Effects of group-based educational songwriting on craving in patients on a detoxification unit: A cluster-randomized effectiveness study

Abstract

Psychosocial methods for reducing craving are essential for people with substance use disorders. Although songwriting is a commonly-used music therapy intervention for people with addictions, there is no randomized controlled music therapy study systematically investigating how songwriting impacts craving in patients on a detoxification unit. The purpose of this cluster-randomized effectiveness study was to measure the effects of a single group-based educational songwriting intervention on craving with patients on a detoxification unit. To provide treatment to all participants in an inclusive single-session design, participants (N = 129) were cluster-randomized to one of three conditions: educational songwriting targeting relapse prevention and recovery, recreational music therapy targeting social and affective gains, or wait-list control. There was a significant difference (p = .033) in the craving subscale of expectancy between the educational songwriting and control conditions. Although no other difference reached significance, participants in the songwriting condition tended to have lower subscale and total craving mean scores than participants in the control and recreational music therapy conditions. Group-based educational songwriting interventions may temporarily relieve craving by distracting patients in an engaging, motivating, and creative intervention. Implications for clinical practice, suggestions for future research, and limitations are provided.

Keywords

addiction craving detoxification music therapy randomized songwriting substance abuse

Treatment for substance use rehabilitation typically revolves around relapse prevention and recovery and remains complex, expensive, highly idiosyncratic, and multifaceted. Carroll (1996) reviewed 24 controlled trials and found that relapse prevention interventions can be effective in the treatment of addiction. However, the active mechanisms responsible for client change within these treatments were unknown. Upon further investigation, McKay (1999) found that many authors of addiction-related studies noted that self-reported craving is a predictor of treatment outcome and relapse. Accordingly, other authors have noted the craving that people experience as they withdraw from the effects of the drugs represents major precipitants of relapse and continued misuse (Sussner et al., 2006; Wexler et al., 2001).

People who are in a state of substance withdrawal frequently have a craving, or compelling desire, for the drug to which they are addicted as the substance will immediately provide effective symptomatic relief from the excruciating withdrawal experience. Although craving as a construct can be perceived as vague, subjective, and difficult to measure (Miller, Westerberg, Harris, & Tonigan, 1996), craving has long represented an essential factor when attempting to explain and comprehend the relapse phenomenon (Marlatt, 1978). As such, researchers proposed a Craving Withdrawal Model (CWM) for the clinical diagnosis of alcohol dependence, wherein craving and withdrawal are required for diagnoses (de Bruijn, Korzec, Koerselman, & van Den Brink, 2004). Therefore, craving is regularly included in relapse prevention efforts and conceptualized both in physiological and psychological aspects (Roelofs & Dikkenberg, 1987).

From a cognitive behavioral perspective, drug use is supported and maintained by consequences that include craving and withdrawal, negative affective states, and a focus on problems and stressors (Craske, 2010). Additionally, “over time, environmental stimuli present during the euphoric state become conditional” (Craske, 2010, p. 24). Thus, environmental stimuli can elicit conditional urges, or cravings, to use the drug despite known destructive consequences of drug misuse. This model, known as the Conditioned Appetitive Motivational Model of Craving (Stewart, de Wit, & Wikelboom, 1984), can be used to elucidate the challenging experiences that people in substance use recovery have upon returning to the environments where their addictions originated. Therefore, from a psychosocial treatment perspective, it is vital to impart skills including self-awareness, self-management, distraction, and positive coping skills in an attempt to prevent relapse due to undesirable experiences such as craving.

Heather, Stallard, and Tebbutt (1991) utilized open-ended client inquiry to investigate relapse and found craving to be a primary factor. Other researchers have studied craving, continually noting its prominence in treating people who misuse various substances (Mezinskis, Honos-Webb, Kropp, & Somoza, 2001; Otto, Quinn, & Sung, 1998; Weiss, Griffin, & Hufford, 1995). Specific to inpatient detoxification facilities, craving can be particularly consequential as the primary focus of these programs is not necessarily relapse prevention or facilitating cognitive and behavioral change, but rather medical stabilization and patient monitoring to protect against health emergencies via a coordinated and overseen detoxification process. Ironically, this process typically involves pharmacological intervention: in detoxification units, medication is used in 80% of detoxifications (SAMHSA, 2014).

