Running head: MUSIC IN EATING DISORDER TREATMENT 1 Music-Based Interventions in the Treatment of Eating Disorders: 1 A Scoping Review 2 3 Annie Heiderscheit1*, Julia Gawronska2, Jodie Bloska1, Anya Ragnhildstveit3, 4 Thandi Milton4, Sharon A.S. Neufeld3 5 6 1 Cambridge Institute for Music Therapy Research, Anglia Ruskin University, Cambridge, 7 UK 8 2 Centre for Health, Performance, and Wellbeing, Anglia Ruskin University, Cambridge, UK 9 3 Department of Psychiatry, University of Cambridge, Cambridge, UK 10 4 Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK 11 12 Corresponding Author: Annie Heiderscheit, PhD, MT-BC, MFT; Professor of Music 13 Therapy and Director of the Cambridge Institute for Music Therapy Research, Anglia Ruskin 14 University, Faculty of Arts, Humanities, Education and Social Sciences, Cambridge School of 15 Creative Industries, CB1 1PT, England, United Kingdom. Email: 16 annie.heiderscheit@aru.ac.uk; ORCID ID: https://orcid.org/0000-0002-8311-7188 17 18 Keywords: music therapy1, music-based interventions2, eating disorders3, scoping 19 review4 20 21 Acknowledgements: S.A.S.N. was supported by the Wellcome Trust Early-Career Award 22 (226392/Z/22/Z). A.R. was supported by the Reginald John Smith Studentship; the King’s 23 College Studentship; the Cambridge Commonwealth, European, and International Trust; and 24 the NIHR Cambridge Biomedical Research Centre in partnership with the Cambridgeshire and 25 Peterborough NHS Foundation Trust (G127435). All research in the Department of Psychiatry 26 at the University of Cambridge is supported by the NIHR Cambridge Biomedical Research 27 Centre (NIHR203312) and the NIHR Applied Research Collaboration East of England. The 28 views expressed are those of the authors and not necessarily those of the NIHR or the 29 Department of Health and Social Care. The funders had no involvement in the collection, 30 analysis, or interpretation of data, writing of the report, or the decision to submit the article for 31 publication. 32 33 mailto:annie.heiderscheit@aru.ac.uk https://orcid.org/0000-0002-8311-7188 Running head: MUSIC IN EATING DISORDER TREATMENT 2 34 35 36 AUTHOR INFORMATION 37 38 Annie Heiderscheit, PhD., MT-BC, MFT1* 39 annie.heiderscheit@aru.ac.uk 40 ORCID ID: 0000-0002-8311-7188 41 42 Julia Gawronska, PhD2 43 julia.gawronska@aru.ac.uk 44 ORCID ID: 0009-0008-1766-9719 45 46 Jodie Bloska, MA1 47 jodie.bloska@aru.ac.uk 48 ORCID ID: 0000-0001-9647-1437 49 50 Anya Ragnhildstveit, BSc3 51 amr210@cam.ac.uk 52 ORCID ID: 0000-0002-5796-3428 53 54 Thandi Milton, MD, MSc4 55 thandi.milton@nhs.net 56 ORCID ID: 0000-0003-2444-1217 57 58 Sharon A.S. Neufeld, PhD3 59 sasn2@medschl.cam.ac.uk 60 ORCID ID: 0000-0001-5470-3770 61 62 63 64 65 66 67 mailto:annie.heiderscheit@aru.ac.uk mailto:julia.gawronska@aru.ac.uk mailto:jodie.bloska@aru.ac.uk mailto:amr210@cam.ac.uk https://orcid.org/0000-0002-5796-3428 mailto:thandi.milton@nhs.net mailto:sasn2@medschl.cam.ac.uk Running head: MUSIC IN EATING DISORDER TREATMENT 3 ABSTRACT 68 Introduction: Eating disorders (EDs) are potentially life-threatening conditions characterized 69 by persistent eating- and body-related disturbances that negatively impact nutritional intake, 70 psychological well-being, and physical health. While psychological therapies remain the 71 primary treatment for patients with EDs, music-based interventions (MBIs) show significant 72 promise for addressing symptoms in clinical practice. However, little is known about the 73 methods employed in these interventions or their effectiveness in addressing or improving 74 ED outcomes. 75 76 Methods: Following PRISMA-ScR guidelines, we conducted a scoping review of the 77 literature. Eight electronic databases were systematically queried from inception to May 2025 78 for studies evaluating MBIs in patients engaged in ED treatment. Data regarding study 79 design, sample characteristics, intervention components, and primary outcomes were 80 extracted and analysed utilising either reflexive thematic analysis or descriptive statistics. The 81 quality of intervention reporting was additionally examined utilising the established MBI 82 reporting guidelines. 83 84 Results: Of the 114 articles screened, 21 met inclusion criteria. The final sample comprised 85 10 case studies, 6 qualitative studies, 4 quantitative studies, and 1 mixed methods study, with 86 all but one conducted in high-income countries. Settings included inpatient (n = 12), 87 outpatient (n = 7), and combined (n = 2) ED programs. Most MBIs involved music therapy 88 (n = 18), while others incorporated vibroacoustic therapy (n = 1), background music during 89 mealtimes (n = 1), and group singing (n = 1). Delivery formats encompassed individual (n = 90 14), group (n = 5), and hybrid (n = 1) sessions, or were not indicated. Qualitative synthesis 91 identified seven themes reflecting symptom management, self-development, and treatment 92 engagement. Quantitative studies reported improvements in anxiety, mood, ED symptoms 93 and increased food eaten and weight gain. However, robust conclusions were limited by 94 small sample sizes, a lack of control group, non-randomisation, or another intervention being 95 implemented with the MBI. Overall, reporting of MBI components was inconsistent, with a 96 mean completeness of 45–100%. 97 98 Discussion: To our knowledge, this is the largest scoping review to map the breadth and 99 depth of studies assessing MBIs in ED treatment. Preliminary evidence supports positive 100 psychological and behavioural outcomes for patients with EDs. However, conclusions are 101 Running head: MUSIC IN EATING DISORDER TREATMENT 4 limited by lack of methodological rigor, variable outcome measures, and inconsistent 102 reporting of intervention components or theoretical framework. The complex and 103 multifaceted nature of EDs and high rates of comorbidities and trauma histories further 104 complicates interpretations. To advance research and clinical application of MBIs in ED care, 105 standardized approaches to intervention design and reporting are needed, as well as 106 randomised controlled studies clearly testing MBIs against other interventions. 107 108 109 INTRODUCTION 110 Individuals diagnosed with eating disorders (EDs) present with a variety of eating-related 111 behaviours that negatively impact nutritional intake, affect psychological and psychosocial 112 wellbeing, and result in somatic complications1,2. ED diagnoses (including anorexia nervosa, 113 bulimia nervosa, binge eating disorder and other specified feeding or eating disorders) have 114 an onset at the developmentally vulnerable period of adolescence (ages 15-25 years), with a 115 peak age onset of 15.5 years and an average duration of six years3,4. Further, mortality rates 116 for individuals with EDs are higher than the general population: a six times higher mortality 117 rate for those with anorexia nervosa (AN), and a doubled mortality rate for those with other 118 EDs5. 119 Research indicates significant increases in EDs over the past two decades6,7,8. An 120 estimated 55.5 million people globally were living with an ED in 20199. In 2020, during the 121 COVID-19 pandemic, there was a reported 15% increase in the incidence of EDs10,11. 122 Overall, the data indicate a worsening burden of the illness7 and an increase in the associated 123 treatment and economic costs due to an increasing prevalence of EDs12. 124 The complex profile of ED patients is exacerbated by multiple comorbidities, with an 125 estimated 56%-95% presenting with an additional psychiatric disorder, depending on the type 126 of ED13,14,15. The most prevalent comorbidities are substance use disorders (SUD), ranging 127 from 20% to 51%16, followed by post-traumatic stress disorder (PTSD) at 25%17. Further, 128 33% of individuals with EDs have experienced sexual trauma and 21% physical assault18,19. 129 Perfectionism, and impaired affect regulation and cognitive processing are common features 130 in EDs which complicate treatment20,21. Additionally, there are a myriad of medical 131 complications associated with EDs because of malnutrition, purging, laxative abuse, 132 excessive exercise, and weight loss22,23. Thus, ED behaviours can impact every system of the 133 body, resulting in gastrointestinal, dermatologic, endocrine, neurological, haematological, 134 pulmonary, and cardiac issues and abnormalities24-29. 135 Running head: MUSIC IN EATING DISORDER TREATMENT 5 ED treatment programs apply psychological therapies, which address different 136 presenting issues common to individuals with EDs30. Therapies include cognitive behavioural 137 therapy (CBT), dialectical behaviour therapy (DBT), family-based therapy (FBT), and 138 interpersonal therapy (IPT)31. The focus of CBT is on addressing thoughts and feelings as 139 these relate to and impact ED behaviours31. DBT addresses issues related to affect regulation 140 and how this impacts ED behaviours32,33. FBT focuses on engaging families as a resource to 141 help make changes to reduce and eliminate ED behaviours34. IPT aims at addressing 142 interpersonal issues and how disordered eating and ED behaviours impact relationships35. 143 However, estimates indicate that ED treatment is effective for about 50% of individuals36, 144 suggesting that ED treatment needs further development to more adequately address the 145 complex matrix of ED behaviours37,38. 