Taotlus

The Arts in Psychotherapy 77 (2022) 101872

Available online 1 December 2021 0197-4556/© 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Development of a music therapy micro-intervention for stress reduction

Martina de Witte a,b,c,d,*,1, Anne Knapen b, Geert-Jan Stams a, Xavier Moonen a,e, Susan van Hooren d,e,f

a Research Institute of Child Development and Education, University of Amsterdam, PO Box 19268, Nieuwe Achtergracht 127, 1018 WS Amsterdam, The Netherlands b HAN University of Applied Sciences, PO Box 6960, Kapittelweg 33, 6525 EN Nijmegen, The Netherlands c Stevig, Expert Treatment Centre for People with Mild Intellectual Disabilities, PO Box 9, 6591 RC Gennep, The Netherlands d KenVaK, Research Centre for the Arts Therapies, PO Box 550, 6400 AN Heerlen, The Netherlands e Zuyd University of Applied Sciences, Faculty of Healthcare, PO Box 550, 6400 AN Heerlen, The Netherlands f Open University, Faculty of Psychology, PO Box 2960, 6401 DL Heerlen, The Netherlands

A R T I C L E I N F O

Keywords: Music therapy Stress Arousal Micro-intervention Literature Review Delphi Method

A B S T R A C T

Negative stress is a serious risk factor for the onset and progression of a wide range of physical illnesses and emotional problems. In the literature, an increasing examination of music therapy interventions for stress reduction over the past decade is seen, yet music therapy interventions for stress reduction have not been sys- tematically developed and described. Moreover, there is a growing need for micro-interventions, which are defined as short-term interventions in which the therapist uses specific therapeutic techniques to work on a client’s goals. In this study, a music therapy micro-intervention for stress reduction was developed based on both empirical and practice-based knowledge. First, the micro-intervention was described based on both findings from empirical studies (N = 52) focused on the effects of music therapy on stress reduction, and from a previously conducted focus group study focused on the perspectives of music therapists. Second, the Delphi technique was applied to collect feedback on the micro-intervention described, by surveying a panel of 16 music therapy experts. This procedure resulted in an improved description of the music therapy micro-intervention for stress reduction, including a receptive and an active intervention variant. Implications for clinical practice and recommendations for future research are discussed.

Introduction

The negative impact of stress can be a serious risk factor for the onset and progression of a wide range of physical and emotional problems (American Psychological Association [APA], 2017; Australian Psycho- logical Society [APS], 2015). It is well known that music can provide relaxation and calmness, which ensures that music therapy in- terventions are increasingly used to reduce stress and enhance the well-being of clients across a variety of clinical populations (Agres et al., 2021; Bainbridge et al., 2020; Juslin & Västfjäll, 2008; de Witte et al., 2020). Several reviews show positive effects of music therapy in- terventions on stress reduction (e.g. Bradt, Dileo, Magill, & Teague, 2016; de Witte, da Silva Pinho et al., 2020; de Witte, Spruit et al., 2020; Landis-Shack, Heinz, & Bonn-Miller, 2017; Martin et al., 2018; Pelletier,

2004). However, no specific music therapy intervention for stress reduction has yet been systematically described or protocolized. From a scientific point of view, clear intervention descriptions are needed to further investigate what is effective in music therapy interventions (Hoffmann et al., 2014).

The impact of stress

In daily life, almost everyone experiences stress from time to time. In the short term, stress can lead to reduced concentration and difficulty learning new information (The American Institute of Stress, n.d.). Long-term stress can lead to psychopathology such as anxiety disorders, depression, addictions and burnout (Akin & Iskender, 2011; Pittman & Kridli, 2011; Wang, Wang, & Wang, 2019), as well as to health issues,

* Corresponding author at: Research Institute of Child Development and Education, University of Amsterdam, PO Box 19268, Nieuwe Achtergracht 127, 1018 WS Amsterdam, The Netherlands

E-mail addresses: [email protected] (M. de Witte), [email protected] (A. Knapen), [email protected] (G.-J. Stams), [email protected] (X. Moonen), [email protected] (S. Hooren).

1 https://orcid.org/0000-0002-6385-9563.

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The Arts in Psychotherapy

journal homepage: www.elsevier.com/locate/artspsycho

https://doi.org/10.1016/j.aip.2021.101872 Received 25 June 2021; Received in revised form 10 November 2021; Accepted 27 November 2021

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such as high blood pressure, cardiovascular disease, insomnia and an increase or decrease in weight (Bally, Campbell, Chesnick, & Tranmer, 2003; Keech, Cole, Hagger, & Hamilton, 2020; Pittman & Kridli, 2011). To cope with stressors, millions of people around the world use tran- quilizing medications, which are associated with numerous contraindi- cations and negative side effects (e.g., Bandelow et al., 2015; Olfson, King, & Schoenbaum, 2015; Puetz, Youngstedt, & Herring, 2015). It is therefore important to develop and examine promising non-pharmacological interventions for the prevention and management of stress, such as experiential approaches which focus on the “here and now” while guided by a therapist through stress responses and real-time emotional regulation. Through safely structured active experiences, stress inducing situations can be co-navigated, and stress reducing strategies can be developed and/or practiced (de Witte, Bellemans, Tukker, & van Hooren, 2017; de Witte, da Silva Pinho et al., 2020).

Music therapy for stress reduction

Music therapists are specifically trained to use the unique qualities of music, also known as musical components, (e.g., melody, rhythm, tempo, dynamics, pitch) in the therapeutic relationship to work on the patient’s treatment goals (Bruscia, 1987; de Witte, da Silva Pinho et al., 2020; Wheeler, 2015). During music therapy sessions, music therapists attune to the patient by adjusting the way of music-making as an im- mediate response to the client’s needs (Aalbers et al., 2019; Magee, 2019). This can be related to the term “synchronization,” meaning that the music therapist and the patient interact simultaneously and are regu- lated through time, yielding a similar expression in movement, match- ing pulse, rhythm, dynamics and/or melody (Aalbers et al., 2019; Bruscia, 1987; de Witte, da Silva Pinho et al., 2020; Schumacher & Calvet, 2008). For example, the music therapist may influence patients’ perceived stress during musical improvisation by synchronizing with the patient’s music-making, subsequently changing the musical expression by playing slower and less loudly (de Witte, da Silva Pinho et al., 2020). This specific form of patient-therapist attunement is commonly used in music therapy practice and refers to the so-called Iso Principle (e.g., Altshuler, 1948; Heiderscheit & Madson, 2015). The literature shows that the tempo and loudness are important for the experienced intensity of the music (Gabrielsson & Lindström, 2010), and music with a slow steady rhythm may provide stress reduction by altering inherent body rhythms, such as heart rate (Thaut & Hoemberg, 2014; Thaut, Kenyon, Schauer & McIntosh, 1999). Thus, the stress reducing effect of music therapy interventions can be explained by music itself as well as the continuous attunement of music by the music therapist to the individual needs of a patient.

There has been a rapid increase of research on the effects of music therapy on stress reduction. Results of a recent meta-analytic review (de Witte, da Silva Pinho et al., 2020), including 47 quantitative controlled studies, showed an overall medium-to-large effect of music therapy on stress-related outcomes (d = 0.723, [.51–0.94]). This is in line with previous reviews and meta-analyses, which show positive effects of music interventions on the reduction of stress or state-anxiety (Bradt & Dileo, 2014; Bradt, Dileo, & Shim, 2013; Bradt, Dileo, Grocke, & Magill, 2011; Bradt, Dileo, Potvin et al., 2013; Carr, Odell-Miller, & Priebe, 2013; de Witte, Spruit et al., 2020; Gold, Solli, Krüger, & Lie, 2009; Kamioka et al., 2014).

The need for music therapy micro-interventions

In music therapy literature, the term “intervention” may refer to both a specified therapeutic action and a process of intervening characterized by a structured and coherent collection of therapeutic actions (Aalbers et al., 2019; de Witte, Lindelauf et al., 2020). Music therapy in- terventions may thus vary from one single technique or action within a single music therapy session to therapy programs or protocols consisting of multiple therapy sessions. In the last decade, there has been a growing

recognition that one-size-fits-all approaches to intervention may be suboptimal for the patient and healthcare system alike (Gauthier et al., 2017; Rush et al., 2004). Moreover, it is assumed that intervention ef- fects are variable across patients both in magnitude and time (Cuijpers et al., 2012; Kessler et al., 2017). This argues for the need to develop more flexible and more widely applicable interventions in accordance with the patient’s needs, such as micro-interventions. A music therapy micro-intervention can be regarded as a short part of a session in which the music therapist uses specific therapeutic techniques or steps to work on specific patient’s goals (Hakvoort & van der Eng, 2020; Hakvoort, 2020). Despite the fact that micro-interventions are short-lived, they have been systematically described and follow a step-by-step approach based on both recent theoretical models as well as the latest scientific evidence.

The development of music therapy micro-interventions is important to music therapy practice, on the one hand because the way of inter- vening in micro-interventions is strongly linked to core components of music therapy, on the other hand because describing interventions helps to further develop the profession. As the level of a clients’ perceived stress can differ from session to session, it is important that music therapists can respond directly to their clients’ stress levels, at the time it is needed in the specific context of that moment. This fits well with the specific way of patient-therapist attunement widely used in music therapy and which can be seen as one of the main characteristics of music therapy. Therefore, short-term therapeutic interventions that align easily with the existing structure of the session or clients’ musical preferences are particularly suitable. Describing micro-interventions may also stimulate transferability of valuable clinical practices which in turn may strengthen thinking about the relationship between clinical practice, theory, and research (Aigen, 1999; Smeijsters & Vink, 2006; Stige, 2015).

Purpose of the present study

In the literature, we have seen an increasing examination of music therapy for stress reduction in the last decade (de Witte, Spruit et al., 2020; de Witte, da Silva Pinho et al., 2020). In addition, there is a growing need for music therapists to be more explicit about their’ tacit knowledge in order to create more transferability in the way they work on a client’s stress relief (see also: de Witte, Lindelauf et al., 2020). Without these descriptions, music therapists face difficulties in reliably implementing interventions in their clinical practices and researchers can experience difficulties replicating studies (Hoffmann et al., 2014). By developing a micro-intervention in this context, we are in line with the recent developments in healthcare that emphasize the importance of short-term and flexible therapeutic interventions in general. In addition, the development of a micro-intervention is an important first step to- wards achieving more insight into which specific therapeutic factors lead to change, which is becoming increasingly important in the field of music therapy research (de Witte et al., 2021).

In order to provide a comprehensive analysis of music therapists’ stress-reducing interventions, it is necessary to integrate the available practice-based knowledge. Published trials often demonstrate a lack of transparency in reporting detailed information on the content of the music therapy interventions (Aalbers et al., 2019; Robb, Carpenter, & Burns, 2011). This is also evident in the recent meta-analysis by de Witte, da Silva Pinho et al. (2020) in which the included studies mainly examined receptive (music listening) interventions, whereas in daily practice music therapists prefer to use active (music making) in- terventions to reduce their clients’ stress (de Witte, Lindelauf et al., 2020). In addition, developing a music therapy micro-intervention through an iterative process aimed at integrating theory-based, evi- dence-based, and practice-based knowledge is consistent with how other creative arts therapy interventions have been successfully developed (e. g., Aalbers et al., 2019; Bellemans et al., 2018; Haeyen, van Hooren, Dehue, & Hutschemaekers, 2017). The main purpose of the present

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study is therefore to provide a detailed description of a music therapy micro-intervention for stress reduction, which can be used directly by music therapists as well as provide a clear basis for future research.

Method

In this study, two developmental phases can be distinguished, namely, (a) describing the micro-intervention by analyzing and inte- grating the perspectives from both literature and clinical practice, and (b) consulting experts in the field of music therapy to reach consensus on the content and application of the micro-intervention developed. See Fig. 1 for the procedural diagram of the method of the current study.

Phase 1: the development of the micro-intervention

We used a recently developed format by Hakvoort and van der Eng (2020) to describe the micro-intervention as this was particularly designed for describing music therapy micro-interventions. The use of this format ensures a comprehensive and detailed description and en- courages a grounded scientific rationale. The format consists of several sections that must be described, such as specification of the target group, treatment domains, function of music, requisites, therapeutic attitude, the scientific / theoretical foundation, and a stepwise description of the micro-intervention.

Describing the rationale

To describe a theoretical rationale for the use of the music therapy micro-intervention, we needed both to clearly understand the problem of stress as well as a framework for how music therapy leads to stress reduction. To make both the origins and consequences of stress more concrete, we searched for literature in common online databases.2 To provide a theoretical framework on the relationship between music and stress, we mainly used the rationales of two recent meta-analytic reviews on the effects of music interventions and music therapy on stress-related outcomes (de Witte, Spruit et al., 2020; de Witte, da Silva Pinho et al., 2020). Both studies can therefore be regarded as providing key input to describing the scientific rationale for the micro-intervention. In addi- tion, the introductory sections of the empirical studies on the effects of music interventions on stress included in the analysis of this study, were screened for additional theoretical background information.

Analyzing Intervention Descriptions based on Literature

The following step involved analyzing the intervention descriptions of 52 empirical studies examining the effects of music therapy in- terventions on stress-related outcomes to create a solid basis for the content of the micro-intervention. The majority of the studies (n = 47) correspond to those included in the recently performed meta-analysis by de Witte, da Silva Pinho et al. (2020). The primary aim of this earlier study was to demonstrate the overall effect of music therapy in- terventions on stress-related outcomes, in which a detailed analysis of the interventions examined was not taken into account. In this study, we therefore provide an in-depth analysis of particularly the content of the music therapy interventions examined. Five studies were initially excluded in the meta-analysis due to lack of quantitative data, however, we included them for the purpose of our study. The included studies concerned both clinical controlled trials (CCT) and randomized controlled trials (RCT) conducted in medical and mental health care settings, examining the effects of music therapy interventions on phys- iological and/or psychological stress-related outcomes. Only those studies in which a trained and qualified music therapist offered the

intervention were selected. See De Witte, da Silva Pinho, et al. (2020) for more information about the applied search strategy and selection criteria; an overview of the characteristics of the 52 studies included in our study can be found in the Supplemental materials.

We then analyzed the extracted intervention descriptions using the coding principles of qualitative content analysis, which is frequently applied to answer questions such as what, why, and how, whereby the common patterns in the data were deduced using a consistent set of codes to organize text into identified categories of similar meanings (Cho & Lee, 2014; Moretti et al., 2011). To first gain more insights into how the initial data related to the particular sections of the format for the micro-interventions described by Hakvoort and van der Eng (2020), the open codes were grouped into “interventions and methods”, “non-musical interventions”, “preconditions”, “instruments and genres”, and “treatment goals”. Open codes either identical or very similar to each other were then grouped, such as “patient chooses song”, “patient selects songs” and “patient chooses music”. If a code could not be merged with others, we left it separate. This axial coding step led to the categorization of codes based on their overarching similarities to prop- erty levels (Corbin & Strauss, 2008).

Integrating practice-based data

After the analysis of intervention descriptions, the next step was the examination of practice-based knowledge, as outcome studies do not always reflect clinical practice in all its facets. For this purpose, we used an existing dataset of a previous qualitative study. The aim of this particular study was to gain insights into how music therapists reduce their clients’ stress, especially in people with mild intellectual disabil- ities. It consisted of three focus groups held in three different countries in which 13 music therapists participated (see de Witte, Lindelauf et al., 2020). The data from this study was transcribed and open coded by topic. The topic “interventions used within the music” proved particu- larly relevant for purposes of the present study. The open codes were extracted and then added to the initial categories that emerged from the analysis of the intervention descriptions from the literature.

Analysis of combined data

Due to the differing amounts of data, the categories consisting of either at least 4 codes from intervention descriptions from the empirical literature or at least 2 codes from the practice-based data were included as an intervention component. The categories formed by practice-based codes only were counted twice compared to those from the literature. Selective coding was then applied to create an integrated model in which those categories of intervention components could be linked to each other to interpret the steps of the micro-intervention (Charmaz, 2003). To minimize possible bias on the part of the researcher who analyzed the data, the entire process of data analysis was continuously monitored by two co-authors (SH and MDW) and decisions were made in consensus to ensure that the confirmability criteria were met.

Description of the micro-intervention

Based on the analyzes of the empirical literature and the qualitative data, the micro-intervention was described following Hakvoort and van der Eng (2020), consisting of a theoretical rationale, intervention goals, type of setting, treatment phase in which it can be applied, and con- traindications. In order to further shape the specific intervention con- tent, we used the integrated model of intervention components that emerged from data analysis. To establish consensus on the summarized narratives, we organized a final member check of a subgroup of the research team (MdW, AK, SvH).

2 PubMed, PsycINFO, Web of Science, Wiley Online Library, ScienceDirect and Google Scholar

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Phase 2: expert consultation

In the second phase, the Delphi technique was applied in order to arrive at a group opinion by surveying a panel of experts, and to reach consensus through an iterative process of collecting feedback (Linstone & Turoff, 1975; McMillan et al., 2016; Skulmoski et al., 2007). As in other studies, we used a modified Delphi technique to better fit the ob- jectives of the current study (Mullen, 2003; Wheeler et al., 2019). One of the modifications is that we did not use measures of central tendency and dispersion of the rankings by the respondents, which is usually re- ported in Delphi studies. Although the first consultation round collected individual rankings, the second round was sent by e-mail to check whether the adjustments made met respondents’ expectations. There- fore, calculating central tendency and dispersion was not feasible in the present study (see also Wheeler et al., 2019). Another modification concerns the use of a structured questionnaire to obtain focused feed- back from the respondents. Because the present study was designed to consult music therapists to strengthen the description of the micro-intervention, rather than to develop the intervention as a whole, a modified Delphi technique best suited our purposes.

Participants

Participants were sixteen music therapists and researchers in the field of music therapy. All had at least eight years of working experience as a music therapist. Six of them had already participated in one of the focus group interviews from our recent qualitative study (de Witte, Lindelauf et al., 2020). Ten participants were recruited through the in- ternational network of music therapists and researchers associated with Kenvak – a research center for arts therapies (www.kenvak.nl). Selected participants were located in four different countries, namely Belgium, Germany, the Netherlands and the United States. All participants gave informed consent and anonymity of the participants was ensured, both among the included participants and the researchers who analyzed the data.

