Depressed adults’ experiences of listening to their own clinical improvisations at home : A process evaluation of the music therapy homework

This is a sel -a chi ed e sion o an o iginal a icle. This e sion may di e om he o iginal in pagina ion and ypog aphic de ails. Au ho (s): Ti le: Yea : Ve sion: Copy igh : Righ s: Righ s u l: Please ci e he o iginal e sion: CC BY 4.0 h ps://c ea i ecommons.o g/licenses/by/4.0/ Dep essed adul s’ expe iences o lis ening o hei own clinical imp o isa ions a home : A p ocess e alua ion o he music he apy homewo k © 2023 The Au ho (s) Published e sion Snape, Ne dinga; Saa ikallio, Su i; Ala-Ruona, Esa; Ha mann, Ma in; B aban , Oli ie ; E kkilä, Jaakko Snape, N., Saa ikallio, S., Ala-Ruona, E., Ha mann, M., B aban , O., & E kkilä, J. (2023). Dep essed adul s’ expe iences o lis ening o hei own clinical imp o isa ions a home : A p ocess e alua ion o he music he apy homewo k. No dic Jou nal o Music The apy, Ea ly online. h ps://doi.o g/10.1080/08098131.2023.2291434 2023 Full Te ms & Condi ions o access and use can be ound a h ps://www. and online.com/ac ion/jou nalIn o ma ion?jou nalCode= njm20 No dic Jou nal o Music The apy ISSN: (P in ) (Online) Jou nal homepage: h ps://www. and online.com/loi/ njm20 Dep essed adul s’ expe iences o lis ening o hei own clinical imp o isa ions a home: A p ocess e alua ion o he music he apy homewo k Ne dinga Snape, Su i Saa ikallio, Esa Ala-Ruona, Ma in Ha mann, Oli ie B aban & Jaakko E kkilä To ci e his a icle: Ne dinga Snape, Su i Saa ikallio, Esa Ala-Ruona, Ma in Ha mann, Oli ie B aban & Jaakko E kkilä (19 Dec 2023): Dep essed adul s’ expe iences o lis ening o hei own clinical imp o isa ions a home: A p ocess e alua ion o he music he apy homewo k, No dic Jou nal o Music The apy, DOI: 10.1080/08098131.2023.2291434 To link o his a icle: h ps://doi.o g/10.1080/08098131.2023.2291434 © 2023 The Au ho (s). Published by In o ma UK Limi ed, ading as Taylo & F ancis G oup. View supplemen a y ma e ial Published online: 19 Dec 2023. Submi you a icle o his jou nal View ela ed a icles View C ossma k da a ORIGINAL RESEARCH ARTICLE Dep essed adul s’ expe iences o lis ening o hei own clinical imp o isa ions a home: A p ocess e alua ion o he music he apy homewo k Ne dinga Snape , Su i Saa ikallio, Esa Ala-Ruona, Ma in Ha mann, Oli ie B aban and Jaakko E kkilä Depa men o Music, A and Cul u e S udies, Uni e si y o Jy äskylä, Jy äskylä, Finland ABSTRACT In oduc ion: Dep ession has a nega i e impac on millions o people wo ldwide, necessi a ing esea ch in o app op ia e he apeu ic me hods. The aim o his quali a i e s udy is o in es iga e how music he apy clien s expe ience lis ening o hei own clinical imp o isa ions a home, as a pa o ea men o dep ession. Me hod: Adul s wi h majo dep essi e diso de we e o e ed 12 indi idual sessions o bi-weekly in eg a i e imp o isa ional music he apy, as pa o a andomised con- olled ial. Pa icipan s we e asked o comple e an online dia y a e lis ening o hei clinical imp o isa ions. Re lexi e hema ic analysis was pe o med on dia y en ies, and con en analysis was applied o music he apis s’ epo s. Resul s: Fou een o 32 pa icipan s submi ed a o al o 58 dia y en ies. Pa icipan s' expe iences we e ep esen ed by i e hemes: music (playing, lis ening, music pe cep ion, music pa ame e s), he apy ( he apeu ic p ocessing, illness, music he apy ial), emo ions (posi i e emo ions, nega i e emo ions, o he emo ions), embodimen (body pa s, sensa- ions, ac ions) and na a i e (ch onology, symbolic e e ences). Music he apis s’ epo s indica ed ha low compliance and nega i e expe iences du ing he ask could be a ec ed by se e i y o dep ession, and ease o use o he echnological in e ace. Discussion: Pa icipan s’ expe iences a ied om ex emely nega i e o posi i e in e e y heme, inding music hey p oduced beau i ul o hideous, eeling p oud o ashamed o making i , being ene gised, o exhaus ed by i , eeling suppo ed o p essu ed by he music he apis , and ecalling happy o e i ying memo ies. The indings sugges ha a homewo k ask can a ec he he apeu ic p ocess in bo h posi i e and nega i e ways