146 147 Music-based interventions in eating disorder treatment 148 Music-based interventions (MBIs) include a broad range of practices that utilise 149 music to support health and wellbeing. These can integrate the use of music in various ways, 150 including listening to, singing, playing, composing, and improvising music39. MBIs can be 151 distinguished by the way one engages with the music (for example, listening to songs and 152 discussing them, listening to instrumental music for relaxation, actively playing instruments 153 or singing songs, improvising instrumentally or vocally, composing a song or instrumental 154 music) and by who facilitates the MBI. MBIs may be facilitated by qualified music therapists 155 (music therapy) or other healthcare professionals (non-music therapists) as well as musical 156 experiences led by community musicians or the use of self-selected music implemented by 157 the client themselves39. The accessible nature and myriad ways of engaging with music 158 allows for the use of MBIs in various contexts and for a range of client needs, across 159 therapeutic and community-based settings27. While music therapy is encompassed in this 160 broad category, it is a specialist-delivered intervention differentiated by formal training and 161 qualification. Music therapists are allied health professionals trained in a wide range of music 162 therapy theories, approaches and methods to address therapeutic goals across clinical 163 populations. Music therapists use both active and receptive methods, adapting sessions 164 reflexively to meet emerging and changing needs of the individual or group throughout the 165 therapeutic process40-42. MBIs therefore can encompass a continuum of music use for 166 wellbeing, from personal use to specialist music therapy sessions43. 167 There has been a recent increase in reviews evaluating the use and potential outcomes 168 of music in people with or at risk of EDs44-47. Testa et al. completed a systematic review that 169 Running head: MUSIC IN EATING DISORDER TREATMENT 6 included 16 studies examining the effects of music in people with EDs or at risk of EDs. 170 Studies were limited to experimental or observational designs which reported measurable 171 outcomes, and thus only one qualitative study was included44. Results indicated that listening 172 to music improved nutritional intake, group singing reduced anxiety after meals, while 173 songwriting assisted in processing various therapeutic issues. A recent systematic review of 174 controlled studies utilizing music therapy in ED treatment found no randomised studies and 175 only two relevant publications from one treatment-as-usual (TAU) controlled study45. Pre-176 post results (quantitative and qualitative) indicated a decrease in post-meal stress and anxiety 177 following 1-hour music therapy group sessions twice per week, which was greater for the 178 music therapy intervention than TAU48,49. The group sessions integrated various music 179 therapy methods such as singing, listening to music, and songwriting. Chang et al. conducted 180 a narrative systematic review that evaluated therapeutic outcomes in individuals with EDs, 181 where music was a component of the intervention46. Results from 16 quantitative, qualitative 182 and mixed methods studies indicated that the intervention improved mood regulation, helped 183 manage distress associated with mealtimes, and improved emotional wellbeing. The authors 184 indicate generalisability of the results is limited due to small sample sizes (16 studies ranged 185 from 3 to 20 participants) and the lack of detailed information about the MBIs. While in a 186 recent systematic review exploring the extent to which music therapy and systemic or family-187 based therapy is integrated into ED treatment, the examination of 26 studies revealed 188 common parallels across where both facilitated embodiment and interconnectedness, served 189 as a gateway of deeper engagement with self and illness, fostered and self-expression, and 190 supported emotion regulation47. 191 Each of these systematic reviews have captured a corpus of the literature, helping to 192 explicate the use of music in the context of EDs or subclinical disorder. However, there has 193 been a lack of singular focus on studies where music is a key component to the intervention, 194 which is instrumental to a clearer understanding of the impact of MBIs. For example, all the 195 above reviews except one45 included studies where background music was played in a video, 196 but music was not a focus of the intervention. Further, systematic reviews can limit the type 197 of research literature included, resulting in rich therapeutic descriptions from clinical case 198 studies being excluded. A recent study revealed widespread adaptation of music therapy 199 methods to meet the needs of patients in ED treatment50. Case studies illustrating these varied 200 and nuanced ways of delivering and engaging with MBIs would further inform literature 201 reviews and support clinicians employing MBIs in building an evidence-based practice. 202 Running head: MUSIC IN EATING DISORDER TREATMENT 7 Therefore, the aim of this scoping review was to encompass studies where music 203 comprised an essential component of the intervention in a therapeutic ED setting, including 204 case studies to contextualise and more comprehensively understand the use of MBIs in the 205 context of ED treatment. A challenge in reviewing and evaluating MBIs in research is that 206 there is often a lack of clarity in the literature due to inconsistent terminology and quality of 207 reporting51,52. As a result, MBI reporting guidelines were introduced in an effort to improve 208 the transparency and specificity of MBIs as well as to evaluate the quality of the research and 209 ensure that it can be replicated51. The present scoping review therefore also expands on prior 210 systematic reviews by examining the clarity of reporting based on these MBI reporting 211 guidelines. 212 213 METHODS 214 A scoping review of the literature was conducted, using a systematic and iterative approach 215 to evidence synthesis. This adhered to the Preferred Reporting Items for Systematic Reviews 216 and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines53 and was pre-217 registered with the Open Science Framework (osf.io/4xv9f). 218 219 Search strategy 220 Eight electronic databases were queried for relevant articles from inception to May 2025, 221 including MEDLINE (National Library of Medicine), Embase (Elsevier), Scopus (Elsevier), 222 APA PsycArticles (American Psychological Association), APA PsycINFO (American 223 Psychological Association), Psychology and Behavioural Sciences Collection (EBSCO), Web 224 of Science (Clarivate), and Cochrane Library (The Cochrane Collaboration). The following 225 search terms were applied: (music therapy OR music-based intervention OR guided imagery 226 and music OR songwriting OR song composition OR drumming OR music listening OR 227 music improvisation OR song discussion OR active music making) AND (eating disorders 228 OR anorexia nervosa OR bulimia nervosa OR binge eating disorder OR pica OR rumination 229 disorder OR avoidant restrictive food intake disorder OR unspecified feeding OR eating 230 disorder). There were no restrictions on publication date or status; however, articles were 231 filtered by subject (humans only), study type (peer-reviewed), and language (English). In 232 addition to database searches, reference lists and relevant conference abstracts were hand-233 searched to identify supplementary eligible studies. 234 235 https://osf.io/4xv9f Running head: MUSIC IN EATING DISORDER TREATMENT 8 Study selection 236 The following inclusion criteria were applied to evaluate eligibility in the qualitative 237 synthesis: (1) patients of any age and sex with a primary ED diagnosis; (2) MBIs (i.e. any 238 intervention utilising music as a core component, including music therapy and other non-239 music therapist delivered music experiences used in the treatment or management of EDs 240 across any clinical or community setting; (3) qualitative, quantitative, and mixed methods 241 studies, whether prospective or retrospective, including case reports; and (4) peer-reviewed 242 articles and published in the English language. To ensure breadth and relevance, inclusion 243 was not limited by study design, publication status, or geographical location. Primary 244 outcomes of interest encompassed physical and mental health following the implementation 245 of MBIs. We included all study designs, excluding review articles, book chapters, nonhuman 246 studies, conference abstracts, and articles in a language other than English. Studies were 247 excluded if ED was not the primary diagnosis, if the MBI was not a key component of the 248 intervention, or the paper was not available in English. Screening of the articles was 249 independently performed by four reviewers (AH, AR, JB, JG). Any disagreements were 250 resolved during discussions between the reviewers. 251 252 Data charting 253 Data from eligible studies were charted by five independent reviewers (AH, AR, JB, JG, 254 TM), including two (JG, TM) with no prior content knowledge of the topic. This approach 255 allowed for both subject-matter expertise and naïve interpretation, helping to minimize 256 potential bias while enhancing objectivity and transparency. Using a standardised charting 257 form created in Microsoft Excel, the following variables were extracted: author, publication 258 year, country, study design, and outcome measures; sample size, participant age, and ED 259 diagnosis; intervention type, duration, and setting; and primary outcomes and any other 260 pertinent findings. Details were recorded when studies indicated the facilitator’s theoretical 261 approach and methods or techniques used. A sixth reviewer (SASN) examined all extracted 262 data to ensure alignment with inclusion criteria and internal consistency. Discrepancies were 263 resolved through team consensus. The charting form was updated iteratively to accommodate 264 emerging themes and variations in data reporting across studies. 