The first consultation round

An online questionnaire3 (available in Dutch and English) along with the described micro-intervention was sent to the experts. The

questionnaire was focused on all sections of the described micro- intervention. For each topic, the level of agreement could be indicated with a four-point scale. In addition, the participants could add com- ments in each section, e.g. on reason of disagreements, new suggestions, and other feedback. In addition, the questionnaire included questions on the participants’ professional background to gain more insights into their individual perspectives. The amount of agreement was calculated for each section. All suggestions and comments were listed in a file and analyzed by content. Then, every suggested change from the original micro-intervention description was discussed (MdW, AK, SvH) and de- cisions were made in consensus with each other. This procedure resulted in a renewed and improved description.

The second consultation round

For the second consultation round, the adapted version of the micro- intervention was sent again to the participants with a brief summary of the processed feedback and suggestions. They were asked to respond within two weeks if they disagreed with aspects of the new version of the micro-intervention.

Results

The first phase: the development of the micro-intervention

Describing the rationale

Identifying the problem of stress. In the short term, it is known that the negative impact of stress can lead to reduced concentration and diffi- culties when learning and memorizing new information (Schwabe & Wolf, 2010). As a result, working on treatment goals when the client is experiencing stress will be less effective and inefficient (de Witte, Lin- delauf et al., 2020). It is therefore important to first reduce stress and tension so that the client is able to focus on the initial treatment goals. An overview of related health consequences of both long term and short term stress are described in the introduction of this study. A leaner narrative of this information is described in the format of the micro-intervention at “Specific domain that is targeted or treated” (see Table A.1 in Appendix).

Clarifying the stress-reducing effect of music interventions. Both music listening and music making/singing have been associated with a reduction of physiological arousal which increases during stress; this is

Fig. 1. Procedural diagram of the method.

3 The questionnaire can be requested from the first author.

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visible in a reduction of cortisol levels or decrease in heart rate and blood pressure (e.g. Hodges, 2011; Koelsch et al., 2016; Kreutz, Murcia, & Bongard, 2012; Linnemann, Ditzen, Strahler, Doerr, & Nater, 2015; Nilsson, 2009). In addition, a large body of neuroimaging studies show that music can influence stress-related emotional states by modulating activity in brain structures, such as the amygdala, that are known to be involved in emotional processes (e.g. Blood & Zatorre, 2001; Hodges, 2011; Koelsch, 2015; Levitin, 2009; Moore, 2013; Zatorre, 2015). An increased dopamine activity in the mesolimbic reward brain system has been shown to be associated with feelings of happiness in response to listening to favorite/own-preferences music (e.g., Blood & Zatorre, 2001; Salimpoor et al., 2013; Salimpoor, Benovoy, Larcher, Dagher, & Zatorre, 2011; Zatorre, 2015).

Plausible explanations for the positive effects of music interventions on stress, can also be sought in psychological and behavioral oriented scientific theories. Listening to pleasant music may have a positive in- fluence on emotional valence, which can be explained by the degree of attraction that an individual feels towards a specific object or event (Jäncke, 2008; Juslin & Västfjäll, 2008). Music experienced as pleasant increases the intensity of emotional valence (the felt happiness), which has a stress-reducing effect (Jiang, Rickson, & Jiang, 2016; Rohner & Miller, 1980; Sandstrom & Russo, 2010; Witvliet & Vrana, 2007). Listening to music can also provide direct distraction from stressful feelings or thoughts (Bernatzky, Presch, Anderson, & Panksepp, 2011; Chanda & Levitin, 2013). Research that shows the benefits of music to distract people from aversive states is supported by short-term music interventions for acute stress reduction (de Witte, Spruit et al., 2020; Fancourt, Ockelford, & Belai, 2014; Linnemann et al., 2015). Lastly, music listening or music making together with others is also related to stress relief (Juslin, Liljeström et al., 2008). This can be explained by the fact that people synchronize with each other during music activities which evokes feelings of togetherness and social cohesion during the music experience (Boer & Abubakar, 2014; Linnemann, Strahler, & Nater, 2016). This in turn may be explained by the release of the neu- rotransmitters endorphin and oxytocin (e.g., Dunbar, Kaskatis, Mac- Donald, & Barra, 2012; Freeman, 2000; Tarr, Launay, & Dunbar, 2014; Weinstein, Launay, Pearce, Dunbar, & Stewart, 2016), which are posi- tively associated with the defensive response to stress (e.g. Amir, Brown, & Amit, 1980; Dief, Sivukhina, & Jirikowski, 2018). A short narrative of these findings is presented in the format of the micro-intervention at “Function of music during the intervention” (see Table A.1 in the Appendix).

Analysis of the interventions from literature

Some of the included studies only offered limited descriptions of the examined intervention, whereas others offered detailed and rich inter- vention descriptions or even intervention protocols. However, each intervention description led to one or more open codes. Intervention descriptions showed both receptive interventions (n = 22), such as listening to live or pre-recorded music, as well as active interventions (n = 10), such as improvisation, playing existing songs, and song- writing. A combination of both receptive and active interventions was found in 20 of the intervention descriptions. In addition, in 20 of the studies, a complementary intervention/technique was offered along with music therapy, such as breathing exercises, muscle relaxation, and mindfulness exercises. In 38 intervention descriptions, the specific use of music (musical instruments or singing) was reported. Singing was mentioned in most studies (n = 28), followed by percussion instruments (n = 21), guitar (n = 15), and piano (n = 10). After the open coding step, categories were formed through axial coding by similar codes being grouped.

Integration of the practice-based data

Data-analysis of the focus groups indicated that the participating

music therapists mainly use many active interventions (14 in- terventions) and few receptive interventions (one mentioned) for stress reduction. The active interventions included musical improvisation, playing existing music, songwriting, recording own music, and singing mantras or preferred songs. In addition, data showed that the following therapeutic techniques are most often used to reduce a client’s stress: synchronization, pacing, structuring, increasing and decreasing dy- namics and tempo, repeating themes, simple musical structures, and using familiar instruments and songs. The first coding step resulted in 33 categories and remaining single codes.

Analysis of the combined data

The final analysis resulted in a total of 14 categories of intervention components, which we present in order of the total number of codes counted: music based on preferences (10), patient chooses song (7), expressing emotions (5), recording music (4), patient chooses intervention (4), therapist chooses intervention (4), verbal processing of emotions (4), using familiar songs (4), music based on emotional state (4), accelerating tempo (4), keeping appropriate physical distance (4), simplicity in harmony (4), slowing down tempo (4), and lower register (4). These intervention components formed input for the further design of the micro- intervention.

Description of the micro-intervention

The next step was to describe the music therapy micro-intervention in detail. Information on the theoretical background of the problem of stress and the rationale for using music interventions to lower people’s stress levels were added in the format for music therapy micro- interventions (Hakvoort and van der Eng, 2020). Then, the interven- tion goal, the target population and field, possible contra-indications, requisites, and specification of the setting, were supplemented. In order to remain as close as possible to the results of the data analysis, we described both an active and a receptive variant of the music therapy micro-intervention. This allows music therapists to choose the variant that best suits the client’s needs and possibilities at that moment.

Because the micro-intervention is specifically designed to directly reduce the client’s stress, i.e., in the music therapy session itself, the intervention goal was formulated as follows: “reducing tension and stress directly in the music therapy session”. We consider the micro- intervention as transdiagnostic and therefore it does not only relate to the treatment of one specific condition or disorder. However, as research shows that some client populations are more vulnerable to stress, such as people with mild intellectual disabilities or those with impaired cogni- tive functions (e.g., Emerson, 2003; Scott & Havercamp, 2014), we expect that the music therapy micro-intervention might be particularly suitable for these client groups. Precisely because of this broad appli- cability and the fact that we developed two variants, there were no contra-indications. However, clients with severe autism, severe intel- lectual disabilities, or clients suffering from acute psychosis are expected to have difficulty participating because of their reduced ability to be in contact with the therapist. The main prerequisites for applying the micro-intervention include a sound-isolated room (especially in clinical settings), chairs for the client(s) and music therapist, access to a suffi- cient selection of musical instruments (active variant), and sheet music of the client’s preferred music (receptive variant). Furthermore, the micro-intervention can be applied both individually and in groups. See the Appendix for more details of the abovementioned content of the micro-intervention.

All 14 intervention components were included in one of the micro- intervention variants (see Figs. 2 and 3). However, analysis showed that the intervention components “patient chooses the intervention” and “therapist chooses the intervention” appeared to contradict each other. If the client chooses the intervention, often used to appeal to client au- tonomy, it means that the therapist is not able to decide to use the micro-

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intervention. As music therapists use the micro-intervention precisely when it is needed to lower their client’s stress levels, it is not possible to have the client choose the intervention themselves. However, to encourage client autonomy in another way, instead of letting them

choose the intervention, we decided to offer them the choice of the song in the receptive variant and that they could take the lead role in the active variant by building up the music tempo and dynamics.

Fig. 2. The active variant of the micro-intervention.

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The second phase: expert consultation

The first consultation round Analysis of the experts’ feedback led to significant changes in the

description of the micro-intervention.4 Based on their suggestions, we added information, i.e. “voice” as one of the main instruments, allowing the client to experience the present stress before reducing it, specifying the therapeutic role and attitude with four functional domains, and the supporting role of the group when the micro-intervention is offered to just one of the group members. A note was added on contra-indications regarding clients suffering from trauma or anxiety disorders and on the function of the concepts “synchronizing” and “containing” which are related to stress reduction.

The second consultation round

The second round of consultation resulted in consensus among all experts, meaning that no further changes had to be made. The final description of the micro-intervention can be found in the Appendix.

Discussion

In our study, we systematically developed a music therapy micro- intervention aimed at stress reduction based on findings from theoret- ical and empirical studies as well as practice-based knowledge. The micro-intervention was developed for and evaluated by music therapists for use during the music therapy session when it is necessary to lower clients’ stress levels. Although the micro-intervention does not relate only to the treatment of one specific condition or disorder and can be considered as broadly applicable, the literature indicates that some

Fig. 3. The receptive variant of the micro-intervention.

4 An overview of the feedback given can be requested from the first author.

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client populations may benefit more due to their higher vulnerability to stress, such as people with mild intellectual disabilities (MID) or those with impaired cognitive functions (e.g., Emerson, 2003; Scott & Havercamp, 2014). For them, an experiential approach may be more appropriate than the cognitive approach (de Witte, Lindelauf et al., 2020; Didden et al., 2016). To our knowledge, this is the first study in which a music therapy micro-intervention has been systematically developed with the aim of direct stress reduction in the music therapy session.

Strengths and limitations of the present study

The way the micro-intervention was developed has several strengths. First, the systematic and comprehensive approach, which relied on data both from empirical studies as well as from clinical practice, resulted in a well-described micro-intervention. This approach has many similarities to the “Intervention Mapping” approach, a systematic method for the development, implementation, and evaluation of health interventions by constructing programs grounded both in theory and on empirical data (Bartholomew, Parcel, Kok, & Gottlieb, 2006). However, Inter- vention Mapping was originally designed to create larger or longer-term intervention and treatment programs (Bartholomew-Eldridge et al., 2016), and therefore does not fully align with the concept of micro-interventions, which are short-term interventions and can even be used as stand-alone techniques in existing treatment programs (de Witte, Lindelauf et al., 2020). Second, the inclusion of data derived from controlled outcomes studies (RCTs and CCTs: N = 52) offered a scien- tifically robust foundation for the core elements of the micro-intervention. This is relevant so that the basic claims made in the present study are clear (Aalbers et al., 2019; Crooke, Smyth, & McFer- ran, 2016). Moreover, the included outcome studies were derived from a recently conducted meta-analytic review (de Witte, da Silva Pinho et al., 2020) in which the inclusion criteria exactly matched the aims of this study. It can also be argued that this study strengthens the overall sci- entific basis of music therapy for stress reduction, as the previous meta-analysis looked primarily at effects using quantitative analyses, while in this study we qualitatively analyzed the content of the inter- vention, thus answering the how music therapeutic interventions can lead to stress reduction. Third, in the second phase of this study, the micro-intervention was submitted for consultation to music therapy experts from different countries in order to reach consensus in a collaborative process. Thus, thanks to this expert evaluation, the micro-intervention does not rely solely on pre-existing data. This strengthens its generalizability and makes it more plausible that the micro-intervention can be implemented easily in clinical practice.

Some limitations need to be noted. Through the years, several theoretical models have been developed to provide insights into the influence of music on stress. One of the most widely used models of the last decade involves models rooted in biological and neurological the- ories, so we also used these models to provide theoretical explanations of the relationship between stress and music. These models formed the basis of two earlier meta-analytical reviews of music interventions for stress reduction (de Witte, Spruit et al., 2020; de Witte, da Silva Pinho et al., 2020). However, we are aware that the general construct of stress integrates many scientific fields, in which both environmental, psy- chological, and biological/physical factors are interrelated within a comprehensive framework (Aldwin, 2007; Cohen, Janicki-Deverts, & Miller, 2007). In this sense, the strength of exclusively including inter- vention information from controlled outcome studies can be seen as a limitation; information on the content of interventions can also be ob- tained from less robust designs, such as case studies or one group de- signs. However, the importance of analyzing intervention content that demonstrates positive effects was paramount in our study. Related to the previous, the data from this large number of outcome studies mainly showed descriptions of receptive interventions, while the practice-based data almost exclusively showed active interventions. This may indicate a

gap between what is applied in clinical practice and what is investigated in robust research designs (de Witte, Lindelauf et al., 2020). However, it may also be related to the context of a specific target group, such as clients with MID, who were central in the practice-based data. Because we wanted to stay as close as possible to the initial data, this led to the development of two different variants of the micro-intervention: the active and the receptive variant (see Figs. 2 and 3).

Recommendations for future research

Clear intervention descriptions are needed to further investigate what is effective in music therapy interventions (Hoffmann et al., 2014). Future research should focus on whether the developed music therapy micro-intervention for stress reduction does lead to stress reduction during the session. However, methods that can measure the direct ef- fects of the micro-intervention on stress-related outcomes will be needed. Previous reviews of stress measures show that many researchers emphasize the importance of measuring stress outcomes related to both physiological arousal as well as to people’s subjective experiences (Scott and Havercamp, 2014; de Witte, Spruit et al., 2020; de Witte et al., 2021).

As it is still unclear how and why music therapy interventions lead to certain outcomes such as stress reduction, more research on therapeutic factors5 is needed to further develop music therapy micro-interventions. In our micro-intervention, music tempo can be seen as one of the most important elements, and therefore we expect it to be an important therapeutic factor leading to stress relief. This is in line with previous research showing that music tempo can be considered one of the most significant moderators of music-related arousal and relaxation effects (e. g., Bringman, Giesecke, Thörne, & Bringman, 2009; de Witte, Spruit et al., 2020). We therefore recommend that future research includes a secondary research question that focuses on therapeutic factors, such as the tempo of the music, in order to increase knowledge not only regarding efficacy, but also regarding what contributes to these effects.

Micro-interventions also allow researchers to conduct a micro-anal- ysis of specific parts of the music therapy session (Lee, 2000; Wosch & Wigram, 2007). The most important questions are: “what exactly happened and why?”. Through micro-analysis, therapy processes can be better understood or clarified, for example by analyzing the musical activity, social interaction, or nonmusical behavior of a short segment of a session (Wosch & Wigram, 2007). Micro-interventions are therefore highly suitable for pinpointing specific therapeutic factors that cannot be examined when testing over a larger period of time (de Witte et al., 2021).

Implications for clinical practice

Micro-interventions lend themselves well to music therapy practice because of their flexible character and the way in which the therapist can respond to the client’s needs in the moment itself. By offering a musical frame, any musical expression produced by the client can be musically encouraged and responded to in a musical dialogue (e.g., Aigen, 2005; MacDonald, Kreutz, & Mitchell, 2013; Nordoff & Robbins, 1965). Most components of our developed micro-intervention are strongly related to certain therapeutic factors of music therapy, namely “musical dialogue” and “shared musical experiences”. Other important therapeutic factors concern the structuring nature of music, such as tempo. A recent review shows that it is precisely these therapeutic fac- tors that are often associated with positive change in music therapy (de Witte et al., 2021). In addition, the content of the micro-intervention is also in line with Bruscia’s (1987) principles, who developed 64 musical

5 Therapeutic factors are those factors identified by empirical studies that lead to therapeutic change and are associated with particular outcomes (Kaz- din, 2009; Elliot, 2010).

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improvisation techniques based on using the unique qualities of music to establish or influence the musical dialogue with the client; these still form the basis of global music therapy education. However, the concept of the micro-intervention provides more insights into (a) the needs and abilities of certain client populations that the intervention is focused on, (b) particular outcomes, (c) specific characteristics of the intervention, and (d) the underlying theoretical models that explain the relationship between music (therapy) and the targeted outcome. By describing this information, which is mainly subconsciously understood and applied by music therapists, it may stimulate them to strengthen the transferability of their clinical work and may provide more insights into the relation- ship between clinical practice, theory, and research (Aigen, 1999; Smeijsters & Vink, 2006; Stige, 2015).

Appendix A. Supporting information

Supplementary data associated with this article can be found in the online version at doi:10.1016/j.aip.2021.101872.

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Smeijsters, H., & Vink, A. (2006). Research in practice. Music Therapy Today, 7, 791–838. Stige, B. (2015). The practice turn in music therapy theory. Music Therapy Perspectives, 33

(1), 3–11. https://doi.org/10.1093/mtp/miu050 Tarr, B., Launay, J., & Dunbar, R. I. M. (2014). Music and social bonding: “Self-other”

merging and neurohormonal mechanisms. Frontiers in Psychology, 5, Article 1096. https://doi.org/10.3389/fpsyg.2014.01096

Thaut, M. H., & Hoemberg, V. (Eds.). (2014). Handbook of neurologic music therapy. Oxford University Press.

