Virtual Music Therapy for Substance Use Disorders in a Federally Qualified Health Center
========================================================================================

* Julie Schoonover
* Andrew Rossetti
* Ariel Jacobs
* Susan E. Rubin

## Abstract

*Background:* Music therapy (MT) is an effective adjunctive treatment for substance use disorders (SUD), which is primarily available in inpatient treatment centers and rarely provided in outpatient primary care.

*Methods:* We evaluated the feasibility and acceptability of a virtual group MT program for SUD in a Federally Qualified Health Center (FQHC), and secondarily assessed patient perceptions of its effect. Feasibility was measured by implementation-related process measures, attendance and use of technology. Qualitative interviews eliciting participant perceptions were conducted to evaluate acceptability and effect. Mood scores, substance use and craving were measured before and after the intervention.

*Results:* Onboarding of the music therapist took 3.5 months. All MT sessions were attended by 1 to 5 individuals out of 6. Participants reported that group MT was “soothing” and “calming,” gave them tools to treat cravings and stress, and created a sense of community. They reported that during sessions their cravings decreased. Anxiety and depression scores trended down, as did the number of days of substance use. They all stated they would seek out MT again.

*Discussion:* Our results suggest that remote group MT is feasible and acceptable to our FQHC patients with SUD. Patients reported an improvement in mood and their ability to manage stress, and a decrease in substance use.

*Conclusion:* We wish to build on the results of this study to enhance our understanding of the effects of MT in the outpatient setting, and broaden our patients’ access to MT in primary care.

*   Community Health Centers
*   Craving
*   Health Services Accessibility
*   Integrative Medicine
*   Medically Underserved Area
*   Minority Health
*   Music Therapy
*   Outpatients
*   Primary Health Care
*   Qualitative Research
*   Substance-Related Disorders
*   Telemedicine
*   Vulnerable Populations

## Introduction

Substance use disorder (SUD) treatment in outpatient primary care is expanding and requires multimodal approaches to succeed.1,2 One adjunctive option to medication for addiction treatment is music therapy (MT), which uses music as a tool within a therapeutic relationship to achieve a clinical goal.3 For decades, music therapists have treated individuals with SUD in rehabilitation programs,4⇓⇓⇓–8 decreasing the frequency of substance use and increasing the time engaged in medical care.9,10 Virtual MT has been successful for a variety of diagnoses,11 and SUD can be treated via telemedicine.12 Group-based treatments for opioid use disorders are feasible and acceptable,13 and group MT is feasible in underserved primary care environments, specifically to treat chronic pain.14,15 Despite its use in a myriad of clinical conditions, MT is rarely provided in the primary care setting.16

While separately, there is evidence and experience in virtual MT, group-based care for SUD and provision of MT in underserved primary care, there are no published studies about the combination of virtual group MT in underserved primary care. Thus, we designed a study to assess the feasibility and acceptability of a virtual group MT program to treat people with SUD at a Federally Qualified Health Center (FQHC). The secondary aim was to evaluate the participants’ perception of its effect on depression and anxiety levels, craving, and frequency of substance use.

## Methods

The study design is a single group intervention with prepost evaluation using mixed methods. Eligible subjects were adult patients at our FQHC network who met DSM-V criteria for active moderate-to-severe SUD.17 We recruited participants via provider referrals and direct calls to patients with the goal sample size of 6. All interactions were entirely remote. The study was approved by The Institute for Family Health’s Institutional Review Board.

The intervention consisted of 8 weekly hour-long virtual MT sessions and was derived from the Medical Music Psychotherapy model18,19 aimed at increasing resilience and developing coping mechanisms.20 The sessions consisted of a series of structured sections that allowed for individual expression within a predictable schema (*see* Table 1). Each section created a sense of group cohesion while providing participants with resources for self-regulation, impulse control, and down-regulation. These resources were discussed throughout each session, and participants had space to process their experiences and learn how to apply techniques to their daily lives.

