Flow and meaningfulness as predictors of therapeutic outcome within songwriting interventions

Abstract

There has been inadequate consideration of how flow and meaning impact health within music therapy interventions. The purpose of these analyses was to determine if flow and meaningfulness of songwriting were related to and functioned as predictors of therapeutic outcome within songwriting interventions for adult inpatients on an acute care psychiatric unit (Study 1) and a detoxification unit (Study 2). Correlational and multiple regression analyses were conducted on data with inpatients who had participated in a single-session highly structured blues songwriting intervention with a music therapist. Therapeutic outcomes were state indices of hope (Study 1; N = 54 adults on an acute care psychiatric unit) and readiness to change (Study 2; N = 170 adults on a detoxification unit). In both studies, there tended to be positive and significant correlations between flow and meaningfulness of songwriting and therapeutic outcomes. Multiple regression analyses indicated that flow was a significant predictor of therapeutic outcome but that meaningfulness of songwriting was not a significant predictor of therapeutic outcome during both studies. Flow may represent a positively framed and less invasive method for measuring patients’ perceptions of the therapeutic outcomes. Implications, limitations, and suggestions for future research are included.

Keywords

addiction chemical dependency detoxification flow mental disorder mental health music therapy psychiatric songwriting substance abuse

In a 2012 Cochrane Review, authors found that, when combined with standard care, music therapy can help improve global state, mental state, and social functioning for people with schizophrenia and schizophrenia-like illnesses (Mossler, Chen, Heldal, & Gold, 2012). This review included eight studies and 483 participants. Mechanisms responsible for change in psychodynamic music therapy have often been attributed to Stern’s Vitality Affects Theory (Stern, 2010a, 2010b). However, many music therapists working with people with mental disorders utilize a cognitive behavioral approach and little is understood about mechanisms of change for people with mental disorders from this orientation.

Songwriting is a flexible and commonly utilized music therapy intervention (Baker, Wigram, Stott, & McFerran, 2008) wherein a client, or group of clients, work collaboratively with the music therapist to create lyrics, music, or a combination of both music and lyrics. Within psychiatric settings, many music therapists use songwriting interventions (Silverman, 2007, 2009) to address a plethora of clinical objectives. Researchers found group-based songwriting can improve quality of life and spirituality in psychiatric consumers (Grocke et al., 2014). Songwriting interventions can be especially meaningful for music therapy clients as they may find therapeutic value and meaning both during the process of composing the music and from the product that constitutes the final musical composition.

In group-based psychiatric music therapy settings, clients can creatively articulate their unique and personalized narratives via songwriting experiences (Baker et al., 2008). When patients hear each other’s narratives during group-based clinical practice, it may facilitate aspects conducive of a therapeutic environment and promote cognitive, affective, or behavioral change. Due to the group-based processes and products inherent within group-based therapeutic songwriting, clients may experience universalization and normalization when they share and listen to other patients’ narratives. As patients’ problems and issues tend not to be idiosyncratic or unique, patients may find relief and can be more amenable to change when they become aware and acknowledge that other people have similar or related problems and situations (Mansell, Carey, & Tai, 2013). Recognizing that other people in the group may have similar situations and problems can function as universalization, which is considered a transtheoretical mechanism of therapeutic change (Corsini, 2008). Group-based songwriting interventions may augment this capacity due to the unique ability to share narratives via structured and creative music therapy experiences.