Thaut, M. H., Kenyon, G. P., Schauer, M. L., & McIntosh, G. C. (1999). The connection between rhythmicity and brain function. IEEE Engineering in Medicine and Biology Magazine, 18, 101–108. https://doi.org/10.1109/51.752991

The American Institute of Stress. (n.d.). Stress effects. 〈https://www.stress.org/stress -effects〉.

Wang, X., Wang, C., & Wang, J. (2019). Towards the contributing factors for stress confronting Chinese Ph.D. students. International Journal of Qualitative Studies on Health and Well-Being, 14(1), 1–12. https://doi.org/https://dx.doi.org/10.1080% 2F17482631.2019.1598722.

Weinstein, D., Launay, J., Pearce, E., Dunbar, R. I. M., & Stewart, L. (2016). Singing and social bonding: Changes in connectivity and pain threshold as a function of group size. Evolution and Human Behaviour, 37(2), 152–158. https://doi.org/10.1016/j. evolhumbehav.2015.10.002

Wheeler, B. L. (Ed.). (2015). Music therapy handbook. Guilford Publications. Wheeler, B. L., Cassity, M. D., Lesiuk, T. L., Rosetti, A., Burns, D. S., & Hanser, S. B.

(2019). Music therapy and music medicine studies in oncology: Part II: The use of the delphi technique. Music and Medicine, 11(3). https://doi.org/10.47513/mmd. v11i3.672

de Witte, M. D., Bellemans, T., Tukker, K., & van Hooren, S. A. H. (2017). Vaktherapie. In J. de Bruijn, J. Vonk, & A. van den Broek (Eds.), Handboek emotionele ontwikkeling en verstandelijke beperking [Handbook emotional development and intellectual disability] (pp.277–90). Amsterdam: Boom.

de Witte, M., da Silva Pinho, A., Stams, G.-J., Moonen, X., Bos, A. E. R., & van Hooren, S. (2020). Music therapy for stress reduction: a systematic review and meta-analysis. Health Psychology Review. https://doi.org/10.1080/17437199.2020.1846580

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analyses. Health Psychology Review, 14(2), 294–324. https://doi.org/10.1080/ 17437199.2019.1627897

Witvliet, C. V. O., & Vrana, S. R. (2007). Play it again Sam: Repeated exposure to emotionally evocative music polarises liking and smiling responses, and influences other affective reports, facial EMG, and heart rate. Cognition and Emotion, 21(1), 3–25. https://doi.org/10.1080/02699930601000672

Wosch, T., & Wigram, T. (2007). Microanalysis in music therapy: Introduction and theoretical basis. In Microanalysis: Methods, techniques and applications for clinicians, researchers, educators and students (pp. 13–28). Jessica Kingsley.

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M. de Witte et al.

VAT seansi struktuur

TLÜ VAT laboris

Lülitada sisse tehnikatorni kõik seadmed. NB: taustamuusika CD-

mängijat on võimalik sisse lülitada ainult siis, kui taustamuusika võimendi

on sisse lülitatud.

Seada voodiruum korda (enne kliendi saabumist): lülitada sisse

lisaks suurele põrandalambile ka väiksed põrandalambid tehnikatorni

laua all, korrastada voodi.

1. Pakkuda kliendile istet.

Ainult esimesel seansil

2. Lühike selgitus VAT meetodist kliendile.

Igal seansil

3. Jäädvustada kliendi hetkeseisund mõõdikute/intervjuu jne abil.

4. Paluda kliendil VAT voodile selili heita nii, et tema jalad jäävad

taustamuusika kõlarite poolsesse otsa. Kui selili ei ole mugav (on valus,

ei ole võimalik), siis leida mugavaim kehaasend. Öelda, et seansi ajal

võib soovi korral kehaasendit muuta: võib keerata külili või kõhuli, kui

selliselt on mugavam.

5. Küsida padja kõrguse sobivuse kohta – vajadusel panna lisapadi või

võtta padi ära.

6. Küsida, kas soovib tekki peale. Asetada tekk vastavalt kliendi soovile

(pikka kasvu klientidele 2 tekki – üks nii, et katab ülakeha, teine nii, et

katab alakeha ja jalad).

7. Selgitada, et järgnevalt lülitad sisse madalasagedusliku vibratsiooni

(vibatsiooniprogrammi CD-mängija on tehnikatornis kõige ülemine

seadeldis, vastava kleebisega esipaneelil; muusika CD-mängija on

tehnikatornis alt kolmas seadeldis, samuti varustatud vastava

kleebisega; CD-mängija nupud: ▲ - plaadisahtli avamise/sulgemise

nupp, ►∕║ - plaadi mängima-/pausilepanemise nupp, ■ - plaadi

peatamise nupp, |<< - eelmise heliraja valiku nupp, >>| - järgmise

heliraja valiku nupp).

8. Reguleerida vibratsiooni helitugevus patsiendile sobivaks. Selleks

kasutada vibratsiooniprogrammi helivõimendit, mis tehnikatornis on

kõige alumine seadeldis (vastava kleebisega). Järgnevalt võimendi

helinivoode regulaatorite tähised:

 CH1 – turjapiirkonna valjuhääldi;

 CH2 – nimmepiirkonna valjuhääldi;

 CH3 – reitepiirkonna valjuhääldigrupp;

 CH4 – säärtepiirkonna valjuhääldigrupp.

Aja kokkuhoiu mõttes võib kõik neli regulaatorit mõjutusele eelnevalt

keerata tähiseni „1“. Kui klient on juba voodis pikali, siis vibratsiooni

helitugevuse reguleerimist alustada säärtepiirkonna valjuhääldigrupist –

kui regulaator on juba tähiseni „1“ keeratud, siis küsida, kas klient juba

vibratsiooni tunnetab. Kui jah, siis küsida, kas vibratsioon säärte

piirkonnas on paraja tugevusega või tuleks seda tugevamaks/nõrgemaks

seada. Kui säärtepiirkonna vibratsiooni sobiv tugevus (mitte liiga nõrk

ega ebameeldivalt tugev) on leitud, siis sarnaselt äsjatoodule reguleerida

vibratsiooni helitugevused ka ülejäänud valjuhääldigruppide jaoks (NB!

Kuna peale viimase valjuhääldigrupi sobiva helitugevuse leidmist tajub

inimene kehas kõigi valjuhääldigruppide helitugevuste summat, siis

küsida, kas helitugevus summaarselt on sobiv). Kui sobivad nivood on

leitud, siis esimese (paari) seansi puhul keerata kõigi valjuhääldigruppide

helitugevus veidi vähemaks, sest mõjutuse jooksul keha

vibratsioonitundlikkus suureneb.

9. Selgitada, mis protseduuri ajal edasi toimub, nt: „Kui järgnevalt

taustamuusika helitugevus on sobivaks reguleeritud, jään mina mõjutuse

ajaks kuuldeulatusse samasse ruumi, kus praegu viibin. Kui midagi

juhtub või on ebamugav, siis andke häälega märku, reageerin kohe.“

10. Reguleerida taustamuusika helitugevus kliendile sobivaks. Selleks

kasutada taustamuusika helivõimendit, mis tehnikatornis on alt teine

seadeldis (vastava kleebisega). Kui taustamuusika heli hakkab kostma,

küsida, kas see on kliendi jaoks sobiv helitugevus. Reguleerida vastavalt

kliendi antud tagasisidele.

12. Küsida kliendilt, kas tal on mugav, kas kõik on sobiv. Eitava vastuse

korral kõrvaldada puudujäägid, positiivse vastuse korral nt soovida

„Head lõdvestumist“.

13. Jääda laua taha kuni VA mõjutuse lõpuni (umbes 23 min, jälgida

kellalt).

14. Kui VA mõjutus on lõppenud, siis keerata taustamuusika helitugevus

aeglaselt ja sujuvalt „nulli“.

15. Kui klient on uinunud, siis äratada rahulikult.

16. Jäädvustada kliendi hetkeseisund mõõdikute/intervjuu jne abil.

Küsida mõjutuse ajal kogetu kohta. NB! Kliendi hetkeseisundit võib

jäädvustada ka pärast kliendi voodist tõusmist laua ääres istudes.

17. Kui kliendi hetkeseisund on jäädvustatud, siis paluda kliendil

aeglaselt ja rahulikult voodis istuli tõusta, ja mõne aja pärast püsti tõusta.

Pärast seansi muude formaalsuste lõpetamist (nt järgmise seansi aja

kokku leppimine) võib klient VAT ruumist lahkuda.

Enne VAT ruumist lahkumist keerata nii vibratsiooniprogrammi kui

taustamuusika võimendi helinivoo regulaatorid „nulli“, seejärel

lülitada kõik seadmed ja lambid välja.

Music-Based Relaxation Intervention (MBRI) – Protokoll ja tõenduspõhisus

Lühikirjeldus: Music-Based Relaxation Intervention (MBRI) on struktureeritud

lühisekkumine, mis kombineerib juhendatud lõõgastuse ja muusika kuulamise. Sekkumine on

suunatud ärevuse, stressi ja emotsionaalse erutuse vähendamisele ning sobib madala

intensiivsusega teenustesse.

Protokoll (20–30 min sessioon)

1. Eesmärgistamine (1–3 min)

- kliendi seisundi kaardistamine

- eesmärgi sõnastamine (nt ärevuse vähendamine)

2. Lõõgastusinduktsioon (5–10 min)

- juhendatud hingamine või progressiivne lihaslõdvestus

- tähelepanu suunamine kehale

3. Muusikapõhine regulatsioon (10–20 min)

- rahustava muusika kuulamine (tempo 60–80 bpm)

- tähelepanu hingamisel ja kehatunnetusel

- tempo ja struktuur toetavad autonoomse närvisüsteemi regulatsiooni tähelepanu:

hingamisel, kehal, kujutluspiltidel.

- muusika võib olla terapeudi valitud või individuaalselt kohandatud

4. Refleksioon (3–5 min)

- kogemuse sõnastamine

- seos igapäevaeluga

Toimemehhanism

✓ autonoomse närvisüsteemi regulatsioon

✓ südamerütmi ja hingamise sünkroniseerimine

✓ emotsionaalse erutuse vähenemine

✓ stressihormoonide (nt kortisool) vähenemine

Tõenduspõhisus: Meta-analüüsid ja süstemaatilised ülevaated näitavad, et muusikapõhised

sekkumised vähendavad stressi ja ärevust ning parandavad emotsionaalset regulatsiooni.

Efektid on keskmise suurusega ning ilmnevad ka lühiformaadis sekkumiste puhul.

Uuringud näitavad, et isegi üksikseansid võivad vähendada ärevust ja füsioloogilist

stressireaktsiooni. Muusika mõju autonoomsele närvisüsteemile hõlmab südamerütmi,

vererõhu ja kortisooli taseme muutusi.

Viited:

• de Witte, M., Spruit, A., van Hooren, S., Moonen, X., & Stams, G. J. J. M. (2020). Effects

of music interventions on stress-related outcomes: A systematic review and two meta-

analyses. Health Psychology Review, 14(2), 294–324.

https://doi.org/10.1080/17437199.2019.1627897

• Pelletier, C. L. (2004). The effect of music on decreasing arousal due to stress: A meta-

analysis. Journal of Music Therapy, 41(3), 192–214.

https://doi.org/10.1093/jmt/41.3.192

• Thoma, M. V., La Marca, R., Brönnimann, R., Finkel, L., Ehlert, U., & Nater, U. M. (2013).

The effect of music on the human stress response. PLoS ONE, 8(8), e70156.

https://doi.org/10.1371/journal.pone.0070156

• de Witte, M., Pinho, A. S., Stams, G. J. J. M., Moonen, X., Bos, A. E. R., & van Hooren,

S. (2022). Development of a music therapy micro-intervention for stress reduction. The

Arts in Psychotherapy, 77, 101873. https://doi.org/10.1016/j.aip.2021.101873

Vibroakustilise muusikateraapia sekkumise protokoll

Skille–Wigram mudel on vibroakustilise teraapia (VAT) kõige mõjukam ja laialdasemalt

kasutatav teoreetiline-kliiniline raamistik, mille töötasid välja Olav Skille ja Tony Wigram

1980.–1990. aastatel.

1. Hindamine (Assessment)

Vibroakustilise muusikateraapia (VAT) sekkumine algab kliendi põhjaliku hindamisega.

Hindamine hõlmab anamneesi kogumist (neuroloogiline, psühholoogiline ja füüsiline seisund),

vastunäidustuste välistamist (nt ägedad põletikud, tromboos, teatud raseduse etapid) ning

terapeutiliste eesmärkide seadmist (nt valu vähendamine, ärevuse leevendamine, lihaspinge

alandamine).

2. Seadistus (Equipment & Setup)

VAT sekkumiseks kasutatakse vibroakustilist lamamistooli või madratsit, mis edastab

madalsageduslikku heli kehale. Kasutatakse sagedusvahemikku 20–120 Hz. Keskkond peab

olema rahulik, vaikne ja minimaalse stimulatsiooniga.

3. Sagedusprotokoll

Tüüpiline sessioon kestab 20–45 minutit, sagedusega 1–3 korda nädalas. Sagedused valitakse

vastavalt eesmärgile: 20–50 Hz lõõgastuseks, 40 Hz neuroloogiliseks stimulatsiooniks, 60–80

Hz lihaspinge reguleerimiseks. Sageli kasutatakse sweep-tehnikat (muutuv sagedus).

4. Muusikaline komponent

Muusika valitakse terapeutiliselt: aeglane tempo (60–80 BPM), madal dünaamika ja

harmooniline stabiilsus. Muusika võib olla eelnevalt salvestatud või live-esitus.

5. Terapeutiline protsess

Klient lamab seadmel ning terapeut jälgib füsioloogilisi reaktsioone, kohandab sagedusi ning

juhendab vajadusel hingamist või kujutluspilte.

6. Järelhindamine

Seansi järel hinnatakse subjektiivseid ja objektiivseid muutusi, sealhulgas valu (VAS), ärevust

ja füsioloogilisi näitajaid.

Viited

• Chesky, K., & Michel, D. (1991). The effect of music and vibrotactile stimulation on

perception of pain. Journal of Music Therapy, 28(4), 191–202.

• Grocke, D., & Wigram, T. (2007). Receptive methods in music therapy. Jessica Kingsley

Publishers.

• King, L. K., et al. (2009). The effects of vibroacoustic therapy on motor function in

Parkinson’s disease. Journal of Rehabilitation Research.

• Naghdi, L., et al. (2015). The effectiveness of vibroacoustic therapy in rehabilitation: A

systematic review. Journal of Rehabilitation Research.

• Punkanen, M., & Ala-Ruona, E. (2012). Contemporary vibroacoustic therapy: Perspectives

on clinical practice. Music and Medicine.

• Skille, O. (1989). Vibroacoustic therapy. Music Therapy, 8(1), 61–77.

• Wigram, T. (1996). The effects of vibroacoustic therapy on clinical populations. Music

Therapy Perspectives, 14, 20–28.

• Wigram, T. (2005). Music therapy research and practice in medicine. Jessica Kingsley

Publishers.

1

Sotsiaalministri 17.03.2026 määrus nr 1.2-2/27-1

„Väheintensiivsete psühholoogiliste sekkumiste

rakendamise toetus“ Lisa 1

Taotlusvorm

1. Taotleja andmed

1.1. Asutuse/ettevõtte nimetus: Ojaveere Nõustamine OÜ

1.2. Registrikood: 14576910

1.3. Postiaadress: Rapla maakond, Rapla vald, Rapla linn, Tallinna mnt 22, 79512

1.4. Arvelduskonto (IBAN): EE972200221070258412

1.5. Esindaja nimi ja ametikoht: Siiri Viil, juhatuse liige

1.6. Kontaktisiku andmed (nimi, e-post, telefon): Siiri Viil [email protected] 55 155 78

1.7. Taotletav toetuse kogusumma (käibemaksuta): 62 550 eur

1.8. Projekti elluviimise periood: 1.6-31.12.2026

2. VIPS-i kirjeldus

2.1. Nimetus: Music Therapy Micro-Interventions

2.2. Lühikirjeldus (sh metoodiline alus): Music Therapy Micro-Interventions (MTMI) sobib

rakendamiseks madala lävega vaimse tervise teenustes tänu oma lühiformaadile, struktureeritusele

ja skaleeritavusele. MTMI defineeritakse kui lühiajaline, struktureeritud terapeutiline sekkumine,

milles kasutatakse spetsiifilisi muusikateraapia tehnikaid kliendi konkreetse eesmärgi

saavutamiseks (de Witte et al., 2022). RECEPTIVE MICRO-INTERVENTION (kuulamisel

põhinev) struktuur: 1) eesmärgi seadmine (nt ärevuse vähendamine) 2) juhendatud muusika

kuulamine 3) füsioloogilise ja emotsionaalse seisundi jälgimine (nt hingamise aeglustumine) 4)

refleksioon ja tähenduse loomine. ACTIVE MICRO-INTERVENTION (aktiivne variant)

struktuur: 1) emotsionaalse seisundi kaardistamine 2) aktiivne muusikaline tegevus (rütm,

improvisatsioon, hääl) 3) emotsioonide väljendamine ja reguleerimine 4) refleksioon.

2.3. Sihtrühm (vanuserühm jne): 15-64. Gruppide korral vanusepõhiselt 15–24, 25–44, 45–64.

2.4. Piirkond: Saaremaa, Rapla maakond

2.5. Formaat (individuaal, grupi, kombineeritud): nii individuaal kui grupp

2.6. Struktuur (seansside arv, ühe seansi kestus minutites, grupisekkumiste korral inimeste arv grupis):

Individuaalne 1–8 sessiooni; seansi pikkus 45-60 minutit. Grupisekkumise korral 4-8 sessiooni,

grupis kuni 12 osalejat ning sekkumise pikkus 90 minutit.

2.7. Vorm (kohapeal, veebis jne): kohapeal (individuaalne ja grupp), veebis (individuaalne)

2.8. Tõenduspõhisus (viidata uuringutele, rahvusvahelisele kasutusele; lisada viited või allikad): MTMI

on teaduspõhiselt arendatud ja ekspertide poolt valideeritud muusikateraapia lühisekkumine, mis

sisaldab struktureeritud receptive ja active sekkumist (de Witte et al., 2022). Sekkumine töötati välja

52 empiirilise uuringu analüüsi ning praktikute kogemuse põhjal ning valideeriti Delphi meetodil

16 eksperdi hinnangute kaudu. Tulemused näitavad olulist mõju stressi ja ärevuse vähendamisel.