and should be u he esea ched be o e implemen a ion. ARTICLE HISTORY Recei ed 7 Ma ch 2023; Accep ed 4 No embe 2023 KEYWORDS Clinical imp o isa ion; homewo k; dep ession; e lexi e hema ic analysis In oduc ion Dep ession is a common mood diso de , a ec ing mo e han 300 million people wo ldwide and linked o o e 700,000 dea hs by suicide e e y yea (Wo ld Heal h CONTACT Ne dinga Snape [email p o ec ed] Uni e si y o Jy äskylä, Musica, Building M, Room 302, Seminaa inka u 15, Jy äskylä 40014, Finland Supplemen al da a o his a icle can be accessed online a h ps://doi.o g/10.1080/08098131.2023.2291434. NORDIC JOURNAL OF MUSIC THERAPY h ps://doi.o g/10.1080/08098131.2023.2291434 © 2023 The Au ho (s). Published by In o ma UK Limi ed, ading as Taylo & F ancis G oup. This is an Open Access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion License (h p://c ea i ecommons. o g/licenses/by/4.0/), which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed. The e ms on which his a icle has been published allow he pos ing o he Accep ed Manusc ip in a eposi o y by he au ho (s) o wi h hei consen . O ganiza ion, 2021). I is a se ious heal h condi ion ha impai s p o essional, domes- ic, and social unc ioning and is ecognized as one o he leading causes o disabili y wo ldwide (Na ional Ins i u e o Men al Heal h, 2022; Wo ld Heal h O ganiza ion, 2021). A combina ion o psycho he apy and medica ion is ecommended as he bes ea men plan (Kameno e al., 2017; No d e al., 2021), bu cu en me hods a e no su icien ly e ec i e as he isks o elapse and suicidali y emain high (Baldessa ini e al., 2017; De Maa e al., 2006; Henga ne e al., 2018). Resea ch shows ha music he apy is success ully used o educe he symp oms o dep ession and inc ease he gene al unc ioning o hose who su e om i (Aalbe s e al., 2017; Ma a os e al., 2008). Music he apy is based on musical expe iences and a clien –music he apis ela ionship (B uscia, 2014; Jacobsen e al., 2019). Du ing a cou se o music he apy, he clien is encou aged o engage in a a ie y o ac i e (e.g. playing an ins umen o singing) and ecep i e (lis ening) me hods, o en combined wi h e bal dialogue (Da is e al., 2008). Music he apy can be in indi idual o g oup se ings, depending on a clien ’s needs and he capaci y o he ea men acili y. Imp o isa ional music he apy enables clien s o spon aneously exp ess hemsel es and in e ac wi h a music he apis h ough p oduced sounds. Clinical imp o isa ion allows non- e bal p ocessing and communica ion, which is especially ad an ageous in he case o dep ession, as i o en impai s e bal communica ion (Newell e al., 2018). I is impo an o no e ha music he apy clien s ypically ha e no, o e y li le, musical aining, hus he music p oduced in he he apeu ic se ing is o en e y simple in o m and no in ended o be expe ienced as an objec o aes he ic app ecia ion (Aigen, 2005). Whils he li e a u e and clinical p ac ice sugges ha music he apy is an e icacious ea men o dep ession, he inne mechanisms o complex music-based in e en ions a e no ye ully unde s ood (Bonde, 2016; Ma a os e al., 2018). Lis ening o music is widely u ilised in ecep i e music he apy. In he Guided Image y and Music (GIM; G ocke & Moe, 2015; Mulle , 2012) app oach clien s imme se hemsel es in Wes e n classical music and alk abou hei expe iences o a music he apis . GIM is ound o be an e ec i e ea men o a ious mood diso de s, including dep ession (Hamme , 1996; McKinney & Honig, 2017; McKinney e al., 1997). In Analy ically O ien ed Music The apy (AOM), lis ening o eco dings o clien --music he apis imp o isa ions is inco po a ed in o he music he apy session. Bo h clien and music he apis lis en o he eco dings and will alk and/o play abou i a e wa ds (Eschen, 2002; Scheiby, 2010). Di e en ly om GIM and AOM, home lis ening asks, as a pa o ac i e music he apy, do no ha e an elemen o immedia e music he apis suppo . I is no clea o wha ex en ha would a ec he p ocess and i s ou comes. The e is b oad li e a u e on he sel - egula o y bene i s o music lis ening in e e yday li e (Bal aza & Saa ikallio, 2016; Chin & Ricka d, 2014; G oa ke & Hogan, 