sessions.
Very few participants received other psychotherapy (n = 4). The reasons for 16 drop-
out participants were as follows: being transferred to another prison (n = 11), physical
illness (n = 2), lack of motivation (n = 1), and reduced sentences (n = 2; Figure 1).
Outcome data were not available for those who dropped out.

Effects of Music Therapy

Table 2 compares outcomes in each group, based on t tests. At mid-program, anxiety
(STAI) and depression (BDI) scores were significantly lower (STAI-State: p = .006, d
= 0.40; STAI-Trait: p = .001, d = 0.49; BDI: p < .001, d = 0.54) and self-esteem (TSBI)
score was significantly higher (p = .011, d = 0.37) in music therapy than in standard
care. At post-program, anxiety (STAI) and depression (BDI) scores were significantly
lower (STAI-State: p < .001, d = 0.87; STAI-Trait: p < .001, d = 1.03; BDI: p < .001,
d = 0.87) in music therapy; self-esteem (TSBI and RSI) scores were significantly
higher in music therapy (RSI: p < .001, d = 0.51; TSBI: p = .001, d = 0.51) than in
standard care. All effect sizes were larger in the post-program than in the mid-pro-
gram; most effect sizes were from medium to large. In the post-program, large effect
sizes were found for anxiety (STAI) and depression (BDI) scores, and medium effect
sizes were found for self-esteem (RSI and TSBI) scores (Table 2). In the repeated-
measures ANOVAs, all Time × Group interactions were significant (BDI: p < .001;
RSI: p < .01; STAI-State: p < .001; STAI-Trait: p < .001; TSBI: p < .05). This con-
firmed the results from between-group tests reported above suggesting significant
effects of music therapy compared with standard care. Clustering by department and
batch did not appear to play an important role in this study, as the results of LMEs (not
shown) were similar to those in the t tests, and all significant effects remained signifi-
cant. The same was the case for the LMEs based on change scores.

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10 International Journal of Offender Therapy and Comparative Criminology 

Table 1.  Baseline Comparison of Demographic and Clinical Characteristics of Participants in

Music Therapy and Standard Care.

Music therapy Standard care

(n = 100) (n = 100) Difference

Characteristic n (%) n (%) Chi-square (df) p

Categorical variables
  Criminal record
  First offence 51 (51) 49 (49)  
   One prior offence 22 (22) 26 (26) 0.450 (2) .798
   More than one prior 27 (27) 25 (25)  
offence
  Crime type
  Physical injury 38 (38) 43 (43)  
  Gambling 17 (17) 15 (15) 2.169 (3) .538
  Theft 43 (43) 37 (37)  
   Others (including fraud, 2 (2) 5 (5)  
sexual harassment, illegal
transaction)

  M (SD) M (SD) t (df) p

Continuous variables
  Age (years) 35.29 (9.83) 35.75 (10.07) −0.327(198) .744
  Years of education 8.50 (2.73) 8.13 (2.49) 1.00 (198) .319
  Months of current sentence 13.21 (2.23) 12.83 (2.00) 1.271 (198) .205
  Test scores
  State and Trait Anxiety 48.52 (9.67) 48.03 (9.95) −0.353 (198) .724
Inventory–State
   State and Trait Anxiety 48.70 (8.98) 48.52 (10.12) −0.133 (198) .894
Inventory–Trait
   Beck Depression Inventory 24.72 (10.18) 23.90 (11.11) −0.544 (198) .587
  Rosenberg Self-Esteem 25.92 (4.11) 26.04 (3.65) 0.218 (198) .827
Inventory
   Texas Social Behavior 97.30 (15.34) 97.56 (15.22) −0.120 (198) .904
Inventory

We conducted further LMEs to examine the interaction effects of covariates (char-

acteristics of the offenders, including age, years of education, crime type, and criminal
record) with the effects of music therapy. The results (Table 3) indicated that age and
educational level as predictors influenced the effects. Effects of music therapy on
STAI-Trait scores were smaller in participants with older age (p < .05) at mid-test, but
not at post-test. Participants with lower education showed greater improvement on
anxiety (STAI-State and STAI-Trait) at post-test than those with higher education (p <
.003; p < .001). In addition, music therapy indicated greater effects for younger partici-
pants (p = .02) on self-esteem (RSI) at post-test.