While some literature exists supporting music therapy as a psychosocial treatment for substance use disorders (Albornoz, 2011; Baker, Gleadhill, & Dingle, 2007; Cevasco, Kennedy, & Generally, 2005; Dingle, Gleadhill, & Baker, 2008; Jones, 2005; Silverman, 2009b, 2011a, 2011b, 2012, 2015a, 2015b, 2016), Mays, Clark, and Gordon (2008) conducted a systematic review and found a need for randomized controlled studies. While the current author contends that all types of data and paradigms represent valuable additions to the literature, there is a contemporary emphasis on randomized controlled trials within the medical community that can eventually be used in meta-analyses in order to determine effect sizes.

In a descriptive study of music therapy clinicians specializing in addictions work, Silverman (2009a) found that songwriting was a commonly-used intervention. Within songwriting interventions, patients can compose lyrics, music, or lyrics and music to creatively and expressively share and depict their unique narratives (Baker, 2015). In addiction settings, music therapists can encourage therapeutic and motivational dialogue by having patients write lyrics and songs related to clinical objectives such as change (Silverman, 2012), the identification of situational risk factors (i.e., triggers; Silverman, 2015a), and coping skills (Silverman, 2015a, 2015b). This approach can be categorized as educational music therapy, wherein the intervention is primarily designed to augment illness management, relapse prevention, and recovery (Silverman, 2015c) and immediate symptomatic alleviation – although still important – functions as a secondary gain. Educational music therapy is direct, highly structured, and problem- and solution-oriented and thus may be ideal in short-term settings (Silverman, 2015c), such as detoxification.

Concerning music therapy and craving, studies of how lyric analysis interventions of songs by the Red Hot Chili Peppers influenced craving (Silverman, 2011b, 2016) were conducted with patients on a detoxification unit. In the initial study (Silverman, 2011b), adult participants on a detoxification unit were cluster-randomized to one of three conditions: rockumentary, recreational music therapy, or verbal therapy. Although there was no significant between-group craving difference, both music therapy conditions had lower mean craving scores than the verbal therapy condition. Thus, music – and not necessarily an educational intervention targeting relapse prevention and recovery such as the rockumentary – may have been the active component that impacted craving. In a more recent study (Silverman, 2016), adult participants on a detoxification unit were cluster-randomized to a lyric analysis or control condition. Similar to the results of the initial study (Silverman, 2011b), although there was no significant between-group craving difference, participants in the lyric analysis condition had lower mean craving than participants in the control condition. In these studies, it is theorized that the active engagement of the lyric analysis intervention distracted patients from their craving by engaging them in a relapse prevention and recovery-focused dialogue based upon the song lyrics. In both studies, Silverman measured the effects of a lyric analysis intervention on craving via the Brief Substance Craving Scale (BSCS; Somoza, Dyrenforth, Goldsmith, Mezinskis, & Cohen, 1995) and there is a need to conduct research using other craving inventories and interventions, including songwriting. Moreover, it is important to systematically investigate isolated components of music therapy interventions to determine active components within the intervention that facilitate change.

With heightened emphases on effect sizes in systematic reviews and meta-analyses, there is a need for additional randomized music therapy studies that utilize a control condition. Additionally, there is a need to compare various types of active music therapy interventions (i.e., educational songwriting and recreational music therapy that use different mechanisms to facilitate change and have differing targets) with control conditions in an attempt to determine best practice music therapy for adults in detoxification settings. Comparing educational songwriting with recreational music therapy would constitute treatment dismantling, as both of these conditions contain a music component but target different objectives (i.e., relapse prevention and recovery or social and affective gains, respectively). Therefore, the purpose of this cluster-randomized effectiveness study was to determine if group-based educational songwriting can impact craving in patients on a detoxification unit. The guiding research question was: When compared to recreational music therapy and control conditions, will there be between-group differences in craving for patients on a detoxification unit who participate in a single group-based educational songwriting intervention?

