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The effectiveness of group music psychotherapy in improving the self-concept of breast cancer survivors

Dissertation
Author: Joy L. Allen
Abstract:
Several studies have investigated the psychosocial impact of breast cancer, however, there is a paucity of research examining interventions geared towards breast cancer survivors. This study investigated the effects of group music psychotherapy on improving the self-concept of breast cancer survivors. Eleven breast cancer survivors where randomly assigned to one of two treatment groups - group music psychotherapy or a cognitive behavioral based support group. Pre and post intervention comparisons were made using the Body Image After Breast Cancer Scale and the Tennessee Self-Concept Scale on measures of identity, role performance, self-esteem, and body image. After ten weeks, results from the Wilcoxon U test indicated participants in the music psychotherapy group significantly improved on measures on identity, family role relationships, self-esteem, and body image. Furthermore, as compared to participants in the cognitive behavioral support group, participants in group music psychotherapy improved on measures of identity, role relationships, and body image. Implications and suggestions for further research are discussed.

TABLE OF CONTENTS

Page

ABSTRACT ………...…………………………………………………………………. iii

ACKNOWLEDGEMENTS ………..……………………………………...…………… iv

DEDICATION ……...…………………………………………………………………… v

LIST OF TABLES …………...………………………………………………………… vii

CHAPTER

1.

INTRODUCTION …………… ……….……………………………………. 1

2.

RELATED LITERATURE ……………...…………………………………..11

3.

METHODS …………………………...……………………………………..29

4.

RESULTS …………………………...………………………………………37

5.

DISCUSSION ………………………………………………………...……..45

6.

CONCLUSIONS & IMPLICATIONS …...………………………................64

REFERENCE S CITED …………………...……………………………………………..66

APPENDICES

A.

INSITUTIONAL REVIEW BOARD APPROVAL …...…………………....82

B.

INFORMED CONSENT ……………………………...………………….....84

C.

PERMISSION TO AUDIO TAPE …………………...……………..............90

D.

GENERAL WELL - BEING SCALE ………………...………………………92

E.

COG NITIVE BEHAVIORAL GROUP DECISION TREE …...……………93

F.

MUSIC PSYCHOTHERAPY GROUP DECISION TREE …...…………....96

G.

MUSIC PSYCHOTHERAPY PROCESS DECISION TREE………..…….104

vii

LIST OF TABLES

1.

Mean Scores……………………………………………………………37

2.

General Well - being Questionnaire Results…………… ……………….43

3.

General Well - being Overall Significance………………………………44

CHAPTER ONE

I NTRODUCTION

Breast Cancer

Breast cancer is the most commonly diagnosed cancer among women in the United States, accounting for more than one in four cancers. Currently, approxi mately thirteen (13) percent of women, or nearly one in eight, are diagnosed with breast cancer. It is estimated that in 2008, 182,480 new cases of invasive breast cancer and another 67,770 cases of in situ breast cancer will be diagnosed in American wome n (American Cancer Society, 2008). But while breast cancer rates are rising in most western countries, deaths from breast cancer have decreased as a result of improved screening and treatment. According to the American Cancer Society (2008), when breast cancer is confined to the breast, the five - year survival rate is approaching 100%.

Many cancers have changed in definition from incurable diseases to chronic illnesses, and so has the definition of a cancer survivor. The National Coalition for Cancer Sur vivorship (NCCS) embraces a broader definition, proposing that cancer survival begins at the moment of diagnosis and proceeds along the continuum through and beyond treatment to remissions, recurrences, cure , and the final stages of life. Today, many heal th providers differentiate between survivors who are receiving therapy of any kind and survivors who have completed treatment (Leigh & Clark, 2002).

Mullan (1985 ) outlined a model of life after a cancer diagnosis that consists of three stages: acute, exte nded, and permanent stages. The acute stage begins at the moment of diagnosis and extends through the initial treatments such as surgery, chemotherapy, and/or radiation.