265 266 267 268 269 Running head: MUSIC IN EATING DISORDER TREATMENT 9 Evidence synthesis 270 Qualitative and quantitative studies were summarised in a narrative format. Qualitative data 271 were then analysed thematically. Additionally, evaluation of MBI reporting for each study 272 was also conducted following established MBI reporting guidelines51,54. 273 274 Figure 1 Flowchart of search process 275 276 277 278 279 280 Running head: MUSIC IN EATING DISORDER TREATMENT 10 Qualitative data analysis 281 Qualitative data was integral to 17 of the studies and was initially reviewed by one research 282 team member (AH) to begin the reflexive thematic analysis. This process entailed reviewing 283 and coding the data following the six-step process55,56. Emergent themes were identified 284 based on integrating the outcome data from these studies. This iterative process included 285 grouping themes into categories of similar orientation. The next step involved examining 286 these categories to identify points of connection and patterns. This led to developing 287 subordinate themes which were then reviewed by all members of the research team and 288 integrated into a comprehensive framework. When discrepancies emerged, the reviewers 289 returned to the data to inform their discussion and understanding of the themes. This iterative 290 process continued until reviewers (AH, SN) reached a mutually agreeable decision. 291 Following this, other research team members were asked to complete a final review of the 292 themes to ensure full team consensus. 293 294 RESULTS 295 The literature search identified 152 relevant citations. After removing duplicates and 296 conducting title and abstract screening, 56 articles remained for further evaluation. Full texts 297 of all potentially eligible papers underwent a thorough review, resulting in the exclusion of 298 35 articles. After careful consideration, 21 articles met all the criteria and were included in 299 the scoping review. The PRISMA flow diagram illustrating the study selection process can be 300 seen in Figure 1. 301 302 Study characteristics 303 Study characteristics and participant demographics are reported in Table 1 (qualitative 304 studies) and Table 4 (quantitative studies) including country of publication, study design, 305 sample size, participants' age, gender, participant diagnostic information, type of music 306 intervention, source of outcome assessment used, setting, and assessment based on reporting 307 guidelines. This included identifying how many of the 11 recommended and relevant 308 components from the 7 criteria were included in the MBI reporting of the study50,53. The 309 component of treatment fidelity was not included in evaluating case reports as it is not 310 relevant to this type of research. 311 The majority of included studies were carried out in Europe (n=10) followed by North 312 America (n=6), Australia (n=4), Asia (n=1), for studies with available data. Overall, 254 313 participants (range:1-66) were included from ages 11 to 62 for studies with available data. 314 Running head: MUSIC IN EATING DISORDER TREATMENT 11 The research methods used were primarily qualitative (n=16), with the remainder quantitative 315 (n=4) or mixed-methods (n=1). Most studies reported on anorexia nervosa (n=19), followed 316 by bulimia nervosa (n=7), binge eating disorder (n=4), other specified feeding or eating 317 disorder (n=4), emotional eating (n=1), chronic dieter (n=1), and eating disorder not 318 otherwise specified (n=4). Evaluation of reporting guidelines differed across studies, with a 319 range of 45-100% and a mean of 76%, equivalent to reporting on nearly 8 of the 11 320 components. 321 322 Table 1 General characteristics of qualitative studies 323 324 Author, Year Country Study design Total N Age Female % Eating disorder Music intervention( s) Outcome Assessment Setting Reporting guidelines Bauer, 201057 Germany Case study (pre- post) 1 28 100 Bulimia nervosa Individual Music therapy (Instrumental improvisation) Therapist observation Inpatient 100% Fendel et al., 201858 Germany Qualitat ive intervie ws post- interven tion 20 M: 28.3 100 Anorexia nervosa1 Individual vibro-acoustic stimulation Subjective bodily experiences during treatment explored through semi- structured interview Inpatient 45% Heal and Hara, 199359 UK Case study 1 28 100 Anorexia nervosa1 Individual music therapy (Instrumental improvisation and song composition) Therapist observation Outpatien t 91% Heidersc heit and Madson, 201560 US Case study 1 57 100 Eating disorder not otherwise specified1 Individual music psychotherapy (Song/music collage/playlist ) Self-reported measures of depression (10-Point Likert Scale), anecdotal reports and clinical observations Outpatien t 91% Heidersc heit and Murphy, 202161 US Case study 1 27 100 Anorexia nervosa1 Individual music therapy (Music relaxation, directed music imaging, stimulative music listening, toning, and chanting) Anecdotal reports and clinical observations Outpatien t 91% Running head: MUSIC IN EATING DISORDER TREATMENT 12 Heidersc heit, 202362 US Qualitat ive 8 M: 36, R: 23- 58 100 Anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder1 Individual music psychotherapy (Bonny Method of Guided Imagery) Self-reported measures of feasibility and helpfulness, thematic analysis of feedback Both, inpatient and outpatient 100% Heidersc heit, 202463 US Qualitat ive 8 M: 36, R: 23- 58 100 Anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder1 Individual music psychotherapy (Bonny Method of Guided Imagery) Thematic and intertextual analyses of GIM session transcripts Both, inpatient and outpatient 100% Hilliard, 200164 US Case study NR R:14 -55 NR Eating disorder not otherwise specified1 Group & individual music therapy (songwriting, singing, drumming, and song discussion) Anecdotal reports and clinical observations Inpatient 82% Lejonclo u and Trondale n, 200965 Sweden Case study 2 R:19 -35 100 Anorexia nervosa, bulimia nervosa Individual music therapy (Song discussion, Instrumental improvisation, song composition, singing and music and movement) Descriptions of the two patients' experiences, observations, drawings, and writings; therapist observation Inpatient 82% McFerra n et al., 200666 Australia Qualitat ive (analysi s of patients ’ song lyrics) 15 M: 15, R: 12- 17 100 Anorexia nervosa Individual music therapy (songwriting) Lyric analysis - a modified content analysis approach to categorise the lyrics f0-0rom songs written by the patients into different themes Inpatient 64% Running head: MUSIC IN EATING DISORDER TREATMENT 13 McFerra n et al., 200867 Australia Qualitat ive (analysi s of patients ’ song lyrics) 15 M: 15, R: 12- 17 100 Anorexia nervosa Individual music therapy (songwriting) Lyric analysis - a modified content analysis approach to categorise the lyrics from songs written by the patients into different themes Inpatient 64% Pavlakou , 200968 UK Qualitat ive 8 R: 18- 62 100 Bulimia nervosa, anorexia nervosa, binge eating, chronic dieter, emotional eating Group singing workshop Descriptions of the patients' experiences, diaries, thematic analysis of feedback Outpatien t 82% Robarts and Sloboda, 199469 UK Case study 2 M: 15.5, R: 11- 20 100 Anorexia nervosa Individual music therapy (Instrumental improvisation) Therapist observation Inpatient 91% Robarts, 200070 UK Case study 1 14 100 Anorexia nervosa1 Individual music therapy (Instrumental improvisation) Therapist observation Inpatient 91% Shah et al., 202171 Canada Mixed- method s design (pre- post and focus groups as well as verbal and music contribu tions in music therapy) 21 R: 16- 58 95 Anorexia nervosa, bulimia nervosa1 Group music therapy (Instrumental improvisation, singing, drumming, music listening) Self-reported measures of Positive and negative affect scale, Difficulties in emotion regulation scale, Emotion regulation questionnaire, therapist observation, transcripts from focus groups. Inpatient 73% Running head: MUSIC IN EATING DISORDER TREATMENT 14 Trondale n and Skårderu d, 200772 Norway Case study 1 19 0 Anorexia nervosa Individual music therapy (Instrumental improvisation) Musical improvisation sessions recorded, semi- structured interview after therapy, therapist's reflective notes Outpatien t 91% Trondale n, 200373 Norway Case study 1 26 100 Anorexia nervosa Individual music therapy (Instrumental improvisation and music listening) Therapist observation Outpatien t 91% 1 indicates studies that reported comorbid mental health diagnoses which included Bipolar Disorder, Borderline Personality 325 Disorder, Dissociative Identity Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, Obsessive Compulsive 326 Disorder, and Post-traumatic Stress Disorder, Substance Use Disorder. 327 328 Table 2 General characteristics of quantitative studies 329 Auth or, Year Count ry Study design Tot al N Age Female % Eating Disorder MBI(s) Outcome Assessment Setting Reporting guidelines Bibb et al., 20154 48 Austra lia Non- randomi sed pre- post design, pilot study 18 R:20- 58 94 Anorexia nervosa Group music therapy (Singing, song discussion, and song composition ) Self-reported measure of Subjective units of distress scale (anxiety/distr ess) Inpatien t 64% Bibb et al., 20194 9 Austra lia Single group pre-post design 13 R:18- 41 100 Anorexia nervosa1 Group music therapy (Singing and song discussion) Self-reported measure of Subjective units of distress scale (anxiety/distr ess) Outpati ent 82% Running head: MUSIC IN EATING DISORDER TREATMENT 15 Wang and Xiao, 202174 China RCT, pre-post design, per- protocol analysis excluded dropouts 66 M:16. 