Hinnates aktiivse variandi mõju depressioonile (Erkkilä et al., 2011) leiti depressiooni, ärevuse ja

stressi vähenemist. Sekkumise mõju põhineb: närvisüsteemi regulatsioonil (tempo, rütm);

2

emotsionaalsel väljendusel ja töötlemisel; terapeutilisel attunement’il (muusikaline kooskõla

spetsialisti ja kliendi vahel).

Meta-analüüsid ja süstemaatilised ülevaated näitavad, et muusikateraapia sekkumised vähendavad ärevust (SMD ≈ -0.36) ning parandavad emotsionaalset regulatsiooni ning on efektiivsed ka lühiformaadis sekkumistena sh Cochrane Collaboration (Bradt et al., 2016; de Witte et al., 2020; de Witte et al., 2022; Gold et al., 2009). Muusikateraapia sekkumised on seotud: kortisooli taseme vähenemisega; südamerütmi ja erutuse regulatsiooniga; emotsionaalse seisundi paranemisega. isegi üksikseansid võivad vähendada ärevust ja füsioloogilist stressi (de Witte et al., 2022). Lisaks näitavad meta-analüüsid, et muusikateraapia vähendab ärevust ja stressi, parandab emotsionaalset regulatsiooni ning on efektiivne ka lühiformaadis sekkumistena (Bradt et al., 2016; de Witte et al., 2020; de Witte et al., 2022; Gold et al., 2009; Lee et al., 2025). Muusikateraapia tõenduspõhisust on kirjeldatud ka Põld, Kleinberg et al. 2024 tuues välja, et muusikateraapia on depressiooniga noorukitel lastel tavaraviga võrreldes oluliselt efektiivsem.

2.9. Kinnitus sekkumise juhendi olemasolu kohta (lisada näidis või kirjeldus): MTMI protokoll on

kirjeldatud de Witte et al. 2022 ning lisatud ka taotlusele (Lisa 1)

2.10. Varasem rakendamine (rakendamise maht ja kestus): MTMI on rakendatud siiani

muusikaterapeutide poolt nii lühisekkumisena, sotsiaalses rehabilitatsioonis, tööalases

rehabilitatsioonis kui haiglaravis. Kuna eraldi ei ole mõõdetud sekkumise mahtu, siis seda välja

tuua on keeruline. Samas on nii sotsiaalses rehabilitatsioonis kui KOV vaimse tervise teenustena

loovteraapiad üheks enimkasutatud teenuseks, mistõttu võib väita, et sekkumist on rakendatud

olulises mahus.

2.11. Tagasiside kogumise viis: Eraldiseisvalt ei ole sekkumise osas tagasisidet kogutud vaid tulemusi

on mõõdetud kõigi kliendile võimaldatud sekkumiste kogumine. Edaspidi saab VIPS

rakendamisel mõju mõõtmisel kasutatakse EEK-2 või WHO-5 heaolu indeks (enne ja pärast).

Mõlemad hindamismeetodid on valideeritud ning sobilikud sihtgrupile (Allgaier et al, 2012;

Streimann et al. 2021).

3. Nimetus: Music-Based Relaxation Interventions

3.1. Lühikirjeldus (sh metoodiline alus): Music-Based Relaxation Interventions (MBRI) on

struktureeritud madala intensiivsusega sekkumine, mis ühendab muusika kuulamise (keskmiselt

tempoga 60-80bpm) ja lõõgastus- ja regulatsioonitehnikatega (nt hingamine, juhendatud

kujutluspildid või progressiivne lihaslõdvestus). Sekkumine sobib rakendamiseks lühiformaadis

ning sisaldab eesmärgistamist, füsioloogilise rahustamise faasi, muusikapõhist regulatsiooni (10–

20 min, tempo 60–80 bpm) ning refleksiooni. Protokoll põhineb meta-analüüsidel ja kontrollitud

uuringutel, mis näitavad, et muusikapõhised sekkumised vähendavad stressi ja ärevust ning

mõjutavad autonoomset närvisüsteemi.

3.2. Sihtrühm (vanuserühm jne): 15-64

3.3. Piirkond: Saaremaa, Rapla maakond

3.4. Formaat (individuaal, grupi, kombineeritud): individuaalne, grupp

3.5. Struktuur (seansside arv, ühe seansi kestus minutites, grupisekkumiste korral inimeste arv grupis):

6-10 korda sagedusega 1-2 korda nädalas, kestvus 30 minutit. Grupi puhul kestvus 60 minutit

ning grupis kuni 8 osalejat. Sekkumine on eelneval juhendamisel ka kliendi poolt iseseisvalt

rakendatav.

3.6. Vorm (kohapeal, veebis jne): kohapeal

3.7. Tõenduspõhisus (viidata uuringutele, rahvusvahelisele kasutusele; lisada viited või allikad: Meta-

analüüsid ja randomiseeritud uuringud näitavad ärevuse ja stressi vähenemist ning emotsionaalse

regulatsiooni paranemist (de Witte et al., 2020, Giordano et al, 2022, Nguyen et l., 2023,

Eckhouse et al. 2014, Chi et al., 2015, Bradt et al., 2013).

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3.8. Kinnitus sekkumise juhendi olemasolu kohta (lisada näidis või kirjeldus): Lisatud fail – Lisa 3.

MBRI protokoll

3.9. Varasem rakendamine (rakendamise maht ja kestus): MBRI on rakendatud siiani

muusikaterapeutide poolt nii lühisekkumisena, sotsiaalses rehabilitatsioonis, tööalases

rehabilitatsioonis kui haiglaravis. Kuna eraldi ei ole mõõdetud sekkumise mahtu, siis seda välja

tuua on keeruline. Samas on nii sotsiaalses rehabilitatsioonis kui KOV vaimse tervise teenustena

loovteraapiad üheks enimkasutatud teenuseks, mistõttu võib väita, et sekkumist on rakendatud

olulises mahus.

3.10. Tagasiside kogumise viis: Eraldiseisvalt ei ole sekkumise osas tagasisidet kogutud vaid tulemusi

on mõõdetud kõigi kliendile võimaldatud sekkumiste kogumine. Edaspidi saab VIPS

rakendamisel mõju mõõtmisel kasutatakse EEK-2 või WHO-5 heaolu indeks (enne ja pärast).

Mõlemad hindamismeetodid on valideeritud ning sobilikud sihtgrupile (Allgaier et al, 2012;

Streimann et al. 2021).

4. Nimetus: Vibroakustilise teraapia

4.1. Lühikirjeldus (sh metoodiline alus): Vibroakustiline teraapia (VAT) on ravimeetod, mille puhul

kasutatakse madalasageduslikke siinushelisid vahemikus 30–120Hz kombineerituna muusikaga

(Rüütel, 1998a). Tänapäeval on madalsagedusega helivibratsiooniteraapia üks muusikateraapia

rakendusi, mida praktiseeritakse kogu maailmas. Rüütel (1998a) toob välja, et vibroakustilises

teraapias kasutatav muusika on reeglina mahe, improviseeritud ja ilma rõhutatud rütmita. VAT

sekkumise ajal kasutatakse juhendatud relaksatsiooni samaaegselt muusikaga. Kliinilises praktikas

ja teadusuuringutes kasutatakse tüüpprotokolli: Eesmärgistamine (2–5 min),

Lõõgastusinduktsioon (5–10 min), Muusikapõhine lõõgastus (15–25 min), Refleksioon (5–10

min)

4.2. Sihtrühm (vanuserühm jne): 15-64

4.3. Piirkond: Saaremaa, Rapla maakond

4.4. Formaat (individuaal, grupi, kombineeritud): individuaalne

4.5. Struktuur (seansside arv, ühe seansi kestus minutites, grupisekkumiste korral inimeste arv grupis):

8-10 korda sagedusega 1-2 korda nädalas, kestvus 45-60 minutit.

4.6. Vorm (kohapeal, veebis jne): kohapeal

4.7. Tõenduspõhisus (viidata uuringutele, rahvusvahelisele kasutusele; lisada viited või allikad:

Teadusuuringutes on tõendatud VAT sekkumiste abistavat mõju nii ühekordse sekkumise korral

(Kantor et al, 2022, Bergström-Isacsson et al, 2007) kui ka pikemate sekkumiste võimaldamisel

(Sigurdardóttir et al, 2019; Ahonen, Deek, Kroeker, 2012; Rogers et al, 2007; Leandertz et al,

2021, Skille ja Wigram, 1995; Rüütel ja Vinkel (2011). Bartel ja Mosabbir (2021) metanalüüs toob

ulatuslikult välja uurimistööde rohkuse helivibratsiooni kasutamisel füsioloogilisest,

neuroloogilisest ja biokeemilisest mõjust, sh 40Hz kasutamisest. Lõõgastustehnikad koos juhitud

kujutlustega on osutunud tõhusaks valu, ärevuse, depressiooni ja ravimite kasutamise

vähendamisel (Tusek et al, 1997) nii täiskasvanutel kui lastel (Álvarez-García ja Yaban, 2020) ning

seda eriti juhul, kui muusika ja juhitud kujutlust kasutatakse VAT sekkumise ajal (Alam et al,

2016). Sigurdardóttir et al (2019) uuringus oli 18 depressiivset klienti vanuses 18–70 a, kellele

võimaldati tavapärasele depressiooniravile lisaks 3–4 nädala jooksul kaheksa 20 minutilist VAT

seanssi koos muusikaga. Uuringus oli ka 20 liikmega kontrollgrupp, kes sai tavapärast

depressiooniravi. Tulemusena leiti, et võrreldes kontrollgrupiga oli VAT sekkumist saanud

patsientide depressioon vähenenud oluliselt rohkemal määral kui kontrollgrupis. Tegemist on ühe

kvaliteetseima uuringuga viimastel aastatel, mis valideerib VAT ravi depressiooniravis. Ahonen,

Deek, Kroeker (2012) viisid samuti läbi uuringu hindamaks VAT mõju stressi korral. 10

4

muusikavaldkonna üliõpilasega (vanuste vahemikkus ei ole esitatud) uuringus oli sekkumise

pikkuseks 30–60 minutit sõltuvalt osaleja vajadustest, sekkumiste arv oli 6–8 seanssi ning kasutati

sagedusi vahemikus 27–113Hz. Uuringu tulemusel nenditi, et sekkumisgrupil suurenes

subjektiivne heaolutunne (füüsiline ja emotsionaalne lõõgastus, vähenenud valu ja stress,

suurenenud emotsionaalne võimekus ja kontsentreerumine). Kantor et al (2022) uurisid

ühekordse VAT ja muusika sekkumise mõju 22 akuutsete stressinäitajatega ülikooli üliõpilasega,

vanuses 18–40. a. Kasutatud sagedus sekkumisgrupis oli 0–100Hz ning seansi pikkus kuni 50

minutit. Uuringus oli ka 28 osalejaga kontrollgrupp, kes kuulas sekkumisgrupiga sama muusikat

kuid ilma madalsagedusliku vibratsioonita. Stressinäitajatena kasutati pulsi sagedust, stressiga

seotud valu (hindamise mõõdik Visual analogue scales) ja lihaste lõdvestust. Selle pilootuuringu

tulemused näitasid, et madala sagedusega heli võib kasutada stressijuhtimise vahendina

hariduskeskkonnas, nt ülikoolis. Leiti, et madala sagedusega heli suurendab parasümpaatilise

närvisüsteemi aktiivsust ning toetab subjektiivse stressireaktsiooni ja lihaspingete leevendamist.

Soomes asub meetodi arendamise eestvedaja (https://www.vibrac.fi/vibroacoustic-therapy/ )

ning Soomes rakendatakse VAT rehabilitatsioonis muusikateraapia teenuse raames. Teadustöid

on rohkelt kajastatud ka Next Wave Physio veebilehel.

4.8. Kinnitus sekkumise juhendi olemasolu kohta (lisada näidis või kirjeldus): VAT protsess on

kirjeldatud Rüütel et al (2004). Sekkumise protokoll lisatud failina – „Lisa 2. VAT seansi

struktuur_TLÜ VAT laboris“ ning Lisa 4 – VAT protokoll, Skille-Wigram mudel.

4.9. Varasem rakendamine (rakendamise maht ja kestus): VAT on rakendatud siiani

muusikaterapeutide poolt nii lühisekkumisena, sotsiaalses rehabilitatsioonis kui haiglaravis.

4.10. Tagasiside kogumise viis: mõju mõõtmisel kasutatakse EEK-2, ESDS-6, NRS. Mõõtmisvahendid

on toodud kompaktsena Rüütel 2002; Rüütel et al, 2004; Viil. S., 2023.

5. Kavandatud maht

5.1. Seansside koguarv toetusperioodil: 789

5.2. Teenusesaajate arv: 155 (95 individuaalselt ja 60 gruppides)

5.3. Keskmine seansside arv ühe teenusesaaja kohta: 5,1

5.4. Maht piirkondade kaupa: Saaremaal 35 individuaalselt ja 20 grupis, Raplamaal 60

individuaalselt ja 40 grupis

5.5. Sihtrühmani jõudmise ja suunamise kanalid: sotsiaalmeedia, KOV teavituskanalid (KOV ajaleht,

osavaldade ajalehed Saaremaal), Raplamaal Raplamaa Sõnumite podcast, perearstid ja

sotsiaaltöötajad

6. Meeskond ja rakendusvõimekus

6.1. Spetsialistide arv (vähemalt 5, lisada viie inimese info allolevasse tabelisse):

Ees- ja perekonnanimi Haridus (eriala, kraad) Lepingu (nt töö-, töövõtu- või käsundusleping) sõlmimise kuupäev

Siiri Viil Terviseteaduste magister, loovteraapia kutse 7, pereterapeut, kogemusnõustaja

10.2019

Kaili Inno Terviseteaduste magister, loovteraapia kutse 7, pereterapeut, suprviisor

1.7.2025

Kadi Uibo Muusikapedagoogika magister, muusikaterapeut

28.6.2025

Epp Sussen Terviseteaduste magister, loovteraapia kutse 7

15.12.2023

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Liisi-Katarina Verk Lõpetamas Tallinna Ülikoolis sotsiaalse rehabilitatsiooni BA, varasem kogemus sotsiaaltöötajana ning juhtumikorraldajana

12.3.2026

Ave Verk Sotsiaalpedagoogika magister, pereterapeut (superviseeritav)

1.7.2025

Laima Parik Psühholoogia magister, loovterapeut 1.7.2025

6.2. Spetsialistide kvalifikatsioon: spetsialistid, kes muusikateraapia sekkumisi rakendavad on kõik

asjakohase baasharidusega ning kogemustega vaimse tervise valdkonnas. Kõik töötavad

igapäevaselt klientidega.

6.3. Superviisorite arv ja kvalifikatsioon: Superviisor Kaili Inno (loovterapeut kutse 7)

6.4. Supervisiooni sagedus ja korraldus: grupi supervisioonina vähemalt kord kvartalis. Individuaalse

supervisioonina vastavalt vajadusele.

6.5. Riskijuhtimise plaan: Keskus on tegutsenud aastaid ning meie meeskond on laiem kui taotluses

välja toodud. Seega on risk, et teenuseosutajal tekib personali puudus, väike. Seadmed VAT

osutamiseks on olemas ning vajadusel on olemas võimekus ka soetada seadmeid juurde. Samuti

on muusikateraapiliste lühisekkumiste osutamiseks vajalikud töövahendid olemas. Ruumid on

keskusel olemas nii Raplas kui Saaremaal (Orissaares ja Kuressaares). Teenuse järjepidevuse

tagamiseks on keskusel piisaval arvul spetsialiste, kes on kvalifitseeritud teenuseid osutama.

Teenuse kättesaadavuse osas informatsiooni jagamisel kasutatakse kohalikke tervishoiu- ja

sotsiaalvõrgustikke, sotsiaalmeediat, haridusvaldkonna asutusi, valdkonnas elanikke koondavaid

MTÜsid. Samuti on mõlemas piirkonnas TERVIK ettevalmistuseks loodud koostöömudelid,

mille kaudu informatsiooni teenuse olemasolust on võimalik jagada.

6.6. Kinnitus metoodika kasutusõiguse kohta: Kinnitame õigust metoodikaid rakendada. Spetsialistid

on väljaõppe läbinud

7. Ühe seansi maksumuse ja kulude põhjendus

7.1. Ühe seansi maksumus (koos seansi formaadiga, kui sama taotlus/VIPS sisaldab erinevaid

formaate): MTMI 45-60min 90eur; grupp 90 min 200eur. MBRI 30 min 60eur; grupp 60

minutit 170eur. VAT 60min 70eur

7.2. Keskmine kulu ühe teenusesaaja kohta: 403,55 eur

7.3. Seansi maksumuse struktuur – esitada kulude jaotus, sh tööjõukulud, supervisioon, koolitus,

koordineerimine, litsentsi- ja platvormikulud ning kaudsed kulud (kuni 7% taotletava toetuse

üldmahust):

üldkulud (ruumid, vahendid, taristukulud) 28,24

spetsialisti tööjõukulud 262,24

supervisioonifond 40,34

REHA litsensikulu 4,8

koordineerimine 67,82

kokku 1 teenusesaaja keskmine kulu 403,44

8. Koolitustegevused (vajaduse korral)

8.1. Koolituste kirjeldus ja maht (tundides):

8.2. Koolitatavate spetsialistide arv:

8.3. Koolitatavate superviisorite arv:

8.4. Seos kavandatud rakendamisega ja proportsionaalsuse põhjendus:

8.5. Koolituskulude kogusumma (eurodes) ja osakaal toetuse eelarvest (%):

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9. Selgitus, kuidas kavandatav tegevus aitab tervikuna suurendada VIPS-i rakendamise võimekust Eestis

(nt spetsialistide ettevalmistus, sekkumise kättesaadavus, rakendamise maht või organisatsiooniline

suutlikkus).

