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Research on DBT and Music Therapy

 Lauren Bonavitacola, PsyD, MT-BC, is a psychologist, DBT-Linehan Board of Certification Certified Clinician™, and board-certified music therapist working for Cognitive & Behavioral Consultants of Westchester and Manhattan (CBC), an outpatient CBT- and DBT-based treatment, training, and consultation center. She is the Director of Trauma-Focused Treatment Programs at CBC and works with adolescents, adults, couples, and families. 

The following is the forward Dr. Bonavitacola wrote to the book she co-authored with Deborah Spiegel MT-BC and Suzanne Makary MT-BC called Creative DBT Activities Using Music (Interventions for Enhancing Engagement and Effectiveness in Therapy) – Jessica Kingsley Publishing 2020.  Read about how she refers to research.

As an excited and motivated second-year psychology graduate student, I learned about the work of Deborah Spiegel at a training that she conducted at Immaculata University in Pennsylvania. I was studying clinical psychology at the Graduate School of Applied and Professional Psychology (GSAPP) at Rutgers University and had just started to dive deeper into my training and understanding of DBT under the direction of Shireen Rizvi, PhD, a former graduate student of the treatment developer herself, Marsha Linehan, PhD. Prior to graduate school, I had completed my undergraduate degree in music therapy and it was during my internship at a child and adolescent inpatient hospital that I was first introduced to DBT. I was pretty immediately drawn into its pragmatic nature and could easily see how this approach could be beneficial for the emotionally dysregulated teens I was working with at the hospital. I had always hoped that during graduate school and beyond I would find a way to integrate clinical psychology and music therapy; therefore, when I saw that Deborah had found a way to infuse music therapy interventions into the teaching of DBT, I was very intrigued! Attending this initial workshop marked the start of what would end up being a very rewarding and enriching professional relationship and collaboration.

As excited as I was about integrating music therapy into my work as a budding psychologist implementing DBT, I still had a lot of questions about this approach. Being indoctrinated into the world of evidence-based psychotherapies in graduate school instilled in me a deep desire to ensure that the work I was doing and the treatments I disseminated to others were based in a solid research base. Therefore from the beginning of my collaboration with Deborah, I wanted to know: where’s the evidence? How do we know that incorporating music into the teaching of DBT will make a difference in client learning or generalization of these skills? Are there other variables that the addition of music impacts, such as level of engagement, that could enhance overall outcomes? My quest to answer these questions began.

I started by reviewing the music therapy literature. One of the most robust science-minded communities of researchers in the music therapy field would arguably be made up of those who hail from The Academy of Neurologic Music Therapy (NMT). Preeminent researchers including the late Robert Unkefer and Michael Thaut have expanded the literature in the realm of neurologic music therapy significantly, helping bring clout to this field and its evidence-based techniques that have been shown to improve so many functional behaviors. Within this literature exist many research studies demonstrating the effects of music on the brain and on various neurological and physiological processes including affect arousal and regulation, memory, language acquisition, pain perception, and sensorimotor development and
rehabilitation to name a few. There are countless studies to cite, but several books and meta-analyses exist that summarize the literature nicely (Lee, 2016; Thaut, 2005; Thaut & Hoemberg, 2014; Pelletier, 2004). Additionally, the NMT Academy has a bibliography of the evidence base for its interventions located at: https://nmtacademy.co/supporting-research-by-technique.

It is not a far stretch to see the overlap in these areas with many of the goals of DBT skills training, for example:
◆ One of the aims of emotion regulation skills is to learn how to modulate emotion intensity, which can be achieved through music interventions.
◆ Mindfulness skills aim to help us have control over where we place our attention, which can reduce pain perception, as can music.
◆ Distress tolerance skills sometimes incorporate relaxation, which music can enhance.
◆ Mnemonic devices are used for so many DBT skills to facilitate memory of a skill, in the same way as musical mnemonic devices.

Therefore, if we know that music can impact some of the very processes that we expect to be impacted through DBT skills training, how does the combination of the two impact DBT skills training outcomes?

To date, there is a dearth of research that has been published in this area. Chwalek and McKinney (2015) interviewed music therapists conducting DBT to understand more about how DBT is perceived by these therapists and how it is being implemented. Results indicated what we already know:

There is a lack of empirical evidence to inform, refine, and guide practice, though components of DBT were valued by those interviewed. I am aware of only two published studies examining the role of music therapy within a DBT program, both of which are published in German by German researchers (Kupski, 2007; Plener et al., 2010). Translations indicate that the studies are in case study form and thus no quasi-experimental or randomized controlled studies exist comparing music therapy DBT to standard DBT to determine if it has an added benefit. Deborah Spiegel and Music Therapy Assistant Professor from The University of Kansas, Abbey Dvorak, PhD, were interested in exploring this gap in the literature further. They conducted a quasi-experimental study with Lindsey Landeck, MT-BC and William Dyer, MS, LLP of Kalamazoo Psychiatric Hospital. They compared participant outcomes from a DBT skills group with a combined DBT skills and music therapy group on attendance, participation, quantity, and frequency of skills practiced as reported on the diary card, and client comprehension of the skills. This study is close to completion and is in the data analysis phase (Dvorak et al.).