53, R:14- 19 92 Anorexia nervosa Music therapy combined with cognitive behavioural therapy (Music listening) Unspecified whether individual or group sessions Self-reported measures of eating disorder examination questionnaire , Beck anxiety inventory, Beck depression inventory, treatment satisfaction, Body mass index, and abdominal subcutaneous fat thickness measured by the therapist Inpatien t 55% 1 indicates studies that reported comorbid mental health diagnoses which included Generalized Anxiety Disorder, Major 330 Depressive Disorder and Obsessive-Compulsive Disorder. 331 332 MBIs were identified when details regarding the music experience were provided. 333 MBIs are reported as music therapy when facilitated by a qualified music therapist and other 334 MBIs (non-music therapist delivered) are reported by the type of intervention only. Within 335 the included studies, the majority investigated music therapy (n=18). Music therapy sessions 336 included individual (n=12), group (n=4), and both individual and group sessions (n=1). One 337 study did not specify whether the sessions were in a group or individual format. Music 338 therapy sessions utilized receptive music experiences (n=10) (song discussion, music 339 listening for relaxation, or music directed imaging), instrumental improvisation (n=8), 340 songwriting or song/music collage (n=7), singing or chanting/toning (n=5), drumming (n=2) 341 or movement to music (n=1). One music therapy intervention combined music listening with 342 cognitive behavioural therapy. MBIs led by non-music therapists (n=3), two qualitative and 343 one quantitative) included vibroacoustic stimulation, a singing workshop, and music listening 344 during mealtimes. Details of the music therapy theoretical approaches, when indicated, are 345 further outlined in subsequent sections. 346 347 348 349 350 Qualitative results 351 Running head: MUSIC IN EATING DISORDER TREATMENT 16 Qualitative studies included a total of 106 participants, which were comprised 352 predominantly of case reports/studies (n=10), and qualitative designs (n=6), followed by 353 mixed methods pre-post design (n=1). Nine were conducted in an inpatient setting, six in 354 outpatient settings, and two studies across both inpatient and outpatient settings. Gender of 355 study participants was between 95-100% female; one case report did not report gender. Nine 356 of the studies reported comorbid mental health diagnoses that included bipolar disorder, 357 dissociative identity disorder, generalized anxiety disorder, major depressive disorder, 358 obsessive compulsive disorder, post-traumatic stress disorder, and substance use disorder. 359 Study outcomes were based on therapist observations (n=9), self-report (n=3), analysis of 360 content from sessions (song lyrics, musical improvisation, imagery) (n=5), and semi-361 structured interviews (n=2). Evaluation of the reporting of the qualitative studies represents a 362 range of 45-100% with a mean of 84%, reflecting reporting of approximately 9 of the 11 363 components. 364 Table 2 highlights study duration within the context of design, detailing information 365 on the MBI, theoretical approaches, and any other intervention components. Finally, the main 366 results from the studies are indicated. We note that length of intervention varied widely 367 across these studies, from two weeks to 2.5 years. Main results were further explored through 368 the thematic analysis. This analysis resulted in seven emergent outcome themes being 369 identified including: building interpersonal capacity, managing the emotional landscape, 370 developing capacity in self, embracing novelty and growth, mental processes, experience and 371 relationship with body, and fostering engagement in ED treatment. Table 3 presents the 7 372 themes with the 13 emergent subthemes, along with related outcomes and quotes. Quotes 373 from the studies included in the analysis provide examples of content that informed the 374 themes. We note that negative outcomes were only reported in one study and consisted of 375 experiencing the body more consciously and a negative evaluation of new experiences. 376 377 Table 2 Results of the qualitative studies 378 379 Author, Year Study duration and design MBI Treatment intervention Control group Other intervention components Main outcomes Bauer, 201057 10-months, case report (pre-post) Music therapy No control group None Improved self-awareness, emotional expression and sense of community as well as mutual support, increased motivation. Running head: MUSIC IN EATING DISORDER TREATMENT 17 Fendel et al., 201858 2-weeks, qualitative interviews post- intervention Three one-to-one vibro-acoustic stimulation sessions with the Body Monochord (“BoMo”, body sound treatment instrument) No control group The standard treatment for eating disorders Qualitative analysis of interviews using grounded theory found the following categories related to the subjective bodily experiences of participants during the BoMo sessions: - Differentiated perception - Focused attention - Emergence of body-related feelings - Emergence of emotions - Emergence of thoughts - Emergence of inner images, - Relaxation, - Spatial and temporal experience - New bodily experiences - Self-reflection Experiences during treatment were not exclusively focused on body problem areas and were independent of patient body shape or weight and had both positive and negative connotations. Heal and Hara, 199359 approx. 1.5 years, case study Music therapy (improvisation or spontaneous sound pictures) No control group Weekly psychotherapy sessions over a year The clinic reported changes: Client was able to report her ideas and thoughts verbally (no longer needing to write anything down) and was able to verbalise her concerns, activities, and anxieties or unhappiness. Her weight remained stable although she reported that she did have episodes of anorexia nervosa behaviours when stressed. Heiderscheit and Madson, 201560 4-weeks, case report Iso principle: music psychotherapy using systematically programmed classical music (therapeutic playlist) to change and manage different mood states and tempos No control group None The patient’s depression worsened mid-treatment prompting switch from the Bonny Method of Guided Imagery in Music to iso principal method; increased hope, optimism, and empowerment; greater ability to manage depression and engage in social activities; improved engagement in treatment and recovery. Heiderscheit and Murphy, 202161 3-months, case report Trauma-informed music therapy (co- created, adapted, and tailored to patient’s strengths, interests, and music preferences) No control group Daily practices of coping skills Shame reported when using symptoms vs. new coping skills; responded better to stress and anxiety by end of treatment; learned to relinquish maladaptive skills and interrupt pathological cycles; improved coping behaviours and emotion dysregulation allowing for continued trauma work. Running head: MUSIC IN EATING DISORDER TREATMENT 18 Heiderscheit, 202362 12-months, qualitative Bonny method of guided imagery: in- depth music psychotherapy using therapist-selected classical music to elicit emotional processing No control group Optional homework post-sessions, journal or create mandala Therapist observation throughout sessions and post study questionnaires showed: initial apprehension; perceived benefit: insight, emotional processes, and growth; perceived challenges: fear of unfamiliar and learning to trust self; no disruption to treatment schedule or program; empowered participants to engage in treatment planning and recovery process; highly feasible to implement across levels of treatment. Heiderscheit, 202463 12-months, qualitative Bonny method of guided imagery: in- depth music psychotherapy using therapist-selected classical music to elicit emotional processing No control group Optional homework post-sessions, journal or create mandala Thematic analysis of imagery themes from 116 GIM session transcripts. Three themes and nine sub themes emerged including emotional landscape (feeling stuck, acknowledging emotions, working through unresolved emotions), relationships (self, others and ED), and experiencing transformation. Intertextual analysis indicated a therapeutic arc representative of The Hero’s Journey Hilliard, 200164 NR, qualitative Cognitive-behavioural music therapy No control group None Therapist observation throughout sessions: stress and fatigue reported during behavioural and cognitive stages, respectively; decreased stress, anxiety, and discomfort, especially during and after meals; improved coping skills, empowerment, and laughter; group sessions were well-attended and well- received by patients, families, and professionals. Lejonclou and Trondalen, 200965 1st case- 3 years; 2nd case - 2 years, clinical case study Individual music therapy using a psychodynamic approach, focusing on relating experiences through music (songwriting, improvisation, movement/dance, listening to music, and verbal processing) No control group 1st case - training activities of daily living. 