The role of music listening in the music therapy process for people with anxiety disorders : The therapist’s perspective

This is a self-archived version of an original article. This version may differ from the original in pagination and typographic details. Author(s): Title: Year: Version: Copyright: Rights: Rights url: Please cite the original version: CC BY 4.0 https://creativecommons.org/licenses/by/4.0/ The role of music listening in the music therapy process for people with anxiety disorders : The therapist’s perspective © 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group Published version Taipale, Marianne; Carlson, Emily; Saarikallio, Suvi Taipale, M., Carlson, E., & Saarikallio, S. (2024). The role of music listening in the music therapy process for people with anxiety disorders : The therapist’s perspective. Nordic Journal of Music Therapy, Early online. https://doi.org/10.1080/08098131.2024.2377974 2024 Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=rnjm20 Nordic Journal of Music Therapy ISSN: (Print) (Online) Journal homepage: www.tandfonline.com/journals/rnjm20 The role of music listening in the music therapy process for people with anxiety disorders: The therapist’s perspective Marianne Taipale, Emily Carlson & Suvi Saarikallio To cite this article: Marianne Taipale, Emily Carlson & Suvi Saarikallio (30 Jul 2024): The role of music listening in the music therapy process for people with anxiety disorders: The therapist’s perspective, Nordic Journal of Music Therapy, DOI: 10.1080/08098131.2024.2377974 To link to this article: https://doi.org/10.1080/08098131.2024.2377974 © 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. Published online: 30 Jul 2024. Submit your article to this journal Article views: 120 View related articles View Crossmark data ORIGINAL RESEARCH ARTICLE The role of music listening in the music therapy process for people with anxiety disorders: The therapist’s perspective Marianne Taipale a,b , Emily Carlson a,b and Suvi Saarikallio a,b a The Centre of Excellence in Music, Mind, Body and Brain, University of Jyväskylä, Jyväskylä, Finland; b Department of Music, Art and Culture Studies, University of Jyväskylä, Jyväskylä, Finland ABSTRACT Introduction: Anxiety is a commonly diagnosed mental health disorder, but it remains underrepresented in music therapy research. Music listening (ML) seems to be an effective tool for anxiety self-management, but there is evidence that high anxiety level may complicate the self-regulation process. The links between ML in music therapy and everyday life have received little attention. The aim was to study what roles ML can have throughout a music therapy process for anxiety treatment, according to music therapists. Method: The data were collected by interviewing eight music therapists with experience of patients with anxiety disorders. The data were analyzed with the six-step approach to thematic analysis. The results were grouped into three categories: information carrier, musical identity development, and self-care tools. Results: ML appears to have three roles in music therapy for the treatment of anxiety: ML is a familiar part of the patient’s everyday life and provides valuable information about the patient’s inner world and their current state to the therapist; in therapy, ML represents safety, promotes conversation, and works as a bridge towards more active methods; and as a result of the therapeutic process, ML returns to patients’ everyday lives as a developed tool for self-regulation. Discussion: ML seems to function as a low-threshold activity, through which patients with anxiety disorders can share and reflect their mental state. With the assistance of a music therapist, they can learn to use music more beneficially in their anxiety selfmanagement and develop a healthier musical identity that can foster their emotional health. ARTICLE HISTORY Received 27 June 2023; Accepted 12 June 2024 KEYWORDS Music listening; music therapy; anxiety disorders; anxiety treatment; therapist’s perspective; thematic analysis Introduction Anxiety is the most diagnosed and rapidly increasing mental health disorder in the European Union (OECD & European Union, 2022), however, in music therapy CONTACT Marianne Taipale [email protected] NORDIC JOURNAL OF MUSIC THERAPY https://doi.org/10.1080/08098131.2024.2377974 © 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons. org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent. research, it has received little attention as its own entity, as it is often studied in relation with other disorders such as depression (Aalbers et al., 2017; Erkkilä et al., 2011). The effects of music listening (ML) on wellbeing have been extensively studied, for example, in terms of emotion regulation (Carlson et al., 2015; Saarikallio, 2008, 2012). Emotion regulation with music is not always successful among people with mental health disorders, but there is evidence that with the guidance of a music therapist, ML can become a method of self-care and a resource of health for patients (Vaillancourt et al., 2022). As an affordable, easily transferable method of music therapy (Harney et al., 2022), ML could help alleviate anxiety in various therapy settings, as well as in people’s everyday lives. Definition of anxiety Arroll and Kendrick (2018, p. 125) define anxiety as “a universal adaptive response to a threat”. Anxiety can also be described as a stress reaction (Ressler et al., 2015), and can evoke fight–flight responses (Buckley & Punkanen, 2020; Craske et al., 2011). However, anxiety exists more as a longer-term mood than, for example, acute fear. According to Barlow (2004), anxiety and fear are separated as follows: Anxiety is a future-oriented mood, in which a person expects negative things to happen, and fear is an alarm reaction to immediate danger. Although experiencing anxiety is a normal and healthy part of everyday life, excessive or unwarranted anxiety can play a part in serious illness. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recognizes 11 different types of anxiety disorders, which can involve symptoms such as fear, panic, hypertension, apprehension, chronic pain, agoraphobia, compulsive rituals, excessive worry, agitation, difficulty concentrating and sleep disturbances. Many of these symptoms can also appear in depression or stress disorders (Cummings et al., 2014). The most common anxiety disorders are generalized anxiety disorder (GAD), panic disorder and phobias (Hardy & Gray, 2011). In addition, anxiety is often related to obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), depression, substance abuse, long-term illnesses, trauma, and social anxiety disorder (SAD) (Arroll & Kendrick, 2018; Hardy & Gray, 2011). Anxiety may sometimes be undiagnosed due to comorbidity, or because the focus is mainly on the patient’s somatic symptoms, such as pain or insomnia (Bandelow et al., 2015). Music therapy for anxiety treatment Music psychotherapy is a common treatment for mental health disorders. Music, with its capacity to evoke deep emotions and work as a non-verbal medium, offers a unique tool for reflecting and expressing emotional content in therapy (Erkkilä et al., 2011). Music therapy methods can be categorized into two groups: active methods, in which the patient is playing an instrument, singing, or engaging bodily with the producing of music; and receptive methods, in which the patient does not produce the music, but is an active recipient of the musical information (Maratos et al., 2008). A clinical pilot study by Gutiérrez and Camarena (2015) found that music therapy combined with pharmacological treatment seems to reduce anxiety levels for patients with generalized anxiety disorder. Their pilot intervention study used both active and receptive methods of music therapy and they found the receptive methods to be 2M. TAIPALE ET AL. important, especially in encouraging the expression of memories and emotions. The possibilities of ML in music therapy should not be underestimated; while being a seemingly simple method, ML can provide highly meaningful individual experiences and help in building the connection between the patient and therapist (McCaffrey, 2016). The goals of ML can be, for example, to evoke physiological or affective responses, stimulate or relax the patient, evoke imagery, or stimulate discussion (Aigen, 2014; Grocke, 2016). Music for self-regulation Self-regulation can be defined as the ability to change one’s own physical, mental, or emotional state by adapting to the environment and its demands or challenges (Oettingen & Gollwitzer, 2015). Since anxiety is an emotional state that can be accompanied by strong bodily sensations, such as a feeling of tension, a fast heart rate or high blood pressure, relieving anxiety is not only about mental regulation skills, but also about regulating the body (Amstadter, 2008). Music can have a beneficial effect on stress-related physiological, cognitive, and emotional processes (Thoma et al., 2013). Emotion regulation is an often-mentioned underlying reason for ML (Saarikallio, 2011). The goals of everyday ML are most often related to relaxation, cheering up and strengthening the listener’s perceived emotion (Peltola et al., 2022, p. 387). A lot of research has been done in relation to ML behaviors in adolescents and adults. Although the goals in ML are generally related to healthy self-regulation, research into ML behaviors in adolescents and adults has shown that not all listeners use music in a way that improves their wellbeing (Garrido et al., 2022; Groarke et al., 2020). Stewart et al. (2019) discovered that young people with depression use music a lot in their everyday lives, but they are often not aware of how their music choices affect their wellbeing. In a recent experience sampling study, music listeners in an anxious state reached their self-regulation goals less successfully compared to all other negative states (Randall et al., 2023). This result indicates that the specific factors related to ML and anxiety require further investigation. ML in anxiety management has been studied previously from the everyday life perspective (Carlson et al., 2015; Saarikallio, 2011), and clinically for example related to state anxiety before medical procedures (Thoma et al., 2015; Mackintosh et al., 2018; Vachiramon et al., 2013). A meta-analysis of controlled studies by Harney et al. (2022) concludes that although ML was found to be effective for reducing anxiety in a variety of groups, more research on clinical groups with diagnosed mental health problems is required. Successful emotion regulation with music requires a person to know how to use music beneficially for them. A person’s own relationship with music, and beneficial music use can sometimes be examined in the music therapy process. Anxiety is a complicated state that has not been addressed very centrally in music therapy