2018; Van den Tol & Edwa ds, 2015), howe e , hese s udies do no add ess how music he apy clien s expe ience hei own clinical imp o isa ions wi hou immedia e music he apis ’s suppo . Homewo k is a commonly used me hod in a ious he apeu ic app oaches, and indings om cogni i e beha iou al psycho he apy esea ch indica e ha people wi h dep ession can g ea ly bene i om i (Kazan zis e al., 2000, 2010; Mausbach e al., 2010; Thase & Callan, 2006). Homewo k is a ask ha is ca ied ou by he clien independen ly be ween he apy sessions wi h he goal o aiding he apeu ic p ocessing. To da e i has no been widely used in ac i e music he apy. In Emo ion- egula ing Imp o isa ional Music The apy (EIMT), Aalbe s e al. (2020, 2021) sugges using 2N. SNAPE ET AL. homewo k as a means o expe imen ing wi h eelings, exp ession, bodily esponses, and ac ion endencies in o de o imp o e emo ion egula ion. They p opose 10 iden ically s uc u ed sessions o music he apy, and he assigned homewo k can a y each ime and be music ela ed, such as singing o playing an ins umen , o in ol e non-musical ac i i ies such as alking, w i ing, o walking (Aalbe s e al., 2019). In G oup Imp omp u Music The apy (GIMT) clien s a e equi ed o eco d hei posi i e coping s a egies and eelings in he ace o emo ional di icul ies. Al hough music is no in ol ed in he homewo k i sel , he au ho s sugges ha he ask o sel - e lec ion enhances he e ec i eness o he GIMT in e en ion (Zhang e al., 2022). Gi en all he abo e, i is plausible ha engaging in music he apy homewo k be ween sessions could aid he apeu ic goals, migh inc ease mo i a ion, and deepen sel - e e en ial p ocessing and unde s anding. This s udy is embedded in o a la ge andomised con olled ial (RCT) o dep ession (E kkilä e al., 2019, 2021), which aimed o examine whe he addi ional componen s, such as homewo k o slow-paced b ea hing would esul in mo e success ul eco e y. The esul s o his RCT showed ha lis ening homewo k was no as e ec i e as he b ea hing in e en ion in educing he symp oms o dep ession. To da e, no quali a i e da a om his andomised con olled ial ha e been published. The aim o his s udy is o in es iga e how music he apy clien s expe ienced he ask o lis ening o hei own clinical imp o isa- ions a home. The wo main objec i es o his s udy a e (a) o disco e wha is ele an o pa icipan s pe sonally and (b) o asce ain whe he music lis ening homewo k has po en ial as a me hod in imp o isa ional music he apy, as seen om bo h clien s’ and music he apis s’ pe spec i es. Me hod Design This p ocess e alua ion s udy is embedded in a 2 × 2 ac o ial RCT o dep ession (E kkilä e al., 2019, 2021). All pa icipan s en olled in he RCT we e o e ed 12 ace- o- ace bi-weekly one-hou sessions o indi idual music he apy o e a pe iod o six weeks. Hal o he pa icipan s we e ins uc ed o lis en o hei imp o isa ions a home in addi ion o hei music he apy sessions. These pa icipan s a e he subjec s o his s udy. Pa icipan s A numbe o 32 adul s aged be ween 21 and 57, wi h a p ima y diagnosis o majo dep essi e diso de (F32/F33 acco ding o ICD-10) we e assigned o he home lis en- ing and dia y w i ing ask be ween hei music he apy sessions. Pa icipan s we e no equi ed o ha e any musical skills bu we e excluded om he ial in ins ances o co- occu ing men al illnesses (e.g. psychosis, bipola diso de , pe sonali y diso de s, se e e subs ance misuse). Music he apy In eg a i e Imp o isa ional Music The apy (IIMT) is a e sa ile and lexible model sui able o a wide a ie y o clien popula ions (E kkilä e al., 2019, 2021). IIMT is based on psychoanaly ical music he apy and in eg a i e NORDIC JOURNAL OF MUSIC THERAPY 3 psycho he apy, oo ed in he belie ha musical exp ession is connec ed o abs ac men al con en and expe iences, hus ep esen ing unconscious emo- ional p ocesses (B uscia, 1998; E kkilä, 2004; E kkilä e al., 2012) ha ake place in e e changing dynamic li e ci cums ances (No c oss & Gold ied, 2005). F ee imp o isa ion is an in eg al pa o IIMT, whe e clien s can spon a- neously exp ess hemsel es in a dyadic musical in e ac ion wi h a music he apis . Du ing music he apy