Running head: MUSIC THERAPY AND EATING DISORDERS: A LITERATURE REVIEW 1

Music Therapy and Eating Disorders: A Literature Review

Christopher Jones

Queens University
MUSIC THERAPY AND EATING DISORDERS: A LITERATURE REVIEW 2

Music Therapy and Eating Disorders

Eating disorders affect an estimated 10 million females and 1 million males in the United

States (Various, 2015). There are currently three major types of eating disorders listed in the

Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR): Anorexia nervosa (AN),

Bulimia Nervosa (BN), Binge Eating Disorder (BED), and Eating Disorder Not Otherwise

Classified (EDNOS). Out of these three types of eating disorders Binge Eating Disorder affects

both males and females the most at 2% and 3.5% respectively, while Anorexia Nervosa is listed

as one of the mental illnesses with the highest fatality in the United States (Various, 2015).

Individuals suffering from Anorexia Nervosa refuse to maintain body weight either at or

above what is considered normal for their age and height and there is remarkable influence on

how the person’s body weight or shape determines the person’s sense of self. They refuse to

acknowledge that they are grossly underweight and in women there may be an absence of three

menstrual cycles. There are two types of Anorexia Nervosa: The Restricting Type and the Binge-

Eating Purging Type. In the first one an individual will induce weight loss either through dieting,

fasting or excessive exercising, and in the second they will eat large amounts of food in a small

span of time and then purge the food through self-induced vomiting, overuse of laxatives, use of

diuretics or enemas (Tileston, 2013).

Bulimia Nervosa has symptoms that include the following: recurrent episodes of eating

larger than normal amounts of food for most people in a short period of time, a sense of lack of

self-control during these episodes, causing the person to take measures to prevent weight gain

such as self-induced vomiting, misuse of laxatives, diuretics, enemas or other medications,

fasting or excessive exercise; binge eating episodes occurring at least twice a week for three

times a month, and a sense of self overly determined by the person’s body weight and shape.
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There are two types of this disorder: the Purging Type and the Nonpurging Type. In the former

the person will self-induce vomiting, misuse laxatives, diuretics or enemas, while in the latter

condition they will not use these behaviors (Tileston, 2013).

An individual who has a Binge-Eating Disorder eats a large amount of food within a two-

hour period and during these episodes typically feels as if they have no control over it. The

binge-eating instances are associated with three (or more) of the following: eating much faster

than normal, eating until overly full, eating large amounts of food when not hungry, eating alone

due to embarrassment, and feeling depressed, disgusted with oneself, or extremely guilty for

having done so (Tileston, 2013).

Eating-Disorder Not Otherwise Classified doesn’t meet any of the above criteria in the

previous disorders but instead may meet some or most of the criteria of a specific disorder but

not all. An example would be a female with AN who has regular menstrual cycles, or an

individual who despite a large amount of weight loss is still in their normal weight range.

Another example may be a case of BN where all the criteria are met but the frequency and

duration are less than is typical for the disorder. A person who is normal body weight but who

uses inappropriate behaviors, such as inducing vomiting after eating two cookies, may be

included in this category as could someone who chews but does not swallow and instead spits

out large amounts of food (Tileston, 2013)

According to the website Eating Disorder Hope out of all the males and females in the

United States .9% females will have AN, 1.5% will have BN and 3.5% will have BED. For

males the numbers are lower at .3% for AN, .5% for BN, and 2% for BED (Various, 2015).

However as Tileston (2013) points out “according to the website on the National Alliance on

Mental Illness (NAMI) ‘far more individuals suffer from EDNOS than from bulimia and
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anorexia combined, and the risks associated with EDNOS are just as profound’ (Tileston, 2013,

p. 403).

Prior to starting this internship I was not very familiar with eating disorders despite the

fact that I have had three people close to me in my life suffer from two of the three disorders

listed. Working in the mental health field during this time I learned that people with eating

disorders might also have concurring psychiatric symptoms and diagnoses like depression,

anxiety, obsessive compulsive disorders, social phobias, borderline personality disorder,

posttraumatic stress disorder (PTSD), bipolar disorder or dissociative disorder (Tileston, 2013).