2nd case – none 1st case – Participant gained weight, left the hospital and returned to a normal life. Participant acquired a new self-confidence and linked positive feelings to her body. 2nd case – The participant became more satisfied with her body. The binging and purging almost disappeared after the therapy. Participant was able to share ‘parts of her feelings’ and talk about bulimia nervosa diagnosis with some of her friends. Running head: MUSIC IN EATING DISORDER TREATMENT 19 McFerran et al., 200666 2- years, qualitative (analysis of patients’ song lyrics) Individual song- writing sessions No control group Multidisciplinary eating disorder program The theme of ‘identity’ was used most frequently (28%) in the lyrics, with the sub-theme of ‘exploring new behaviours, positive self-talk’ being addressed most often (12.5% of total). Songwriting was able to reveal information that had not been discussed with other treatment team members. McFerran et al., 200867 2.5-years, qualitative (analysis of patients’ song lyrics) Individual song- writing sessions No control group Multidisciplinary eating disorder program The sub-theme ‘relationship with mother’ was used 8.15% in the lyrics. The results highlight the importance of the mother-daughter relationship for adolescents with eating disorders. Descriptive results show an avoidance of negativity and an emphasis on the positive and not placing blame on parents. Pavlakou, 200968 3-weeks, qualitative Group singing workshop No control group Physical warm-ups, stretching, breathing and vocal exercises at the beginning of every session Through the singing activity, participants reported physical relaxation, awareness of their body, emotional release and ability to distance themselves from their everyday problems. Through the rehearsal process, participants reported increased self-esteem, opportunities to express themselves freely, and were able to value and appreciate themselves, as well as boost of confidence, and a sense of accomplishment. Through the group experience, participants reported healthy interactions with group members (meeting new people, socialising and interacting with group members during sessions and the breaks); feeling connected with the group members; sense of belonging; feeling of equality due to issues with food; Overall, the group workshops helped participants to feel less stressful, more empowered and positive, and to increase their self-esteem. Running head: MUSIC IN EATING DISORDER TREATMENT 20 Robarts and Sloboda, 199469 4-months, case study Music improvisation (instrument playing) No control group Ward treatment and re- feeding programme 1st case- The patient left the unit and did not require readmission. The therapist considered the music played in the last session to be much more interactive than the earlier playing. The music had a sense of wholeness and integration. The therapist described the music as 'folksy', 'earthy' and 'grounded'. The patient also initiated musical ideas and responded to the therapist's ideas. The therapist was left with a sense of a personality that is strong and alive. 2nd case- The patient left the unit after nine months and did not require readmission. Positive feedback from a therapist. The patient began to develop an acceptance of herself and began to overcome her defensive as well as controlling behaviour. The playing became more spontaneous, self-expressive and exploratory. Robarts, 201070 NR, case study Music therapy No control group Inpatient care Case material used to illustrate the clinical function and application of musical phenomena, in particular the “tonal-rhythmic field of sympathetic resonance” and the use of motifs. Shah et al., 202171 4-weeks, pre-post design Group music therapy sessions using a combination of improvisation, singing, drumming, listening back to recorded group improvisations and responding through visual art, and mindfulness-based exercises No control group Inpatient eating disorder treatment - largely group-based, including psychoeducation and psychotherapy sessions based on dialectical behaviour and cognitive behavioural therapy, creative arts programming, recreation and horticultural therapies Positive and negative affect scale showed that participants experienced a decrease in negative affect (p = 0.006) after a 4-week music therapy programme, compared to pre- intervention data. There was no significant overall change in positive affect. Qualitative data suggested that participants discovered music’s ability to represent various aspects of themselves and their recovery journeys, music’s potential to support them to externalise, shift, and stay with emotions, and music’s capacity to foster social connection. Running head: MUSIC IN EATING DISORDER TREATMENT 21 Trondalen and Skårderud, 201072 12-months, case report Individual music therapy sessions involving free improvisation No control group None High participation rate of 83% when invited to write songs. Songwriting allowed exploration of the theme of identity development. Musical improvisation facilitated "affect attunement" - sharing/matching of inner feeling states through intensity, form, timing, etc. Suggested a link between the musical relating experience and subsequent verbal processing could support a more coherent sense of self. Trondalen, 200373 10-months, case report Music therapy involving improvisation, singing, instrument playing, “self-listening" experience No control group Psychotherapy The "self-listening" experience became very important in the therapeutic process. The experience promoted a sense of belonging in time and space. 380 Table 3 Qualitative Studies: Outcome Themes following MBIs 381 Themes Sub themes Outcomes Quotes Building interpersonal capacity Promoting social engagement Fostering a sense of belonging Fostered social engagement and connection Supported affect attunement Supported exploration of relationships Fostered development of healthy relationships Reduced feelings of isolation Decreased feelings of loneliness Musicking provided experience of support - Engaging in making music with others provided a way to connect - Making music with others fostered healthy social interactions - Co-creating music offered a shared emotional experience -Engaging with others in music helped foster recognition of the need to connect -Offered positive and shared creative experience -Making and sharing music fostered sense of support Running head: MUSIC IN EATING DISORDER TREATMENT 22 Managing the Emotional Landscape Fostering emotional expression Coping with emotions Managing stress Developed willingness to explore feelings Increased willingness and capacity to express emotions Helped shift emotions Helped to cope with and process difficult emotions Elevated and managed mood Fostered physical relaxation Provided opportunities to practice stress management Decreased stress -Making music (nonverbal) serves as a referent to project, explore or recast one’s inner experiences -Music experiences afforded opportunities to practice feeling and tolerating difficult emotions -Listening to and creating music provides a safe way to externalize and explore emotions - Listening to and making music provided a way to shift and change mood -Using music as a resource to manage stress and anxiety provided a comfortable way to engage one’s body physically -Music therapy decreased the different intensities of meal-related stress and anxiety -Music therapy helped significantly reduce anxiety at different stages of recovery Developing Self-capacity Insight Self-esteem Fostered self-reflection Fostered development self- awareness Fostered change in self-perception Improved self-appreciation Fostered positive self-talk - -Fostered a fusion of personal narratives to challenge and change perception -Music experiences fostered exploration and externalization of inner experiences to help make meaning and comprehend - Engaging in music experiences enables an exploration of one’s identity beyond that of the ED (discovering their musical identity) - Creating music (songwriting) provide a means to practice sharing personal information and communicating positive messages to oneself Embracing Novelty and Growth Engagement with novelty Personal development Fostered development of spontaneity Supported exploration of new behaviours and skills Provided opportunities to practice new skills Fostered change in personal growth Supported exploration of aspects of self Perspective and insight gained on one’s life story Fostered hope for future & recovery -Creating and making music provided opportunities to engage in new experiences -Leaning into new ways of engaging with music fostered facing fears - Engagement with symbolism and metaphor in music experiences supported engagement cognitive and affective processes that support growth and transformation -Embodied aesthetic experience allows an individual to project their unique feelings, thoughts, and experiences to be explored and they can exert psychological control and pace their process Running head: MUSIC IN EATING DISORDER TREATMENT 23 Improving Mental Processes Cognition Served as a means of cognitive distraction Decreased defences and controlling behaviours Improved focused attention -Music provided a means of distraction to manage anxiety and intrusive thoughts -Engaging in making music provides opportunities to be present in the moment and not focused on ED Improved Relationship with Body Body awareness & comfort Provided new bodily experiences Fostered awareness of body (spatial and temporal) Improved self-image Decreased discomfort during and after meals - Engaging in music afforded experiences to start to move into one’s body -Active music engagement supports a developing a closer connection with the mind and body - Self exploration in music and imagery experiences enables individuals to see themself from new and different perspectives -Music therapy as a distress tolerance technique (at mealtime) emphasises practicing through experience rather than discussion Engagement in ED treatment Motivation Revealing unaddressed issues Demonstrated high rate of participation Well received by patients and families Improved engagement in treatment Improved