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Those newly diagnosed may be dealing with a fear of dying, treatment related side ef fects, and disruption in family and social roles (Leigh, 2005). Next is the extended stage; survivors in the extended stage may be in remission or receiving the maintenance therapy of Tamoxifen. Issues that generally arise during this stage include sever ing of treatment based support - systems, feelings of ambiguity related to the joy of being alive and fear of recurrence, adjusting to physical or psychosocial changes, reintegrating and reorganizing individual and family concerns, isolation secondary to ext ernal or self - imposed forces, and seeking community - based support groups (Christ, 1991; Fredette, 1995; Rowland & Massie, 1998; Leigh, 2005). Last, the permanent stage of survival represents a time of diminished probability for disease recurrence. Within breast cancer, permanent survivors may still be adapting to a number of physical and psychosocial changes not limited to lowered self - esteem, diminished social support, and workplace discrimination (Leigh, 2005). The focus of this study will be on those survivors in the extended or permanent stages of survival.

Significance of Self - Concept

Many patients and families will attest to a concern that nearly all control within their lives is lost during diagnosis and treatment for cancer. However, this loss of control may be amplified post - treatment, secondary to no longer actively doing anything to battle cancer. While many may think the last day of treatment will signal the end of a “challenge,” most women report ongoing physical and emotional issues (both

intermediate and long - term) associated with breast cancer survivorship (Rowland & Massie, 1998).

While one’s sense of self is normally relatively stable, cancer can cause a

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woman to question her place in the world and to rethink who she is. Additionally , changes in the body (both appearance and functioning) and role performance resulting from a chronic illness can profoundly affect the sense people have of themselves. This impact may be long - term or delayed (Leigh, 1998; Moore & Hobbie, 2000). As indiv iduals begin to deal with the physical and emotional impact of treatment, they may begin to understand that a new person has evolved with new responses and uncertainties (Shell & Kusch, 2001). Adult cancer survivors admit that to recognize and accept the “new” self, they must grieve the loss of the “old” self as they once knew it (Nessims & Ellis, 1991).

Self - concept is an individual’s conceptualization about how he or she thinks about himself or herself (Gale Encyclopedia of Psychology, 2001). It is a su bjective sense of the self and a complex mixture of unconscious and conscious thoughts, attitudes, and perceptions (Potter & Perry, 2005). Furthermore, it influences thinking, talking, acting, how one sees and treats others, the ability to give and receiv e love, the ability to take action and change things, and the choices one makes (Potter & Perry, 2005). Self - concept provides a frame of reference that affects the management of many situations and relationships with others. In relation to illness, examp les of situations that can have an effect on a person’s self - concept include hospitalization, surgery, the loss of bodily function, a decline in activity tolerance, and difficulty in managing a chronic illness (Potter & Perry, 2005). Furthermore, what ind ividuals think and feel about themselves affects the way in which they care for themselves both physically and emotionally , as well as the way in which they are able to care for others. For example, individuals with poor self - concepts often do not feel in control of their situations and may not feel worthy

4

of care. Components of self - concept include identity, body image, role performance, and self - esteem (Potter & Perry, 2005).

Identity involves the internal sense of individuality, wholeness, and consist ency of a person over time (Potter & Perry, 2005). Aspects of identity include demographical information, beliefs, values, personality, and character as well as structural characteristics. Chryssochoou (2003) suggests that identity is a particular form o f social representation that mediates the relationship between the individual and the social world. Furthermore, identity functions to inscribe the person in the social environment, to communicate positions, and to establish relationships with others (soci al recognition) . Being diagnosed with a chronic illness brings forth an added component to one’s identity and can cause increases in anxiety, depression, and fear. Kaiser (2008), in a qualitative study of breast cancer survivors, reports being given the identity of a “survivor” can result in substantial increases in anxiety related to fear of recurrence.

Body image issues are often associated with impaired self - concept. Body image includes

one’s perceptions of shape, size, appearance, structure, and s ignificance of one’s own body (Potter & Perry, 2005). Feelings about body image also include those related to sexuality, femininity, health, and strength. The majority of women, in general, experience some degree of body dis s atisfaction, which can affect

their overall self - concept .