literature as its own entity. Anxiety seems to be a challenging state also in terms of self-regulation and a high level of anxiety may lead to unsuccessful emotion regulation or maladaptive musical behavior. ML is a commonly used method in music therapy for mental health care, but its role in anxiety treatment has not been defined. More research is needed to define how ML is used in music therapy specifically for anxiety treatment, and what are the possible links of ML in therapy and ML in everyday life. NORDIC JOURNAL OF MUSIC THERAPY 3 Study aims This qualitative, phenomenological study examines the role of ML in different stages of the music therapy process when treating young adults and adults (aged 18–65 years) with anxiety. The phenomenon is explored from the perspective of music therapists. The research question is: What is the role of music listening in music therapy from the perspectives of music therapists for treating people with anxiety disorders? Method Design This interview study with eight music therapists was conducted with a phenomenological design to reach the in-depth details of their experiences, perceptions, and expertise on the subject (Wilson, 2015). Music therapists use various techniques, and their expertise can be built on very different educational backgrounds (Ahonen-Eerikäinen, 1999). The phenomenological approach in this study allowed the exploration of different views and lived experiences on the topic (McFerran & Grocke, 2007). The theoretical framework of this study leant towards music psychotherapy, which is a common music therapy approach to treat people with mood disorders. Music psychotherapy emphasizes the meaning of the relationship between therapist and patient, and approaches treatment in a holistic way (Zarate, 2022). The researchers’ position in the interviews was to be objective outsiders, and not bring out any own experiences or views on the topic. Participants Participant recruitment started with searching for music therapists from the web pages of local and national organizations. Therapists were contacted via email if their profile stated that their work related to adults and mental health. Participant selection was done with a purposive sampling method. Purposive sampling is a non-probabilistic selection method where researchers can choose participants who meet specific criteria or possess characteristics that are of particular interest to the study (Guest et al., 2013). This approach was chosen for its suitability to find participants who had the required expertise for this study. Participants were included if they had work experience of treating over 18-year-old patients with an anxiety disorder. Data collection The interview method in this study was a semi-structured interview, where the interview can be based on defined themes and questions, maintaining a clear structure while leaving room for further developments and free discussion (Hirsjärvi & Hurme, 2008; von Soest, 2022). The interview procedure contained: a greeting and introduction informing the participant about the study; filling out the form for their consent for participation and recording (by paper or online); and the actual interview part. The interview themes and questions were decided before the interview, but questions were formulated to stimulate discussion, allowing the participant to bring their own perspectives. All participants were asked the same questions about their education, work experience, and their views about the role of music listening in music therapy, as well 4M. TAIPALE ET AL. as their habits of using music with their patients and their observations about anxious peoples’ music engagement (see Appendix), but depending on the flow of the conversation, the order of the questions could vary slightly. Each participant was interviewed once. Interviews lasted about 30 minutes each. To ensure epistemic access to the researched subject, the researcher conducting the interviews had completed groundwork to build their awareness of the field, for example, the terminology of the field when discussing with an expert (Hyvärinen et al., 2017). At the beginning of the interview, the participants were encouraged to use the terminology of the music therapy field, as the interviewer had experience and background education from said field. The interviews were held either online or in person, in Finnish, as all the participants and the interviewer were native Finnish speakers. All participants provided information regarding their age, educational background, work experience, and estimated number of patients with anxiety symptoms seen during their careers. Ethical considerations This study was performed in accordance with guidelines and regulations of the Finnish National Board on Research Integrity TENK (2019). The study did not contain interventions that affect participants’ physical integrity, expose them to exceptionally strong stimuli, increase their risk of mental harm or pose a threat to their safety, nor were the participants under the age of 15 or contributing to the research without their own consent. Therefore, according to these guidelines and regulations, ethical approval was not required for this research. Participants were informed about the procedures before the interview and provided their written informed consent to participate and agreed to the recording of the interview. The audio data were accessible only to the researcher, and the audio files were stored