PhD Thesis by Timothy Honig

This research project examines GIM as a therapeutic approach specifically for persons who have depression. GIM is a music-centered integrative therapeutic method in which specially designed music programs facilitate client imagery experiences in non-ordinary states of consciousness.

PhD Thesis by Timothy Honig: Guided Imagery and Music (GIM) For Persons With Depression. A Three-Part Investigation.

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This project constitutes a systematic investigation of Guided Imagery and Music (GIM) as a therapeutic method for working with persons who have depression. GIM is a music-centered integrative therapeutic method in which specially designed music programs facilitate client imagery experiences in non-ordinary states of consciousness. With the support of the therapist, these experiences provide transformative spaces for growth. Prior research has shown that a series of GIM sessions can lead to positive mood-related outcomes for persons with a variety of physical and mental health concerns. In addition, case studies have documented GIM as a therapeutic method that can be used with persons who have depression. This research project examines GIM as a therapeutic approach specifically for persons who have depression.

This thesis is composed of three articles and this linking text. The central focus was a feasibility randomized controlled trial examining the therapeutic effects of a series of GIM sessions for persons with depression as well as the feasibility of studying these effects within a randomized controlled design. In relation to the feasibility study, this thesis also includes investigations of the therapeutic method itself by designing a tool to describe what occurs in GIM sessions and by exploring similarities and differences between in-person and telehealth formats of GIM sessions.

Article 1 describes the development of the GIM Treatment Fidelity Instrument. A preparatory step for the feasibility study, this instrument was designed as a way to monitor treatment fidelity in GIM sessions in order to establish internal and external validity when investigating this complex and highly individualized therapeutic method. The instrument was created in collaboration with a mixed group of GIM therapists, trainers, and researchers and was piloted in 28 individual GIM sessions that were conducted by two GIM providers. It provides a descriptive rather than prescriptive model for monitoring treatment fidelity within objectivist GIM research.

Article 2 describes a multi-site feasibility randomized controlled trial (RCT) investigating therapeutic outcomes of a series of GIM sessions with persons who have depression. The study was framed within the post-positivist research paradigm and utilized an effectiveness design. The primary research aim was to investigate the feasibility of the research design, and the secondary aim was to examine effects on depression, anxiety, stress, and mental wellbeing. N = 14 participants were randomly assigned to receive either a series of 10 biweekly individual GIM sessions, or an equivalent waiting period followed by four group GIM sessions. Data were gathered at four timepoints. Due to the onset of the COVID-19 pandemic midway through the research study, enrollment was terminated early before reaching the targeted sample of N = 28. At that time, all research procedures involving in-person contact were suspended for approximately 6 months before resuming sessions online via telehealth

and completing research procedures for all participants who had already enrolled. Feasibility results showed that a series of 10 individual GIM sessions had high safety, acceptability, and tolerability, and that they required minimal variation from the traditional GIM session method when used with persons who have depression.

Results also indicated that GIM sessions could be successfully shifted to a telehealth format. The waitlist control group was suitable as a comparator group. With minor alterations to the data collection instruments and procedures, the design was found to be feasible for a larger-scale trial. Outcome results were limited by the small sample size and numerous confounds that resulted from adaptations to the COVID-19 pandemic.

ART-ANOVA tests revealed no significant effects for depression, anxiety, stress, or mental well-being. Within the GIM group, highly exploratory post-hoc Wilcoxon Signed Rank tests revealed small, medium, and large effect sizes for the dependent variables at midpoint, which attenuated at subsequent timepoints. More research with adequately-sized samples is warranted to further investigate therapeutic outcomes of a series of GIM sessions for persons who have depression. Additionally, future research should explore under what conditions telehealth GIM may be a viable alternative to in-person sessions.

Article 3 followed up on the feasibility RCT by exploring participants’ experiences of shifting from in-person to telehealth GIM sessions, an adjustment made in response the COVID-19 pandemic. Utilizing an interpretivist design, the research aims were to examine participants’ experiences of shifting from in-person to telehealth sessions during the feasibility RCT and to explore possible similarities and differences between how participants experienced GIM sessions in telehealth versus in-person formats. Two participants from the feasibility RCT were selected using purposive sampling and engaged in interviews on their experiences of shifting to a telehealth format of GIM.”. Thematic analysis revealed four emergent themes: Participants experienced telehealth sessions to be effective overall, but generally less powerful than in-person sessions. Their relationship with their GIM provider was important to their experiences; however, the telehealth sessions initially felt less personal. Their experiences were affected by the combined home and virtual setting. Finally, the participants’ experiences of telehealth sessions became more positive as they gained familiarity with the format. More research is needed to better understand indications and contraindications for telehealth GIM, to explore whether a series of GIM sessions can be initiated safely via telehealth, and to gain the perspectives of GIM therapists on telehealth sessions.

This linking text outlines the research framework for this thesis, including the theoretical grounding for Guided Imagery and Music as a therapeutic method. It also includes a discussion of the pragmatist research approach that undergirds this thesis, which frames the complementary research paradigms employed in each of the three articles. This discussion provides a space for reflections on the ontological, epistemological, and methodological aspects of each of the articles. These reflections include important methodological considerations and decisions that shaped each of the three articles, including ways in which ethical care of the participants was considered at each stage of this thesis.

After providing summaries of each of the articles, the final chapter of this linking text weaves together the findings of the three articles. Integration of the overall findings leads to a discussion of clinical and methodological implications for GIM practice and research. Then, two case descriptions add detail to the integrated findings and illustrate the methodological complementarity among the three articles. The text closes with conclusions and limitations for this thesis, as well as directions for future research.

This research was funded in part by grants from the Mid-Atlantic Region of the American Music Therapy Association (MAR-AMTA) and the Association for Music and Imagery (AMI) and was supported by a PhD scholarship from Aalborg University.

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