In an attempt to develop a theoretical model for understanding optimal experiences in human behavior, Csikszentmihalyi (1975) is credited with developing the concept of a type of consciousness where a person is powerfully engaged in a gratifying activity, often referred to as flow. While experiencing flow, the person is completely immersed in a task that is intrinsically rewarding, able to ignore distractions, and the difficulty of that task is enough to warrant focus without boredom or anxiety. This highly engaged state results in an experience where nothing else seems to matter (Csiksztenmihalyi, 1990; Jackson & Csiksztentmihalyi, 1999). During the time of its theoretical development, flow was conceptualized as an alternative to psychoanalytic explanations of the dynamic interaction between the challenge of a task and the person’s skills and abilities (Jonsson & Persson, 2006). Flow theory has guided researchers’ understanding of the relationships and intersections between various tasks, occupations, wellbeing, and life satisfaction (e.g., Jackson & Eklund, 2004; Jackson, Thomas, Marsh, & Smethurst, 2001; Martin & Jackson, 2008; Wrigley & Emmerson, 2013). From a neural perspective, Ulrich, Keller, Hoenig, Waller, and Gron (2014) used functional magnetic resonance perfusion imaging and found flow to be associated with a deeper sense of cognitive control, decreased negative arousal, and decreased self-referential processing.

Maslow’s theory of self-actualization (1968, 1970), wherein he attempted to understand intrinsic motivation, was partially responsible for providing the theoretical bases of flow. Self-actualization can be facilitated by moments when a person is fully engaged in an activity. Maslow (1970) believed that people’s “healthiest moments” (p. 97) occurred when they fully utilized their abilities, which may provide an initial rationale for the exploration of flow as a therapeutic agent. Thus, flow theory may have implications for health, therapeutic encounters, and songwriting during music therapy. Anecdotally, it would seem that many patients – and therapists – experience flow within psychotherapeutic settings. However, despite its potential implications and applicability, there is a lack of research literature systematically investigating flow within music therapy settings.

While it may seem that flow represents an abstract concept, many musicians might relate to the concept of flow and it has thus received research attention in music-related literature (O’Neill, 1999). In fact, Csikszentmihalyi (1990) theorized that artists and athletes, in particular, may be prone to experiencing flow. People can also experience flow during receptive music experiences as (1990) noted that flow can result when a person is totally emerged in a music listening activity. Musicians have noted experiencing flow during peak performance (MacDonald & Wilson, 2006) and popular songwriters have articulated experiencing flow during the creation of their best works (Kruger, 2005; Zollo, 1997). For flow to occur in music-based activities, Diaz (2011) suggested three criteria based on the flow literature: goals are clearly established, contingent feedback is available, and skills are matched with challenges. These three criteria are also conducive to therapeutic encounters.

Emerson (1998) noted that when a person is in a state of flow, she or he might also experience other beneficial states, including: positive affect, motivation, high cognitive efficiency, and high activation. Moreover, increased activation involves positive aspects that are conducive to therapy and learning, including energy, interest, alertness, and arousal (Csikszentmihalyi & Larson, 1987; Csikszentmihalyi & Mei-Ha Wong, 1991). Flow may also relate to wellbeing, performance, skill development, quality of life, self-esteem, happiness, leisure, personal growth, life satisfaction, the opportunity of self-actualization, and other aspects conducive to counseling and therapeutic experiences (Asakawa, 2004; Carlson & Clark, 1991; Csikszentmihalyi, 1990; Han, 1988). Fritz and Avsec (2007) studied the relationship between flow and subjective wellbeing in music students and found several aspects of flow that positively related to measures of wellbeing. The authors concluded that flow was more related to emotional wellbeing than cognitive wellbeing. Due to potential implications for flow in a person’s occupational setting, a number of researchers noted that flow theory can be an important therapeutic element in the occupational therapy literature base (Christiansen & Baum, 2004; Emerson, 1998; Neistadt & Crepeau, 1998; Wright, 2004).

Byrne, MacDonald, and Carlton (2003) and MacDonald, Byrne, and Carlton (2006) examined the relationship between flow and music composition students’ creative output. By measuring creativity ratings, the researchers found a significant correlation between student flow and the quality of their group-based compositions. Baker and MacDonald (2013) measured the flow experiences of retirees and students during songwriting experiences facilitated by a trained music therapist. The researchers found flow was strong during songwriting and a correlation between the meaningfulness of songwriting experiences and flow. During follow-up interviews, participants described flow experiences as they were fully immersed in the songwriting activity, noted an altered perception of time, and a balance between ability and effort (Baker & MacDonald, 2014). Baker and MacDonald (2013) conjectured that music therapy participants may experience flow during songwriting interventions wherein participants tell their stories, compose original music, and explore their creativity. Despite potential positive ramifications due to its applicability in music, flow has rarely been examined in the music therapy literature base. Therefore, the purpose of these analyses was to determine if flow and meaningfulness were associated with and functioned as predictors of therapeutic outcome within songwriting interventions with acute care adult psychiatric inpatients. Specific research questions were as follows:

Are there relationships between flow, the meaningfulness of the songwriting process, and songwriting product and clinical outcomes in patients on an acute psychiatric unit (Study 1) and patients on a detoxification unit (Study 2)?

Do flow, the meaningfulness of the songwriting process, and songwriting product predict clinical outcomes in patients on an acute psychiatric unit (Study 1) and patients on a detoxification unit (Study 2)?

Method

Design

Both analyses were based on data collected during randomized controlled trials. Study 1 involved inpatient participants in an acute care psychiatric unit. These patients were cluster randomized into one of three conditions: group songwriting, group lyric analysis, and a wait-list control condition. Study 2 involved inpatient participants in a detoxification unit. These patients were cluster randomized into one of two conditions: group songwriting and a wait-list control condition. During both studies, only participants in the songwriting condition were involved in the current analyses and only the data pertaining to analyses of songwriting are reported here. Once recruited and randomized into one of the group songwriting clusters, participants engaged in a single group blues songwriting session facilitated by a music therapist with over 13 years of experience with adult psychiatric inpatients. Immediately following the session, participants completed flow, meaningfulness of songwriting, and treatment outcome self-report measures.

Songwriting intervention

All sessions were approximately 45 minutes in duration. After an initial introduction, explanation of the study, and distribution of consent forms, verbal informed consent was sought and obtained. In an attempt to provide treatment to as many potential patients as possible, group members were permitted to participate in the session even if informed consent to participate in the study was not received. Given the clinical population and setting, the Institutional Review Board granted a waiver of signatures on informed consent forms to augment confidentiality.

Following a 12-bar blues warm-up intervention wherein patients stated their names and something about themselves, the music therapist facilitated the creation of an original 12-bar blues song based on the theme of hope for psychiatric recovery (Study 1; acute psychiatric participants) and need for sobriety (Study 2; detoxification group). In both groups, participants first brainstormed ideas of why they wanted to recover from their illness or be sober. These ideas, categorized as motivators for recovery and sobriety, were then shaped into lyrics and organized to create the song’s first verse. The music therapist wrote these ideas and lyrics on a dry-erase board. Examples of lyrical themes described in the first verse included family, friends, health, vocational aspirations, and happiness. Utilizing the same approach, the therapist then facilitated the creation of a second verse with the thematic focus on modes of recovery and sobriety. Examples of lyrical themes outlined in the second verse included taking medications as prescribed, adhering to therapy plans, monitoring the illness, attending and participating in various treatment groups, and having a positive attitude.

Due to time constraints of a single therapy session on the inpatient acute care units, participants only wrote lyrics for two complete verses. At the conclusion of the session, the therapist verbally processed the session, thanked the participants for their participation, and distributed the posttests to participants who volunteered to complete them. In all sessions, the therapist accompanied himself on a steel-string acoustic guitar (Yamaha FG720S), wrote the lyrics on a sheet of paper at the conclusion of the session, and made copies of the song lyrics for participants to keep. Although patients did not make harmonic decisions due to the use of the 12-bar blues, the therapist used the guitar accompaniment to facilitate lyrical composition. Musical notation was not used as music therapy groups were programmatic, meaning that all patients on the unit were allowed to attend and participate in the sessions regardless of their previous music experiences. During the songwriting process, the therapist sang the song and sometimes group members spontaneously sang along. The therapist delivering treatments applied transdiagnostic theory (Fairburn, Cooper, & Shafran, 2003) in an illness management and recovery approach, meaning that he placed less emphasis on the patient’s diagnosis and more emphasis on helping the patient solve his or her problems and reintegrate into the community, which is congruent with contemporary acute inpatient care (Green et al., 2014).