sessions, clien s we e able o choose o imp o ise on acous ic djembe d ums o digi al malle ins umen s (one o he clien and one o he music he apis ). Clinical imp o isa ions can be ei he comple ely ee, o ollow a heme p oposed by he music he apis o he clien . Imp o isa ions a e ypically ollowed by a e bal in e ac ion, whe e clien s can e balise and u he p ocess hei expe iences. P ocedu e Ele en clinically ained music he apis s wi h ex ensi e p io expe ience in IIMT unde wen a 24-hou aining cou se in p epa a ion o his RCT and con inued o ecei e g oup supe ision e e y wo weeks du ing he clinical wo k phase o he s udy o ensu e ea men ideli y. Music he apis s eminded pa icipan s o lis en o hei clinical imp o isa ions a home and o keep a digi al dia y. A pa icipan ’s home dia y had ins uc ions o w i e down any eelings, hough s, memo ies, bodily sensa ions, o o he expe iences ha a ose while lis ening o hei imp o isa ions. Music he apis s we e encou aged o discuss he clien ’s expe iences o doing homewo k du ing he subsequen he apy sessions, bu hey we e allowed o be lexible wi h he apy s uc u e. Da a collec ion Da a we e collec ed be ween 2018 and 2019 in he Music The apy Clinic o T aining and Resea ch a he Depa men o Music, A , and Cul u e S udies o he Uni e si y o Jy äskylä. Pa icipan s we e ec ui ed ia a newspape ad e isemen . Du ing music he apy sessions, music he apis s made audio eco dings o clinical imp o isa ions using P o Tools 11.3.1. and sha ed hem wi h clien s using con inuous ile synch onisa- ion p og am Sync hing ( e sion 0.14.39). In be ween music he apy sessions, each pa icipan was able o lis en o as many imp o isa ions as o en as hey wan ed using he music playe Can a a ( e sion 2.2) on hei home compu e . Pa icipan s we e asked o ill in an indi idualised online dia y a e each lis ening ins ance. A e all he pa icipan s comple ed hei music he apy sessions, he music he apis s we e asked o ill in an online su ey abou hei expe iences and opinions ega ding he home lis ening ask. E hical conside a ions This s udy ecei ed e hical app o al om he E hical boa d o Cen al Finland heal h ca e dis ic , 7 Sep embe 2017, e .: 17 U/2017, and was also egis e ed a he In e na ional T adi ional Medicine Clinical T ial Regis y (ISRCTN11618310). All pa icipan s we e equi ed o sign in o med consen du ing he ini ial assessmen . Anonymized in o ma ion was used o ensu e ha no pa icipan s could be iden i ied om esea ch da a. 4N. SNAPE ET AL. Da a analysis Deduc i e analysis o music he apis s’ epo s was pe o med using he con en analysis me hod, whils induc i e dia y da a analysis was pe o med using he e lexi e hema ic analysis me hod. Seman ic and la en coding was applied o he dia y en ies, ollowing he six s eps sugges ed by B aun and Cla ke (2019, 2021): (1) Da a amilia isa ion. The i s au ho was in ol ed in he s udy design and da a collec ion and was amilia wi h he ma e ial om i s incep ion. Subsequen ly, he i s au ho was in ol ed in he ansla ion p ocess, in ol ing mul iple mee ings wi h a ansla o . A e he ansla o inished hei wo k, he i s au ho double-checked he ex , compa ed i o he o iginal ex o ensu e u mos accu acy, and en e ed he da a in o A las. i so wa e ( e sion 22). (2) Ini ial code gene a ion. The i s au ho c ea ed de ailed ini ial codes in he A las. i so wa e. A e he i s ound o coding he i s au ho decided ha , o he pu poses o his pape , codes would only be analysed ha we e men ioned by a leas wo pa icipan s. I is emphasised ha his decision was no made o he pu poses o eliabili y o c edibili y, because e lexi e hema ic analysis is based on an inhe en ly in e p e i is pa adigm. This decision was made o enable a single esea che o code a la ge amoun o da a and cons uc a cohe en o e iew om a mul i ude o expe iences and opinions. (3) Gene a ing (ini ial) hemes. Fou hemes – MUSIC, THERAPY, EMOTIONS, and EMBODIMENT – we e dis inc om he e y beginning. Remaining codes we e ini ially assigned o hemes ha changed in he subsequen coding p ocess. (4) Theme e iew. A his s age Au ho s 2 and 3 we e b ie ed and included in discussions. I was decided ha al hough pa