motivation for recovery Identified issues not explored by other members of treatment team Uncovered issues unaddressed in verbal therapy -Music therapy clinicians report that groups are well attended - patients and their families share with staff how music therapy has helped in crisis, challenged cognitive distortions, and help them gain insight -GIM session fostered discovery of inner resources vital to moving forward in recovery - Music therapy enabled exploration and expression of complex feelings and experiences that were difficult to address in verbal therapy - GIM supported exploration of therapeutic issues unresolved or unaddressed in verbal therapy 382 Organization of these themes reflects various stages of the treatment and recovery 383 process. Figure 2 illustrates how these themes follow differing levels of treatment, beginning 384 with symptom management that focuses on fostering emotional expression, stress 385 management and developing coping skills which leads to improved attention and cognitive 386 restructuring, leading to improved body awareness and body image. This therapeutic work 387 supports transitioning to self-development that highlights improved self-awareness and self-388 esteem, developing a growth mindset through engaging in new and novel experiences, and 389 supporting the development of interpersonal skills through social engagement. The 390 therapeutic work in these areas fosters engagement in treatment through increased motivation 391 and responsiveness by addressing contributing or underlying issues that have not been 392 addressed by conventional treatment. Figure 2 illustrates that these processes are not linear 393 Running head: MUSIC IN EATING DISORDER TREATMENT 24 but rather circuitous, meaning an individual may move back and forth through these at 394 different levels of ED treatment. 395 396 Figure 2: Alignment of emerging qualitative outcomes align with ED treatment and recovery 397 processes 398 399 Quantitative results 400 Overview of quantitative study characteristics (SN) included only five studies which 401 met inclusion criteria (see Table 4, with one study included in Table 1 & 2 as a mixed 402 methods study). Three studies focused on patients with anorexia and two studies also 403 included other EDs. Comorbid mental health diagnoses were reported in two studies. Subjects 404 were 92-100% female (seven males out 169 total participants across studies), all but one 405 study was conducted in adults, and all studies used a pre-post design. Table 5 outlines the 406 results of the quantitative studies, explicating study duration, design, music intervention and 407 main outcomes. A Canadian study of group music therapy (MT, e.g. improvising and 408 drumming) showed a significant decrease in negative affect and emotional suppression 409 following MT; however the MT also included mindfulness and was accompanied by 410 treatment as usual (TAU) such as CBT and DBT71. With this multifaceted intervention and 411 no control group, one cannot discern whether the MT or other intervention components were 412 instrumental in driving this observed improvement. Two Australian studies involved 413 interventions comprised solely of group MT (e.g. singing and discussing songs), based on a 414 Running head: MUSIC IN EATING DISORDER TREATMENT 25 humanistic therapeutic approach48,49. While neither study had random assignment, both 415 interventions showed a significant decline in anxiety and distress immediately post 416 intervention and one study showed a steeper decline in the intervention versus inpatient TAU 417 control48. A crossover study (where participants receive all conditions and so are their own 418 control) of an MBI in Italian inpatients showed that compared with no music being played at 419 supervised mealtimes, when patients listened to either classical or pop music during 420 mealtimes they consumed more food and had greater positive emotions following the meal74. 421 However, there was no waiting period between the interventions to ensure the effects of the 422 first treatment wore off before delivering the next treatment75. Finally, a Chinese study on 423 adolescents involved a receptive (music listening) MT intervention plus CBT and TAU 424 compared with inpatient TAU only as the control group76. While these groups were randomly 425 assigned, the study conducted per-protocol analyses without dropouts, and there was a 426 significantly greater dropout in the control vs intervention group (22.5% vs 5.4%). The study 427 reported a greater increase in post-treatment weight, BMI, and abdominal subcutaneous fat in 428 the MT + CBT arm compared with the control group. However, it is impossible to determine 429 whether this was due to MT, CBT, or both. MBI reporting of the quantitative studies ranged 430 from 55-82% with a mean of 67%, reflecting reporting on about 7 of the 11 components. 431 While no negative outcomes were reported in any of the quantitative studies, null findings 432 were reported in two of the studies (e.g. positive affect and impulse control71; negative affect, 433 stress, satiety74). In sum, coupled with small sample sizes, none of the quantitative studies 434 implemented best practice of randomly assigning individuals to clear MBI and control 435 groups, precluding firm conclusions about the efficacy of MBIs in people with EDs. 436 437 Table 5 Results of the quantitative studies 438 Author, Year Study duration and design MBI Treatment intervention Control group Other intervention components Main Outcomes Bibb et al., 201547 36-weeks, non- randomised pre-post design, pilot study Group music therapy post mealtime, twice a week: singing, listening to songs, discussing music, and collaboratively writing songs Inpatient treatment as usual: structured post meal support therapy which involved one- hour group sessions including games, art, discussions of feelings. None Decrease in anxiety/distress in the intervention condition (pre-post M: 8 to 5.6) and control group (pre-post M: 8.1 to 7.1). Significant difference between the control group and intervention condition (p < 0.001). Running head: MUSIC IN EATING DISORDER TREATMENT 26 Bibb et al., 201948 13-weeks, single group pre- post design 1 hour group music therapy (singing and song discussion) following a weekly group lunch at local cafe (social eating challenge) and before afternoon tea each week No control group None Significant decrease in anxiety/distress following the intervention (M: 5.1 vs 2.9, p < 0.001). Wang and Xiao, 202173 3-months, RCT, pre- post design, per- protocol analysis excluded dropouts Music therapy (MT) - patients were asked to listen to music related to health promotion in their daily life, chosen by the therapists based on the therapeutic method of combining Chinese and Western music Conventional outpatient treatment including dietary adjustments and low-dose antipsychotic medications for insomnia or emotional issues Conventional outpatient treatment as per control group, plus CBT for anorexia, adapted for Chinese setting (12 two-hour sessions) Post treatment MT+CBT vs control: weight and BMI higher (p < 0.05), abdominal subcutaneous fat thicker (p < 0.05), eating disorder examination questionnaire scores lower (p < 0.05), Beck anxiety inventory and Beck depression inventory scores lower (p < 0.05), more participants satisfied with the intervention (p < 0.05). 439 Discussion 440 This scoping review examined a broad body of evidence allowing for a general synthesis of 441 outcomes following MBIs for individuals in ED treatment. It included 20 studies that 442 investigated MBIs for individuals engaged in ED treatment. This resulted in 16 studies that 443 examined purely qualitative data (including case reports), four that assessed quantitative 444 outcomes and one mixed methods study. Due to the specialized nature of ED treatment and 445 the limited body of literature related to MBIs in ED treatment, this scoping review was 446 conducted to capture and review a broader scope of research literature focused on MBIs as a 447 primary intervention for ED, which differs from previous reviews44-47. This helped to capture 448 research with diverse methodologies as it included clinical case reports that are reflective of 449 clinical practice and the therapeutic process. As a result, it helps contextualize and provide a 450 more comprehensive understanding of the use of MBIs in research and in practice of music 451 therapy in ED treatment64,78. 452 The nature of a scoping review is not to provide an overall assessment of quality of 453 the literature, as this rigor can lead to missing or excluding relevant research79. Capturing a 454 diverse body of literature can provide deep and rich data to examine thorough descriptions of 455 the therapeutic process80. This scoping review examined studies published in English which 456 precluded non-English language studies and as a result limits generalisability in some 457 cultures81,82. Furthermore, our review only found one study which was not from a high 458 income Western country, and there were very few males studied, pointing to the importance 459 of focused work in these groups. Given the majority of the literature reviewed included case 460 Running head: MUSIC IN EATING DISORDER TREATMENT 27 studies, feasibility and pilot studies with small sample sizes and no control groups includes a 461 risk of selection or information bias which limits the generalisability of the results83. Further, 462 it is worth noting that synthesizing the findings was challenging as therapeutic work within 463 case reports is tailored and unique to each individual and at times a lack of clear and detailed 464 information is provided when reporting the MBI. As a result, the findings are less directly 465 relevant to clinical or treatment guidelines but can help to identify clinical considerations for 466 treatment and inform recommendations for future research50. Further, negative outcomes 467 were only reported in one study and were specific to the use of the body monochord (BoMo) 468 during inpatient ED treatment which resulted in experiencing the body more consciously and 469 a negative evaluation of new experiences. Further, it is not clear what experience or training 470 the therapist had with the BoMo as the therapist was not a qualified music therapist59. These 471 findings may indicate the need to identify at what point in the treatment trajectory is most 472 appropriate for this type of body based therapeutic work. The limited reporting of negative 473 outcomes across studies may indicate bias and a need for more transparent reporting. 