Method

Participants

Research participants (N = 129) were inpatients on the detoxification unit of a large teaching hospital in the Midwestern part of the United States. The primary function of this unit was a safe and supervised medical detoxification. This goal was primarily addressed through pharmacological interventions and minimal psychosocial treatment programming was provided. Regardless of specific drug, all patients on this unit had a substance use disorder or dependency diagnosis. Some patients on this unit were transferred to longer-term facilities for additional treatment while others were discharged to their home living environments. Patients typically remained on the unit for two to four days. All patients on the unit were invited to attend and participate in the sessions but not all those who took part in the sessions completed the voluntary pre- or posttest. In an attempt to be as inclusive as possible to accurately represent contemporary clinical practice in this effectiveness study, treatment was not contingent upon study participation. Aside from being a consenting inpatient on the unit and being able to read English, there were no additional inclusion or exclusion criteria for study participation.

Instrument

The Alcohol Craving Questionnaire-Short Form (ACQ-SF-R; Singleton, 1997) contains 12 items from the original 47-item Alcohol Craving Questionnaire (ACQ-NOW) that was developed to assess craving for alcohol in the current context (i.e., right now). Items were derived from the initial validation study wherein the ACQ-NOW was administered to 219 participants who had used alcohol within the last 30 days. The ACQ-SF-R contains 12 items strongly correlated with the four subscales (compulsivity, expectancy, purposefulness, and emotionality) and total ACQ. Compulsivity refers to urges and desires in anticipation of loss of control over using and the standardized alpha coefficient was .79. Expectancy refers to the urges and desires to use in anticipation of the positive benefits of using and the standardized alpha coefficient was .77. Purposefulness refers to urges and desires coupled with intent and planning to use and the standardized alpha coefficient was .77. Emotionality refers to urges and desires to use in anticipation of relief of withdrawal and negative affect and the standardized alpha coefficient was .77. Higher scores represent more intense craving. For the purposes of the current study, drinking was altered to drug use to be more inclusive of various addictions typically found in people on the detoxification unit. As a result of this change, the current researcher calculated Cronbach’s Alpha scores for the data in this study and found them to be adequate: Compulsivity: .764; Expectancy: .822; Purposefulness: .543; Emotionality: .878; and Total Craving: .901.

Design

Due to the short-term setting and desire for all participants to receive music therapy, the researcher utilized a cluster-randomized single-session three-group wait-list control design. In the current study, the term CR (clinician researcher) is used to recognize the dual role of the music therapy clinician who delivered the intervention being studied and the researcher who was responsible for study design, data collection, and analyses.

After the CR explained and obtained informed consent, participants in the songwriting condition took part in a group-based songwriting session and then completed the instrument (posttest only). After the researcher explained and obtained informed consent, participants in the recreational music therapy condition took part in a group-based rock and roll bingo session and then completed the instrument (posttest only). After the researcher explained and obtained informed consent, participants in the wait-list control condition completed the instrument and then took part in a group-based rock and roll bingo session (pretest only). This design enabled the researcher to obtain control data to compare with two different music therapy interventions (i.e., educational songwriting and recreational music therapy) within the time constraints of a single treatment session, often the norm in detoxification settings (Soshensky, 2007). This design has been utilized in related music therapy research to provide treatment to participants in the control condition but still investigate participants in the control condition uninfluenced by the treatment (James, 1988). Additionally, the CR did not utilize both pre- and posttests in an attempt to avoid testing fatigue of a highly negative construct such as craving in the single-session study (Bradt, 2012).