View this table:
[Table 1.](http://www.jabfm.org/content/early/2023/12/13/jabfm.2022.220316R3/T1)

Table 1. 
Structure of Weekly Music Therapy Sessions

### Measures

Feasibility was measured by program implementation including onboarding and session completion, participant attendance, and interactions with technology.22 Acceptability was determined by satisfaction rates and qualitative data. We evaluated the intervention effect with qualitative data and survey responses.

Before and after the intervention, we administered validated surveys evaluating substance use and craving from the PhenX Toolkit,23 and depression and anxiety scores (PHQ-9 and GAD-7). After each session, participants rated their satisfaction with that day’s session using a 5-point Likert scale. At the end of the 2-month intervention, we conducted individual structured qualitative interviews that explored participants’ overall thoughts about the experience. The interview guide was designed in response to content from the MT sessions and surveys, and tested with 2 individuals.

Three authors (JS, AJ, and SER) independently analyzed the qualitative data using grounded theory methodology. The team met twice to define emerging themes and identify relevant quotations. JS organized these into unifying themes.

## Results

### Feasibility

We decided to assess feasibility using a combination of implementation-related process measures, attendance and use of technology, as well as qualitative data from participants relating to other barriers and facilitators.

Over 3.5 months, a board-certified music therapist was onboarded at the FQHC network. A total of 6 people enrolled in the intervention (*see* Table 2) and attended 0 to 7 MT sessions - one could not attend due to work. Three attended most sessions offered (*See* Figure 1). The groups ranged in size from 1 to 5 participants. The midday session time was a barrier for at least 2 participants, who recommended offering evening sessions.

![Figure 1.](http://www.jabfm.org/https://www.jabfm.org/content/jabfp/early/2023/12/13/jabfm.2022.220316R3/F1.medium.gif)

[Figure 1.](http://www.jabfm.org/content/early/2023/12/13/jabfm.2022.220316R3/F1)

Figure 1. 
Participant recruitment flowchart.

View this table:
[Table 2.](http://www.jabfm.org/content/early/2023/12/13/jabfm.2022.220316R3/T2)

Table 2. 
Participant Characteristics (*n* = 6)

A technology gap due to low technological literacy and unequal Internet access became evident. Some lacked familiarity with the video platform, requiring technical support at each session. Patchy Internet and cellular service meant that individuals were sometimes unable to complete a session. A poor Internet connection could also interrupt sound or cause feedback, which affected sound quality.

### Acceptability

We evaluated survey data, and the content of the MT sessions and individual interviews to explore acceptability. Participants shared mostly positive comments about the MT, demonstrating acceptability through the themes “the importance of community,” “an appreciation of music,” and “ambivalence about in-person versus online MT” (*see* Table 3*)*. Not only did they look forward to each session, they also stated that they wished to continue MT if financially feasible. After every session, participants consistently rated that they were “satisfied” or “very satisfied” with the MT.

View this table:
[Table 3.](http://www.jabfm.org/content/early/2023/12/13/jabfm.2022.220316R3/T3)

Table 3. 
Acceptability of Virtual Music Therapy (MT) Intervention

Participants emphasized “the importance of community” in the therapeutic environment. One said, “*community is the opposite of addiction*.” There was a preference for group as opposed to individual MT. As stated by several, in groups *“I was able to hear other peoples’ perspectives, and I think you can learn a lot from listening.”* 2 sessions had 1 participant only, who reported that while they appreciated the individual attention, something essential was lost.

Music had always been important to the participants, and they reported “an appreciation of music.” They described the music therapist’s “*soothing voice*” and valued the use of the guitar. Music enhanced the effect of the meditation exercise at the core of each session, facilitating relaxation and reducing anxiety. As 1 person said, “*that quality to the music helps because it is easier for me to meditate or to slow down.*” Several suggested that there be more group music-making and a greater variety of instruments played.

Regarding the format of the intervention, participants were “ambivalent about in-person versus online MT.” They voiced concerns over the technology gap. They also said that community-building was decreased when meeting online. On the other hand, all reported that it was more convenient to participate in MT online as it removed the need to commute. One suggested offering a hybrid option with both in-person and virtual participation.