icipan s sha ed a lo o de ails abou hei li es, o he pu poses o his pape , h ee ini ial hemes (In e nal wo ld, Ex e nal wo ld, and Ch onology) could all be me ged in o NARRATIVE. (5) Theme de ining and naming. In la e coding s ages, i became appa en ha concep s needed clea de ini ions, because some codes we e o e lapping. Fo example, in memos abou he THERAPY heme, clea cu dis inc ions we e made be ween naming he issues (s a ing a p oblem), insigh (making a connec ion be ween he cause and e ec ), dealing wi h issues (iden i ying an ac ion ha could po en ially help), and change (execu ing he ac ion). (6) Repo p oduc ion. To aid eadabili y, hemes a e w i en in uppe case (e.g. NARRATIVE), sub hemes a e bold (e.g. Ch onology), codes a e i alicised and unde lined (e.g. Childhood), and subcodes a e i alicised (e.g. School). The i s au ho no ed ha he ini ial manusc ip did no e lec all pa icipan s’ oices equally. Appa en ly, he so wa e was a ec ing he selec ion o quo es, biassing owa ds pa icipan s wi h lowe numbe s. Consequen ly, he i s au ho in en- ionally included quo es om all pa icipan s by sc olling down he Quo a ion lis using he A las. i Code Manage , and no jus choosing he i s ew quo es o he code. Las ly, all he au ho s e iewed he manusc ip and p o ided hei eedback. NORDIC JOURNAL OF MUSIC THERAPY 5 Resul s Homewo k ask compliance was low wi h only 14 pa icipan s ou o 32 aking pa in his equi emen . In o al, 14 pa icipan s p oduced 58 dia y en ies con aining 19,041 wo ds. Eigh pa icipan s w o e 1–3 en ies (151 wo ds pe en y on a e age) whils six pa icipan s w o e mo e han h ee en ies (95 wo ds pe en y on a e age). Dep essed clien s’ expe iences o lis ening o hei own clinical imp o isa ions a home can be summa ised by i e main hemes, namely MUSIC, THERAPY, EMOTIONS, EMBODIMENT, and NARRATIVE, comp ising 15 sub hemes in o al (see Figu e 1). These codes a ose om e y ich da a (see supplemen a y online ma e ial o mo e de ails); he e o e, hey cap u e only he mos salien hemes ega ding he subjec o his pape . I is impo an o no e ha al hough codes wi hin a heme we e mu ually exclusi e (e.g. a single musical ac i i y is ei he Playing o Lis ening, no bo h), a single code could appea in di e en hemes (e.g. he same ac i i y can be bo h EMOTIONAL Playing and EMBODIED Playing). An illus a ion, aken om he i s au ho ’s analy ic memos, is p esen ed he e o aid a concep ualisa ion o he da a and show he in e connec edness o hemes (Figu e 2). Themes a e exempli ied wi h ele an quo es om pa icipan s (P, numbe ). Al hough dia ies we e ansla ed, quo es om hem a e p esen ed in as close o o iginal s yle and idiosync asy as possible. Music Playing Pa icipan s o en eminisced abou hei music-making expe iences du ing music he apy, as making music was a ai ly new expe ience o he majo i y o hem, whe he i was a Nega i e (“I go annoyed when I pe o med and ied o imi a e he he apis ’s playing, I also no iced I was ashamed o own playing and hands and my being, I didn’ unde s and he poin o playing” P10) o Posi i e (“So lo ely o play oge he because hey ha e suppo ed me app o - ingly wi h hei own playing” P24). Pa icipan s also men ioned he impo ance o Skills (“I don’ know wha ha eeling should sound like le alone how o play i wi h ins umen s I don’ know how o play” P8), some imes admi ing o he s, o he imes wishing o ha e he abili y o exp ess hemsel es musically. Lis ening Valence o he Lis ening homewo k was posi i e (“I was deligh ed as I was lis ening o ou playing” P24), neu al, o e en nega i e (“Lis ening el bo ing and unpleasan ” P8). Valence a ied no only om pe son o pe son, bu day- o- Figu e 1. Themes and sub hemes om dep essed pa icipan s’ dia ies 6N. SNAPE ET AL. day o he same indi idual (“I wonde wha he lis ening will eel like oday” P16). Some pa icipan s also men ioned an Impac on hei body (“Du ing he lis ening, he e is a mild ‘pain’ ha sp eads on one side o my head” P16), o he s conside ed a gene al impac o he ask on hei li es (“Lis ening o his so o hing could be use ul when I need o be eady o do some hing” P21). Fo some pa icipan s, i e oked a wish o play ou side