in a password-protected, locked location. Data were transcribed and anonymized, and all audio data files were destroyed no later than 12 months after the interviews. The research was conducted in an ethical and responsible manner. Analysis Data were first roughly transcribed with a focus on accuracy of content over linguistic details, a method which is well-suited for thematic analysis (Halcomb & Davidson, 2006). The data were analyzed using Braun and Clarke’s (2012) six step approach to thematic analysis, which included familiarization, generating initial codes, searching for themes, reviewing themes, defining, and naming themes and writing the report. ATLAS. ti mac (Version 22.0.6.0) was used as a tool for coding, thematizing, analyzing and visualizing the data, as well as taking notes and keeping a research diary. The notes and diary were used for keeping track of the subjective reflection and the research group discussions throughout the process ensure the reflexivity of the study. Bracketing was used in each state to increase the integrity and validity of the study. The audio data were transcribed within a week of the interviews. A compression process was made on the original transcriptions, in which some meaningless parts were removed, such as repeated words and the researcher’s affirmative answers. Familiarization with the data included reading through the documents and taking notes on potentially interesting or frequently NORDIC JOURNAL OF MUSIC THERAPY 5 occurring issues. Initial codes were generated while reading through the documents in the ATLAS.ti software. During the reading, the codes increased and became more detailed. The coding of the documents was examined through several rounds of reading, so that the level of the codes in the documents matched each other. Themes were searched by categorizing the clearly matching codes to groups with ATLAS.ti. Codes that were left without a group were explored further. If the content was found upon further consideration to fit with any of the existing groups, the name of the code was modified to reflect its relationship more accurately to the theme, and the code was added to the group. If they did not match with any existing themes, the code was examined through its frequency to assess the importance of the code overall: If it appeared very infrequently, it was discarded from the preliminary results. The themes were identified based on their relevance and frequency of appearance. Codes and themes were discussed among all authors, and the themes were reviewed, defined, and named to create the initial structure of the results. The analysis was made by first mirroring the main themes to the theoretical framework and research questions. Each theme’s codes were reviewed side by side to find the relevant content. If the codes contained information related to other topics, the relevant information was added to notes for later review. The analysis was then taken to the level of quotations, correspondences and relations between quotations were sought, and new categories were found within the themes, whereby cohesion gradually emerged between the individual quotations. Results were compiled by constructing a text from the rearranged data, corresponding to the research questions. The authors of this paper include both Finnish and English native speakers, all of whom understand and speak both languages on a high level. The translation process of the quotations from Finnish to English was handled by the authors. Results Eight music therapists participated in this study. The participants’ ages varied between 32 and 63 years. In addition to their music therapist education, each had a different background education and different work experience. On average, the participants had completed three different degrees, the most common being a master’s degree in education or arts, as well as degrees in other fields of therapy, such as occupational therapy and psychotherapy. The participants’ work experience as a music therapist ranged from 2.5 to 26 years, so the interviews captured information from music therapists who were at different career phases and had been trained at different times. On average, the participants had about 13 years of work experience in music therapy. All participants used a variety of methods in their music therapy practice, with a focus on a patient-led approach. The diversity of patient target groups varied between the participants. Each participant had experience with several anxious patients, often up to dozens of different cases. Some of the participants had worked very extensively in their careers with different target groups and age groups, while others’ work was more focused on a specific clinical group. However, every participant had work experience related to mental health and anxiety with young adults and adults. Thus, the focus of the research is on the experiences related to treating anxiety in the lives of young adults and adults in both private practice and institutional care. 6M. TAIPALE ET AL. As background information, the participants described how anxiety usually appears in music therapy. These general-level findings about the appearance of anxiety are presented to build an overview of the phenomenon before presenting the main themes. Anxiety was described to appear as challenges in (a) regulation of body and alertness, (b) regulation of emotions and (c) social situations. The bodily reactions were even considered