### Effect

Using the same source material, we explored the participants’ perception of the effect of the intervention, which became apparent through the following themes: “a sense of calm and comfort,” “a means of self-care,” and “a decrease in cravings” (*see* Table 4).

View this table:
[Table 4.](http://www.jabfm.org/content/early/2023/12/13/jabfm.2022.220316R3/T4)

Table 4. 
Effect of Virtual Music Therapy (MT) Intervention

Universally, participants reported that the MT gave them “a sense of calm and comfort.” They used words like “*calming*,” “*soothing*” and “*grounding*” to describe the effect. MT seemed to have an immediate effect on their mood during the meditation and visualization interventions: “*I can say that my mood has changed, and for the positive, drastically since doing those 2 exercises.*” They also found a sense of safety: “*it feels good, like, it is a flood of emotions when I know I am safe*.”

The musical exercises were designed to be applied to daily life, providing “a means of self-care.” Importantly, outside of the MT sessions, participants began to use music as a way to self-soothe when feeling cravings or stress, *“so when I do get cravings, it is like alright, slow down, let me put the music on*.” They now also use music to improve their mood: “*now I will play music that I know is going to put me in a better mind state rather than something that is going to negatively affect my emotion.*”

Participants also noticed that their cravings diminished or disappeared in anticipation of the group, “*knowing I was going into the group, that was comforting, so my cravings were lessened*.” They knew this would be a set time during which they would not use their substance, “*I do not drink at the time when I am doing [MT]. And I do not have the desire to.*” One did state that her cravings increased after some sessions ended because she would find herself alone again in her home.

Over the course of the study, participants’ depression and anxiety scores trended down, as did the frequency of substance use in the prior 2 weeks. However, the severity of craving did not seem to change.

## Discussion

This study suggests that virtual group MT for people with SUD is feasible and acceptable in the FQHC primary care setting. The intervention was successfully implemented and completed as planned, and participants looked forward to each session. While only half of participants regularly attended sessions, 2 participants regretted they could not attend due to their work or school schedules, suggesting that remote MT is acceptable to individuals with SUD. Offering the MT groups at different times may improve attendance.

Participants reported positive effects from the intervention. They stated that their mood improved and they reported having new tools for self-care that helped decrease the frequency of substance use. Despite experiencing some technology barriers, participants found the remote intervention beneficial and wished to continue MT on their own time.

Our study has a number of limitations that include the phrasing of certain survey questions, self-selection bias and a small sample size. The substance use measures, while validated in larger studies, are limited as they do not distinguish between harmful and any drug use. For future studies, we plan to reword these questions to reflect harmful use of substances. A self-selection bias was inherent to this study as participants already had a positive relationship with music. Finally, the small sample size prevents us from establishing a causal relationship with the intervention.

Given the disparities in access to nonpharmacologic therapies reported in similarly underserved urban and rural populations,24,25 and the urgent need to expand access to care for SUD within primary care,2 virtual, group MT is another feasible and acceptable tool that can improve the care of individuals with SUD within FQHCs. The terms that came up most often, “*soothing*” and “*calming,*” suggest that this intervention may be valuable to a population carrying other diagnoses such as anxiety, depression, hypertension and insomnia. We plan to expand this project to evaluate effectiveness in SUD and other diseases. Future directions include determining ways to fund this work and bill the group sessions to insurance companies to ensure financial sustainability.

## Acknowledgments

The authors would like to thank Matthew Beyrouty, Gabrielle Bouissou, Christina Cho, Joanne Loewy, Saskia Shuman, and Eve Walter, for their contributions to study design, implementation, and analysis.

## Notes

*   This article was externally peer reviewed.

*   This is the Ahead of Print version of the article.

*   *Funding:* The study was supported by a grant from the Empire Clinical Research Investigator Program (ECRIP) of New York State.

*   *Conflict of interest:* None.

*   To see this article online, please go to: [http://jabfm.org/content/00/00/000.full](http://jabfm.org/content/00/00/000.full).

*   Received for publication September 15, 2022.
*   Revision received October 31, 2022.
*   Revision received April 21, 2023.
*   Revision received May 15, 2023.
*   Accepted for publication June 12, 2023.

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