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Chen et al. 11

Table 2.  Differences in Outcome Scores Between Music Therapy and Standard Care in
Mid-Test and Post-Test (Intention-to-Treat): Continuous Outcomes.

Music therapy Standard care Test for difference Effect size

Outcome M (SD) M (SD) t p d

State and Trait Anxiety Inventory–State
 Mid-test 45.67 (11.29) 49.74 (9.11) 2.763 .006* 0.40
 Post-test 40.53 (8.74) 48.58 (9.86) 5.870 <.001*** 0.87
State and Trait Anxiety Inventory–Trait
 Mid-test 45.56 (10.82) 50.10 (7.76) 3.354 .001** 0.49
 Post-test 40.58 (8.47) 49.09 (8.17) 6.933 <.001*** 1.03
Beck Depression Inventory
 Mid-test 15.59 (11.66) 22.08 (12.23) 3.786 <.001*** 0.54
 Post-test 11.51 (7.78) 20.32 (12.47) 5.765 <.001*** 0.87
Rosenberg Self-Esteem Inventory
 Mid-test 28.09 (5.01) 26.80 (4.84) −1.821 .070 0.26
 Post-test 29.27 (4.25) 27.01 (4.60) −3.462 <.001*** 0.51
Texas Social Behavior Inventory
 Mid-test 103.54 (17.55) 97.44 (15.42) 2.569 .011* 0.37
 Post-test 104.35 (13.62) 96.81 (16.00) 3.437 .001** 0.51

Note. Mid-test: Music therapy, n = 97; standard care, n = 97. Post-test: Music therapy, n = 93; standard
care, n = 91. Mid-test df = 192; Post-test df = 182.
*p < .05. **p < .01. ***p < .001.

Discussion
Main Findings
This study was the largest randomized trial of music therapy for prisoners to date. It
showed that music therapy in prison can help improve anxiety, depression, and self-
esteem in offenders with mental health problems. Age and educational level predicted
the effects of music therapy. It took less time for younger prisoner to improve state
anxiety than older prisoners, but no significant differences showed at the end of the
therapy. Younger prisoners also demonstrated a greater improvement in self-esteem.
Anxiety was reduced more markedly in prisoners with a lower educational level.
This study confirms and extends the findings from previous smaller studies (Gold,
Assmus, et al., 2013; Thaut, 1989). An early study investigating the impact of music
therapy showed the effectiveness in improving mood and relaxation level for prisoners
with schizophrenia (Thaut, 1989). However, the quality of the results was limited
because of small sample size (N = 50), lack of control group, and lack of standardized
measures. In a recent study with rigorous research methodology and large sample size
(N = 113), state anxiety improved significantly in the intervention group after 2 weeks
of music therapy, but the results were not compared with the control group at that time
point (Gold, Assmus, et al., 2013). Researchers of this study recommended clear

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12 International Journal of Offender Therapy and Comparative Criminology 

Table 3.  Interaction Statistics of the Characteristics of the Participants in Music Therapy
and the Outcome Scores in Mid-Test and Post-Test.
Mid-test (after 10 sessions; Post-test (after 20 sessions;
n = 194) n = 184)