Randomization

Throughout 24 music therapy treatment sessions, the researcher cluster-randomized consumers into conditions by session. A computer program was used for randomization. As all participants were on the same unit, the only between-cluster difference was the treatment condition. The numbers one to 24 were randomized into three groups and each group was assigned to either the educational songwriting, or recreational music therapy, or control condition. In an attempt to be as inclusive as possible and accurately represent contemporary clinical practice, participants were allowed to attend multiple sessions but data were only collected after completion of the first session.

Intervention theory

Using an educational approach (Silverman, 2015c) incorporating principles and techniques from motivation enhancement therapy (Miller & Rollnick, 2002), the CR attempted to engage songwriting participants in a dynamic and motivating songwriting intervention targeting relapse prevention and recovery. It was theorized that this intervention would be engaging and motivating and therefore might distract patients from any craving they may have been experiencing. The CR designed the group-based songwriting intervention to be aesthetically pleasing and therapeutically relevant so patients would learn methods for changing cognitive, behavioral, and affective aspects of their addictions and be motivated for additional treatment by recognizing their addictions prohibited them from accomplishing self-directed and personalized goals. A potential limitation of this approach is that patients who were motivated for treatment may have been more engaged in songwriting – and therefore more distracted from their craving – than patients who were less motivated (Silverman, 2016). Finally, an advantage of songwriting with patients in detoxification is that patients may not have previous associations with the music that induce craving, as they might during a lyric analysis intervention that uses a familiar song (Silverman, 2015c).

Treatments

Educational songwriting (posttest only): in an introductory exercise, the CR first asked participants to state their names and something about themselves (such as a favorite band or artist) within a 12-bar blues progression in the key of E played on a steel string acoustic guitar (Yamaha FG720S). The CR then informed patients they would be composing lyrics for an original blues song about recovery but they would begin by brainstorming ideas of why patients wanted to recover for the first verse. The CR wrote down patients’ ideas and suggestions in a “lyric bank” on the dry erase board. Common ideas concerned family, friends, health, vocational aspirations, and happiness. The CR then facilitated group songwriting utilizing patients’ suggestions. Thus, the first verse of the blues song concerned why patients wanted recovery and therefore focused on motivators for change and sobriety. The CR used a similar procedure for the second verse but focused on how patients would recover. Common ideas concerned attending and participating in meetings, being honest with oneself and others, and adhering to a schedule. The songs were 12-bar blues songs in the key of E and, due to time constraints of a single session, patients only composed lyrics. Patients thus wrote a two-verse song, with the first verse concerning why they wanted recovery and the second verse concerning how they would recover. At the conclusion of the session, the CR verbally processed the session, thanked patients for participation, asked for questions and comments about the session, and distributed posttests to patients who volunteered to complete them. The CR made copies of the song lyrics for patients to keep. Thus, this intervention constituted educational music therapy targeting recovery and relapse prevention.

Recreational music therapy (posttest only): in an introductory exercise, the CR first asked participants to state their names and something about themselves (such as a favorite band or artist). Participants played rock and roll bingo and each had their own cards with 25 song titles. The CR played approximately 20 seconds of each song and, if participants had that song title on their card, they put a small piece of paper on the song title on their card. The CR asked questions and facilitated discussions based upon songs, artists, and memories associated with the music. At the conclusion of the session, the CR distributed posttests to patients who volunteered to complete them. Thus, this condition was music therapy as it contained music and was delivered by a music therapist. However, recreational music therapy purposely did not contain an educational component targeting relapse prevention or recovery but rather focused on socialization and affective change via engagement with the music.

Wait-list control (pretest only): this condition was identical to the recreational music therapy condition, with the exception that participants completed the questionnaire before the intervention instead of after it.

The CR, a Board-Certified Music Therapist with 15 years of experience working with people in substance use treatment at the onset of the study, provided all sessions. Sessions were conducted on Tuesday mornings throughout a period of five months and lasted approximately 45 minutes. The Institutional Review Board worked in tandem with the detoxification unit and approved the study (1410S55003). The CR provided and obtained voluntary informed consent from all participants.