to be the primary visible sign of anxiety. Descriptions of embodied anxiety included physical restlessness, tension, shallow breathing and overor understimulation of the body. These symptoms could be seen during the relaxation and ML exercises, which were common approaches in the early stages of the therapy. In terms of emotion, anxiety became visible as irritation, superficiality, lack of facial expression and challenges in emotion regulation. Somatic symptoms extended to communication and social situations and caused fears, difficulty in speaking and expressing feelings and lack of trust for other people. At times, anxiety could distort self-expression, and lead to unusually quiet or loud musical or verbal expression. Avoidance of social situations was particularly challenging if it affected attending school, work, or therapy. The anxiety-related social and emotional challenges were one of the reasons that therapy with anxious patients was said to progress very slowly and through especially low threshold music exercises. Overall, anxiety was seen to be very common among different patients. One participant said that: “I don’t even really have a client that wouldn’t have some kind of anxiety” [P1]. Anxiety was considered a very holistic problem, and one participant described it to appear in many ways: “Every patient’s anxiety is a little different; the patients are different, their experiences are different, and their personality, habits and ways to express it can be so diverse” [P5]. These descriptions created the general outline for understanding how anxiety appears in music therapy, which worked as a foundation for defining the role of ML in anxiety treatment. Figure 1 presents the findings of this study. Among the results, three main themes for the role of ML in anxiety treatment were identified: (1) Information carrier, (2) Musical identity development and (3) Self-care tools. The first theme describes how ML works as an information carrier between the patient’s everyday life and therapy, the second theme highlights the development and changes in Figure 1. The role of ML in music therapy for anxiety treatment NORDIC JOURNAL OF MUSIC THERAPY 7 and associations, while rhythm and tempo were the traits that guided the therapists’ choices of music. This is understandable, as melody and harmony are considered the most language-like and emotionally meaningful aspects in music, while rhythm and tempo are more structural and timeline-creating, lower-level features (see e.g. Patel, 2008; Schmuckler, 2016; Gabrielsson, 2014). Lyrics are overall considered a very central aspect in mood regulation; reflection, connection and comfort are the main experiences achieved of listening to favorable music (Bhattacharya et al., 2023). With the patients referred to in this study, these meanings seemed quite similar to normal population. Our participants commented on the importance of the therapeutic relationship and circumstances in anxiety treatment; the importance of the therapeutic relationship is accentuated with patients with anxiety disorders, for whom treatment adherence is sometimes challenging (Hardy & Gray, 2011). In light of our findings, ML seems to have a central role in anxiety treatment in building the relationship between the patient and therapist. Low-threshold exercises, such as listening to music together, were crucial at the beginning of therapy for learning about the patient’s inner world, and for building a close therapeutic relationship with the patient. Changes in the patient’s mood could sometimes be sensed through music first. This aligns with Erkkilä et al. (2011), who note that methods of music psychotherapy commonly operate on different levels of consciousness, which is why it is possible that a skilled therapist can sense some changes in the music before they emerge on a more conscious level, even to the patients. This phenomenon can reflect a very developed and deep therapeutic relationship. In these results, the music patients brought to therapy reflected their therapeutic change. These examples were related to development and recovery, but it remains an open question for future research whether the changes towards negative development can be seen as clearly in the ML as the positive changes. Musical identity is a big part of personality, and changes in musical identity can reflect a person’s wellbeing (MacDonald & Saarikallio, 2022). Current findings on how music reflects the patients’ mental change in music therapy can be very central to the recovery process. Engagement with music on a psychologically insightful level can help the patients develop healthier musical identities. In addition, the development in the patient’s musical identity appears to lead to the patient taking an increasingly active and dynamic role in the therapy process. The increase in agency has previously been seen to relate to the mechanisms of change in psychotherapy (Huber et al., 2021). Therefore, it seems that while changes in the content of ML can change along with the patient’s mood, the changes in the patient’s agency in therapy reflects the mental change in a similar manner. Anxiety can lead to an increased need for support in self-regulation (Villaggi et al., 2015). In cognitive therapy, homework assignments have been shown to correlate with a good outcome (Garland & Scott, 2002). Compared to cognitive therapy, the psychotherapeutic approach usually emphasizes deeper insight over targeted