Outcomes Value (SE) t p Value (SE) t p

State and Trait Anxiety Inventory–State

 Age 0.09 (0.16) 0.55 .59 0.19 (0.14) 1.27 .20
  Years of education 0.09 (0.61) 0.14 .88 1.98 (0.56) 3.57 <.001***
  Crime type
  Physical injury −7.14 (4.61) −1.55 .12 −2.41 (4.30) −0.56 .58
  Gambling −1.52 (3.7) −0.41 .68 −2.39 (3.30) −0.73 .47
  Theft −7.38 (9.60) −0.77 .55 −0.02 (8.43) −0.00 1
  Criminal record
  First offence −2.25 (3.90) −0.58 .56 4.21 (3.59) 1.17 .24
  Recidivism −1.96 (4.05) −0.48 .63 −0.81 (3.60) −0.23 .82
State and Trait Anxiety Inventory–Trait
 Age 0.33 (0.14) 2.31 .02* 0.21 (0.13) 1.64 .10
  Years of education 0.29 (0.54) 0.54 .59 1.51 (0.49) 3.05 .003**
  Crime type
  Physical injury −8.02 (4.08) −1.96 .05 −3.32 (3.82) −0.87 .39
  Gambling −1.18 (3.26) −0.36 .71 −2.94 (2.93) −1.00 .32
  Theft −0.91 (8.45) −0.11 .91 −3.83 (7.50) −0.51 .60
  Criminal record
  First offence −1.83 (3.42) −0.54 .59 −0.80 (3.19) −0.25 .80
   More than one prior offence −0.56 (3.56) −0.16 .87 −3.23 (3.20) −1.01 .31
Beck Depression Inventory
 Age 0.21 (0.18) 1.13 .26 0.13 (0.16) 0.84 .40
  Years of education 0.40 (0.70) 0.58 .56 0.95 (0.60) 1.58 .12
  Crime type
  Physical injury −4.18 (5.27) −0.79 .43 −1.34 (4.66) −0.29 .77
  Gambling −5.07 (4.23) −1.20 .23 −6.14 (3.54) −1.73 .09
  Theft −5.21 (10.95) −0.48 .64 0.58 (9.08) 0.06 .95
  Criminal record
  First offence −2.63 (4.44) −0.59 .55 −5.76 (3.83) −1.50 .13
  Recidivism −0.64 (4.61) −0.14 .89 1.13 (3.88) 0.29 .77
Rosenberg Self-Esteem Inventory
 Age −0.13 (0.08) −1.71 .09 −0.16 (0.07) −2.32 .02*
  Years of education −0.27 (0.29) −0.94 .35 −0.46 (0.27) −1.73 .09
  Crime type
  Physical injury 3.12 (2.17) 1.44 .15 3.31 (2.05) 1.61 .11
  Gambling −0.12 (1.74) −0.07 .95 0.39 (1.57) 0.25 .80
  Theft 4.31 (4.51) 0.95 .34 1.57 (4.02) 0.39 .70
  Criminal record
  First offence 1.27 (1.83) 0.69 .49 2.24 (1.70) 1.31 .19
  Recidivism 0.41 (1.90) 0.22 .83 0.22 (1.72) 0.13 .90
Texas Social Behavior Inventory
 Age −0.17 (0.26) −0.65 .52 −0.15 (0.24) −0.64 .52
  Years of education −0.48 (0.98) −0.49 .62 −0.84 (0.91) −0.93 .35
(continued)

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Chen et al. 13

Table 3.  (continued)

Mid-test (after 10 sessions; Post-test (after 20 sessions;

n = 194) n = 184)

Outcomes Value (SE) t p Value (SE) t p

  Crime type
  Physical injury 6.63 (7.40) 0.90 .37 6.83 (7.05) 0.97 .33
  Gambling 6.97 (5.92) 1.18 .24 4.41 (5.31) 0.83 .41
  Theft −11.46 (15.35) −0.75 .46 −14.11 (13.95) −1.04 .30
  Criminal record
  First offence −5.82 (6.22) −0.94 .35 −5.78 (5.77) −1.00 .32
  Recidivism −8.14 (6.47) −1.26 .20 −2.25 (5.84) −0.39 .70

Note. Mid-test: df = 170; post-test: df = 160. All statistical procedures were performed by using linear mixed-effects
models.
*p < .05. **p < .01. ***p < .001.

clinical criteria in the selection of target participants, sufficient length of stay for the
participation, and flexible intervention methods. With careful considerations of these
factors in this study, the findings strengthen the randomized evidence for music ther-
apy on improving emotional well-being of prisoners. The effect of music therapy on
improving self-esteem shown in this study also supports previous findings (Kennedy,
1998). In addition, this study measured social self-esteem with the TSBI (Zeigler-Hill,
2010). The finding broadens the dimension of self-esteem in the previous study (i.e.,
global self-esteem) and provides evidence for the effects of music therapy on self-
esteem in prisoners’ social behavior.
The individual’s age influenced state anxiety at mid-test but not at the end of the
intervention. This might be because older prisoners have more complex life histories,
and their affects are more difficult to change than younger people. It may take them
longer to build a therapeutic alliance with the therapist and become engaged with music
therapy. Age also played a role in the change of self-esteem at the end of the treatment.
This might be because older prisoners tend to have more stable self-esteem. Relating
this finding to the previously demonstrated dose–effect relation in music therapy (Gold
et al., 2009), it seems that an increase in session numbers enabled music therapy to be
more beneficial for people of different ages. It is notable that the effect sizes of all out-
comes increased with the increase of session numbers. The impact of education on the
effects might be because criminal records may cause more difficulties in more highly
educated people’s future life compared with those with lower education.