Participant enrollment

Participants were enrolled in the study from June to November 2015 resulting in a sample of 129. Using a linear mixed model analysis of variance with three treatment groups, 126 participants were required to detect an effect size of .28 when α = .05 for a power of .80 (Kotrlik, Williams, & Jabor, 2011).

Figure 1 depicts participant flow through the phases of the study.

Figure 1.

Participant flowchart.

Analyses

Four analyses of variance (ANOVAs) were conducted to determine if there were between-group differences in (a) the number of consumers taking part in each session who volunteered to be research participants, (b) the total number of consumers in each session, (c) the research participants’ ages, and (d) the number of times participants had been in a rehabilitation/detoxification facility. Chi-squared tests were conducted to determine if there were between-group differences in the frequencies of participants’ demographics concerning (a) gender, (b) race/ethnicity, and (c) primary drug.

To analyze data for potential between-group craving differences, the researcher fit a linear mixed model with treatment group as a fixed effect and cluster as a random effect using the univariate function in SPSS version 19.0.0. Levene’s Tests of Equality of Error Variances were not significant, all p ≥ .225. The researcher reported the overall F-test for group differences.

Results

Significant between-group differences were found in the number of patients taking part in each session who volunteered to be research participants and the total number of patients in each session. In both cases, the educational songwriting condition had lower means than the recreational music therapy and control conditions. No statistically significant between-group difference was found in the other measures, all p > .05. No statistically significant between-group difference was found in demographic frequencies, all p > .05. Table 1 shows descriptive statistics of quantitative variables while Table 2 depicts frequencies of gender, race/ethnicity, and primary drug of participants by condition.

Table 1.

Demographic information by treatment group – quantitative.

Demographic; Statistics	Recreational Music Therapy			Control			Educational Songwriting
Demographic; Statistics	M	SD	n	M	SD	n	M	SD	n
Age; F(2, 131) = 2.391, p = .096, partial η² = .035	38.17	12.80	52	34.67	12.08	51	40.81	13.51	31
Previous admissions; F(2, 127) = 1.52, p = .223, partial η² = .023	5.25	8.72	50	6.10	6.17	49	8.82	12.91	31
Research participants/sessions; F(2, 21) = 7.880, p = .003, partial η² = .429*	6.50	1.69	8 sessions	6.38	1.51	8 sessions	3.88	1.25	8 sessions
Total patients/sessions; F(2, 21) = 8.247 p = .002, partial η² = .440**	7.63	1.69	8 sessions	7.13	1.55	8 sessions	4.63	1.51	8 sessions

Songwriting versus Recreational MT: Mean difference -2.63, p = .006, 95% CI: −4.57, −0.68. *Songwriting versus Control: Mean difference −2.50, p = .009, 95% CI: −4.44, −0.56. **Songwriting versus Recreational MT: Mean difference −3.00, p = .003, 95% CI: −5.067, −0.94. **Songwriting versus Control: Mean difference −2.50, p = .014, 95% CI: −4.56, −0.44.

Table 2.

Demographic information by treatment group – frequencies.

	Recreational Music Therapy(n = 52)	Control(n = 51)	Educational Songwriting(n = 31)
Gender
Female	21	21	12
Male	31	30	19
Ethnic background
African American	1	3	1
Caucasian	44	42	24
Hispanic American	2	2	1
Native American	2	1	2
Other	2	3	4
No response	1	0	0
Primary drug
Alcohol	24	28	17
Crack cocaine	0	1	0
Heroin	20	16	7
Prescription drugs	7	6	7
No response	1	0	0

p > .05.

Concerning the expectancy subscale, there were significant differences between the control and educational songwriting conditions, with the educational songwriting condition having less expectancy craving than the control condition. Although not significant, all subscale – as well as the total craving – mean scores were lower in the educational songwriting condition. Inferential and descriptive craving statistics are shown in Table 3.

Table 3.

Descriptive and inferential craving statistics.