Muusikateraapia lühisekkumiste laiem rakendamine loob laialdasemad võimalused klienditele, kellel on

raskendatud verbaalne eneseanalüüs või väljendus. Samuti toovad loovteraapia meetodid nähtavale

alateadvusest selle, mida inimene ise ei oska sõnastada. Piisava ja asjakohase täiendõppe korral on

võimalik neid sekkumisi laiapõhjaliselt rakendada alates koolieelsetest lasteasutustest kuni elukaare

lõpufaasis olevatele inimestele. Eeldus väljaõppe läbimiseks on varasem muusikaga kokkupuude (nt

muusikaõpetajad, laste muusikakoolis käimine, individuaalne pilliõpe vms). Perspektiivis näeme 2027

koolitusprogrammi koostamist ja väljeõppe võimaluse pakkumist spetsialistide väljaõppeks mahus 50-

60h sh praktika, mille järel on võimalik taotluses toodud sekkumisi uutel spetsialistidel rakendada.

Õppekava eelnõu on meil koostamisel ning pädevused koolitust läbi viia olemas sh koolitustegevuse

kogemus. Leiame, et muusikateraapia lühisekkumiste kättesaadavuse suurendamisel vähendab see

ühiskonnas uskumust, et ainult kliiniline psühholoog ja psühhiaater on mõjusad vaimse tervise

abivahendid ning keskendumine kahele piirkonnale, mis ei ole nn keskused, tooma kvaliteetsed teenused

elanikkonnale kogukonnas kättesaadavaks laiendades sellega elanikkonna ja sihtrühmade kaetust vaimse

tervise teenustega.

VAT – lühisekkumisena rakendatav kogu elukaare ulatuses ning selle lühisekkumisena rakendamiseks

on uutele spetsialistidele vajalik VAT väljaõpe kättesaadav VIBRAC I mooduli veebikoolitusena1 või

Eestis kohapealse koolitusena (koolitaja pädevus Ivar Vinkel’l). Vajalikud seadmed on võimalik

ühekordse ostuga hankida ning nende hinnaskaala on erinev vastavalt sekkumise pakkuja võimalustele.

Seadmete osas on olemas nii väikesed kaasaskantavad seadme, kaasaskantavad madratsid kuni püsival

asukohaga voodid. Nt Next Wave Physio (Soome tootja), Multivib (Norra tootja), Vibracare. Üheks

võimaluseks on VAT rakendada ka koolides ja lasteaedades, kus on loodud eraldi sensoorsed ja/või

nn rahunemistoad. Seega perspektiivis spetsialistide ettevalmistuse korraldus on lihtne ja ei ole kulukas

ning sekkumine saab olla kättesaadav nii kogukonna teenusena kui haridus- ja sotsiaalasutustes

kohapeal.

Kinnitused Kinnitan, et esitatud andmed on õiged ning vastan määruses sätestatud nõuetele. Kinnitan, et taotluses esitatud kulude katteks ei ole saadud ega taotleta toetust Euroopa Liidu fondidest, riigieelarvest ega muudest avaliku sektori vahenditest. /digitaalselt allkirjastatud/ Siiri Viil Viited

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• Skille, O. & Wigram, T. (1995). The effects of music, vocalization and vibration on brain and muscle tissue: Studies in vibroacoustic therapy. In T. Wigram, B. Saperston, & R. West (Eds.), The art & science of music therapy: A handbook. Chur, Switzerland: Harwood Academic Publishers.

• Tusek, D., Church, J. M. & Fazio, V. W. (1997) Guided imagery as a coping strategy for perioperative patients. AORN Journal. 66(4), 644–649. https://doi.org/10.1016/S0001-2092(06)62917-7

• Viil, S (2023), Vibroakustilise teraapia sekkumistulemuste püsivus gümnaasiumiõpilaste depressiooni, ärevuse ja vaimse kurnatuse sümptomaatikas. Tallinna Ülikool https://www.etera.ee/s/44SmWN5Kmy

Supportive Counseling kui madala intensiivsusega sekkumine

Lühikirjeldus

Supportive counseling on madala intensiivsusega psühholoogiline sekkumine, mis põhineb

aktiivsel kuulamisel, empaatilisel suhtlemisel ja emotsionaalsel toetamisel.

Supportive counseling sekkumine põhineb mitte-direktiivse toetava nõustamise (non-directive

supportive therapy) mudelil, mille keskmes on aktiivne kuulamine, peegeldamine ja emotsionaalne

valideerimine. Sekkumine on sobiv kerge kuni mõõduka psühholoogilise distressi (nt ärevus,

stress, depressiivsed sümptomid) leevendamiseks ning on struktureeritud lühiformaadis (1–6

sessiooni) rakendatav kogukonna- ja esmatasandi teenustes. Sekkumisel on selgelt kirjeldatud

struktuur ja korduvad komponendid, mida rakendatakse kindlas järjekorras.

Sekkumise protokoll (35–50 min sessioon)

1. Avamine ja kontakti loomine (5 min)

- turvalise keskkonna loomine

- avatud küsimuste kasutamine

2. Probleemi eksploratsioon (15–20 min)

- aktiivne kuulamine

- peegeldamine (sisu ja emotsioonide tasandil)

3. Emotsionaalne tugi (10–15 min)

- valideerimine

- normaliseerimine

- empaatia

4. Kokkuvõte ja sulgemine (5–10 min)

- põhipunktide kokkuvõte

- lihtsad toimetuleku sammud

Rakendatavad tehnikad

- aktiivne kuulamine (active listening)

- peegeldamine (reflection)

- valideerimine (validation)

- normaliseerimine (normalization)

- toetav tagasiside (encouragement)

Tõenduspõhisus

Sekkumise efektiivsust toetavad meta-analüüsid, mis näitavad, et mitte-direktiivne supportive

therapy on efektiivne kerge kuni mõõduka depressiooni korral ning avaldavad olulist mõju

depressiooni ja psühholoogilise distressi vähendamisel (Cuijpers et al., 2012; Wampold & Imel,

2015).

Supportive counseling aktiveerib “common factors” mehhanismid, milleks on terapeutiline

suhe, empaatia, kuulamine, mis omakorda on olulised sekkumise mõju ennustajad (Bruce

Wampold & Imel, 2015)

Viited

• Cuijpers, P., Driessen, E., Hollon, S. D., van Oppen, P., Barth, J., & Andersson, G.

(2012). The efficacy of non-directive supportive therapy for adult depression: A meta-

analysis. Clinical Psychology Review, 32(4), 280–291.

https://doi.org/10.1016/j.cpr.2012.01.003

• Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence

for what makes psychotherapy work (2nd ed.). Routledge.

• Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality

change. Journal of Consulting Psychology, 21(2), 95–103.

https://doi.org/10.1037/h0045357

1

Sotsiaalministri 17.03.2026 määrus nr 1.2-2/27-1

„Väheintensiivsete psühholoogiliste sekkumiste

rakendamise toetus“ Lisa 1

Taotlusvorm

1. Taotleja andmed

1.1. Asutuse/ettevõtte nimetus: Ojaveere Nõustamine OÜ

1.2. Registrikood: 14576910

1.3. Postiaadress: Rapla maakond, Rapla vald, Rapla linn, Tallinna mnt 22, 79512

1.4. Arvelduskonto (IBAN): EE972200221070258412

1.5. Esindaja nimi ja ametikoht: Siiri Viil, juhatuse liige

1.6. Kontaktisiku andmed (nimi, e-post, telefon): Siiri Viil [email protected] 55 155 78

1.7. Taotletav toetuse kogusumma (käibemaksuta): 22 500 eur

1.8. Projekti elluviimise periood: 1.6-31.12.2026

Kui taotlus sisaldab mitut VIPS-sekkumist, esitatakse allolev info iga sekkumise kohta eraldi (vajaduse korral dubleerides vastavad väljad).

2. VIPS-i kirjeldus:

2.1. Nimetus: Supportive counceling (Kogukonna psühholoogiline lühinõustamine)

2.2. Lühikirjeldus (sh metoodiline alus): Supportive counseling on madala intensiivsusega

struktureeritud psühholoogiline sekkumine, mis põhineb aktiivsel kuulamisel,

peegeldamisel ja emotsionaalsel valideerimisel. Sekkumine järgib struktureeritud

sessioonimudelit, mis hõlmab probleemi uurimist, empaatilist peegeldamist ja toetavat

kokkuvõtet (Cuijpers et al., 2012; Wampold & Imel, 2015). Sekkumise eesmärk on

parandada kliendi emotsionaalset heaolu, toetada toimetulekuoskusi ning pakkuda turvalist

ruumi kogemuste jagamiseks. Erinevalt kõrgema intensiivsusega psühhoteraapiatest ei

keskendu supportive counseling sügavale psühhodünaamilisele analüüsile ega keerukatele

kognitiivsetele tehnikatele, vaid emotsionaalsele kohalolule ja toetavale suhtele. Empaatial

ja reflektiivsel kuulamisel põhinev lähenemine toetab emotsionaalset regulatsiooni ja

enesemõistmist ning tugevdab sekkumise mõju. Sekkumine on sobiv kerge kuni mõõduka

psühholoogilise distressi (nt ärevus, stress, depressiivsed sümptomid) leevendamiseks ning

rakendatav lühiformaadis (1–6 sessiooni) kogukonna- ja esmatasandi teenustes. Supportive

counseling on mitte-direktiivne, emotsionaalset tuge pakkuv sekkumine, mis keskendub a)

aktiivsele kuulamisele, b) emotsioonide valideerimisele c) toimetuleku toetamisele.

Uuringutes on toodud korduv selge sessiooni struktuur ja komponendid.

2.3. Sihtrühm (vanuserühm jne): 15-64. Gruppide korral vanusepõhiselt 15–24, 25–44, 45–

64.

2.4. Piirkond: Saaremaa, Rapla maakond

2.5. Formaat (individuaal, grupi, kombineeritud): nii individuaalne

2

2.6. Struktuur (seansside arv, ühe seansi kestus minutites, grupisekkumiste korral inimeste arv

grupis): individuaalse kohtumise pikkus 30-60 minutit. Tegemist võib olla ühekordse

sekkumise või pikemaajalise (kuni 6 kohtumist).

2.7. Vorm (kohapeal, veebis jne): kohapeal ja veebis

2.8. Tõenduspõhisus (viidata uuringutele, rahvusvahelisele kasutusele; lisada viited või allikad):

Juhendatud sekkumised (st sekkumised, kus osalejat toetab juhendaja või nõustaja) on

osutunud oluliselt efektiivsemaks kui täielikult iseseisvad eneseabivormid, näidates

suuremat mõju sümptomite vähenemisele ning paremat sekkumises püsimist (Baumeister

et al., 2014). Madala lävega kogukonnakeskustes pakutav psühholoogiline lühinõustamine

ja aktiivne kuulamine on kooskõlas rahvusvaheliselt tunnustatud low-intensity psychological

interventions mudeliga, mille efektiivsust toetavad arvukad randomiseeritud

kontrolluuringud ja süstemaatilised ülevaated. Eriti tugev tõendus on kognitiiv-

käitumuslikel ja juhendatud eneseabi sekkumistel, mis on efektiivsed kerge kuni mõõduka

depressiooni ja ärevuse vähendamisel. Aktiivne kuulamine ja empaatiline suhtlus on nende

sekkumiste keskne komponent, toimides terapeutilise liidu ja muutuse mehhanismina.

Meta-analüütilised uuringud on ka näidanud, et terapeutiline liit, empaatia ja valideerimine

on olulised ennustajad positiivsetele ravitulemustele sõltumata konkreetsest

teraapiameetodist (Wampold & Imel, 2015). Supportive counseling põhineb teaduskirjanduses

kirjeldatud ja manualiseeritud lähenemistel, sh Brief Supportive Psychotherapy (BSP),

mida on kasutatud randomiseeritud uuringutes ning mille keskmes on empaatia, aktiivne

kuulamine ja fookus emotsioonidel (Markowitz, 2022). Madala intensiivsusega

sekkumistes täidab aktiivne kuulamine mitut funktsiooni: loob turvalise ja toetava

keskkonna, suurendab osaleja motivatsiooni ja kaasatust, toetab eneserefleksiooni ja

probleemilahendust. Seetõttu on aktiivne kuulamine käsitletav mitte üksnes toetava

elemendina, vaid olulise toimemehhanismina, mille kaudu sekkumine avaldab mõju. Mõju:

1) kognitiivsete mustrite muutus (nt mõttemustrite muutmine); 2) Käitumuslik

aktivatsioon (rohkem tegevust → parem meeleolu); 3) sotsiaalse toe ja kuuluvustunde kasv;

4) Enesetõhususe kasv (inimene õpib ise toime tulema). Tõenduspõhisus näitab, et sellised

mitte-direktiivsed sekkumised on efektiivsed kerge kuni mõõduka distressi vähendamisel

(Cuijpers et al., 2012; Wampold & Imel, 2015).

2.9. Kinnitus sekkumise juhendi olemasolu kohta (lisada näidis või kirjeldus): Sekkumise

protokoll lisatud failina – Lisa 1 Supportive counceling protokoll. Samuti rakendame

vajadusel täiendava materjalina Tervisekassa töövihikuid (depressioon, unevihik (sh

noorte unevihik), ärevus jt).

2.10. Varasem rakendamine (rakendamise kirjeldus, maht ja kestus): Oleme sekkumist

kasutanud mitme aasta vältel erinevate spetsialistide poolt klientidega, kes ei vaja

psühhoteraapiat. Samuti noorte nõustamisel. Näeme, et sageli on piisavalt abistav see, kui

klient saab väljendada enda mõtteid ja tundeid ning teda kuulatakse ja peegeldatakse (ei

rakendata suhtlemistõkkeid) ning läbi turvalise keskkonna ja toetuse leiab inimene ise

lahendused või ressursi. On hulk sihtgruppe, keda veebipõhised sekkumised ei toeta, kuna

nad ei kasuta neid ega ka hakka kasutama. Meie kogemusel on äärmiselt oluline, et

kogukonnapõhises madala lävendiga vaimse tervise keskustes on elanikul võimalus tulla ja

saada kohest abi. Meie keskusesse on selliselt tulnud emotsionaalselt madalseisus olevad

inimesed, sõprade poolt kohale toodud suitsiidsete mõtetega inimesed, noorukid, kes

kogevad üksildust jne. Sealjuures erinevates vanusegruppides. Senise kogemuse baasil

3

oleme näinud teadusuuringutes toodud psühholoogilise nõustamise kohest mõju ning

näeme vajadust seda püsivalt pakkuda.

2.11. Tagasiside kogumise viis: seni läbi keskuse rahulolu uuringu, mis ei ole sekkumise

põhine. Iga spetsialist on kliendiga kohtumiste lõppedes suuliselt teinud kokkuvõtte

eesmärkide saavutamisest või enesetunde muutusest.

3. Kavandatud maht

3.1. Seansside koguarv toetusperioodil: 250

3.2. Teenusesaajate arv: 50

3.3. Keskmine seansside arv ühe teenusesaaja kohta: 5

3.4. Maht maakondade kaupa: Raplamaal 30 ja Saaremaal 20 inimest

3.5. Sihtrühmani jõudmise ja suunamise kanalid: sotsiaalmeedia, KOV teavituskanalid (KOV

ajaleht, osavaldade ajalehed Saaremaal), Raplamaal Raplamaa Sõnumite podcast,

perearstid ja sotsiaaltöötajad

4. Meeskond ja rakendusvõimekus

4.1. Spetsialistide koguarv (vähemalt 5, lisada viie inimese info allolevasse tabelisse):

Ees- ja perekonnanimi Haridus (eriala, kraad) Lepingu (nt töö-, töövõtu- või käsundusleping) sõlmimise kuupäev

Siiri Viil Terviseteaduste magister, loovteraapia kutse 7, pereterapeut, kogemusnõustaja

10.2019

Kaili Inno Terviseteaduste magister, loovteraapia kutse 7, pereterapeut, superviisor

1.7.2025

Marianne Mändmets-Tuvikene

sotsiaalpedagoogika ja lastekaitse magister, pereterapeut (superviseeritav)

27.4.2023

Epp Sussen Terviseteaduste magister, loovteraapia kutse 7

15.12.2023

Liisi-Katarina Verk Lõpetamas Tallinna Ülikoolis sotsiaalse rehabilitatsiooni BA, varasem kogemus sotsiaaltöötajana ning juhtumikorraldajana

12.3.2026

Ave Verk Sotsiaalpedagoogika magister, pereterapeut (superviseeritav)

1.7.2025

Laima Parik Psühholoogia magister, loovterapeut 1.7.2025

Greta Vaus Usuteaduste magister, meditsiiniõde 16.4.2024

1.1. Spetsialistide kvalifikatsioon: spetsialistid, kes muusikateraapia sekkumisi rakendavad on

kõik asjakohase baasharidusega ning kogemustega vaimse tervise valdkonnas. Kõik

töötavad igapäevaselt klientidega.

1.2. Superviisorite arv ja kvalifikatsioon: Superviisor Kaili Inno (loovterapeut kutse 7)

1.3. Supervisiooni sagedus ja korraldus: grupi supervisioonina vähemalt kord kvartalis.

Individuaalse supervisioonina vastavalt vajadusele.

4

1.4. Riskijuhtimise plaan: Keskus on tegutsenud aastaid ning meie meeskond on laiem kui

taotluses välja toodud. Seega on risk, et teenuseosutajal tekib personali puudus, väike.

Seadmed VAT osutamiseks on olemas ning vajadusel on olemas võimekus ka soetada

seadmeid juurde. Samuti on muusikateraapiliste lühisekkumiste osutamiseks vajalikud

töövahendid olemas. Ruumid on keskusel olemas nii Raplas kui Saaremaal (Orissaares ja

Kuressaares). Teenuse järjepidevuse tagamiseks on keskusel piisaval arvul spetsialiste, kes

on kvalifitseeritud teenuseid osutama. Teenuse kättesaadavuse osas informatsiooni

jagamisel kasutatakse kohalikke tervishoiu- ja sotsiaalvõrgustikke, sotsiaalmeediat,

haridusvaldkonna asutusi, valdkonnas elanikke koondavaid MTÜsid. Samuti on mõlemas

piirkonnas TERVIK ettevalmistuseks loodud koostöömudelid, mille kaudu

informatsiooni teenuse olemasolust on võimalik jagada.