B ut disturbances in body image can be greatly exaggerated when a change in health status occurs. Research indicates that over fifty - percent (50%) of breast cancer survivors experience body image problems (Fobair et al., 2005; Ganz et al. 1998a,b). Physical changes may involve loss of body parts, scarring, disfigurement, weight changes, adjusting to prosthesis, and adjusting to limitations in functional ability

5

(Anderson & Johnson, 1994). These changes may evoke feelings of m utilation, diminished self - worth, loss of a sense of femininity, decrease in sexual attractiveness and function, and feelings of anxiety, depression, guilt, shame, and abandonment (Shakin - Kunkel & Chen, 2003). Furthermore, studies assessing investment in Concern About Appearance (a belief that a woman must look good to feel good about herself) and Concern About Body Integrity (a belief that when something goes wrong with a person’s body that person is never really whole again) indicated that concerns about body integrity lead to emotional distress, greater loss of the sense of attractiveness and sexual desirability, greater disruption of social activities, several indicators of psychosexual disruption, concerns about further adverse outcomes from treatment, and estrangement from the self (Carver et al., 1998; Petronis et al., 2003). Last, body image is important to younger and older (Figueiredo, et al., 2005) breast cancer survivors and has lasting implications on levels of emotional distress (Carver, et al ., 1998; Yurek et al., 2000; Petronis et al., 2003).

Role performance is the way in which an individual perceives his or her ability to carry out significant roles (Potter & Perry, 2005). Common feminine roles include mother, wife, daughter, employee or e mployer, sister, and friend. Each role involves meeting certain expectations , and fulfillment of these expectations leads to an enhanced sense of self. Difficulty or an inability to meet role expectations often contributes to an altered self - concept. Sh ifts in roles or family responsibilit ies among women and their partners and/or children are not uncommon (Walsh et al., 2005). While some families continue to maintain daily routines despite the addition of major stressors, others report a severe disrupti on of family life (Kuhn & Dow, 2003). Northhouse et al., (1998) and

6

Holmberg et al., (2001) found that couples facing breast cancer reported greater decreases in their marital and family functioning, more uncertain appraisals, and more adjustment problems ; this includes adjustments in conflict resolution and less open communication associated with the illness when compared to couples with a benign diagnosis. Walsh et al., (2005) report that 61% percent of mothers report negative effects of breast cancer o n their relationship with their children. This included feeling a huge loss in quality of time with their children, loss of their maternal role, and shifts within the overall family dynamic. Last, employment and insurance discrimination can force survivo rs to remain in the “sick” role long after they are ready to move forward with their life. Denial of a promotion, loss of a job, denial of benefits, hostility in the workplace, and difficulty obtaining health and life insurance can all be additional remin ders of a cancer diagnosis (Clark, 1995).

Self - esteem is the emotional appraisal of self - concept. It represents the overall judgment of personal worth or value and includes self - efficacy and self - respect (Judge & Bono, 2001; Bertero, 2002). Self - esteem i s an ongoing mental process and an important variable in determining how an individual functions in the world (Potter & Perry, 2005). Furthermore, the relationship between self - esteem and psychological well - being (e.g., absence of depression, social anxie ty, loneliness, alienation) may be an important factor in understanding the self - esteem/health relationship (Blascovich & Tomaka, 1991). Bernard et al. (1996), in an assessment of health - related personality constructs, found high correlations among self - e steem, self - efficacy, ego strength, hardiness, optimism, and maladjustment — all were significantly related to health. Last, Pedro (2001) found self -

7

esteem to be the strongest predictor of health - related quality of life for long - term survivors of cancer.

Ne ed for Study

Given these threats to identity, body image, role performance, and self - esteem, it is not surprising to find that t he growing survivorship movement is calling for greater attention to life after treatment and the rehabilitation needs of cancer patients. In 2004, the Institute of Medicine issued a report examining the psychosocial needs of women with breast cancer. This report urges professionals to focus on the psychosocial needs of breast cancer survivors and research to determine the benefi ts of specific interventions, along with the most effective way to deliver those interventions. While several studies have investigated the psychosocial impact of breast cancer survivors, there is a paucity of research examining interventions geared towar ds breast cancer survivors. A review of the literature on formal support groups for breast cancer survivors

found four descriptive and eight quantitative studies. All studies call for an increase in research into the eff icacy

of various treatment modalit ies .

Music therapy is an established health care profession and a complementary therapy recognized by the American Cancer Society. Music therapy is defined as “a systematic process of intervention wherein the therapist helps the client to promote health, using music experiences and the relationships that develop through them as dynamic forces of change,” (Bruscia, 1998, p.20). Research on the use of music therapy has focused on the physical, emotional, and spiritual needs of cancer patients. Several art icles were found on music therapy with cancer patients , including nine foundational ,

four quantitative, two qualitative, and five case studies. Additionally, one treatment

8

study on music therapy with breast cancer patients was found. These will be review ed in the next chapter. No study examined the self - concept of breast cancer survivors.