Instruments

Most researchers studying psychometric instruments recommend multidimensional measurement based on multiple items for a given scale (Marsh, Craven, & Martin, 2006). However, in research studies where time constraints obviate long instruments and where multiple constructs are measured, brief measures can be appropriate (Martin & Jackson, 2008).

Flow (all participants): the Short State Flow Scale (SSF-S, Martin & Jackson, 2008) is a 9-item self-report assessment designed to measure flow. Each of the nine items corresponds to one of the nine flow factors: challenge-skill balance, action-awareness merging, clear goals, unambiguous feedback, concentration, sense of control, loss of self-consciousness, transformation of time, and autotelic experience (Jackson & Csikszentmihalyi, 1999). Each item is rated on a 5-point Likert-type scale and higher scores indicate higher flow experience. Martin and Jackson (2008) tested construct validity across work, sport, and music domains and the scale has acceptable reliability, with alpha being .82 (Martin, Tipler, Marsh, Richards, & Williams, 2006). These creators of the SSF-S noted, that for music flow state, internal validity (χ² = 44.11) and external validity (χ² = 4056.76) were good.

Meaningfulness of Songwriting (all participants): the Meaningfulness of Songwriting Scale (MoSS; Baker, Silverman, & MacDonald, 2016) consists of 21 items designed to measure 11 domains of the meaningfulness of a songwriting experience and the meaningfulness of the song post-creation: enjoyment, discovery/self-reflection, arousal of emotions, creativity, engagement, challenge, understanding context, associations, achievement, personal value, and identity. Items were all framed in the positive direction and measured across a 5-point Likert-type scale from Strongly Disagree to Strongly Agree. Scores range from 21 to 105 with the larger scores indicative of stronger meaning derived from the experience and song product. The psychometric properties of this scale are reported elsewhere (Baker, Silverman, et al., 2016) and the instrument has also been used in a songwriting study to measure mechanisms of change in a group of people with spinal cord injury and acquired brain injury (Baker, Rickard, Tamplin, & Roddy, 2015).

State Hope (Study 1; acute psychiatric participants only): based on the premise that a person’s cognitions about goal-directed activities constitutes an important aspect of attaining positive outcomes, the State Hope Scale (SHS; Snyder et al., 1996) is a 6-item instrument composed of agency (three items) and pathway (three items) subscales as well as a total State Hope score (six items). Snyder and colleagues (1991) noted that agency and pathway components of hope parallel the self-efficacy and outcome expectancies of social cognitive theory. As people can believe in their abilities to act without being aware of how to research a goal – or vice versa – the agency and pathway subscales are considered additive and reciprocal but not synonymous (Lyndall, 2002). The SHS can be used as an instrument to further understand meditational processes between antecedent and consequent events and the creators noted the SHS “appears to meet the psychometric standards for self-report scales” (Synder et al., 1996, p. 334). Items are scored on an 8-point Likert-type scale with 1 representing “Definitely False” and 8 representing “Definitely True.” Subscale scores can range from 3 to 24 and the total hope scores can range from 6 to 48, with higher scores representing greater hope levels. In the development and testing of the SHS, Snyder et al. (1996) found internal reliability ranged from .82 to .95 with a median alpha of .93 and wrote, “the scale exhibits discriminant validity in that it cannot be explained in terms of other state self-report indices related to social desirability, self-esteem, positive and negative affectivity, and academic performance” (p. 334). In a comprehensive review paper concerning hope in psychiatry, Schrank, Stanghellini, and Slade (2008) noted that the State Hope Scale was frequently used in mental health research, was ideal for routine clinical use, and that it exhibited “robust psychometric properties” (p. 430).