solutions. The adaptation of homework assignments to psychotherapeutic work requires some future research and development. Applications and interfaces develop at a fast pace, and for example, a thorough listing has been done on the tools that can be used in therapy both for musical purposes and for therapist’s reporting (Knight, 2013), but their listing did not address tools for the patient to use between therapy sessions. Our findings about “self-care tools” suggest that people’s awareness of benefits of music 14 M. TAIPALE ET AL. could be better, as well as the role of homework as part of psychotherapeutic work. In addition, there is an imminent need for further research as well as patient-supportive applications and innovations. In light of these results, ML can be considered a multi-purpose method that provides information both to the therapist and the patient about the patient’s recovery and current state, and that can help music therapists to assist their patients develop their self-regulation skills and guide them towards healthier musical identities. In conclusion, these findings highlight the natural connections of ML between everyday life and music therapy and offer thoughts on the developmental needs for anxiety treatment in and out of healthcare contexts. Research implications This study aimed to understand how ML is used in music therapy in Finland. The study was conducted with eight Finnish music therapists, who provided information from their perspective as professional music therapists. Further research with an international group of music therapists could provide a more generalizable view on this topic. The threefold role of listening to music suggested in this study could be further explored by adding interviews with the patients. This study’s results were based on the descriptions of individual therapy settings; studying anxiety-related group music therapy might reveal different aspects of the connections of anxiety and ML. These results suggest what is the role of ML in treating anxiety. The results cannot be generalized to other clinical groups without further research. Conclusion This phenomenological study examines the role of ML in music therapy for anxiety treatment. According to the findings, ML has three important roles in the music therapy process: to work as an information carrier about the patient’s inner world and current state, to reflect the individual development as changes in the music and agency, and to travel back to home as self-care tools which can be developed together in therapy. These findings offer insight into how ML can provide information for patient assessment and help build the therapeutic relationship, and how ML is a needed element for anxiety treatment at the beginning of therapy, building a pathway for more active agency. The findings also highlight how ML is the natural connection to the patient’s everyday world, where the skills learned in therapy and the healthier musical identity developed together with the therapist can support their recovery. Future studies should address how patients’ ML may reflect their recovery or deterioration in therapy, as well as what ML-related scales could be used for anxiety assessment purposes. Disclosure statement No potential conflict of interest was reported by the author(s). Funding This study has been funded by Research Council of Finland [346210]. NORDIC JOURNAL OF MUSIC THERAPY 15 Notes on contributors Marianne Taipale is a Finnish doctoral researcher in musicology, and a music therapist at the University of Jyväskylä. Her main areas of study include anxiety treatment with music psychotherapy, and the underlying processes of anxiety management with music both in clinical settings and in everyday life. Emily Carlson is a senior lecturer in music therapy at the University of Jyväskylä, where she completed her doctoral studies in 2018. Her main areas of research include embodied music cognition, social interaction in music, and music therapy for children with developmental disabilities. Suvi Saarikallio is a professor of music education at the University of Jyväskylä. She and her team conduct research and teaching widely in music psychology, music education, and music therapy. Her research approaches music as human behavior: youth development, emotion regulation, learning and well-being. 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(3) Years of experience as a music therapist? (4) Years of experience with patients with anxiety? (5) Approximate number of patients with anxiety? (6) Other work experience? (7) What populations or age groups do you usually work with? Music listening questions: (1) How would you describe the role and meaning of music listening in music therapy? (2) Describe how you use music listening inside therapy sessions in general? (3) How do you use music with an anxious patient? (Music style, certain time of the session, their preferences?) (4) What observations do you have about music listening habits of the patients with anxiety? (Their musical taste, do they report using music?) (5) Have you used some methods to encourage patients with anxiety to use music in a more beneficial or healthy way in their everyday lives? (6) What do you think of the future directions of using music listening in therapy context for people with anxiety? How about in everyday life and self-care? (7) Would you like to add something that we haven’t discussed yet? NORDIC JOURNAL OF MUSIC THERAPY 19