They may also engage in self-harming behaviors like cutting or burning themselves. Both of

these symptoms can be seen in individuals with Borderline Personality Disorder. Substance

abuse can also occur along with an eating disorder and it is especially high in people with BN at

9-55% and AN at 12-21% (Tileston, 2013).

Music Therapy has been shown to be effective in treating people with eating disorders

and can be classified as Behavioral Music Therapy, Cognitive Music Therapy, Psychodynamic

Music Therapy or Medical Music Therapy. Each of these approaches has different goals and

objectives for the client depending on the method being used and can vary from individual to

individual. Barbara Wheeler identified the following levels of music therapy practice when

working with clients with an eating disorder: supportive, activity-oriented therapy, insight music

therapy with re-educative goals, and insight music therapy with re-constructive goals (Siegel,

2007).

Due to its un-invasive nature music therapy has been shown to be effective for

individuals with an eating disorder but the research literature in the field is still growing.

Common goals for eating disorder clients in Music Therapy may include: increase self-esteem
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and sense of self; decrease anxiety associated with mealtimes, explore thoughts and emotions

directly related to a client’s ED, introduce healthy coping skills, establish healthy interpersonal

relationships, learn to identify cognitive distortions and replace them with recovery-minded

thoughts.

Outpatient settings are typically used in treating eating disorders. In these settings

different professionals may focus on an individual’s self-awareness, feeling and behaviors and

locus of control (Justice, 1994). If a person’s eating disorder has become so severe that they are

in medical danger then inpatient setting may be necessary until the patient is stable enough to

continue in treatment as an outpatient. Music therapy in the inpatient setting is helpful because it

can provide support, giving the patients a better sense of self-control; allow the patient new ways

of expressing themselves; help them to cope with emotions and make connections with other

people.

Justice (1994) identified some useful music therapy interventions for patients in an

inpatient setting including: music reinforced relaxation techniques, structured music therapy

group techniques, and insight oriented music/creative arts and imagery techniques. Music-

reinforced relaxation is used to help a client cope with anxiety and stress and at the same time

offer them different ways in which to deal with them. The techniques used in these interventions

include stretching with music, progressive muscle relaxation with music, breathing with music,

and music guided imagery (Justice, 1994).

Structured music therapy group techniques such as music and movement, handbells and

choir chimes, group singing, and instrumental improvisation can address issues a patient may

have such as building healthy interpersonal skills. Allowing them to be successful in a group

setting this method can also be more comfortable for a patient than a verbal therapy group. The
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end result of this approach is the patient seeing themselves as an integral part of the group

changing how they view themselves, and giving a greater value to them as person; one that is not

based purely on body weight (Justice, 1994).

An Insight-oriented music/creative arts technique focuses on the underlying meaning for

a person’s eating disorder, and often this is body image. Using techniques of Bonny Guided

Imagery and Music it is meant to give the patient greater insight into their eating disorder by

using a symbolic approach and allowing them to connect with deeper issues. The chosen

symbols and metaphors can further be solidified through either graphic arts or writing (Justice,

1994).

Cognitive Behavioral Music Therapy has been shown to be effective in treating women

in a residential eating disorder treatment center. Hilliard (2001) found that by taking elements of

Cognitive Behavioral Therapy and mixing it with elements of music therapy, to create CBMT, it

was useful for assisting clients in three areas of their eating disorders: behavioral, cognitive

distortions; faulty thinking and irrational beliefs. CBMT also addressed the following needs for

the clients: behaviors, which serve the eating disorder and underlying issues inherent in the

patient with the eating disorder (Hilliard, 2001).

The CBMT techniques used in the three stages of treatment included music and

progressive relaxation, music and breathing, music and movement, and music and imagery.

Music was also used to decrease anxiety during mealtimes and allow patients to eat their meals.

Sing alongs, song-writing, and musical games acted as cognitive divergences after mealtimes

allowing the patients to digest their food and decreasing the need to purge after a meal. Lyric

analysis was also used in addition to songwriting and these interventions focused on increasing
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self-esteem, embodying a sense of empowerment, and challenging negative and self-defeating

body distortions (Hilliard, 2001).