474 However, negative outcomes may be mitigated by music therapists’ reported awareness and 475 training regarding avoiding harm in ED therapeutic settings50,84,85. 476 477 Music-based interventions utilised in eating disorder treatment 478 The studies implemented a wide array of MBIs, including music listening (listening to 479 classical or popular music and song discussion, music-based relaxation, music-directed 480 imaging, movement to music, and vibroacoustic stimulation), song writing, instrumental and 481 vocal improvisation and active music making experiences (singing, group singing and 482 drumming), while several studies integrated multiple types of MBIs. Although not reported in 483 many of the included studies, theoretical approaches reported within the music therapy 484 interventions included psychotherapeutic, cognitive-behavioural and trauma-informed music 485 therapy. The large number of interventions utilised illustrates the diversity and depth of MBI 486 options available to meet the emerging and changing needs of a patient at various levels of 487 care and across the treatment process63. These findings are consistent with a recent mixed 488 methods study that surveyed and interviewed music therapists working with patients in ED 489 treatment, which indicated clinicians utilize a wide array of methods in their regular clinical 490 practice to address diverse therapeutic needs across levels of treatment and adapt these to 491 meet the needs of individual patients and groups50. This aligns with the focus on personalized 492 ED care with tailored interventions based on individual psychological, biological, 493 environmental, and genetic profiles86. 494 Running head: MUSIC IN EATING DISORDER TREATMENT 28 While it is evident that the current body of research does not fully represent the 495 diversity of interventions utilized by qualified music therapists and non-music therapists in 496 the context of clinical practice in ED treatment, the inclusion of case reports (half of the 497 studies in our review) gives breadth and depth of understanding and further highlights other 498 methods including song discussion, music listening, group drumming, guided imagery and 499 music, and music and movement. Additionally, it is worth noting that all but two of the 500 studies in the scoping review (18/20) integrated music therapy facilitated by a qualified music 501 therapist, highlighting a need for professional training required to implement MBIs within the 502 treatment of these complex disorders. 503 Overall, the qualitative studies provided detailed information when reporting the MBI, 504 meeting an average of 84% of MBI reporting guidelines51,53, compared to the quantitative 505 studies that reported an average of 67% of the guidelines (note six qualitative studies were 506 published before the MBI guidelines and all quantitative studies were published four or more 507 years after publication of the MBI guidelines). Given that 10 of the 17 qualitative studies 508 include case reports which typically provide rich and thorough descriptions of the therapeutic 509 process, this difference in reporting is not surprising. Information consistently missing from 510 the quantitative studies included details regarding the music intervention and materials 511 utilized in the sessions. Clear and detailed reporting of MBIs is key to transparent reporting 512 of the intervention and for replicating a study. Nonetheless, studies within this review 513 demonstrate an improvement in the overall quality of reporting compared to a previous 514 evaluation of music intervention studies, where reporting was poor52. This may be due to the 515 fact that more of the present studies were, which typically include detailed information about 516 the music-intervention within the therapeutic process. 517 518 Music-based interventions methods of delivery 519 In a majority of the studies in this review the MBIs were facilitated by a qualified 520 music therapist. The other three studies included group singing workshops led by music 521 teachers68, vibroacoustic stimulation led by a therapist (no specific therapeutic training 522 specified)58 and music listening during mealtime delivered by dieticians and nurses75. In the 523 three studies facilitated by non-music therapists, participants reported numerous positive 524 outcomes, with some negative outcomes related to the vibroacoustic body music. These 525 studies illustrate how researchers are flexibly utilizing different ways of engaging with music 526 to address the needs of patients in ED treatment. The reporting of the MBI in these three 527 studies varied significantly, from 5 of the 11 aspects of the intervention58 to 9 of the 1168. 528 Running head: MUSIC IN EATING DISORDER TREATMENT 29 Ensuring that all MBI research adheres to the MBI quality reporting guidelines51,54 is 529 instrumental, so the intervention is described in detail and there is clarity, and transparency in 530 research methodology. The complex nature of music stimuli requires detailed and careful 531 description to ensure a study can be replicated, and necessitates music-based knowledge and 532 expertise to describe it effectively. Since MBIs include music experiences that may be 533 facilitated by music therapists, administered by staff, community musicians, other providers, 534 or self-administered by the patient/patient, clarity in intervention descriptions is vital50,54. 535 Dedication and advocacy to improve the quality of reporting of MBIs will help improve the 536 rigor and reproducibility of these interventions51,52,54,85. 537 It is evident from our review that group and individual sessions offer unique 538 affordances and may help to address different therapeutic needs. Across our reviewed studies 539 (excluding case studies, which by necessity were individual MBIs), individual and group 540 MBIs were used comparably (n=5 and n=4, respectively), with one study not reporting which 541 method was used. Group based music interventions provide opportunities that capitalise on 542 meeting new people, fostering a social connection71, engaging in healthy social interactions, 543 and feeling a sense of belonging68, as well as feeling motivated to engage in treatment64. 544 Group sessions can be economical and providing opportunities for social engagement 545 in a shared or collaborative experience is particularly important if an individual feels isolated 546 due to their ED76. There is also a means of support that can be embedded or experienced in 547 group MBIs that is valuable when engaging in a new or novel experience such as 548 improvisation or songwriting66,73. Conversely, individual sessions can provide therapeutic 549 space needed to address complex or deeply personal issues, which may include ED symptoms 550 (restricting or purging) or trauma that are not appropriate for group based work61,86,87. A 551 trauma-informed approach to MBI practice is recommended to inform clinical decision-552 making and avoid causing harm42,50,61. From synthesising information regarding patient 553 presentation across the studies, we are encouraged that choice of group versus individual 554 MBIs appear to have been selected to best meet patient needs. 555 556 Addressing multiple and diverse issues in eating disorder treatment 557 EDs are complex in nature due to the multiple underlying factors that contribute to 558 their development, the symptoms that negatively impact physical health and psychological 559 wellbeing, a myriad of comorbid diagnoses, and a high incidence of trauma15,86,87. While only 560 half of the studies in our scoping review reported on comorbid mental health conditions, 561 seven comorbid conditions (including trauma-related conditions) were reported across these 562 Running head: MUSIC IN EATING DISORDER TREATMENT 30 studies. This indicates that many MBI studies include complex cases but also highlights that 563 presence (or absence) of comorbid conditions needs more consistent reporting in future 564 studies. This complex clinical matrix necessitates treatment across various levels of care that 565 addresses the diverse and underlying issues needed to support an individual’s ED treatment 566 process 36,37,62. The studies in this scoping review included individuals engaged in various 567 levels of treatment including inpatient, residential, and outpatient. This is consistent with 568 survey data indicating the clinical settings in which music therapists work with patients with 569 EDs50. While ED treatment may occur at specialty ED treatment programs, music therapists 570 also provide services to patients in private practice, mental health units, medical units, long 571 term psychiatric settings, and community mental health settings46,50. Providing treatment 572 across various levels of care indicates that music therapy and MBIs are utilized to address a 573 variety of therapeutic needs. 