Dependent Measure; Statistics	Recreational Music Therapy			Control			Educational Songwriting
Dependent Measure; Statistics	M	SD	n	M	SD	n	M	SD	n
Compulsivity; F(2, 126) = 1.256, p = .288, partial η² = .020	3.79	2.00	49	3.90	1.83	51	3.21	2.01	29
Expectancy; F(2, 126) = 3.448, p = .035, partial η² = .052*	4.26	1.88	49	4.49	1.79	51	3.37	1.99	29
Purposefulness; F(2, 126) = 1.088, p = .340, partial η² = .017	3.82	1.39	49	3.57	1.40	51	3.34	1.54	29
Emotionality; F(2, 126) = 2.073, p = .130, partial η² = .032	4.34	2.09	49	4.46	1.70	51	3.56	2.24	29
Total Craving; F(2, 126) = 2.458, p = .090, partial η² = .038	4.05	1.60	49	4.10	1.43	51	3.37	1.55	29

Control versus songwriting: Mean difference = 1.122, p = .033, 95% CI: .066, 2.179.

Discussion

The purpose of this study was to measure the effects of single-session group-based educational songwriting on craving with patients on a detoxification unit. There were significant differences between the control and educational songwriting conditions in the expectancy subscale, with the educational songwriting condition having less expectancy craving than the control condition. Although not significant, all mean subscale scores, including total craving, were lower in the educational songwriting condition. These results, while not statistically significant, can be considered clinically relevant due to the importance of craving as an undesirable symptom within the unique contextual parameters of the detoxification setting. Although generalizations are typically unwarranted without significant results, it is difficult to contend that the mean between-group differences are inconsequential. In detoxification settings, any type of symptomatic relief is a positive occurrence, especially without pharmaceutical intervention.

Results of the current study are congruent with existing research indicating that participants in music therapy have less craving than control participants (Silverman, 2011b, 2016). However, the current study was unique in that it evaluated educational songwriting whereas the previous two music therapy studies measuring craving used lyric analysis as the treatment. Additionally, the current study used a craving inventory that contained various subscales in order to more holistically measure the multifaceted and complex craving phenomenon. Finally, due to the use of the recreational music therapy condition, there was a condition that used music with which to compare the educational songwriting and control conditions. As there was no difference between educational and recreational music therapy conditions, generalizations are not warranted. However, as educational music therapy can specifically target relapse prevention and recovery while recreational music therapy targets social and affective objectives, perhaps educational songwriting may be preferable.

As patients in detoxification facilities frequently receive pharmacological interventions to reduce their withdrawal and craving symptoms (SAMHSA, 2014), it may inadvertently reinforce reliance upon chemically induced cognitive, affective, and behavioral change. Thus, results of the current study warrant clinical implementation given the well-established Craving Withdrawal Model and the Conditioned Appetitive Motivational Model of Craving (Stewart et al., 1984): using educational songwriting interventions targeting relapse prevention and recovery to reduce craving may be a non-pharmacological method to distract people from their negative symptoms without relying upon medications or reinforcing the effectiveness of chemically-induced change. The educational songwriting intervention also focused on relapse prevention and recovery and thus may target other consequential dependent measures – including stage of change, readiness for treatment, and motivation (Silverman, 2011b, 2012, 2015b) – while concurrently impacting craving. Therefore, participation in music therapy can diminish craving while simultaneously influencing motivation, change, and treatment readiness (Silverman, 2011b, 2012, 2015b).

Similar to other medical facilities, most detoxification units – where medication is used in 80% of detoxifications (SAMHSA, 2014) – are working to decrease pharmacological interventions. Based from the positive, although largely non-significant, results of the current and previous empirical investigations (Silverman, 2011b, 2016), perhaps instead of distributing medications, detoxification unit staff could refer patients to music therapy or distribute music listening devices. However, music listening devices limit social interaction and would likely require both funding and changes in institutional policies as many facilities do not permit the use of the devices due to safety precautions.