Readiness to Change (Study 2; detoxification patients only): the Readiness to Change Questionnaire – Treatment Version (RTCQ-TV) (Heather, Luce, Peck, Dunbar, & James, 1999) is a 15-item questionnaire. The RTCQ-TV is based on Prochaska and DiClemente’s stages-of-change model (1986, 1992) for assignment of people who misuse alcohol excessively to Precontemplation (factors concerning using/abusing substances outweigh factors concerning change), Contemplation (factors concerning change outweigh factors concerning using/abusing), and Action (active utilization of behaviors related to change and sobriety) stages. It complements the original RTCQ, which was intended for non-treatment seekers. The RTCQ-TV is useful in clinical settings for assessing motivation with regard to readiness to stop or control drinking, and can be used to indicate the type of counseling approach in treatment planning. Researchers can also use the RTCQ for treatment outcome research. The RTCQ-TV takes approximately 2–3 minutes to administer. It is applicable for clients undergoing treatment and has adequate psychometric properties: significant relationships were found between stages of change and alcohol consumption and outcome data support its clinical implementation. Cronbach’s alphas for the three scales were .68, .60, and .77, respectively. Test-retest reliabilities for the three scales were .74, .69, and .86, respectively. For the purposes of Study 2, the RTCQ-TV was used to assess both readiness to change drinking and drug use due to the varied addictions of people on the detoxification unit.

Study 1: Inpatients on an adult acute psychiatric unit

Research participants

Participants were 54 (29 female, 25 male) adults hospitalized on an inpatient adult acute psychiatric unit. Typical length of inpatient hospitalization on this unit is three to seven days. These participants were randomized into the songwriting arm of a three-group experiment. Twenty patients were diagnosed with bipolar disorder and major depressive disorder respectively, three patients were diagnosed with schizoaffective disorder, one patient was diagnosed with psychosis, and one patient was diagnosed with schizophrenia. Nine patients did not indicate a diagnosis. Participants had been on the unit for a mean of 5.61 (SD = 4.90) days, had been admitted to a psychiatric institution a mean 4.48 (SD = 6.92) times, and were a mean 37.33 (SD = 12.22) years old. Concerning ethnic background, 40 participants indicated they were Caucasian, seven participants indicated they were African American, four participants indicated they were Native American, and one participant indicated she/he was Hispanic, other, or did not respond to the question. Total group size means during the songwriting interventions were 5.71 (SD = 1.94) while the mean participants who volunteered to participate in the research was 3.93 (SD = 1.53).

Results

Research question 1: Are there relationships between flow, the meaningfulness of the songwriting process, and songwriting product and clinical outcomes?

Not all participants completed all measures and sample sizes are provided for each measure. We performed correlational analyses of pathway and agency subscales of the State Hope Scale with flow, the meaningfulness of songwriting process, and songwriting product scores. All relationships were significant (all p ≤ .016), indicating strong relationships between flow, the meaningfulness of songwriting process, songwriting product, and clinical outcomes. A correlation matrix is depicted in Table 1.

Table 1.

Study 1 correlation matrix.

	Pathway			Agency			Total flow			SW process			SW product
	r	p	n	r	p	n	r	p	n	r	p	n	r	p	n
Pathway	–	–	–	.871	.001	54	.599	.001	52	.402	.003	51	.336	.016	51
Agency				–	–	–	.652	.001	52	.456	.001	51	.377	.006	51
Total flow							–	–	–	.660	.001	51	.587	.001	51
SW process										–	–	–	.883	.001	51
SW product													–	–	–

Research question 2: Do flow, the meaningfulness of the songwriting process, and songwriting product predict clinical outcomes?

We performed multiple regression analyses and found that the overall model significantly predicted both pathway and agency indices of state hope. The model accounted for 36.5% of the variance in the pathway measure of state hope while the model accounted for 43.6% of the variance in the agency measure of state hope. Further examination of the model indicated that flow was the only significant predictor of pathway and agency indices and the meaningfulness of the songwriting process and product did not significantly impact the model. This model is depicted in Table 2.

Table 2.

Study 1 multiple regression model.

