Journal of Creativity in Mental Health

ISSN: 1540-1383 (Print) 1540-1391 (Online) Journal homepage: https://www.tandfonline.com/loi/wcmh20

Reducing Anxiety through Music Therapy at an

Outpatient Eating Disorder Recovery Service

Jennifer Bibb, David Castle & Katrina Skewes McFerran

To cite this article: Jennifer Bibb, David Castle & Katrina Skewes McFerran (2019) Reducing
Anxiety through Music Therapy at an Outpatient Eating Disorder Recovery Service, Journal of
Creativity in Mental Health, 14:3, 306-314, DOI: 10.1080/15401383.2019.1595804

To link to this article: https://doi.org/10.1080/15401383.2019.1595804

Published online: 28 Mar 2019.

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JOURNAL OF CREATIVITY IN MENTAL HEALTH
2019, VOL. 14, NO. 3, 306–314
https://doi.org/10.1080/15401383.2019.1595804

Reducing Anxiety through Music Therapy at an Outpatient

Eating Disorder Recovery Service
Jennifer Bibba,b, David Castlea,c, and Katrina Skewes McFerranb
a
The Body Image Eating Disorders Treatment & Recovery Service (BETRS), St Vincent’s Hospital, Victoria,
Australia; bNational Music Therapy Research Unit, Faculty of Fine Arts and Music, University of Melbourne,
Victoria, Australia; cDepartment of Psychiatry, University of Melbourne, Victoria, Australia

ABSTRACT KEYWORDS
The authors of this study aimed to reduce post-meal related anxiety Eating disorders; music
for people with eating disorders through participation in group music therapy; day program;
therapy in an outpatient day program. A purposively-inclusive pilot anxiety; creativity in
counseling
study design was adopted which utilized the self-report Subjective
Units of Distress Scale (SUDS) to measure anxiety pre and post
a single session. A total of 13 female participants attended a one-
hour music therapy group session following a lunchtime social eating
challenge and contributed to 50 occasions of data collection.
A paired two-tailed t-test indicated a highly statistically significant
difference (p = < 0.0001) between the pre and post session scores,
suggesting that music therapy significantly decreased anxiety.

The anxiety associated with eating and weight gain can result in distressing mealtimes for people
with eating disorders (Hage, Rø, & Moen, 2015). During the post-meal period, physical
discomfort and psychological distress can be experienced, along with thoughts of purging or
feelings of guilt (Harvey, Troop, Treasure, & Murphy, 2002). In a community setting, meal-
related anxiety could be further exacerbated by societal and family pressures and social occasions
involving eating and food. The goals of day hospital treatment for eating disorders in Australia
include improving the capacity to deal with these experiences, to normalize eating behaviors,
and to offer therapy for developing coping skills to aid in long-term recovery (Ashley & Crino,
2010; Touyz, Polivy, & Hays, 2008). It is well documented that support from staff or family
during mealtimes can be helpful for decreasing the anxiety associated with eating (Clinton,
Bjorck, Sohlberg, & Norring, 2004; Federici & Kaplan, 2008; Long, Wallis, Leung, & Meyer,
2012; Offord, Turner, & Cooper, 2006). However, minimal evidence is available which supports
the delivery of specific group activities that reduce anxiety in a day program setting. Some
research suggests that different types of relaxation strategy (Shapiro et al., 2008), or a variety of
cognitive tasks (Griffiths, Hawkes, Gilbert, & Serpell, 2016), can reduce both post-meal related
anxiety and intrusive thoughts for participants. However, there is a paucity of evidence
supporting the use of these strategies in a group setting, which is the most common structure
of therapeutic delivery in outpatient day program services (Touyz et al., 2008).
Previous music therapy research conducted in the inpatient setting of the service described
in this study lent support to the use of group music therapy to reduce post-meal anxiety (Bibb,

CONTACT Jennifer Bibb bibb.jennifer@unimelb.edu.au The Body Image Eating Disorders Treatment & Recovery Service
(BETRS), St Vincent’s Hospital, 10-12 Gertrude St, Fitzroy 3065, Victoria, Australia
© 2019 Taylor & Francis
 JOURNAL OF CREATIVITY IN MENTAL HEALTH 307