he he apeu ic se ing (“Wi h an access o a piano, I con inued playing o e he ack wi h headphones on” P7), o o sha e i wi h people a ound hem (“The desi e o play said music o my lo ed ones” P86). Many pa icipan s no ed di e ences in engagemen and expe iences o Lis ening s. Playing (“The so ow ha bu s ou now while lis ening is comple- ely di e en om he one when I played” P43), and mos appea ed o ha e highe engagemen when playing wi h he music he apis (“When lis ening o i , i doesn’ ha e as s ong an e ec , and I can’ ge inside he eeling as when I played i ” P43). Some, howe e , had an opposi e eac ion and gained new insigh s when lis ening o imp o isa ions a home (“I hough ha maybe I don’ eel eally any hing in pa icula . . . Howe e , when lis ening o he eco dings a e wa ds . . . lis ening b ough up eelings o being mo ed and signi icance” P7). Music pe cep ion Pa icipan s o en no ed he pe cei ed beau y o lack o i in hei imp o isa ions. Aes he ic app ecia ion was a posi i e esou ce o some (“Joy o beau i ul, peace ul music” P24), bu o he s ound Inaes he ic p ope ies o music inc edibly dis essing (“Tha chaos music is so e ible, I can’ s and i o long” P24). In e es ingly, adi- ional beau y was no always conside ed a posi i e in he con ex o music he apy, showing ha pa icipan s unde s ood he di e ences be ween he apeu ic imp o isa- ion and a is ic music (“Do I da e . . . play in a way ha sounds ugly ( ha is, o play ‘w ong’)” P24). Figu e 2. Illus a ion o he dia y hemes and case examples om pa icipan s’ dia ies NORDIC JOURNAL OF MUSIC THERAPY 7 some pa icipan s we e able o gain a new pe spec i e on hei issues, which con i ms ha insigh and inc eased awa eness plays an impo an ole in success ul emo ional p ocessing (Saa ikallio e al., 2022). The heme EMOTIONS comp ised h ee sub hemes: Nega i e Emo ions, Posi i e Emo ions, and O he Emo ions. Nega i e emo ions we e no discussed mo e o in g ea e dep h, which was su p ising as nega i i y bias is common in dep ession (Punkanen e al., 2011; Sakka & Juslin, 2017). I is di icul o explain his esul , bu i migh be caused by in e nalised nega i i y wi h sel -c i ical hough s (Ga ido e al., 2017) o expe ienced psychosoma ically ia bodily pains (Lipsanen e al., 2004), as bo h ypes o expe iences we e discussed equen ly in dia ies. Emo ional eac ions we e a ied and nuanced, o en pleasu able and dis essing a he same ime, and cons an ly luc ua ing, which is in line wi h he indings o a g ea deal o p e ious wo k on music and emo ion (Ga ido & Schube , 2013; Juslin & Laukka, 2004; Juslin e al., 2008). The heme EMBODIMENT is a body- ela ed heme comp ising h ee sub hemes: Body Pa s, Sensa ions, and Ac ions. Al hough p e ious li e a u e o en e e s o he embodied aspec o music cogni ion (Leman & Maes, 2014; Leman e al., 2018) and emo ional expe iences (Hodges, 2016; Schia io e al., 2017), hese indings we e unexpec ed in hei di e si y and g anula i y. NARRATIVE was a s o y- elling heme, comp ising wo sub hemes: Ch onology and Symbolic Re e ences. In e es ingly, he e we e no pe sonally meaning ul e e ences o music in pa icipan s’ pas s, such as a ou i e bands, conce s, o memo ies o emo ional expe iences wi h music, which is con a y o p e ious esea ch on he impo ance o music in e e yday li e (DeNo a, 2004; Ga ido & Schube , 2015). This heme was by a he mos sizable and he e ogenous, highligh ing he complexi y o he way people pe cei e he wo ld, ac in i , and he s o ies hey ell a e wa ds. Rega ding he second aim o he s udy, i seems ha music lis ening homewo k does ha e po en ial as a me hod in imp o isa ional music he apy o clien s who ha e su icien ime, mo i a ion, and a e no o e whelmed by he symp oms o dep ession and anxie y. When compa ing lis ening homewo k o lis ening o clinical imp o isa- ions du ing music he apy sessions, as in he case o AOM, i seems ha he music he apis ’s p esence would sa egua d clien s om engaging in excessi e umina ion o a oidance (Ga ido & Schube , 2015; Mi anda & Claes, 2009; Mi anda e al., 2012). On he o he hand, o pa ien s who ha e su icien sel - egula ion s a egies and a e no in emo ional