574 The present review’s qualitative and quantitative results indicate MBIs focus on a wide 575 array of therapeutic issues and needs. The qualitative themes emerging from these 576 interventions operate across various levels of ED treatment and recovery - that of symptom 577 management, self-development, and treatment engagement as indicated by our model in 578 Figure 1. The organization of these themes aligns with various levels of therapeutic work 579 consistent with previous literature that highlights, “the flexibility of music as a therapeutic 580 agent allows the therapist to individualize the process and meet a wide array of needs 581 simultaneously, especially when feelings and emotions may be fragmented, elusive and 582 inaccessible to language”77 (p.128). Addressing core emotional processes is key, as impaired 583 affective processes are often implicated in the maintenance of disordered eating behaviours87. 584 Recent research including a comprehensive synthesis of 30 years of clinical and empirical 585 evidence underscores the importance of affective temperament, emotion regulation, and 586 personality vulnerabilities related to symptom management (emotions, cognition, and body 587 image) as a prerequisite to self-development89-92. Thus, our model begins with symptom 588 management by fostering emotional expression and learning coping skills to manage stress. 589 This supports changes in cognition such as improved attention, and cognitive restructuring, 590 which helps to decrease distortions. This supports shifting the relationship with one’s body by 591 improved body awareness and image and increasing the level of comfort in one’s body 592 through experiencing new ways of engaging the body. 593 In our model, symptom management then supports engaging in the next level of self-594 development which includes improved self-awareness, understanding, and self-esteem, which 595 is substantiated by research indicating that addressing these emotional underpinning of the 596 Running head: MUSIC IN EATING DISORDER TREATMENT 31 ED enhances treatment outcomes88. Prior MBI literature highlights how songwriting links 597 self-expression to the development of autonomy and exploring or developing one’s 598 identity66,69. Building this self-capacity is key to a growth mindset which is necessary to 599 support embracing challenges by facing fears and engaging in new experiences, which can 600 foster hope and optimism62,63. These experiences are instrumental in having the capacity to 601 develop interpersonal skills through increased social engagement, which helps to foster a 602 sense of belonging and engagement in meaningful relationships61,65. This work can then lead 603 to increased motivation to engage in treatment, fostering responsiveness to address and target 604 contributing issues that have not been addressed in conventional ED treatment44,46,62. 605 However, we note that our model follows an iterative feedback loop, with treatment 606 engagement facilitating further symptom management and self-development, which promotes 607 continued healing and recovery. We further acknowledge that effective initial symptom 608 management must be catalysed by an initial willingness to engage in treatment. 609 The capacity of MBIs to address diverse therapeutic needs across various levels of 610 treatment is also highlighted in Dvorak’s survey of music therapists working in ED 611 treatment50. These therapists reported addressing 90 different treatment areas, with the five 612 most common including self-expression, development of coping skills, managing mood and 613 depression, and identifying and expressing feelings. While these only encompass the first 614 component of the “symptom management” level in our model, cognition and body 615 image/awareness (other components of the “symptom management” level) were treatment 616 areas identified by more than half of therapists in that study. Further, self-esteem and self-617 awareness (operating on the “self-development” level of our model) were identified by 618 therapists as comparably frequent treatment areas to identifying and expressing feelings50. 619 However, interpersonal/social aspects and optimism (other components of the “self-620 development” level) were less frequently cited as treatment areas by therapists in the study, 621 and growth mindset components of embracing challenge and novelty-seeking were not 622 included as a response in this survey. This highlights the importance of qualitative research 623 which can bring out important factors which have been previously unidentified. Our review 624 reveals growth mindset as a potentially important outcome which should be assessed in future 625 MBIs for people with EDs. Indeed, previous research has explicated the unique capacity of 626 creative and aesthetic experiences to afford opportunities to externalize and explore their 627 thoughts and feelings in new and different ways, which helps an individual to develop new 628 understandings and attach new meaning to them63,93,94. This is further evidenced by quotes 629 from Table 3 which indicate that making music (nonverbal) serves as a referent to project, 630 Running head: MUSIC IN EATING DISORDER TREATMENT 32 explore or recast one’s inner experiences65 and that this process of externalizing inner 631 experiences helps to make meaning and comprehend their experiences62. Engagement in a 632 supported creative aesthetic therapeutic experience can help individuals in ED treatment 633 access affective, cognitive and perceptual brain functions which are key to their treatment and 634 recovery process92 and are instrumental in developing insight, fostering growth, and a sense 635 of mastery and self-efficacy62,63,66,72,73. 636 637 Implications of this study and recommendations for future research 638 Although findings generally support positive outcomes for individuals ED treatment 639 following a MBI, our conclusions are impeded by the heterogeneity of interventions and 640 outcomes, and inadequately controlled methods to ascertain effectiveness. Synthesizing this 641 body of literature is also impacted by the complex nature of EDs, including the physical and 642 psychological aspects of the disorder, as well multiple comorbid diagnoses and trauma 643 history. While some research methodologies may not be able to robustly capture the nuanced 644 and complex phenomenon of MBIs, ensuring clear and transparent reporting is necessary to 645 provide a clear understanding of the therapeutic intervention. Further, these shortcomings 646 will be addressed with more rigorous quantitative studies which capture the range of patients 647 treated in practice and appropriately assess treatment effects. To that end, there is a particular 648 need for well-powered randomised controlled trials (RCTs) with distinct and clearly defined 649 comparison groups, implementing intention-to-treat analyses and assessment of and 650 controlling for diverse clinical and background factors96. This will necessitate researchers 651 addressing the challenges and barriers in conducting RCTs with MBIs in ED treatment, 652 particularly balancing the personalisation of therapy with the required standardisation97. 653 Future reviews should aim to understand and explicate the efficacy, benefits, and risks 654 of MBIs in ED treatment, and the role of MBIs in addressing the complex and myriad needs 655 of individuals in the treatment process. Given the established link between emotional rigidity, 656 emotion regulation, and ED symptoms, there is need for specific exploration of MBIs that 657 support the development of temperament-linked coping styles50,78,89. Further, all future 658 studies should provide detailed information on case presentation (including comorbidities), 659 comprehensive descriptions of the MBIs utilized, as well as the experience, qualifications, 660 and theoretical orientation of the professionals facilitating the MBI. Future reviews should 661 assess each study’s adherence to MBI quality reporting guidelines51,54. Due to the unique 662 nature, variety, and complexity of MBIs, adhering to these reporting guidelines to explicate 663 Running head: MUSIC IN EATING DISORDER TREATMENT 33 the different components of the intervention is crucial in supporting replicability and 664 identifying key and active elements in the intervention44,51,52,54. 665 666 Conclusion 667 The high economic cost and incidence of EDs indicates a need for innovative and effective 668 treatment approaches97,98. While there is a small corpus of literature to date on MBIs for EDs, 669 there is clear evidence that MBIs have the capacity to address a wide array of therapeutic 670 needs for individuals across the various levels of ED treatment. The present review shows 671 across a range of case reports and research studies that MBIs can be tailored to individual or 672 group therapy to meet emerging and changing needs over the course of ED treatment. The 673 unique potential of music therapy to not only address a myriad of issues but also uncover 674 issues that have not been addressed in verbal therapy suggests that ED treatment programs 675 would benefit from integrating this type of creative modality alongside psychological 676 therapies. Further rigorous quantitative studies, especially randomised controlled trials 677 evaluating and comparing MBI enhanced therapy to more traditional approaches are required 678 to evidence support of more widespread usage of MBI for people living with ED. 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