1.5. Kinnitus metoodika kasutusõiguse kohta: Kinnitame õigust metoodikaid rakendada.

Spetsialistid on väljaõppe läbinud

2. Ühe seansi maksumuse ja kulude põhjendus

2.1. Ühe seansi maksumus (koos seansi formaadiga, kui sama taotlus/VIPS sisaldab erinevaid

formaate): 90eur

2.2. Keskmine kulu ühe teenusesaaja kohta: 450eur

2.3. Seansi maksumuse struktuur – esitada kulude jaotus, sh tööjõukulud, supervisioon,

koolitus, koordineerimine, litsentsi- ja platvormikulud ning kaudsed kulud (kuni 7%

taotletava toetuse üldmahust):

üldkulud (ruumid, vahendid, taristukulud) 31,5

spetsialisti tööjõukulud 292,5

supervisioonifond 45

REHA litsentsikulu 3

koordineerimine 78

kokku 1 teenusesaaja keskmine kulu 450,00

3. Koolitustegevused (vajaduse korral)

3.1. Koolituste kirjeldus ja maht (tundides):

3.2. Koolitatavate spetsialistide arv:

3.3. Koolitatavate superviisorite arv:

3.4. Seos kavandatud rakendamisega ja proportsionaalsuse põhjendus:

3.5. Koolituskulude kogusumma (eurodes) ja osakaal toetuse eelarvest (%):

4. Selgitus, kuidas kavandatav tegevus aitab tervikuna suurendada VIPS-i rakendamise

võimekust Eestis (nt spetsialistide ettevalmistus, sekkumise kättesaadavus, rakendamise maht

või organisatsiooniline suutlikkus).

Saaremaa piirkonnas ei ole vaimse tervise tugi KOV ja riiklike teenustega kaetud mujal kui ainult

Kuressaares. Ka haridusvõrgu tugiteenused on tsentraliseeritud ning kättesaadavad vaid Kuressaares.

Seetõttu on oluline osa hajaasustusega piirkonnast selline, kus kogu elanikkonnal elukaare ulatuses ei

ole vaimse tervise abi kättesaadav. Meie keskus osutab teenuseid Ida-Saaremaal ning vajadus teenuste

5

järele on suur. Kuna aga Saaremaa on palgavaesuse osas Valga järel teisel kohal, siis elanikel teenuste

eest ise tasumiseks ressurssi ei ole. Raplamaal on küll teenuste kättesaadavus Tallinna lähedusest

tulenevalt parem, kuid potentsiaali astmelise abi mudeli I ja II astme rakendamisel meditsiinisüsteemi

koormuse vähendamisel on oluline. Raplas piloteeritakse ka perearstiteenuse osas pilootmudelit

Confidoga, kus inimestel puudub võimalus saada kontakti oma perearstiga või rääkida telefonitsi enda

pereõega. See on viinud esmatasandi terviseteenused inimestest veel kaugemale ning tekitab tunde, et

kellegagi ei ole võimalik rääkida. Seetõttu on äärmiselt oluline võimaldada antud perearstiteenuse

mudeliga piirkonnas VIPSe, kus on võimalik inimesel kellegagi päriselt rääkida. Psühholoogilise

lühinõustamise kättesaadavuse suurendamisel vähendab see ka ühiskonnas laiemalt uskumust, et ainult

kliiniline psühholoog ja psühhiaater on mõjusad vaimse tervise abivahendid ning keskendumine kahele

piirkonnale, mis ei ole nn keskused, tooma kvaliteetsed teenused elanikkonnale kogukonnas

kättesaadavaks laiendades sellega elanikkonna ja sihtrühmade kaetust vaimse tervise teenustega.

Kinnitused Kinnitan, et esitatud andmed on õiged ning vastan määruses sätestatud nõuetele. Kinnitan, et taotluses esitatud kulude katteks ei ole saadud ega taotleta toetust Euroopa Liidu fondidest, riigieelarvest ega muudest avaliku sektori vahenditest. /allkirjastatud digitaalselt/ Siiri Viil Viited

• Baumeister, H., Reichler, L., Munzinger, M., & Lin, J. (2014). The impact of guidance on

Internet-based mental health interventions — A systematic review. Internet Interventions, 1(4),

205–215.

• Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes

psychotherapy work. Routledge.

• Winston, A., Rosenthal, R. N., & Pinsker, H. (2004). Learning supportive psychotherapy: An

illustrated guide. American Psychiatric Publishing.

• Cuijpers, P., Driessen, E., Hollon, S. D., van Oppen, P., Barth, J., & Andersson, G. (2012).

The efficacy of non-directive supportive therapy for adult depression: A meta-analysis.

Clinical Psychology Review, 32(4), 280–291.

The Arts in Psychotherapy 77 (2022) 101872

Available online 1 December 2021 0197-4556/© 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Development of a music therapy micro-intervention for stress reduction

Martina de Witte a,b,c,d,*,1, Anne Knapen b, Geert-Jan Stams a, Xavier Moonen a,e, Susan van Hooren d,e,f

a Research Institute of Child Development and Education, University of Amsterdam, PO Box 19268, Nieuwe Achtergracht 127, 1018 WS Amsterdam, The Netherlands b HAN University of Applied Sciences, PO Box 6960, Kapittelweg 33, 6525 EN Nijmegen, The Netherlands c Stevig, Expert Treatment Centre for People with Mild Intellectual Disabilities, PO Box 9, 6591 RC Gennep, The Netherlands d KenVaK, Research Centre for the Arts Therapies, PO Box 550, 6400 AN Heerlen, The Netherlands e Zuyd University of Applied Sciences, Faculty of Healthcare, PO Box 550, 6400 AN Heerlen, The Netherlands f Open University, Faculty of Psychology, PO Box 2960, 6401 DL Heerlen, The Netherlands

A R T I C L E I N F O

Keywords: Music therapy Stress Arousal Micro-intervention Literature Review Delphi Method

A B S T R A C T

Negative stress is a serious risk factor for the onset and progression of a wide range of physical illnesses and emotional problems. In the literature, an increasing examination of music therapy interventions for stress reduction over the past decade is seen, yet music therapy interventions for stress reduction have not been sys- tematically developed and described. Moreover, there is a growing need for micro-interventions, which are defined as short-term interventions in which the therapist uses specific therapeutic techniques to work on a client’s goals. In this study, a music therapy micro-intervention for stress reduction was developed based on both empirical and practice-based knowledge. First, the micro-intervention was described based on both findings from empirical studies (N = 52) focused on the effects of music therapy on stress reduction, and from a previously conducted focus group study focused on the perspectives of music therapists. Second, the Delphi technique was applied to collect feedback on the micro-intervention described, by surveying a panel of 16 music therapy experts. This procedure resulted in an improved description of the music therapy micro-intervention for stress reduction, including a receptive and an active intervention variant. Implications for clinical practice and recommendations for future research are discussed.

Introduction

The negative impact of stress can be a serious risk factor for the onset and progression of a wide range of physical and emotional problems (American Psychological Association [APA], 2017; Australian Psycho- logical Society [APS], 2015). It is well known that music can provide relaxation and calmness, which ensures that music therapy in- terventions are increasingly used to reduce stress and enhance the well-being of clients across a variety of clinical populations (Agres et al., 2021; Bainbridge et al., 2020; Juslin & Västfjäll, 2008; de Witte et al., 2020). Several reviews show positive effects of music therapy in- terventions on stress reduction (e.g. Bradt, Dileo, Magill, & Teague, 2016; de Witte, da Silva Pinho et al., 2020; de Witte, Spruit et al., 2020; Landis-Shack, Heinz, & Bonn-Miller, 2017; Martin et al., 2018; Pelletier,

2004). However, no specific music therapy intervention for stress reduction has yet been systematically described or protocolized. From a scientific point of view, clear intervention descriptions are needed to further investigate what is effective in music therapy interventions (Hoffmann et al., 2014).

The impact of stress

In daily life, almost everyone experiences stress from time to time. In the short term, stress can lead to reduced concentration and difficulty learning new information (The American Institute of Stress, n.d.). Long-term stress can lead to psychopathology such as anxiety disorders, depression, addictions and burnout (Akin & Iskender, 2011; Pittman & Kridli, 2011; Wang, Wang, & Wang, 2019), as well as to health issues,

* Corresponding author at: Research Institute of Child Development and Education, University of Amsterdam, PO Box 19268, Nieuwe Achtergracht 127, 1018 WS Amsterdam, The Netherlands

E-mail addresses: [email protected] (M. de Witte), [email protected] (A. Knapen), [email protected] (G.-J. Stams), [email protected] (X. Moonen), [email protected] (S. Hooren).

1 https://orcid.org/0000-0002-6385-9563.

Contents lists available at ScienceDirect

The Arts in Psychotherapy

journal homepage: www.elsevier.com/locate/artspsycho

https://doi.org/10.1016/j.aip.2021.101872 Received 25 June 2021; Received in revised form 10 November 2021; Accepted 27 November 2021

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such as high blood pressure, cardiovascular disease, insomnia and an increase or decrease in weight (Bally, Campbell, Chesnick, & Tranmer, 2003; Keech, Cole, Hagger, & Hamilton, 2020; Pittman & Kridli, 2011). To cope with stressors, millions of people around the world use tran- quilizing medications, which are associated with numerous contraindi- cations and negative side effects (e.g., Bandelow et al., 2015; Olfson, King, & Schoenbaum, 2015; Puetz, Youngstedt, & Herring, 2015). It is therefore important to develop and examine promising non-pharmacological interventions for the prevention and management of stress, such as experiential approaches which focus on the “here and now” while guided by a therapist through stress responses and real-time emotional regulation. Through safely structured active experiences, stress inducing situations can be co-navigated, and stress reducing strategies can be developed and/or practiced (de Witte, Bellemans, Tukker, & van Hooren, 2017; de Witte, da Silva Pinho et al., 2020).

Music therapy for stress reduction

Music therapists are specifically trained to use the unique qualities of music, also known as musical components, (e.g., melody, rhythm, tempo, dynamics, pitch) in the therapeutic relationship to work on the patient’s treatment goals (Bruscia, 1987; de Witte, da Silva Pinho et al., 2020; Wheeler, 2015). During music therapy sessions, music therapists attune to the patient by adjusting the way of music-making as an im- mediate response to the client’s needs (Aalbers et al., 2019; Magee, 2019). This can be related to the term “synchronization,” meaning that the music therapist and the patient interact simultaneously and are regu- lated through time, yielding a similar expression in movement, match- ing pulse, rhythm, dynamics and/or melody (Aalbers et al., 2019; Bruscia, 1987; de Witte, da Silva Pinho et al., 2020; Schumacher & Calvet, 2008). For example, the music therapist may influence patients’ perceived stress during musical improvisation by synchronizing with the patient’s music-making, subsequently changing the musical expression by playing slower and less loudly (de Witte, da Silva Pinho et al., 2020). This specific form of patient-therapist attunement is commonly used in music therapy practice and refers to the so-called Iso Principle (e.g., Altshuler, 1948; Heiderscheit & Madson, 2015). The literature shows that the tempo and loudness are important for the experienced intensity of the music (Gabrielsson & Lindström, 2010), and music with a slow steady rhythm may provide stress reduction by altering inherent body rhythms, such as heart rate (Thaut & Hoemberg, 2014; Thaut, Kenyon, Schauer & McIntosh, 1999). Thus, the stress reducing effect of music therapy interventions can be explained by music itself as well as the continuous attunement of music by the music therapist to the individual needs of a patient.

There has been a rapid increase of research on the effects of music therapy on stress reduction. Results of a recent meta-analytic review (de Witte, da Silva Pinho et al., 2020), including 47 quantitative controlled studies, showed an overall medium-to-large effect of music therapy on stress-related outcomes (d = 0.723, [.51–0.94]). This is in line with previous reviews and meta-analyses, which show positive effects of music interventions on the reduction of stress or state-anxiety (Bradt & Dileo, 2014; Bradt, Dileo, & Shim, 2013; Bradt, Dileo, Grocke, & Magill, 2011; Bradt, Dileo, Potvin et al., 2013; Carr, Odell-Miller, & Priebe, 2013; de Witte, Spruit et al., 2020; Gold, Solli, Krüger, & Lie, 2009; Kamioka et al., 2014).

The need for music therapy micro-interventions

In music therapy literature, the term “intervention” may refer to both a specified therapeutic action and a process of intervening characterized by a structured and coherent collection of therapeutic actions (Aalbers et al., 2019; de Witte, Lindelauf et al., 2020). Music therapy in- terventions may thus vary from one single technique or action within a single music therapy session to therapy programs or protocols consisting of multiple therapy sessions. In the last decade, there has been a growing

recognition that one-size-fits-all approaches to intervention may be suboptimal for the patient and healthcare system alike (Gauthier et al., 2017; Rush et al., 2004). Moreover, it is assumed that intervention ef- fects are variable across patients both in magnitude and time (Cuijpers et al., 2012; Kessler et al., 2017). This argues for the need to develop more flexible and more widely applicable interventions in accordance with the patient’s needs, such as micro-interventions. A music therapy micro-intervention can be regarded as a short part of a session in which the music therapist uses specific therapeutic techniques or steps to work on specific patient’s goals (Hakvoort & van der Eng, 2020; Hakvoort, 2020). Despite the fact that micro-interventions are short-lived, they have been systematically described and follow a step-by-step approach based on both recent theoretical models as well as the latest scientific evidence.

The development of music therapy micro-interventions is important to music therapy practice, on the one hand because the way of inter- vening in micro-interventions is strongly linked to core components of music therapy, on the other hand because describing interventions helps to further develop the profession. As the level of a clients’ perceived stress can differ from session to session, it is important that music therapists can respond directly to their clients’ stress levels, at the time it is needed in the specific context of that moment. This fits well with the specific way of patient-therapist attunement widely used in music therapy and which can be seen as one of the main characteristics of music therapy. Therefore, short-term therapeutic interventions that align easily with the existing structure of the session or clients’ musical preferences are particularly suitable. Describing micro-interventions may also stimulate transferability of valuable clinical practices which in turn may strengthen thinking about the relationship between clinical practice, theory, and research (Aigen, 1999; Smeijsters & Vink, 2006; Stige, 2015).

Purpose of the present study

In the literature, we have seen an increasing examination of music therapy for stress reduction in the last decade (de Witte, Spruit et al., 2020; de Witte, da Silva Pinho et al., 2020). In addition, there is a growing need for music therapists to be more explicit about their’ tacit knowledge in order to create more transferability in the way they work on a client’s stress relief (see also: de Witte, Lindelauf et al., 2020). Without these descriptions, music therapists face difficulties in reliably implementing interventions in their clinical practices and researchers can experience difficulties replicating studies (Hoffmann et al., 2014). By developing a micro-intervention in this context, we are in line with the recent developments in healthcare that emphasize the importance of short-term and flexible therapeutic interventions in general. In addition, the development of a micro-intervention is an important first step to- wards achieving more insight into which specific therapeutic factors lead to change, which is becoming increasingly important in the field of music therapy research (de Witte et al., 2021).

In order to provide a comprehensive analysis of music therapists’ stress-reducing interventions, it is necessary to integrate the available practice-based knowledge. Published trials often demonstrate a lack of transparency in reporting detailed information on the content of the music therapy interventions (Aalbers et al., 2019; Robb, Carpenter, & Burns, 2011). This is also evident in the recent meta-analysis by de Witte, da Silva Pinho et al. (2020) in which the included studies mainly examined receptive (music listening) interventions, whereas in daily practice music therapists prefer to use active (music making) in- terventions to reduce their clients’ stress (de Witte, Lindelauf et al., 2020). In addition, developing a music therapy micro-intervention through an iterative process aimed at integrating theory-based, evi- dence-based, and practice-based knowledge is consistent with how other creative arts therapy interventions have been successfully developed (e. g., Aalbers et al., 2019; Bellemans et al., 2018; Haeyen, van Hooren, Dehue, & Hutschemaekers, 2017). The main purpose of the present

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study is therefore to provide a detailed description of a music therapy micro-intervention for stress reduction, which can be used directly by music therapists as well as provide a clear basis for future research.

Method

In this study, two developmental phases can be distinguished, namely, (a) describing the micro-intervention by analyzing and inte- grating the perspectives from both literature and clinical practice, and (b) consulting experts in the field of music therapy to reach consensus on the content and application of the micro-intervention developed. See Fig. 1 for the procedural diagram of the method of the current study.

Phase 1: the development of the micro-intervention

We used a recently developed format by Hakvoort and van der Eng (2020) to describe the micro-intervention as this was particularly designed for describing music therapy micro-interventions. The use of this format ensures a comprehensive and detailed description and en- courages a grounded scientific rationale. The format consists of several sections that must be described, such as specification of the target group, treatment domains, function of music, requisites, therapeutic attitude, the scientific / theoretical foundation, and a stepwise description of the micro-intervention.

Describing the rationale

To describe a theoretical rationale for the use of the music therapy micro-intervention, we needed both to clearly understand the problem of stress as well as a framework for how music therapy leads to stress reduction. To make both the origins and consequences of stress more concrete, we searched for literature in common online databases.2 To provide a theoretical framework on the relationship between music and stress, we mainly used the rationales of two recent meta-analytic reviews on the effects of music interventions and music therapy on stress-related outcomes (de Witte, Spruit et al., 2020; de Witte, da Silva Pinho et al., 2020). Both studies can therefore be regarded as providing key input to describing the scientific rationale for the micro-intervention. In addi- tion, the introductory sections of the empirical studies on the effects of music interventions on stress included in the analysis of this study, were screened for additional theoretical background information.