Castle, & Newton, 2015). That study found that group music therapy significantly decreased
feelings of anxiety in comparison to standard post-meal support for 18 people with anorexia
nervosa. During qualitative interviews in the same study, participants described music therapy
as a way to take their mind off the meal they had just eaten, get a break from anxiety and
connect with their peers (Bibb, Castle, & Newton, 2016). Although that study supported the
use of music therapy during the post-meal period in an inpatient setting, the use of music
therapy for the same purpose in a day program setting is yet to be investigated. It is important
to explore the use of music therapy for people in an outpatient setting, since the level of
anxiety experienced by consumers after meals in a community setting is likely to be different
than the intensity experienced by people who are in need of an acute environment (Touyz
et al., 2008). Thus, it may be that music therapy is only effective for people with eating
disorders when they are experiencing acute episodes of illness. Anecdotal reports and case
studies support the use of music therapy during outpatient treatment with people with eating
disorders and describe increased motivation for treatment and improved affect (Hilliard,
2001), an opportunity for emotional expression and expression of identity (McFerran, Baker,
Patton, & Sawyer, 2006) and improved self-esteem and feelings of empowerment (Pavlakou,
2009). Despite these positive reports of music therapy from individuals participating in
outpatient services, the evidence base for music therapy in this setting is scarce. The authors
of this study reported here aim to contribute to research of this approach and provide further
clarity about the use of music therapy for adults with eating disorders.
Eating disorders are associated with emotion avoidance and a strong desire to control
emotions (Corstorphine, Mountford, Tomlinson, Waller, & Meyer, 2007; Gale, Holliday,
Troop, Serpell, & Treasure, 2006). It is likely that participation in music therapy acts as
a way of tolerating distressing emotions for participants, as they are able to experience
them through the music resulting in reduced feelings of anxiety (Smeijsters, 2012).
A previous music therapy study made reference to the use of music for distress tolerance,
describing how participants placed negative or sad emotions into the music and felt relief
(Bibb & McFerran, 2018). This relief emphasizes the value of music therapy in this setting
as the therapy occurs through the music rather than through discussion (Aigen, 2005). As
such, music use and participation in music therapy may offer an alternate coping strategy
for consumers with eating disorders in outpatient settings who often report the avoidance
of upsetting emotions or feeling emotionally numb (Schmidt & Treasure, 2006). One
participant in Bibb, Castle and Newton’s (2016) study described her participation in music
therapy as a new way of thawing this feeling of numbness. Participation in music therapy
helped to transform feelings of anxiety and distress so that music use acted as a new
strategy for coping with emotions (Smeijsters, 2012).

Method
Setting
This study was conducted at the outpatient campus of the Body Image and Eating Disorders
Treatment and Recovery Service (BETRS), which is a government-funded program in the inner-
east of Melbourne, Australia. The outpatient campus is a community-based service for people
with eating disorders and their families and caregivers. The Day Patient Program (DPP) is
offered to people who are motivated for recovery as an alternative to inpatient stay and includes
308 J. BIBB ET AL.

a structured group program held four days each week from 9:30am to 3:30pm or 9:30am to
1:30pm (depending on the day). A psychiatry consultant, registrar, and a few allied health
clinicians staff the program. Participants attend group therapy sessions based on different topics
(e.g., nutrition, goal-setting, coping skills, etc.) for the whole day, as well as an individual meeting
with a clinician before or after their attendance in the program each week. The DPP has up to
seven participants at one time and they attended for four week blocks. Upon completion of each
four week block, they could choose to continue for another one or two, four week blocks or exit
the program, which is decided in collaboration with their treatment team. Supported meal times
are a key part of the program and each week participants are encouraged to attend a social eating
challenge. The social eating challenge involves an outing to a local café or restaurant and
ordering and eating a meal together while working on individual eating related goals. The
theoretical approach underpinning the program is based in mental health recovery (Slade, 2009)
and collaborative conceptualization-based work that is person-centered and focuses on indivi-
dualized treatment (Newton, 2012).nutrition, goal-setting, coping skills, etc.)