c isis a he ime, homewo k p o ides a unique oppo uni y o sel - e lec ion, empowe men , and he abili y o p ac ise heal hy emo ion- egula ion s a- egies in hei home en i onmen s. I is impo an o no e ha many pa icipan s we e dis essed, and he majo i y did no comply wi h he homewo k ask. Some pa icipan s had di icul ies unde s anding he aim o he apeu ic music making, o lacked su icien musical skills o exp ess hemsel es, hence did no ind meaning in lis ening o hei clinical imp o isa ions. Fo his eason, i would be ad isable o conside he s age o he music he apy p ocess, and o a oid in oducing clinical imp o isa ion lis ening homewo k oo ea ly. O he pa icipan s we e o e whelmed by nega i e emo ions and did no ha e su icien sel -soo hing and emo ion- egula ing abili ies o ace issues by hemsel es a home wi hou immedia e suppo om he music he apis . Some pa icipan s had issues using compu e so wa e o access hei clinical imp o isa ions, and al hough i mus emain ai ly complica ed due o secu i y easons, clien s should be o e ed echnological aining and con inuous suppo . 14 N. SNAPE ET AL. In his s udy, many pa icipan s exp essed us a ion in hei dia ies ega ding hei inabili y o name hei emo ions. P e ious s udies show ha dep ession can impai cogni i e and e bal p ocessing, making he language pa o he homewo k ask challenging o se e ely dep essed pa icipan s (Hamma & Å dal, 2009; McDe mo & Ebmeie , 2009). I is possible ha lis ening o clinical imp o isa ions migh ha e bene i ed pa icipan s o his s udy mo e i i was a s and-alone ask, and no ollowed by he dia y w i ing a e wa ds. Ano he issue ega ding homewo k implemen a ion could be linked o he impo ance o sys ema ically add essing pa icipan s’ expe iences in ollowing music he apy sessions. Fo example, he EIMT manual (Aalbe s e al., 2020) emphasises main aining an iden ical in e en ion s uc u e, whe e each session begins by discussing p e ious homewo k and ends wi h coming up wi h new homewo k. Mo e s uc u e migh be bene icial o dep essed pa icipan s who lack mo i a ion and emo ional sel - egula ion skills. On he o he hand, some music he apis s in his s udy indica ed ha highly s uc u ed music he apy would impai hei abili y o be spon aneous and is no in line wi h hei p o es- sional app oach. Limi a ions Fi s and o emos , compliance wi h he homewo k ask was so low ha he conclusions o his s udy should be aken cau iously. I mus be also no ed ha his s udy was conduc ed in ea men o dep ession, and one should be cau ious o gene alising indings o o he clinical popula ions. Thi d, po en ial inconsis encies in music he apis s’ app oach o he home lis ening ask migh ha e led some pa icipan s o bene i om i mo e i hei music he apis spen mo e ime alking abou he ask du ing he sessions, bu s udying such e ec s was beyond he scope o his s udy. Fou h, da a analysis was pe o med a e music he apy was con- cluded, so he e was no oppo uni y o alida e indings by asking pa icipan s whe he hese hemes cap u ed hei expe iences well. Finally, alloca ing some expe iences o ca ego ies was no always clea -cu , o example, he expe iences o playing whils lis ening o he eco dings o imp o isa ions could ha e been placed ei he in he playing o lis ening subca ego y, as he ca ego ies hold some le el o concep ual o e lap. Conclusion The indings om his s udy sugges ha lis ening homewo k can be a use ul music he apy me hod, bu i should be used wi h cau ion as i seems o ac as a magni ying glass, enhancing e e y hing whe he i be bene icial o des uc i e. I music he apy sessions a e going well, lis ening o imp o isa ions a home could be implemen ed o aid he apeu ic p ocessing and used as a esou ce o g ounding, elaxa ion, and sel -explo a ion. Bu i he clien has di icul ies unde s anding he aim o he apeu ic music making, signi ican ly lacks musical skills o exp ess hemsel es, o is a isk o dissocia ion, home lis ening asks should be u ilised on a case-by-case basis. O e all, he homewo k ask o he clien lis ening o hei own clinical imp o isa ions needs u he esea ch be o e implemen a ion as pa o imp o isa ional music he apy. NORDIC JOURNAL OF