Analyzing Intervention Descriptions based on Literature

The following step involved analyzing the intervention descriptions of 52 empirical studies examining the effects of music therapy in- terventions on stress-related outcomes to create a solid basis for the content of the micro-intervention. The majority of the studies (n = 47) correspond to those included in the recently performed meta-analysis by de Witte, da Silva Pinho et al. (2020). The primary aim of this earlier study was to demonstrate the overall effect of music therapy in- terventions on stress-related outcomes, in which a detailed analysis of the interventions examined was not taken into account. In this study, we therefore provide an in-depth analysis of particularly the content of the music therapy interventions examined. Five studies were initially excluded in the meta-analysis due to lack of quantitative data, however, we included them for the purpose of our study. The included studies concerned both clinical controlled trials (CCT) and randomized controlled trials (RCT) conducted in medical and mental health care settings, examining the effects of music therapy interventions on phys- iological and/or psychological stress-related outcomes. Only those studies in which a trained and qualified music therapist offered the

intervention were selected. See De Witte, da Silva Pinho, et al. (2020) for more information about the applied search strategy and selection criteria; an overview of the characteristics of the 52 studies included in our study can be found in the Supplemental materials.

We then analyzed the extracted intervention descriptions using the coding principles of qualitative content analysis, which is frequently applied to answer questions such as what, why, and how, whereby the common patterns in the data were deduced using a consistent set of codes to organize text into identified categories of similar meanings (Cho & Lee, 2014; Moretti et al., 2011). To first gain more insights into how the initial data related to the particular sections of the format for the micro-interventions described by Hakvoort and van der Eng (2020), the open codes were grouped into “interventions and methods”, “non-musical interventions”, “preconditions”, “instruments and genres”, and “treatment goals”. Open codes either identical or very similar to each other were then grouped, such as “patient chooses song”, “patient selects songs” and “patient chooses music”. If a code could not be merged with others, we left it separate. This axial coding step led to the categorization of codes based on their overarching similarities to prop- erty levels (Corbin & Strauss, 2008).

Integrating practice-based data

After the analysis of intervention descriptions, the next step was the examination of practice-based knowledge, as outcome studies do not always reflect clinical practice in all its facets. For this purpose, we used an existing dataset of a previous qualitative study. The aim of this particular study was to gain insights into how music therapists reduce their clients’ stress, especially in people with mild intellectual disabil- ities. It consisted of three focus groups held in three different countries in which 13 music therapists participated (see de Witte, Lindelauf et al., 2020). The data from this study was transcribed and open coded by topic. The topic “interventions used within the music” proved particu- larly relevant for purposes of the present study. The open codes were extracted and then added to the initial categories that emerged from the analysis of the intervention descriptions from the literature.

Analysis of combined data

Due to the differing amounts of data, the categories consisting of either at least 4 codes from intervention descriptions from the empirical literature or at least 2 codes from the practice-based data were included as an intervention component. The categories formed by practice-based codes only were counted twice compared to those from the literature. Selective coding was then applied to create an integrated model in which those categories of intervention components could be linked to each other to interpret the steps of the micro-intervention (Charmaz, 2003). To minimize possible bias on the part of the researcher who analyzed the data, the entire process of data analysis was continuously monitored by two co-authors (SH and MDW) and decisions were made in consensus to ensure that the confirmability criteria were met.

Description of the micro-intervention

Based on the analyzes of the empirical literature and the qualitative data, the micro-intervention was described following Hakvoort and van der Eng (2020), consisting of a theoretical rationale, intervention goals, type of setting, treatment phase in which it can be applied, and con- traindications. In order to further shape the specific intervention con- tent, we used the integrated model of intervention components that emerged from data analysis. To establish consensus on the summarized narratives, we organized a final member check of a subgroup of the research team (MdW, AK, SvH).

2 PubMed, PsycINFO, Web of Science, Wiley Online Library, ScienceDirect and Google Scholar

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Phase 2: expert consultation

In the second phase, the Delphi technique was applied in order to arrive at a group opinion by surveying a panel of experts, and to reach consensus through an iterative process of collecting feedback (Linstone & Turoff, 1975; McMillan et al., 2016; Skulmoski et al., 2007). As in other studies, we used a modified Delphi technique to better fit the ob- jectives of the current study (Mullen, 2003; Wheeler et al., 2019). One of the modifications is that we did not use measures of central tendency and dispersion of the rankings by the respondents, which is usually re- ported in Delphi studies. Although the first consultation round collected individual rankings, the second round was sent by e-mail to check whether the adjustments made met respondents’ expectations. There- fore, calculating central tendency and dispersion was not feasible in the present study (see also Wheeler et al., 2019). Another modification concerns the use of a structured questionnaire to obtain focused feed- back from the respondents. Because the present study was designed to consult music therapists to strengthen the description of the micro-intervention, rather than to develop the intervention as a whole, a modified Delphi technique best suited our purposes.

Participants

Participants were sixteen music therapists and researchers in the field of music therapy. All had at least eight years of working experience as a music therapist. Six of them had already participated in one of the focus group interviews from our recent qualitative study (de Witte, Lindelauf et al., 2020). Ten participants were recruited through the in- ternational network of music therapists and researchers associated with Kenvak – a research center for arts therapies (www.kenvak.nl). Selected participants were located in four different countries, namely Belgium, Germany, the Netherlands and the United States. All participants gave informed consent and anonymity of the participants was ensured, both among the included participants and the researchers who analyzed the data.

The first consultation round

An online questionnaire3 (available in Dutch and English) along with the described micro-intervention was sent to the experts. The

questionnaire was focused on all sections of the described micro- intervention. For each topic, the level of agreement could be indicated with a four-point scale. In addition, the participants could add com- ments in each section, e.g. on reason of disagreements, new suggestions, and other feedback. In addition, the questionnaire included questions on the participants’ professional background to gain more insights into their individual perspectives. The amount of agreement was calculated for each section. All suggestions and comments were listed in a file and analyzed by content. Then, every suggested change from the original micro-intervention description was discussed (MdW, AK, SvH) and de- cisions were made in consensus with each other. This procedure resulted in a renewed and improved description.

The second consultation round

For the second consultation round, the adapted version of the micro- intervention was sent again to the participants with a brief summary of the processed feedback and suggestions. They were asked to respond within two weeks if they disagreed with aspects of the new version of the micro-intervention.

Results

The first phase: the development of the micro-intervention

Describing the rationale

Identifying the problem of stress. In the short term, it is known that the negative impact of stress can lead to reduced concentration and diffi- culties when learning and memorizing new information (Schwabe & Wolf, 2010). As a result, working on treatment goals when the client is experiencing stress will be less effective and inefficient (de Witte, Lin- delauf et al., 2020). It is therefore important to first reduce stress and tension so that the client is able to focus on the initial treatment goals. An overview of related health consequences of both long term and short term stress are described in the introduction of this study. A leaner narrative of this information is described in the format of the micro-intervention at “Specific domain that is targeted or treated” (see Table A.1 in Appendix).

Clarifying the stress-reducing effect of music interventions. Both music listening and music making/singing have been associated with a reduction of physiological arousal which increases during stress; this is

Fig. 1. Procedural diagram of the method.

3 The questionnaire can be requested from the first author.

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visible in a reduction of cortisol levels or decrease in heart rate and blood pressure (e.g. Hodges, 2011; Koelsch et al., 2016; Kreutz, Murcia, & Bongard, 2012; Linnemann, Ditzen, Strahler, Doerr, & Nater, 2015; Nilsson, 2009). In addition, a large body of neuroimaging studies show that music can influence stress-related emotional states by modulating activity in brain structures, such as the amygdala, that are known to be involved in emotional processes (e.g. Blood & Zatorre, 2001; Hodges, 2011; Koelsch, 2015; Levitin, 2009; Moore, 2013; Zatorre, 2015). An increased dopamine activity in the mesolimbic reward brain system has been shown to be associated with feelings of happiness in response to listening to favorite/own-preferences music (e.g., Blood & Zatorre, 2001; Salimpoor et al., 2013; Salimpoor, Benovoy, Larcher, Dagher, & Zatorre, 2011; Zatorre, 2015).

Plausible explanations for the positive effects of music interventions on stress, can also be sought in psychological and behavioral oriented scientific theories. Listening to pleasant music may have a positive in- fluence on emotional valence, which can be explained by the degree of attraction that an individual feels towards a specific object or event (Jäncke, 2008; Juslin & Västfjäll, 2008). Music experienced as pleasant increases the intensity of emotional valence (the felt happiness), which has a stress-reducing effect (Jiang, Rickson, & Jiang, 2016; Rohner & Miller, 1980; Sandstrom & Russo, 2010; Witvliet & Vrana, 2007). Listening to music can also provide direct distraction from stressful feelings or thoughts (Bernatzky, Presch, Anderson, & Panksepp, 2011; Chanda & Levitin, 2013). Research that shows the benefits of music to distract people from aversive states is supported by short-term music interventions for acute stress reduction (de Witte, Spruit et al., 2020; Fancourt, Ockelford, & Belai, 2014; Linnemann et al., 2015). Lastly, music listening or music making together with others is also related to stress relief (Juslin, Liljeström et al., 2008). This can be explained by the fact that people synchronize with each other during music activities which evokes feelings of togetherness and social cohesion during the music experience (Boer & Abubakar, 2014; Linnemann, Strahler, & Nater, 2016). This in turn may be explained by the release of the neu- rotransmitters endorphin and oxytocin (e.g., Dunbar, Kaskatis, Mac- Donald, & Barra, 2012; Freeman, 2000; Tarr, Launay, & Dunbar, 2014; Weinstein, Launay, Pearce, Dunbar, & Stewart, 2016), which are posi- tively associated with the defensive response to stress (e.g. Amir, Brown, & Amit, 1980; Dief, Sivukhina, & Jirikowski, 2018). A short narrative of these findings is presented in the format of the micro-intervention at “Function of music during the intervention” (see Table A.1 in the Appendix).

Analysis of the interventions from literature

Some of the included studies only offered limited descriptions of the examined intervention, whereas others offered detailed and rich inter- vention descriptions or even intervention protocols. However, each intervention description led to one or more open codes. Intervention descriptions showed both receptive interventions (n = 22), such as listening to live or pre-recorded music, as well as active interventions (n = 10), such as improvisation, playing existing songs, and song- writing. A combination of both receptive and active interventions was found in 20 of the intervention descriptions. In addition, in 20 of the studies, a complementary intervention/technique was offered along with music therapy, such as breathing exercises, muscle relaxation, and mindfulness exercises. In 38 intervention descriptions, the specific use of music (musical instruments or singing) was reported. Singing was mentioned in most studies (n = 28), followed by percussion instruments (n = 21), guitar (n = 15), and piano (n = 10). After the open coding step, categories were formed through axial coding by similar codes being grouped.

Integration of the practice-based data

Data-analysis of the focus groups indicated that the participating

music therapists mainly use many active interventions (14 in- terventions) and few receptive interventions (one mentioned) for stress reduction. The active interventions included musical improvisation, playing existing music, songwriting, recording own music, and singing mantras or preferred songs. In addition, data showed that the following therapeutic techniques are most often used to reduce a client’s stress: synchronization, pacing, structuring, increasing and decreasing dy- namics and tempo, repeating themes, simple musical structures, and using familiar instruments and songs. The first coding step resulted in 33 categories and remaining single codes.

Analysis of the combined data

The final analysis resulted in a total of 14 categories of intervention components, which we present in order of the total number of codes counted: music based on preferences (10), patient chooses song (7), expressing emotions (5), recording music (4), patient chooses intervention (4), therapist chooses intervention (4), verbal processing of emotions (4), using familiar songs (4), music based on emotional state (4), accelerating tempo (4), keeping appropriate physical distance (4), simplicity in harmony (4), slowing down tempo (4), and lower register (4). These intervention components formed input for the further design of the micro- intervention.

Description of the micro-intervention

The next step was to describe the music therapy micro-intervention in detail. Information on the theoretical background of the problem of stress and the rationale for using music interventions to lower people’s stress levels were added in the format for music therapy micro- interventions (Hakvoort and van der Eng, 2020). Then, the interven- tion goal, the target population and field, possible contra-indications, requisites, and specification of the setting, were supplemented. In order to remain as close as possible to the results of the data analysis, we described both an active and a receptive variant of the music therapy micro-intervention. This allows music therapists to choose the variant that best suits the client’s needs and possibilities at that moment.

Because the micro-intervention is specifically designed to directly reduce the client’s stress, i.e., in the music therapy session itself, the intervention goal was formulated as follows: “reducing tension and stress directly in the music therapy session”. We consider the micro- intervention as transdiagnostic and therefore it does not only relate to the treatment of one specific condition or disorder. However, as research shows that some client populations are more vulnerable to stress, such as people with mild intellectual disabilities or those with impaired cogni- tive functions (e.g., Emerson, 2003; Scott & Havercamp, 2014), we expect that the music therapy micro-intervention might be particularly suitable for these client groups. Precisely because of this broad appli- cability and the fact that we developed two variants, there were no contra-indications. However, clients with severe autism, severe intel- lectual disabilities, or clients suffering from acute psychosis are expected to have difficulty participating because of their reduced ability to be in contact with the therapist. The main prerequisites for applying the micro-intervention include a sound-isolated room (especially in clinical settings), chairs for the client(s) and music therapist, access to a suffi- cient selection of musical instruments (active variant), and sheet music of the client’s preferred music (receptive variant). Furthermore, the micro-intervention can be applied both individually and in groups. See the Appendix for more details of the abovementioned content of the micro-intervention.

All 14 intervention components were included in one of the micro- intervention variants (see Figs. 2 and 3). However, analysis showed that the intervention components “patient chooses the intervention” and “therapist chooses the intervention” appeared to contradict each other. If the client chooses the intervention, often used to appeal to client au- tonomy, it means that the therapist is not able to decide to use the micro-

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intervention. As music therapists use the micro-intervention precisely when it is needed to lower their client’s stress levels, it is not possible to have the client choose the intervention themselves. However, to encourage client autonomy in another way, instead of letting them

choose the intervention, we decided to offer them the choice of the song in the receptive variant and that they could take the lead role in the active variant by building up the music tempo and dynamics.

Fig. 2. The active variant of the micro-intervention.

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The second phase: expert consultation

The first consultation round Analysis of the experts’ feedback led to significant changes in the

description of the micro-intervention.4 Based on their suggestions, we added information, i.e. “voice” as one of the main instruments, allowing the client to experience the present stress before reducing it, specifying the therapeutic role and attitude with four functional domains, and the supporting role of the group when the micro-intervention is offered to just one of the group members. A note was added on contra-indications regarding clients suffering from trauma or anxiety disorders and on the function of the concepts “synchronizing” and “containing” which are related to stress reduction.

The second consultation round

The second round of consultation resulted in consensus among all experts, meaning that no further changes had to be made. The final description of the micro-intervention can be found in the Appendix.

Discussion

In our study, we systematically developed a music therapy micro- intervention aimed at stress reduction based on findings from theoret- ical and empirical studies as well as practice-based knowledge. The micro-intervention was developed for and evaluated by music therapists for use during the music therapy session when it is necessary to lower clients’ stress levels. Although the micro-intervention does not relate only to the treatment of one specific condition or disorder and can be considered as broadly applicable, the literature indicates that some

Fig. 3. The receptive variant of the micro-intervention.

4 An overview of the feedback given can be requested from the first author.

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client populations may benefit more due to their higher vulnerability to stress, such as people with mild intellectual disabilities (MID) or those with impaired cognitive functions (e.g., Emerson, 2003; Scott & Havercamp, 2014). For them, an experiential approach may be more appropriate than the cognitive approach (de Witte, Lindelauf et al., 2020; Didden et al., 2016). To our knowledge, this is the first study in which a music therapy micro-intervention has been systematically developed with the aim of direct stress reduction in the music therapy session.

Strengths and limitations of the present study

The way the micro-intervention was developed has several strengths. First, the systematic and comprehensive approach, which relied on data both from empirical studies as well as from clinical practice, resulted in a well-described micro-intervention. This approach has many similarities to the “Intervention Mapping” approach, a systematic method for the development, implementation, and evaluation of health interventions by constructing programs grounded both in theory and on empirical data (Bartholomew, Parcel, Kok, & Gottlieb, 2006). However, Inter- vention Mapping was originally designed to create larger or longer-term intervention and treatment programs (Bartholomew-Eldridge et al., 2016), and therefore does not fully align with the concept of micro-interventions, which are short-term interventions and can even be used as stand-alone techniques in existing treatment programs (de Witte, Lindelauf et al., 2020). Second, the inclusion of data derived from controlled outcomes studies (RCTs and CCTs: N = 52) offered a scien- tifically robust foundation for the core elements of the micro-intervention. This is relevant so that the basic claims made in the present study are clear (Aalbers et al., 2019; Crooke, Smyth, & McFer- ran, 2016). Moreover, the included outcome studies were derived from a recently conducted meta-analytic review (de Witte, da Silva Pinho et al., 2020) in which the inclusion criteria exactly matched the aims of this study. It can also be argued that this study strengthens the overall sci- entific basis of music therapy for stress reduction, as the previous meta-analysis looked primarily at effects using quantitative analyses, while in this study we qualitatively analyzed the content of the inter- vention, thus answering the how music therapeutic interventions can lead to stress reduction. Third, in the second phase of this study, the micro-intervention was submitted for consultation to music therapy experts from different countries in order to reach consensus in a collaborative process. Thus, thanks to this expert evaluation, the micro-intervention does not rely solely on pre-existing data. This strengthens its generalizability and makes it more plausible that the micro-intervention can be implemented easily in clinical practice.

Some limitations need to be noted. Through the years, several theoretical models have been developed to provide insights into the influence of music on stress. One of the most widely used models of the last decade involves models rooted in biological and neurological the- ories, so we also used these models to provide theoretical explanations of the relationship between stress and music. These models formed the basis of two earlier meta-analytical reviews of music interventions for stress reduction (de Witte, Spruit et al., 2020; de Witte, da Silva Pinho et al., 2020). However, we are aware that the general construct of stress integrates many scientific fields, in which both environmental, psy- chological, and biological/physical factors are interrelated within a comprehensive framework (Aldwin, 2007; Cohen, Janicki-Deverts, & Miller, 2007). In this sense, the strength of exclusively including inter- vention information from controlled outcome studies can be seen as a limitation; information on the content of interventions can also be ob- tained from less robust designs, such as case studies or one group de- signs. However, the importance of analyzing intervention content that demonstrates positive effects was paramount in our study. Related to the previous, the data from this large number of outcome studies mainly showed descriptions of receptive interventions, while the practice-based data almost exclusively showed active interventions. This may indicate a

gap between what is applied in clinical practice and what is investigated in robust research designs (de Witte, Lindelauf et al., 2020). However, it may also be related to the context of a specific target group, such as clients with MID, who were central in the practice-based data. Because we wanted to stay as close as possible to the initial data, this led to the development of two different variants of the micro-intervention: the active and the receptive variant (see Figs. 2 and 3).