Design
The aim of this study was to determine whether participation in group music therapy would
decrease subjective perception of anxiety during the period following the social eating challenge
(post-meal). The music therapy group was held after the social eating challenge and before
afternoon tea each week. This time was chosen due to staff reports that people in the program
frequently found this period to be the most stressful in their week. In addition, anxiety prior to
meals has been identified as distressing for people with eating disorders (Steinglass et al., 2010).
By positioning the music therapy session after the social eating challenge but before another
meal, there is an increased likelihood that music therapy participation is responsible for any
change in anxiety.
A purposively inclusive pilot study design with no control group was adopted where
quantitative data was collected using a self-report measure. Individuals in this program
were at different stages in their recovery and each session consisted of a different group of
participants. Data was collected using the Subjective Units of Distress (SUDS) scale which
was the same tool used in the study conducted in the inpatient setting of this service in
2014 (Bibb et al., 2015). The tool was completed pre and post each weekly music therapy
session (see ‘materials’ section) over 13 sessions. Although 13 consumers participated in
the research, the number of sessions attended by participants varied, which is why 50
occasions of data were collected in total. This project was approved by the Human
Research Ethics Committee at St. Vincent’s Hospital Melbourne (HREC 033/17).

Participants
Adults who were admitted to the Day Patient Program at BETRS were invited to participate in
the study. They were given the Plain Language Statement and Consent Form upon admission to
the program by the assessment clinician who explained the research to them. Prior to the first
music therapy session they attended, informed consent was then obtained by the music therapist
(first author). Exclusion criteria included: inability to read or understand the Participant
Information and Consent Form, as determined by the assessment clinician. All 13 females
 JOURNAL OF CREATIVITY IN MENTAL HEALTH 309

who attended the program during the period of data collection agreed to participate in the study
(see Table 1).

Materials
Participants were informed how to use the Subjective Units of Distress Scale (SUDS) on
admission to the program. The SUDS is a self-report tool that captures the subjective
intensity of distress or anxiety experienced by a participant at one point in time (Wolpe,
1969). The scale has traditionally been used with a 0 to 100 rating scale, but more recently
scales of 0 to 10 have been developed where participants rate their anxiety on a scale
ranging from 0 which is described as “totally relaxed” to 10 which is described as the
“highest distress/anxiety/fear/discomfort you have ever felt.” In this study, the SUDS took
the form of a “feelings thermometer” with a visual analog scale that aided in the visual
representation of participants’ anxiety ratings (Kendall et al., 2005). A score of 10 indicates
a high level of stress, six, a moderate level of stress, and two or lower, a low level of stress.
Due to the cognitive limitations of people in starvation who are admitted to the program,
this tool was chosen in an attempt to minimize the amount of concentration required of
participants in this study.

Procedure
A one-hour group music therapy session was held following the social eating challenge
each week. A university trained and Registered Music Therapist (first author) facilitated
the music therapy group in the main group therapy room of the outpatient service.
Participants would first debrief with staff upon returning back to the outpatient service
following the outing. They were encouraged to reflect on their goals for the outing, what
strategies they found helpful or unhelpful, and how they were currently feeling. The music
therapist was present for the debriefing so that she was aware of participants’ current
mental state prior to the music therapy session. During music therapy sessions, partici-
pants were encouraged to sing, listen, choose, and discuss familiar songs together. They
were able to choose songs from a songbook that included 50–60 popular songs ranging
from the 1950s-2017 which were played live on voice and guitar by the music therapist.
Participants were also encouraged to share their own preferred music using their smart

Table 1. Participant details.