Dependent measure		B	Standard error	t	p
Pathway F(3, 50) = 9.010, p = .001, r² = .365	Constant	5.070	2.709	1.872	.067
	Flow	0.356	0.092	3.867	.001
	Process	0.036	0.105	0.341	.734
	Product	–0.050	0.129	–0.385	.702
Agency F(3, 50) = 12.905, p = .001, r² = .436	Constant	4.038	2.624	1.539	.131
	Flow	0.386	0.089	4.327	.001
	Process	0.062	0.102	0.605	.548
	Product	–0.068	0.125	–0.547	.587

Study 2: Inpatients on an adult detoxification unit

Research participants

Participants were 170 (60 female, 110 male) adults hospitalized on an adult detoxification unit. Typical length of inpatient hospitalization on this unit is two to five days. These participants were randomized into the songwriting arm of a two-group experiment. We then continued to collect data from non-randomized participants to increase the sample size for the purpose of the current analyses. Seventy-seven patients noted that alcohol was their primary substance, while 61 participants indicated heroin, 12 participants indicated opiates, 10 participants indicated prescription drugs, seven participants did not respond, two participants indicated crystal methamphetamine, and one participant indicated crack cocaine. Participants had been on the unit for a mean of 4.10 (SD = 3.10) days, had been admitted to a substance abuse institution a mean 5.36 (SD = 7.16) times, and were a mean 38.37 (SD = 13.80) years old. Concerning ethnic background, 136 participants indicated they were Caucasian, 14 participants indicated they were African American, 8 participants indicated they were Native American, 8 participants indicated that they were Hispanic, three participants indicated other, and one participant did not respond to the question. Total group size means during the songwriting interventions were 6.68 (SD = 2.11) while the mean participants who volunteered to participate in the research was 6.04 (SD = 2.05).

Results

Research question 1: Are there relationships between flow, the meaningfulness of the songwriting process, and songwriting product and clinical outcomes?

Not all participants completed all measures and sample sizes are provided for each measure. We performed correlational analyses of precontemplation, contemplation, and action subscales of the change scale with flow, the meaningfulness of the songwriting process, and songwriting product scores. Most relationships were significant (all p ≤ .019) except for precontemplation and the meaningfulness of the song product and contemplation and the meaningfulness of the songwriting process and product (p ≥ .150). A correlation matrix is depicted in Table 3.

Table 3.

Study 2 correlation matrix.

	Precontemplation			Contemplation			Action			Total flow			SW process			SW product
	r	p	n	r	p	n	r	p	n	r	p	n	r	p	n	r	P	n
Precontemplation	–	–	–	.262	.001	166	.345	.001	166	.209	.007	166	.182	.019	166	.112	.150	166
Contemplation				–	–	–	.524	.001	166	.227	.003	166	.024	.755	166	.094	.230	166
Action							–	–	–	.367	.001	166	.258	.001	166	.239	.002	166
Total flow										–	–	–	.316	.001	170	.323	.001	170
SW process													–	–	–	.807	.001	170
SW product																–	–	–

Research question 2: Do flow, the meaningfulness of the songwriting process, and songwriting product predict clinical outcomes?

We performed multiple regression analyses and found that the overall model significantly predicted precontemplation, contemplation, and action stages of change. The model accounted for 7.1% of the variance in precontemplation, 7.6% of the variance in contemplation, and 18.7% of the variance in action. Further examination of the model indicated that flow was the only significant predictor of precontemplation, contemplation, and action indices and the meaningfulness of the songwriting process and product did not significantly impact the model. This model is depicted in Table 4.

Table 4.

Study 2 multiple regression model.