MUSIC THERAPY 15 Disclosu e s a emen No po en ial con lic o in e es was epo ed by he au ho s. Funding This s udy ecei ed unding om he Resea ch Council o Finland ( o me ly known as Academy o Finland) o p ojec s “NO PAIN NO GAIN - In e nal Mechanisms o In eg a i e, Imp o isa ional Music The apy in he T ea men o Dep ession” and “Social sus ainabili y o child en and amilies”. No es on con ibu o s Ne dinga Snape is a pos doc o al esea che a he Depa men o Music, A , and Cul u e S udies a he Uni e si y o Jy äskylä. She is a membe o he E hics Commi ee o he Li huanian Music The apy Associa ion. She eaches and esea ches a a ie y o opics in he ields o music he apy and music psychology. She is a membe o he Cen e o Excellence in Music, Mind, Body, and B ain and he P o iling a ea o Social Sus ainabili y o Child en and Families a he Uni e si y o Jy äskylä. Su i Saa ikallio is a P o esso o Music Educa ion a he Uni e si y o Jy äskylä, Finland. She conduc s esea ch and eaches music psychology, music educa ion, and music he apy. She is he Chai man o he Finnish Socie y o Music Educa ion (FiSME), Vice-P esiden o he Eu opean Socie y o he Cogni i e Sciences o Music (ESCOM), and he Eu opean Commissione o he ISME (In e na ional Socie y o Music Educa ion) Resea ch Commission. She cu en ly ac s as a PI o an ERC- unded p ojec MUSICONNECT, a Co-PI o he Cen e o Excellence in Music, Mind, Body & B ain, and a Co-PI o he Uni e si y o Jy äskylä P o iling a ea o he Social Sus ainabili y o Child en and Families. Esa Ala-Ruona, PhD is an Associa e P o esso o Music The apy a he Cen e o Excellence in Music, Mind, Body, and B ain, Uni e si y o Jy äskylä, Finland. He is a music he apis and ad anced le el psycho he apis wo king as a esea che , clinical eache , and supe iso a he Uni e si y o Jy äskylä Music The apy Clinic o Resea ch and T aining. His esea ch in e es s a e in music he apy assess- men and e alua ion, and in s udying musical in e ac ion, meaning making and clinical p ocesses in mul imodal music he apy. He has an ex ensi e expe ience in clinical music he apy in a ious ields o heal h ca e and ehabili a ion. His special expe ise lies on c ea ing clinical models, as well as clinical p ac ice o in eg a i e music psycho he apy, and ib oacous ic he apy. Ma in Ha mann is an Assis an P o esso o Musicology a he Cen e o Excellence in Music, Mind, Body and B ain, Uni e si y o Jy äskylä Finland. His esea ch in e es s include music and mo emen , music pe cep ion and cogni ion, music in o ma ion e ie al, and music he apy. He main ains he MoCap Toolbox, a se o unc ions w i en in MATLAB o he analysis and isualiza ion o mo ion cap u e da a. He cu en ly se es as Associa e Edi o o he jou nal Psychology o Music. Oli ie B aban is a pos doc o al esea che a he Uni e si y o Jy äskylä. His esea ch is abou enhancing he bene i s o music psycho he apy by s a ing he sessions wi h a sho b ea hing in e en ion. Th ough he achie ed elaxa ion, clien s a e be e able o egula e hei emo ions, leading o deepe and mo e p oduc i e wo k du ing he apy. Jaakko E kkilä is p o esso o music he apy a he Depa men o Music, A and Cul u e S udies, Uni e si y o Jy äskylä, Finland. He is one o he module leade s a he Finnish Cen e o Excellence in Music, Mind, Body, and B ain, esponsible o music he apy s udies. His esea ch in e es s include e ec i eness o music he apy based on E idence-Based P ac ice on men al diso de s, ea men model de elopmen , and clinical imp o isa ion. He has ac ed as a PI o wo RCTs on imp o isa ional music he apy o dep ession based on Eu opean Union and Academy o Finland unding. E kkilä is a quali ied music he apis and ad anced le el psycho he apis and he Head o music he apy clinical aining a he Eino Roiha ounda ion, Jy äskylä, Finland. 16 N. SNAPE ET AL. ORCID Ne dinga Snape h p://o cid.o g/0000-0003-3196-0584 Oli ie B aban h p://o cid.o g/0000-0001-6856-7757 Re e ences Aalbe s, S., Fusa ‐Poli, L., F eeman, R. E., Sp een, M., Ke , J. C. F., Vink, A. C., Ma a os, A., C aw o d, M., Chen, X. J., & Gold, C. (2017). Music he apy o dep ession. 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