Participant Age Gender History of eating disorder
1 36 Female 6 years anorexia nervosa with 10 year history of obsessive compulsive disorder
2 41 Female 25 years anorexia nervosa
3 21 Female 4 years anorexia nervosa
4 22 Female 5 years anorexia nervosa
5 20 Female First presentation anorexia nervosa with generalised anxiety disorder
6 19 Female 1.5 years anorexia nervosa
7 22 Female 1.5 years anorexia nervosa and anxiety disorder
8 23 Female 5 years anorexia nervosa
9 28 Female 1 year anorexia nervosa, major depression, obsessive compulsive disorder
10 33 Female 15 years anorexia nervosa
11 18 Female 1 year anorexia nervosa
12 20 Female 5 years anorexia nervosa
13 31 Female 1 year anorexia nervosa and 10 year history of post traumatic stress disorder and depression
310 J. BIBB ET AL.

phone or personal music player and a Bluetooth speaker. Participants tended to choose
live songs played by the music therapist, but this differed each session depending on the
group of participants at the time. Research shows that music that is familiar to a person is
most effective in engaging them in therapy (Grocke & Wigram, 2006), which is why
participants were asked to choose their own songs. Encouraging the participants to listen
to and share their own music preferences increases the likelihood of positive outcomes.
A resource-oriented approach to music therapy (Rolvsjord, 2010) was adopted that is
influenced by humanistic psychology and recovery-oriented frameworks to mental health
care. Resource-oriented music therapy is collaborative and based on both the client and
therapist being active participants in therapy sessions. This approach implies a flexibility in
the roles and methods used in sessions. In this approach the therapist does not decide on the
“right” therapeutic intervention in order to achieve a therapeutic outcome, but rather engages
the client in the session to help themselves. Participants were encouraged to discuss their
preferred musical tastes as well as the song lyrics and song meanings in sessions. Participants
were generally open to listening to each other’s music preferences and engaged in discussion
around their own motivations for enjoying certain artists and genres. Participants spoke
about how they related to the lyrics in the songs they had chosen, and memories associated
with songs. Other topics also emerged in discussions during sessions that related to eating
disorder recovery, body image, and the role of music in their recovery.

Statistical analysis
Data was analyzed using Microsoft Excel version 15. Mean differences between pretest and
post-test SUDS scores; mean standard errors for both scores and the standard deviation
were calculated. A paired two-tailed t-test was then conducted using the Excel data
analysis add-in package “Analysis ToolPak.”

Results
The 13 participants (all female) contributed to 50 occasions of prepost data collection
(n = 50) over 13 music therapy sessions. There were no outliers that may have impacted
the results. Table 2 presents the mean pre-test and post-test scores and mean difference for
each participant. Table 3 presents the combined results. The mean pretest score was 5.1
and the mean post-test score was 2.9, indicating an average decrease in anxiety of 2.3
integers on the SUDS scale. The mean standard error was 0.3 pretest and 0.2 post-test,
while the standard deviation was 1.6. A paired, two-tailed t-test was conducted and
a highly statistically significant difference (p = < 0.0001) between the pretest scores and
post-test scores was found.

Discussion and conclusion

The aim of this study was to assess whether post-meal related anxiety could be ameliorated in
individuals with eating disorders using music therapy. This is, to our knowledge, the first
quantitative study conducted in an outpatient setting to investigate the role of music therapy
in reducing post-meal related anxiety. The results support previous research that was
 JOURNAL OF CREATIVITY IN MENTAL HEALTH 311

Table 2. Individual participant data.

Participant No of occasions Average pretest score Average post-test score Average change
1 2 4.5 2.2 −2.2
2 6 5.2 2.6 −2.7
3 1 6 3.5 −2.5
4 6 5.2 3.3 −1.9
5 6 3 1.6 −1.3
6 3 3.3 2.5 −0.8
7 4 7.7 3.5 −4.2
8 3 7.2 4.5 −2.6
9 4 6.2 1.7 −4.5
10 4 2.5 2.2 −0.2
11 2 4 1.5 −2.5
12 6 7.2 4.5 −2.7
13 3 5.3 4 −1.3

Table 3. Raw data.