Dependent measure		B	Standard error	t	p
PrecontemplationF(3, 161) = 4.028,p = .009, r² = .071	Constant	–1.304	1.970	–0.662	.509
	Flow	–0.144	0.062	–2.334	.021
	Process	–0.078	0.056	–1.373	.172
	Product	0.098	0.076	1.293	.198
ContemplationF(3, 161) = 4.318,p = .006, r² = .076	Constant	–1.235	2.370	–0.521	.603
	Flow	0.236	0.074	3.167	.002
	Process	–0.105	0.068	–1.540	.126
	Product	0.102	0.092	1.114	.267
ActionF(3, 161) = 12.103,p = .001, r² = .187	Constant	–3.577	1.786	–2.003	.047
	Flow	0.248	0.056	4.426	.001
	Process	0.016	0.051	0.310	.757
	Product	0.015	0.069	0.212	.833

Discussion

The purpose of these two analyses was to determine if flow and meaningfulness of songwriting correlated with therapeutic outcome and functioned as predictors of therapeutic outcome within songwriting interventions with adult inpatients on an acute care psychiatric unit (Study 1) and a detoxification unit (Study 2). In both populations and across two different markers of improvement, flow and meaningfulness experienced during songwriting were positive and significantly correlated (Research Question 1). Multiple regression analyses indicated that flow was a significant predictor of state hope in people on an acute psychiatric unit and readiness for change in adults admitted to a detoxification unit. However, the meaningfulness of songwriting was not a significant predictor of changes in hope or readiness for change (Research Question 2). When data from the current study are amalgamated with other studies wherein flow was related to a number of beneficial treatment outcomes and affective states, it seems that flow may have a consequential role in therapeutic encounters. However, it is interesting that meaningfulness of songwriting correlated with therapeutic outcomes but was not predictive of therapeutic outcomes as flow was. Due to the distinct experiences available within music therapy and the role of flow in music, it seems that flow may have a unique role in psychotherapeutic encounters and future investigations utilizing a diverse range of paradigms to holistically understand the phenomenon of flow is warranted.

Although flow may lead to beneficial outcomes, it is not possible to intentionally initiate flow: attempts to consciously introduce flow typically make flow more unobtainable (Csikszentmihalyi, 1990; Jackson & Csikszentmyihalyi, 1999). While certain environmental conditions can be set up to make flow more likely, flow seems to occur spontaneously and organically from engagement in structured activities and by “removing obstacles and providing facilitating conditions will increase its occurrence” (Jackson & Csikszentmyihalyi, 1999, p. 138). Also, situations wherein participants feel that their skills are appropriate for the required task and receive clear and unambiguous feedback also make flow more likely (MacDonald et al., 2006). Perhaps the highly structured songwriting and past clinical experience of the music therapist facilitated flow in the current studies. Congruent with the current studies, Baker and MacDonald (2013) found that creating lyrics did induce flow, but it was stronger when music was also created. As the current studies were single-session therapy and participants only created lyrics for their blues songs, perhaps creating both music and lyrics would augment flow in clinical settings where there is adequate time.

As researchers have found that performing music may lead to lower flow experiences than creating songs (Baker & MacDonald, 2013), perhaps opportunities for performing self-composed songs may enhance the flow experiences further. The high degree of structure used in the single-session 12-bar blues may actually have increased flow because the participants had a comprehensive understanding of the requirements of the task (Jackson & Csikszentmihalyi, 1999).

In mental health studies, the quality of the client’s connection with the therapist is the best predictor of therapeutic outcome (Hubble, Duncan, & Miller, 1999). Thus, perhaps peer relationships or the relationship between the client and therapist were influenced by flow. Future empirical investigations are warranted to determine if and how therapeutic alliance, flow, and therapeutic outcome may be interrelated. Additionally, due to strong relationships between working alliance and therapeutic outcome in the literature base, it may be interesting to determine if flow and working alliance are related. Similar to working alliance, it may also be worthwhile to measure the therapists’ perceptions of flow while working with patients. However, these investigations may be futile as isolating phenomenological experiences and quantifying their implications can be difficult (Sink, 2000).

Due to the group-based and single-session songwriting formats used in the studies, the task of composing two verses within the temporal and contextual parameters was difficult. The literature suggests that the person–activity-fit is an important component to achieve flow, in that the task should be just challenging enough and the skill required of the person should also be just enough. Acute psychiatric care is certainly challenging and perhaps the person–activity-fit was strong enough to result in high flow experiences despite the temporal challenges of single-session group-based treatment.