Carr, Odell-Miller, and Priebe (2013) noted a need for a music therapy model in acute mental health care. This need also exists in acute substance use rehabilitation facilities, such as detoxification. Specific to adult mental health care, Silverman (2015c) noted that educational music therapy for illness management and recovery may meet this need for an acute care model as these interventions are purposely designed to expediently target and teach patients about illness management and recovery. Due to the acute care nature of detoxification (Soshensky, 2007), this educational model also seems to be appropriate for patients hospitalized on detoxification units. Within the contextual parameters of addiction, educational music therapy would be used to teach patients skills and knowledge such as (but not limited to) relapse prevention, recovery, self-monitoring skills, situational risk factors (i.e., triggers for substance use), coping strategies, holistic wellness (Silverman, 2015c), and community resources and supports.

One of the potential limitations of this study is that music may inadvertently induce craving due to previously established associations between music and drug use (Dingle, Kelly, Gleadhill, & Baker, 2013; Short & Dingle, 2015). In the case of the current study, this was especially true in the recreational music therapy condition, wherein patients heard a variety of music that sometimes reminded them of using experiences. These associations highlight the importance of the music therapy assessment and educating patients concerning how some music may function as a situational risk factor for substance use. However, it may be difficult for patients to avoid music in the community and music therapists may need to collaboratively work with patients to identify and implement appropriate coping skills during these situations.

As shown in Table 1, there were significant between-group differences in the number of patients who volunteered to take part in the research and who participated in the sessions. These differences constitute a limitation and were likely resultant of the single-session wait-list design on this short-term unit and were also found in a related study (Silverman, 2016). Frequently, patients were discharged or left music therapy to attend meetings with doctors or discharge coordinators in the middle of the sessions. Thus, these participants were able to complete a pretest if they were members of the wait-list control condition but they were not able to complete a posttest if they were members of the other conditions. While this represents a limitation, it is a realistic phenomenon during clinical practice on acute care units such as detoxification. This result highlights one of the many difficulties of conducting effectiveness research and contemporary clinical practice with patients on detoxification units.

Another limitation includes the dual role of CR that may have resulted in biased responses. Additionally, people who chose to participate in the study may have been more favorably inclined to the songwriting intervention than those who chose not to participate. Another limitation was the use of a sole measurement: rather than using both pre- and posttests, only a pre- or posttest was used. As the CR used both randomization and had an adequate sample size, he did not want to use both pre- and posttests in an attempt to limit testing fatigue within a single session (Bradt, 2012). Additionally, the CR did not want to over-emphasize craving as it represents an extremely undesirable physiological and affective condition that often precipitates relapse. Thus, the CR did not want patients to be overly conscious of such an excruciating experience by having them focus on craving at both pre- and posttest. Patients on a detoxification unit represent an extremely sick clinical population and the CR made decisions concerning the study design in a deliberate, ethical, and judicious manner. Finally, no datum was taken concerning maintenance of treatment effects. Gains resultant of music therapy may have dissipated immediately after the treatment ended.

Future researchers might compare how various music therapy interventions might impact craving with patients with addictions. For example, comparing receptive music therapy with more active forms of music therapy, including songwriting, lyric analysis, and improvisation, may provide data concerning active mechanisms of therapeutic change. Future researchers might measure patients’ engagement, level of commitment, and previous associations with music to determine if and how these factors might influence symptoms, motivation, help seeking, stage of change, and relapse. Follow-up measures could be used to determine potential maintenance of treatment gains. Researchers might consider qualitative or mixed-methods investigations in an attempt to understand patients’ experiences in music therapy. These experiences may lead to better and more innovative ways of measuring the effects of psychosocial treatments on people in detoxification settings. Finally, as there were significant between-group differences in the number of patients who volunteered to take part in the research and who participated in the sessions, future researchers might consider conducting efficacy – instead of effectiveness – studies to have better control over these potentially confounding aspects. Any additions to the literature base, from all research paradigms, would be welcome and contribute to the understanding of if and how music therapy may be used in substance use rehabilitation.

Footnotes

Funding

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

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