Music therapy can be practiced in individual or group settings, depending upon patient need and the goal of therapy. Group music therapy can promote social interaction

and facilitate discussion s

that allow members to share common experiences and support one anothe r (Waldon, 2001; Rykov, 2006; Allen, 2008c). It can help bridge communication barriers and promote reminiscence (Bailey, 1984; Allen, 2008 c ). Additionally, gr oup music therapy provides a non - threatening atmosphere, which encourages both verbal and non - verbal forms of expression by matching the experience to where the person and/or family are (Allen, 2008c ). In music therapy group work with cancer patients, sev en articles were found, two quantitative, three qualitative, and two descriptive studies. No research was found on music therapy - based support groups specifically for breast cancer patients or breast cancer survivors.

The present study is concerned with a group form of music therapy that is based on t he Bonny Method of Guided Imagery and Music (BMGIM) . BMGIM is “an individual form of psychotherapy, healing, self - actualization, or spiritual work in which the client images to specifically designed program s of classical music while in an altered state of consciousness” (Bruscia, 2000, p. 7). It is a form of therapy that allows one to imagine, explore and more fully experience possible life choices in a safe and supportive environment. In relation to music therapy, guided imagery and music is a receptive music therapy technique in which the music is used and viewed as a co - therapist (Justice & Kasayka, 1999). Sessions involve a preliminary conversation, a relaxation

induction, guided music - imaging, return

to an alert state, and a postlude discussion. Within this

9

study, G uided I magery and M usic (GIM) is an “umbrella” term encompassing all types of music therapy based on music listening and imagery. This is in comparison to the Bonny Method of Guided Imager y and Music (BMGIM), which refers to the specific method developed by Helen Bonny (Bruscia, 2000).

S everal studies have examined GIM with breast cancer survivors , including t wo descriptive articles, two quantitative, one qualitative, one mix ed study and fo ur case studies. With the exception of the two descriptive studies, all of the above studies focused on breast cancer survivors. These studies will also be reviewed in the next chapter.

In the present study , Gr oup M usic Psychotherapy (GrMI) refers to a g roup format of Guided Imagery & Music where the therapist guides the imagery of members continuously while listening to selected music in a relaxed state. This method is used for groups that have a common purpose or identity (Grocke & Wigram, 2007). Note that while in GrMI, the therapist continuously guides the clients through the music imagery experience; other forms of group GIM allow the clients to image without verbal intervention by the therapist.

Phases of GrMI sessions include the pre liminary conv ersation , relaxation induction , continuously guided music imaging, and the postlude

discussion . In relation to cancer , one study was found on group GIM . No studies were found on group music and imagery for breast cancer survivors.

Summary

Ultimately, br east cancer survivorship would include a renewed enthusiasm for and enjoyment of life. While several quantitative and qualitative studies have outlined and described the experience of breast cancer survivors, little attention has been focused

10

on meeting t he needs of the growing number of breast cancer survivors. Psychotherapy - based support groups show great promise, but further research is needed to determine their efficacy. The same is true of music therapy and more specifically, group guided imagery an d music; therefore, this study aims to investigate the role of music therapy in meeting the needs of breast cancer survivors. More specifically, the purpose of the present study is to examine the effectiveness of group music psychotherapy in improving the self - concept of breast cancer survivors.

11

CHAPTER TWO

RELATED LITERATURE

In the past decade, much of the research on the psychosocial aspects of breast cancer has focused on describing the emotional experiences of women with breast cancer. As survivor ship has increased, research is beginning to also focus on the identification of interventions that favorably influence survivors’ psychological and social functioning. As there is a paucity of treatment studies addressing survivor needs, this paper will first review foundational studies related to the self - concept of breast cancer survivors followed by a comprehensive review of treatment studies. Foundational studies are defined here as literature that adds to the understanding of a particular issue or a pproach.