It is clear that further research including randomized controlled trials is needed in order to determine whether music’s addition to DBT improves treatment outcomes on these aforementioned variables. Nonetheless, it is promising to see the early phases of this research, along with the robust base of science that exists about music’s impact on the very processes we expect to see impacted by DBT, pointing us in the direction of understanding this area further.

In 2012 Deborah invited me to help train music therapists in DBT and how music therapy interventions could be tailored to the skills acquisition and generalization of DBT skills. Through our online trainings, we have introduced this approach to hundreds of music therapists and have created a more intensive program that includes intensive skills training through Behavioral Tech, webinars on music therapy applied to DBT for each skills training module, personal skills practice and lesson plan writing for each module, and monthly consultation meetings, culminating with an in-depth case report. We wanted to ensure the training was as rigorous as the material requires, taking pride in ensuring that all participants leave theprogram with a solid understanding of DBT skills, group implementation and management, and the knowledge to apply music therapy interventions to enhance skills acquisition and generalization. This has been a very rewarding part of my career thus far and I have felt very honored to have learned from so many creative-minded and eager-to-learn music therapists. A large part of the inspiration in creating this book has come from the creative ideas and contributions of the participants in this program and we want to say thank you! Without them, this book would still be just an idea and not a reality.  In fact, one of the program participants, Suzanne Makary, was invited to be a co-author of this very book because of her particularly creative ideas! Thank you, Suzanne, for being such an active part of the creation process with us.

In Deborah’s first, self-published, edition of this book, she presented music therapy interventions to teach many DBT skills, based on Dr. Linehan’s first edition of the skills training manual (1994) with the music therapist in mind. For this edition, we wanted to expand the audience who could benefit from incorporating these activities into their work and therefore have included activities that do not require music training nor a certification in music therapy to implement them. We have included many types of music activities with the corresponding DBT skills that are being modeled through the activity, so that these activities can be used flexibly and as desired. It is written in lesson plan form, so it is as user friendly as possible. We have also included a second part of this book with additional activities written in a self-help format that can be handed out as supplements to your clients to practice for homework.

Thank you, Deborah, for carrying the passion for DBT and music therapy so strongly and being such a pioneer in this field. Your trainings and ambition have helped countless music therapists broaden their scope as practitioners, allowing them to further disseminate the power of DBT skills within their skill set as music therapists while aiming to preserve the integrity of the treatment. I am excited to share this book with the world so that DBT can continue to enter the lives of those who could benefit from the knowledge and incorporation of these skills, helping them to create the life worth living that they deserve.

Creative DBT Activities Using Music can be found here.

 

Research

The use of music therapy interventions to help teach and reinforce DBT skills has started to grow a research base, including but not limited to the following publications:

Chwalek, C. M. & McKinney, C. H. (2015). The use of dialectical behavior therapy (DBT) in music therapy: A 

               sequential explanatory study. Journal of Music Therapy, 52(2), 282-318.

 Dvorak, A. L. (manuscript in preparation). A conceptual framework for mindfulness-based music therapy
            interventions.

 Dvorak, A. L., Landeck, L., Dyer, W., Spiegel, D. (In progress). Comparison of a DBT skills group and 
            a combined DBT skills with music therapy group on client outcomes.

 Kupski, G. (2007). Borderlinestörung und Musiktherapie im Kontext der Dialektisch-Behavioralen
          Therapie. Musiktherapeutische Umschau, 28(1), 17-27.

 Lesiak, M. & Dvorak, A. L. (manuscript in preparation). Mindfulness-based music therapy group protocol
            for individuals with serious mental illness and chronic illness: A feasibility study.

Gitta Strehlow, Reinhard Lindner. (2015) Music therapy interaction patterns in relation to borderline personality 

           disorder (BPD) patients. Nordic Journal of Music Therapy, 1-25. 

Georg Romer, Thomas Stegemann, Annika Brüggemann-Etchart, Anna Badorrek-Hinkelmann. (2010) Die

                  Funktion von Musik im Zusammenhang mit selbstverletzendem Verhalten und Suizidalität bei

                   Jugendlichen. Praxis der Kinderpsychologie und Kinderpsychiatrie 59:10, 810-830. 

Plener, P. L., Sukale, T., Ludolph, A. G., & Stegemann, T. (2010). “Stop cutting – rock!”: A pilot  study of a music

           therapeutic program for self-injuring adolescents. Music and Medicine,  2(1), 59-65. 

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