Limitations
In this study, all participants were Chinese male adult prisoners with a short term of
imprisonment in one prison, so the generalizability of the results is limited. In addi-
tion, cultural, political, and prison management differences should be taken into con-
sideration when generalizing the results internationally. Moreover, the measures used

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14 International Journal of Offender Therapy and Comparative Criminology 

in this study were all self-reports. Although all measures in the study exhibited appro-
priate levels of reliability and validity, the researchers cannot interpret how truthfully
the participants answered. For example, some prisoners might over-rate scores to
please the therapist. However, the test process was conducted by psychological coun-
sellor, not by the therapist, to prevent this social desirability bias.
Finally, follow-up data regarding the changes of prisoners’ behavior were not avail-
able in this study, and long-term effects of music therapy and its impact on recidivism
remain unclear.

Implications for Practice

Music therapy in correctional services is divided into three main areas: correctional
psychiatry, forensic psychiatry, and prison or community settings (Codding, 2002).
People in the first two areas have a psychiatric diagnosis, whereas people in the third
area usually do not have a current psychiatric diagnosis. There has been considerable
practical and theoretical development of music therapy in all these areas (Compton
Dickinson et al., 2013; Hakvoort et al., 2013; O’Grady, 2011; Smeijsters & Cleven,
2006; Tuastad & O’Grady, 2013). In contrast, randomized-controlled trials that pro-
vide evidence for the effects of music therapy for prisoners are scarce. Together with
previous research, the findings of this study provide empirical evidence to support the
provision of music therapy for prisoners.
With regard to the intervention, the therapist and group members worked together
to choose three music therapy methods to meet the group’s needs but not in a fixed
order. The flexible application of the methods is closely related to typical clinical prac-
tice (Rolvsjord, Gold, & Stige, 2005). This increases the generalizability of this study
to clinical practice.
Of the three methods, group improvisation was applied most frequently. This might
be because group improvisation requires less verbal conversation during the process
than music imagery and song writing. For some participants, it was difficult to express
emotions verbally because of low trust and fear of punishment by prison guards.
During musical improvisation, group members were able to express and communicate
simultaneously, and experience individual and group dynamics without verbal discus-
sion (Stewart, 2002). Improvisation may help to provide a safe way of expression and
sharing, establish a basis of group cohesiveness and cooperation, and facilitate group
progress (Albornoz, 2011). The positive role of group improvisation can be considered
in the practice of music therapy for prisoners, especially at an initial stage. It may have
facilitated in-depth verbal discussion in music imagery and song writing at later stages
in the process.
The findings also have theoretical implications for researchers and professionals in
understanding the role of music therapy in the context of Chinese prisons. The major-
ity of prisoners have a low educational level. The study showed that music therapy can
help prisoners of any age or education level, but is especially beneficial for those of
young age or low education.

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Chen et al. 15

Recommendations for Future Research

More randomized-controlled trials with other populations such as female prisoners
and adolescent delinquents are needed. It is important for future research to investigate
other outcomes (e.g., social skills, aggression management, ability of impulse control,
empathy) relating to psychosocial well-being, behaviors, and cognitive functions.
Characteristics of offence, gender, terms of imprisonment, crime record, age, educa-
tional background, and therapist’s gender, methods, training, and clinical experiences
may be considerable factors affecting the effects of the music therapy intervention,
and can be important variables in future studies. More comprehensive outcome mea-
sures such as behavior observation or physiological measures are needed. More quan-
titative and qualitative research is needed in this field. Besides examining the effects
of music therapy, it is essential to look into the therapeutic process, the detrimental
nature of prison life, the interaction between prisoners, therapists, and the prison envi-
ronment, to gain a more comprehensive and profound understanding of music therapy
in correctional services.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of
this article.

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