Breast Cancer and Self - Concept

Once the initial crisis of diagnosis and treatment has subsided, breast cancer survivors enter a new crisis — the crisis of returning to a “normal” life. Questions and dilemmas that often arise may include identity is sues (“Am I a cancer patient and/or survivor?”), changes in relationships, changes in appearance, reprioritization of daily activities, control issues, and questions of whether personality or behavior affects their health. This all occurs while the patien t is living with the possibility of recurrence and death (Spira & Reed, 2003). The ultimate goal of adjustment is acceptance of the condition and its associated limitations, along with a realistic appraisal and implementation of strengths (Falvo, 2005). Integrating the cancer experience into one’s

12

self - concept is vital to an improved quality of life for extended and permanent survivors of cancer (Zebrack, 2000).

A limited number of studies have examined important aspects of identity in breast cancer survi vors. Sulik (2005), in an exploration of survivors’ feelings of personal responsibility and guilt, suggests that women must revise their gender expectations in order to define their needs and ask for needed support. Furthermore, conceptualizations of car e must be broadened to include care for the self. Naverre (2004), in a study examining survival of middle - aged women with breast cancer, described the period after initial treatment as one of regaining control. This is characterized by a discovery of one ’s true “self” and the creation of one’s own personal destiny as a cancer survivor. Lastly, Clark (2007) and Politi (2007) report that adopting the identity of a breast cancer survivor and the resulting emotional acceptance can be a beneficial coping stra tegy.

Significantly, the removal of the breast should be understood as an amputation of a body part — a body part that symbolizes sexuality, femininity, gender, and maternal issues (Shakin - Kunkel & Chen, 2003). Research on coping with body image changes st resses the importance of acknowledging changes, mourning losses, acceptance, self - care, and open communication surrounding issues of sexuality and intimacy (Coons, 2006 & 2008).

When the demands of breast cancer are superimposed on the usual demands of family life, families must not only cope with day - to - day care of children and emerging careers, but they must also cope with a life threatening diagnosis and the effects of treatment. Walsh et al., (2005) reported the areas of greatest concern for women w ith breast cancer were avoidance of communication and lack of partner support.

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Furthermore, breast cancer patients regard positive relations as significantly more important than their matched controls (Lampic et al., 2003). In addressing role - related chan ges, advocates encourage survivors to approach relationships openly, avoid blame, and stay positive so that others can have a better sense of how they are feeling (Dirken, 2005). Dirken (2005) also reports that breast cancer survivors have an important ro le in supporting other survivors because sharing similar experiences positively impacts self - esteem and re - adjustment to life.

Women deemed to be optimal survivors of breast cancer have reported an increased self - awareness and appraisal of self that includ es an exploration of their past, present, and future life (Pelushi, 1997). Dirksen & Erickson (2002) report a significant relationship between resourcefulness and self - esteem suggesting that greater resourcefulness positively impacts feelings of self - wort h and is an important factor in maintaining a sense of self.

Dirksen (200 2 )

demonstrated social support to be the strongest predictor of higher self - esteem in breast cancer survivors. Moreover, it is theorized that support from significant others strengt hens a person’s self - evaluation through feelings of being appreciated, respected and loved (Bertero, 2002; Dirksen, 2000).

Therapy for Breast Cancer Survivors

The therapeutic goals for extended and permanent breast cancer survival include developing and i mplementing active, emotion - oriented coping strategies; reexamining life values, beliefs and priorities; mediating the expectations of others; offering support to others; and confronting mortality (Carter, 1993; Pelusi, 1997; Spira & Reed, 2003; Westbrook, 2006). Group psychosocial interventions are the most widely available and

14

applied methods of support for cancer patients. Furthermore, group therapies, given th eir reduced cost and combined with research suggesting they are as or more effective than ind ividual therapy, are the preferred method for treating distress in cancer patients (Carlson & Bultz, 2004). Research indicates that these groups substantially reduce the emotional distress associated with cancer, provide important social support, and enha nce adaptive coping skills (Burke & Kissane, 1998; Fawzy et al., 1995; Meyer and Mark, 1995; Michalec, 2005).