Males also can suffer from an eating disorder and both Trondalen and Skarderud (2007)

discuss this in their Nordic Journal of Music Therapy article about a 19-year-old young adult

with anorexia nervosa. Using the music therapy approach of free improvisation and focusing on

the elements of form, intensity and timing during the sessions the concept of affect attunement is

explored.

Affect attunement is the “sharing of inner feeling states” (Skarderud, 2007, p. 100) and in

this case it is through two people: the client and therapist. Analyzing the musical improvisations

of one session and focusing on the six elements of absolute intensity, intensity contour, temporal

beat, duration, and shape showed how, through music, an anorexic may view their emotional

self. This insight can be then used in daily life as the patient better learns how to cope with and

better express emotions while also interacting with others (Skarderud, 2007).

Improvisation was also used in the music therapy sessions of a German woman who

suffered from bulimia nervosa (Bauer, 2010). The patient attended a once-a-week session for 10

months with a music therapist and focused on the goals of eating normally, regaining physical

strength, and feeling better emotionally, especially around her boyfriend. The patient also

focused on self-esteem, recognition, and attachment and addressed these issues each week with

the therapist through different modes of instrument play. By the therapist “just being there”

(Bauer, 2010, p. 10) and supporting her during the music making the woman was able to develop

a stronger sense of Self, strengthening her interpersonal contact and allowing her to eventually

discontinue music therapy and begin to couples’ therapy with her boyfriend. She was also able to

significantly cut back on her binge eating (Bauer, 2010).

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A study done at an Australian inpatient eating disorder clinic for clients with anorexia

nervosa (Jennifer Bibb, 2015) found that by using music therapy directly after mealtimes as a

distress tolerance technique, it was more supportive than standard post meal therapy. Music

therapy acted as a cognitive divergence and allowed the patients to digest their food and focus

their attention on an activity that was more engaging for them. Using interventions such as

singing and listening to songs, talking about and sharing music with others, and group

songwriting allowed the patients to practice coping skills while at the same be distracted from

post-meal anxiety. The music therapist also practiced unconditional positive regard, encouraging

group members to listen to each other and discuss song lyrics and their own musical tastes. This

approach is a less direct than the one taken in cognitive behavioral therapy (Jennifer Bibb, 2015).

Eating disorders have been shown to affect both males and females. While the research is

still in the early stages for the efficacy of music therapy with these disorders the above examples

are just a few of the ways in which it has been shown to be beneficial to both patients in inpatient

and outpatient settings. Using the methods of receptive music therapy, improvisational music

therapy, re-creative music therapy, or compositional music therapy in addition to a client’s other

traditional treatment modalities, such as psychotherapy, music therapy can be a valuable

component of an individual’s overall recovery process from an eating disorder.

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References

Bauer, S. (2010). Music therapy and eating disorders- A single case study about the sound of
Therapy: https://normt.uib.no/index.php/voices

Hilliard, R. E. (2001). The use of cognitive-behavioral music therapy in the treatment of women
with eating disorders. Music therapy perspectives , 19, 109-113.

Jennifer Bibb, D. C. (2015). The role of music therapy in reducing post meal related anxiety for
patients with anorexia nervosa. Journal of Eating Disorders , 3 (50), 1-6.

Justice, R. W. (1994). Music therapy interventions for people with eating disorders in an
inpatient setting. Music Therapy Perspectives , 12, 104-110.

Siegel, S. (2007). Music therapy practice for clients with eating disorders. In M. M.-B.-B.
Barbara J. Crowe (Ed.), Effective clinical practice in music therapy: Music therapy for
children, adolescents, and adults with mental disorders (pp. 165-175). Silver Spring,
MD: American Music Therapy Association.

Skarderud, G. T. (2007). Playing with affects......and the importance of "affect attunement".

Nordic Journal of Music Therapy , 16 (2), 100-111.

Tileston, P. (2013). Adults and adolescents with eating disorders. In L. Eyre, Guidelines for
Music Therapy Practices in Mental Health. Barcelona.

Various. (2015). Eating Disorder Statistics and Research. Retrieved June 10, 2016, from Eating
Disorder Hope: www.eatingdisorderhope.com/information/statistics-studies