Implications for clinical practice concerning flow are numerous and highly relevant. As Howe and Schwartzberg (1988) noted that flow might be an important factor when leading group-based therapy interventions, perhaps therapists can measure flow as a positively framed factor instead of measuring negatively framed symptoms such as depression and anxiety. Emerson (1998) discussed the relevance of flow in occupational therapy and noted that if practitioners are more aware of the conditions and properties of flow, they can subsequently help their clients discover intrinsically motivating occupations that promote wellbeing and meaning. Keller and Blomann (2008) suggested helping people become cognizant that their self-directed goals, which should be measured using observable outcomes, are contingent upon their engagement, motivation, and effort. This effort and resultant realization of progress toward the goal can enhance intrinsic motivation. Thus, people may be more likely to experience flow and the beneficial therapeutic aspects of flow, especially when using a cognitive behavioral approach where the patient and therapist collaboratively construct the goals and concrete measures are used to determine progress toward goals. These concepts can be appropriately applied to clinical practice. For example, a therapist working with psychiatric patients might identify potential flow experiences and relate the attainment of these flow experiences to pharmacological and psychosocial treatment adherence.

Future researchers might use other types of data collection techniques – including longitudinal and follow-up measures of hope and change, behavioral observation, and qualitative paradigms – to understand flow and songwriting meaningfulness in a more holistic manner. Currently, there remains a lack of empirical data and potential between-intervention flow and therapeutic outcome differences warrant important areas for future research consideration. Future researchers might also investigate if there may have been factors predisposing some patients to be more likely to find meaningfulness in the songwriting that correlate with likelihood of a positive therapeutic outcome. Results of the current study indicate that flow may warrant further empirical exploration in the psychotherapeutic literature base to determine how to facilitate optimal conditions for flow.

The current studies demonstrated that flow was a predictor of wellbeing outcomes. However, some limitations are worth mentioning. While regression and correlation analyses indicated associations between the variables, neither regression nor correlation analyses can be interpreted as establishing cause-and-effect relationships. Thus, although flow and therapeutic outcome tended to be positively and significantly related in both studies, it does not necessarily indicate that flow influenced therapeutic outcome or that therapeutic outcome influenced flow. Another potential limitation of the current investigations was the group-based songwriting interventions as songwriting may also take place with a single client and therapist. Group-based songwriting allows for a number of potential benefits associated with group work, including supporting others and being supported by others (O’Grady, 2009) and a sense of belonging, connecting, and bonding with others (Baker & Ballantyne, 2013; Grocke, Bloch, & Castle, 2009; McFerran & Teggelove, 2011; O’Grady, 2009). These processes – specific to group-based songwriting interventions – may also utilize factors including universalization and normalization as mechanisms of therapeutic change (Corsini, 2008). As music therapists more frequently utilize songwriting interventions during individual therapy (Baker, Wigram, Stott, & McFerran, 2009), the group-based format of the songwriting interventions in the current studies represents a limitation. Indeed, as songwriting meaningfulness was significantly linked with wellbeing outcomes in a study of people with brain injury or spinal cord injury receiving individual therapy (Baker, Rickard, et al., 2015), perhaps meaning may be more important during individual contexts and flow may be more important during group contexts. Other limitations include the exclusive use of self-report measures and the first author’s dual role of music therapist and researcher.

The purpose of these analyses was to determine if flow and meaningfulness were associated with and functioned as predictors of state indices of hope in adults on an acute psychiatric unit (Study 1) and of readiness to change in a group of adults on a detoxification unit (Study 2). In both populations and across two different markers of improvement, flow and meaningfulness experienced during songwriting were positive and significantly correlated. Multiple regression analyses indicated that flow was a significant predictor of state hope in people on an acute psychiatric unit and readiness for change in adults on a detoxification unit. However, the meaningfulness of songwriting was not a significant predictor of changes in hope or readiness for change. Future research is warranted to better understand if and how flow may contribute to other therapeutic outcomes and with other clinical and non-clinical populations.

Footnotes

Funding

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

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