Formal support groups are available in a variety of settings and are based on the assertion that patients with breast cancer benefit from contact with other cancer patients through mutual social support. Interventions generally incorporate cognitive - behavioral approaches with group social support and education; the results of these groups have been mixed. Samarel et al., (1997) reported no signif icant differences in symptom distress, emotional distress, or functional status among women who participated for eight weeks in social support and education groups and women who did not participate in any groups. Helgesen et al., (1999 & 2001) in a compar ison of an education group, education plus peer discussion, and peer discussion without education, concluded the education group enhanced vitality, mental health, social functioning, role functioning, and reduced body pain; however, the effects dissipated over time. No benefits were found in the peer discussion group. Targ & Levine (2002), in a study comparing a psychoeducational group with a mind - body - spirit group, concluded that both methods improved measures of health - related quality of life and psycho social functioning. Additionally, the mind - body - spirit group improved spiritual integration and satisfaction. Improved mood, vigor, and fighting spirit were reported by Fukui (2000) in a one - group

study investigating

15

cognitive - behavioral group therapy wi th relaxation and guided imagery. Antoni (2001), in a study investigating the effects of structured group cognitive - behavioral therapy, reported no overall effects; however, there was a reduced prevalence of moderate depression and increased benefit findi ng and optimism . Lastly Samarel et al., (1998) interviewed participants in a social support group. Content analysis, based on the Roy Adaptation Model, revealed physiological, self - concept, role function, and interdependence mode changes (Samarel et al. , 1998). All of the above reviewed studies focused on women newly diagnosed with breast cancer, and they were still in an active treatment stage. Furthermore, only one of the studies had control group comparisons. Last, n o studies were found that invest igated the effects of support groups on extended stage or permanent survivors of breast cancer.

Group Psychotherapy

Group therapy, incorporating psychotherapeutic interventions designed for people with medical illness, can be a powerful intervention (Spira , 1997; Meyer & Mark, 1995). Yalom (1995), an authority on group therapy, described three curative factors in the group setting that contribute to improvement: universality, altruism, and hope. Universality is the opportunity for group members to feel th at they are not alone; being part of a group offers a sense of community that diminishes feelings of alienation and isolation. Altruism provides members a sense of purpose through lending support and guidance to others. Finally, group members have the op portunity to see that others experience similar emotions, cope with similar situations, and still find meaning in life — this instills hope.

16

Group psychotherapy is intended to reduce distress while allowing group members to live as fully and authentically as possible. Spira & Reed (2003) describe the essence of group psychotherapy for women with breast cancer as openly addressing issues related to breast cancer and the impact of this experience on their lives. Additional goal areas include self - expressio n, drawing on the emotional support and understanding of others, finding ways to become actively involved with difficulties one is facing, and using the cancer crises as an opportunity for growth. Typical themes discussed in cancer patient groups include relationships with family, friends, and coworkers; coping with the effects of the disease; group dynamics; adjusting to living with a cancer diagnosis; fear of dying; shifting priorities; and self - image (Spira, 1991; Spira & Spiegel, 1993; Spira & Reed 200 3). Simpson et al. (2001) conducted a six - week investigation on the effects of structured group psychotherapy with early breast cancer survivors. Results indicated that group psychotherapy reduced depression and severity of psychiatric symptoms while enh ancing mood and health - related quality of life. No control group comparison was made.

Supportive expressive group therapy is an approach developed and practiced by David Speigel (Classen et al., 1993; Spiegel, Bloom, & Yalom, 1981; Spiegel & Spira, 1991 ). The goal of this therapy is to create an environment in which participants receive support from one another and can freely express feelings and concerns. Furthermore, this approach is existentially - based with the goal of helping the patient live life more fully in the face of a life - threatening illness. To accomplish this, the therapist must help the patient adjust her internalized view of self to one that more accurately reflects present capabilities. Randomized clinical trials demonstrate that supp ortive, expressive group

Full document contains 112 pages
Abstract: Several studies have investigated the psychosocial impact of breast cancer, however, there is a paucity of research examining interventions geared towards breast cancer survivors. This study investigated the effects of group music psychotherapy on improving the self-concept of breast cancer survivors. Eleven breast cancer survivors where randomly assigned to one of two treatment groups - group music psychotherapy or a cognitive behavioral based support group. Pre and post intervention comparisons were made using the Body Image After Breast Cancer Scale and the Tennessee Self-Concept Scale on measures of identity, role performance, self-esteem, and body image. After ten weeks, results from the Wilcoxon U test indicated participants in the music psychotherapy group significantly improved on measures on identity, family role relationships, self-esteem, and body image. Furthermore, as compared to participants in the cognitive behavioral support group, participants in group music psychotherapy improved on measures of identity, role relationships, and body image. Implications and suggestions for further research are discussed.