Pretest Post-test
n Mean Std error (m) Mean Std error (m) Difference (m) Std dev.
50 5.1 0.3 2.9 0.2 2.3 1.6

conducted in the inpatient arm of this program and also found significant results for music
therapy in reducing post-meal related anxiety (Bibb et al., 2015).
The average pretest score reported by participants in this study was 5/10, and although this
rating of anxiety may still severely impact quality of life and participation in usual daily activities,
previous research has suggested that consumers with eating disorders in outpatient settings can
have as high anxiety levels during and after mealtimes as consumers in inpatient settings (Cardi,
Lounes, Kan, & Treasure, 2013). When comparing the pretest score from this study with the
previous study in the inpatient setting (Bibb et al., 2015), the mean pre-test score (five) was
much lower than the pre-test score in the inpatient study (eight). This is important knowledge,
since it suggests that participation in music therapy can decrease the different intensities of
meal-related anxiety experienced by consumers across community and inpatient settings. The
results of this study also offer support for the role of music therapy in reducing anxiety for
people in differing stages of eating disorder recovery. Although the participants were all
participating in an outpatient program, some were newly diagnosed and/or admitted for the
first time to the service for eating disorder treatment while other participants had over a 10-year
history of eating disorder treatment. Despite the range of participants’ stages of recovery, they
reported a decrease in anxiety by attending music therapy during post-meal time. Thus, the
results of this study hold important implications for eating disorder treatment. If anxiety is
effectively managed by music therapy during heightened periods of anxiety, it may reduce the
need for pharmacological intervention.
Research has found that anxiety can still persist even after recovery from an eating
disorder (Bardone-Cone et al., 2010; Wagner et al., 2006) and, if feelings of anxiety are
not managed, the risk of relapse is increased (Mitchell, Davis, & Goff, 1985). In
addition, learning new coping skills for distress and anxiety (Fogarty & Ramjan,
2016) and new ways to manage feelings (Hannon, Eunson, & Munro, 2017) has
been reported as one of the most important factors in eating disorder treatment and
312 J. BIBB ET AL.

recovery. Thus, effective coping strategies for anxiety are extremely important for the
long-term recovery of eating disorders (Fitzsimmons & Bardone-Cone, 2011). The
availability and accessibility of music means that participants can continue to use
music as a strategy for coping with anxiety once they leave the outpatient service.
Participants in Bibb et al.’s (2016) study identified the potential for the continuation of
music use after mealtimes at home, with one participant reporting how she had begun
to listen to music to manage her anxiety in between attending music therapy sessions.
Ongoing discussions around the healthy and helpful use of music and offering indi-
vidualized playlist creation with the support of a music therapist should continue to be
prioritized (Saarikallio, Gold, & McFerran, 2015) as part of community treatment in
this setting to promote the use of music as a helpful coping strategy for long-term
recovery.

Limitations
This study adopted a non-randomized, pre-post, single session design with no control
condition. Caution should be used in interpreting these findings given the lack of
randomization and no use of a control group. In addition, the same 13 participants
contributed to several occasions of pre-post data collection and only one outcome
measure was used to measure anxiety. Participants were only recruited from one
service, which limits the generalizability of the results. It is also a limitation of the
study that qualitative data was not collected in addition to the pre-post data, as there
was no way of knowing the ways that music therapy was helpful for participants.
There is also potential conflict between the researcher and therapist role as the same
person undertook both positions simultaneously. Despite these limitations, the results
are promising and suggest that further research into this area would be valuable. Two
small feasibility studies have now been conducted measuring the role of group music
therapy in reducing post-meal anxiety for people with eating disorders – one in an
inpatient and one in an outpatient day program setting – and both studies have shown
significant results. A larger, randomized study in this area is now well justified. The
addition of qualitative data in future research is also recommended in order to provide
more detailed information about how and why music therapy is helpful for reducing
anxiety for people with eating disorders.
It is well documented that mealtimes can be distressing for people with eating disorders and
there is currently minimal evidence of what kind of activities effectively reduce anxiety during
this time. This study aimed to reduce post-meal related anxiety for individuals with eating
disorders through participation in group music therapy in an outpatient day program service.
The results indicated that participation in group music therapy after a social eating challenge
significantly decreased (p = < 0.0001) anxiety for participants.

Acknowledgments
We would like to thank the participants who generously contributed their time to this research, as
well as the staff at BETRS for their support of the project.
 JOURNAL OF CREATIVITY IN MENTAL HEALTH 313

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