Recommendations for future research

Clear intervention descriptions are needed to further investigate what is effective in music therapy interventions (Hoffmann et al., 2014). Future research should focus on whether the developed music therapy micro-intervention for stress reduction does lead to stress reduction during the session. However, methods that can measure the direct ef- fects of the micro-intervention on stress-related outcomes will be needed. Previous reviews of stress measures show that many researchers emphasize the importance of measuring stress outcomes related to both physiological arousal as well as to people’s subjective experiences (Scott and Havercamp, 2014; de Witte, Spruit et al., 2020; de Witte et al., 2021).

As it is still unclear how and why music therapy interventions lead to certain outcomes such as stress reduction, more research on therapeutic factors5 is needed to further develop music therapy micro-interventions. In our micro-intervention, music tempo can be seen as one of the most important elements, and therefore we expect it to be an important therapeutic factor leading to stress relief. This is in line with previous research showing that music tempo can be considered one of the most significant moderators of music-related arousal and relaxation effects (e. g., Bringman, Giesecke, Thörne, & Bringman, 2009; de Witte, Spruit et al., 2020). We therefore recommend that future research includes a secondary research question that focuses on therapeutic factors, such as the tempo of the music, in order to increase knowledge not only regarding efficacy, but also regarding what contributes to these effects.

Micro-interventions also allow researchers to conduct a micro-anal- ysis of specific parts of the music therapy session (Lee, 2000; Wosch & Wigram, 2007). The most important questions are: “what exactly happened and why?”. Through micro-analysis, therapy processes can be better understood or clarified, for example by analyzing the musical activity, social interaction, or nonmusical behavior of a short segment of a session (Wosch & Wigram, 2007). Micro-interventions are therefore highly suitable for pinpointing specific therapeutic factors that cannot be examined when testing over a larger period of time (de Witte et al., 2021).

Implications for clinical practice

Micro-interventions lend themselves well to music therapy practice because of their flexible character and the way in which the therapist can respond to the client’s needs in the moment itself. By offering a musical frame, any musical expression produced by the client can be musically encouraged and responded to in a musical dialogue (e.g., Aigen, 2005; MacDonald, Kreutz, & Mitchell, 2013; Nordoff & Robbins, 1965). Most components of our developed micro-intervention are strongly related to certain therapeutic factors of music therapy, namely “musical dialogue” and “shared musical experiences”. Other important therapeutic factors concern the structuring nature of music, such as tempo. A recent review shows that it is precisely these therapeutic fac- tors that are often associated with positive change in music therapy (de Witte et al., 2021). In addition, the content of the micro-intervention is also in line with Bruscia’s (1987) principles, who developed 64 musical

5 Therapeutic factors are those factors identified by empirical studies that lead to therapeutic change and are associated with particular outcomes (Kaz- din, 2009; Elliot, 2010).

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improvisation techniques based on using the unique qualities of music to establish or influence the musical dialogue with the client; these still form the basis of global music therapy education. However, the concept of the micro-intervention provides more insights into (a) the needs and abilities of certain client populations that the intervention is focused on, (b) particular outcomes, (c) specific characteristics of the intervention, and (d) the underlying theoretical models that explain the relationship between music (therapy) and the targeted outcome. By describing this information, which is mainly subconsciously understood and applied by music therapists, it may stimulate them to strengthen the transferability of their clinical work and may provide more insights into the relation- ship between clinical practice, theory, and research (Aigen, 1999; Smeijsters & Vink, 2006; Stige, 2015).

Appendix A. Supporting information

Supplementary data associated with this article can be found in the online version at doi:10.1016/j.aip.2021.101872.

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Zatorre, R. J. (2015). Musical pleasure and reward: Mechanisms and dysfunction. Annals of the New York Academy of Sciences, 1337(1), 202–211. https://doi.org/10.1111/ nyas.12677

M. de Witte et al.

VAT seansi struktuur

TLÜ VAT laboris

Lülitada sisse tehnikatorni kõik seadmed. NB: taustamuusika CD-

mängijat on võimalik sisse lülitada ainult siis, kui taustamuusika võimendi

on sisse lülitatud.

Seada voodiruum korda (enne kliendi saabumist): lülitada sisse

lisaks suurele põrandalambile ka väiksed põrandalambid tehnikatorni

laua all, korrastada voodi.

1. Pakkuda kliendile istet.

Ainult esimesel seansil

2. Lühike selgitus VAT meetodist kliendile.

Igal seansil

3. Jäädvustada kliendi hetkeseisund mõõdikute/intervjuu jne abil.

4. Paluda kliendil VAT voodile selili heita nii, et tema jalad jäävad

taustamuusika kõlarite poolsesse otsa. Kui selili ei ole mugav (on valus,

ei ole võimalik), siis leida mugavaim kehaasend. Öelda, et seansi ajal

võib soovi korral kehaasendit muuta: võib keerata külili või kõhuli, kui

selliselt on mugavam.

5. Küsida padja kõrguse sobivuse kohta – vajadusel panna lisapadi või

võtta padi ära.

6. Küsida, kas soovib tekki peale. Asetada tekk vastavalt kliendi soovile

(pikka kasvu klientidele 2 tekki – üks nii, et katab ülakeha, teine nii, et

katab alakeha ja jalad).

7. Selgitada, et järgnevalt lülitad sisse madalasagedusliku vibratsiooni

(vibatsiooniprogrammi CD-mängija on tehnikatornis kõige ülemine

seadeldis, vastava kleebisega esipaneelil; muusika CD-mängija on

tehnikatornis alt kolmas seadeldis, samuti varustatud vastava

kleebisega; CD-mängija nupud: ▲ - plaadisahtli avamise/sulgemise

nupp, ►∕║ - plaadi mängima-/pausilepanemise nupp, ■ - plaadi

peatamise nupp, |<< - eelmise heliraja valiku nupp, >>| - järgmise

heliraja valiku nupp).

8. Reguleerida vibratsiooni helitugevus patsiendile sobivaks. Selleks

kasutada vibratsiooniprogrammi helivõimendit, mis tehnikatornis on

kõige alumine seadeldis (vastava kleebisega). Järgnevalt võimendi

helinivoode regulaatorite tähised:

 CH1 – turjapiirkonna valjuhääldi;

 CH2 – nimmepiirkonna valjuhääldi;

 CH3 – reitepiirkonna valjuhääldigrupp;

 CH4 – säärtepiirkonna valjuhääldigrupp.

Aja kokkuhoiu mõttes võib kõik neli regulaatorit mõjutusele eelnevalt

keerata tähiseni „1“. Kui klient on juba voodis pikali, siis vibratsiooni

helitugevuse reguleerimist alustada säärtepiirkonna valjuhääldigrupist –

kui regulaator on juba tähiseni „1“ keeratud, siis küsida, kas klient juba

vibratsiooni tunnetab. Kui jah, siis küsida, kas vibratsioon säärte

piirkonnas on paraja tugevusega või tuleks seda tugevamaks/nõrgemaks

seada. Kui säärtepiirkonna vibratsiooni sobiv tugevus (mitte liiga nõrk

ega ebameeldivalt tugev) on leitud, siis sarnaselt äsjatoodule reguleerida

vibratsiooni helitugevused ka ülejäänud valjuhääldigruppide jaoks (NB!

Kuna peale viimase valjuhääldigrupi sobiva helitugevuse leidmist tajub

inimene kehas kõigi valjuhääldigruppide helitugevuste summat, siis

küsida, kas helitugevus summaarselt on sobiv). Kui sobivad nivood on

leitud, siis esimese (paari) seansi puhul keerata kõigi valjuhääldigruppide

helitugevus veidi vähemaks, sest mõjutuse jooksul keha

vibratsioonitundlikkus suureneb.

9. Selgitada, mis protseduuri ajal edasi toimub, nt: „Kui järgnevalt

taustamuusika helitugevus on sobivaks reguleeritud, jään mina mõjutuse

ajaks kuuldeulatusse samasse ruumi, kus praegu viibin. Kui midagi

juhtub või on ebamugav, siis andke häälega märku, reageerin kohe.“

10. Reguleerida taustamuusika helitugevus kliendile sobivaks. Selleks

kasutada taustamuusika helivõimendit, mis tehnikatornis on alt teine

seadeldis (vastava kleebisega). Kui taustamuusika heli hakkab kostma,

küsida, kas see on kliendi jaoks sobiv helitugevus. Reguleerida vastavalt

kliendi antud tagasisidele.

12. Küsida kliendilt, kas tal on mugav, kas kõik on sobiv. Eitava vastuse

korral kõrvaldada puudujäägid, positiivse vastuse korral nt soovida

„Head lõdvestumist“.

13. Jääda laua taha kuni VA mõjutuse lõpuni (umbes 23 min, jälgida

kellalt).

14. Kui VA mõjutus on lõppenud, siis keerata taustamuusika helitugevus

aeglaselt ja sujuvalt „nulli“.

15. Kui klient on uinunud, siis äratada rahulikult.

16. Jäädvustada kliendi hetkeseisund mõõdikute/intervjuu jne abil.

Küsida mõjutuse ajal kogetu kohta. NB! Kliendi hetkeseisundit võib

jäädvustada ka pärast kliendi voodist tõusmist laua ääres istudes.

17. Kui kliendi hetkeseisund on jäädvustatud, siis paluda kliendil

aeglaselt ja rahulikult voodis istuli tõusta, ja mõne aja pärast püsti tõusta.

Pärast seansi muude formaalsuste lõpetamist (nt järgmise seansi aja

kokku leppimine) võib klient VAT ruumist lahkuda.

Enne VAT ruumist lahkumist keerata nii vibratsiooniprogrammi kui

taustamuusika võimendi helinivoo regulaatorid „nulli“, seejärel

lülitada kõik seadmed ja lambid välja.

Music-Based Relaxation Intervention (MBRI) – Protokoll ja tõenduspõhisus

Lühikirjeldus: Music-Based Relaxation Intervention (MBRI) on struktureeritud

lühisekkumine, mis kombineerib juhendatud lõõgastuse ja muusika kuulamise. Sekkumine on

suunatud ärevuse, stressi ja emotsionaalse erutuse vähendamisele ning sobib madala

intensiivsusega teenustesse.

Protokoll (20–30 min sessioon)

1. Eesmärgistamine (1–3 min)

- kliendi seisundi kaardistamine

- eesmärgi sõnastamine (nt ärevuse vähendamine)

2. Lõõgastusinduktsioon (5–10 min)

- juhendatud hingamine või progressiivne lihaslõdvestus

- tähelepanu suunamine kehale

3. Muusikapõhine regulatsioon (10–20 min)

- rahustava muusika kuulamine (tempo 60–80 bpm)

- tähelepanu hingamisel ja kehatunnetusel

- tempo ja struktuur toetavad autonoomse närvisüsteemi regulatsiooni tähelepanu:

hingamisel, kehal, kujutluspiltidel.

- muusika võib olla terapeudi valitud või individuaalselt kohandatud

4. Refleksioon (3–5 min)

- kogemuse sõnastamine

- seos igapäevaeluga

Toimemehhanism

✓ autonoomse närvisüsteemi regulatsioon

✓ südamerütmi ja hingamise sünkroniseerimine

✓ emotsionaalse erutuse vähenemine

✓ stressihormoonide (nt kortisool) vähenemine

Tõenduspõhisus: Meta-analüüsid ja süstemaatilised ülevaated näitavad, et muusikapõhised

sekkumised vähendavad stressi ja ärevust ning parandavad emotsionaalset regulatsiooni.

Efektid on keskmise suurusega ning ilmnevad ka lühiformaadis sekkumiste puhul.

Uuringud näitavad, et isegi üksikseansid võivad vähendada ärevust ja füsioloogilist

stressireaktsiooni. Muusika mõju autonoomsele närvisüsteemile hõlmab südamerütmi,

vererõhu ja kortisooli taseme muutusi.

Viited:

• de Witte, M., Spruit, A., van Hooren, S., Moonen, X., & Stams, G. J. J. M. (2020). Effects

of music interventions on stress-related outcomes: A systematic review and two meta-

analyses. Health Psychology Review, 14(2), 294–324.

https://doi.org/10.1080/17437199.2019.1627897

• Pelletier, C. L. (2004). The effect of music on decreasing arousal due to stress: A meta-

analysis. Journal of Music Therapy, 41(3), 192–214.

https://doi.org/10.1093/jmt/41.3.192

• Thoma, M. V., La Marca, R., Brönnimann, R., Finkel, L., Ehlert, U., & Nater, U. M. (2013).

The effect of music on the human stress response. PLoS ONE, 8(8), e70156.

https://doi.org/10.1371/journal.pone.0070156

• de Witte, M., Pinho, A. S., Stams, G. J. J. M., Moonen, X., Bos, A. E. R., & van Hooren,

S. (2022). Development of a music therapy micro-intervention for stress reduction. The

Arts in Psychotherapy, 77, 101873. https://doi.org/10.1016/j.aip.2021.101873

Vibroakustilise muusikateraapia sekkumise protokoll

Skille–Wigram mudel on vibroakustilise teraapia (VAT) kõige mõjukam ja laialdasemalt

kasutatav teoreetiline-kliiniline raamistik, mille töötasid välja Olav Skille ja Tony Wigram

1980.–1990. aastatel.

1. Hindamine (Assessment)

Vibroakustilise muusikateraapia (VAT) sekkumine algab kliendi põhjaliku hindamisega.

Hindamine hõlmab anamneesi kogumist (neuroloogiline, psühholoogiline ja füüsiline seisund),

vastunäidustuste välistamist (nt ägedad põletikud, tromboos, teatud raseduse etapid) ning

terapeutiliste eesmärkide seadmist (nt valu vähendamine, ärevuse leevendamine, lihaspinge

alandamine).

2. Seadistus (Equipment & Setup)

VAT sekkumiseks kasutatakse vibroakustilist lamamistooli või madratsit, mis edastab

madalsageduslikku heli kehale. Kasutatakse sagedusvahemikku 20–120 Hz. Keskkond peab

olema rahulik, vaikne ja minimaalse stimulatsiooniga.

3. Sagedusprotokoll

Tüüpiline sessioon kestab 20–45 minutit, sagedusega 1–3 korda nädalas. Sagedused valitakse

vastavalt eesmärgile: 20–50 Hz lõõgastuseks, 40 Hz neuroloogiliseks stimulatsiooniks, 60–80

Hz lihaspinge reguleerimiseks. Sageli kasutatakse sweep-tehnikat (muutuv sagedus).

4. Muusikaline komponent

Muusika valitakse terapeutiliselt: aeglane tempo (60–80 BPM), madal dünaamika ja

harmooniline stabiilsus. Muusika võib olla eelnevalt salvestatud või live-esitus.

5. Terapeutiline protsess

Klient lamab seadmel ning terapeut jälgib füsioloogilisi reaktsioone, kohandab sagedusi ning

juhendab vajadusel hingamist või kujutluspilte.

6. Järelhindamine

Seansi järel hinnatakse subjektiivseid ja objektiivseid muutusi, sealhulgas valu (VAS), ärevust

ja füsioloogilisi näitajaid.

Viited

• Chesky, K., & Michel, D. (1991). The effect of music and vibrotactile stimulation on

perception of pain. Journal of Music Therapy, 28(4), 191–202.

• Grocke, D., & Wigram, T. (2007). Receptive methods in music therapy. Jessica Kingsley

Publishers.

• King, L. K., et al. (2009). The effects of vibroacoustic therapy on motor function in

Parkinson’s disease. Journal of Rehabilitation Research.

• Naghdi, L., et al. (2015). The effectiveness of vibroacoustic therapy in rehabilitation: A

systematic review. Journal of Rehabilitation Research.

• Punkanen, M., & Ala-Ruona, E. (2012). Contemporary vibroacoustic therapy: Perspectives

on clinical practice. Music and Medicine.

• Skille, O. (1989). Vibroacoustic therapy. Music Therapy, 8(1), 61–77.

• Wigram, T. (1996). The effects of vibroacoustic therapy on clinical populations. Music

Therapy Perspectives, 14, 20–28.

• Wigram, T. (2005). Music therapy research and practice in medicine. Jessica Kingsley

Publishers.

1

Sotsiaalministri 17.03.2026 määrus nr 1.2-2/27-1

„Väheintensiivsete psühholoogiliste sekkumiste

rakendamise toetus“ Lisa 1

Taotlusvorm

1. Taotleja andmed

1.1. Asutuse/ettevõtte nimetus: Ojaveere Nõustamine OÜ

1.2. Registrikood: 14576910

1.3. Postiaadress: Rapla maakond, Rapla vald, Rapla linn, Tallinna mnt 22, 79512

1.4. Arvelduskonto (IBAN): EE972200221070258412

1.5. Esindaja nimi ja ametikoht: Siiri Viil, juhatuse liige

1.6. Kontaktisiku andmed (nimi, e-post, telefon): Siiri Viil [email protected] 55 155 78

1.7. Taotletav toetuse kogusumma (käibemaksuta): 62 550 eur

1.8. Projekti elluviimise periood: 1.6-31.12.2026

2. VIPS-i kirjeldus

2.1. Nimetus: Music Therapy Micro-Interventions

2.2. Lühikirjeldus (sh metoodiline alus): Music Therapy Micro-Interventions (MTMI) sobib

rakendamiseks madala lävega vaimse tervise teenustes tänu oma lühiformaadile, struktureeritusele

ja skaleeritavusele. MTMI defineeritakse kui lühiajaline, struktureeritud terapeutiline sekkumine,

milles kasutatakse spetsiifilisi muusikateraapia tehnikaid kliendi konkreetse eesmärgi

saavutamiseks (de Witte et al., 2022). RECEPTIVE MICRO-INTERVENTION (kuulamisel

põhinev) struktuur: 1) eesmärgi seadmine (nt ärevuse vähendamine) 2) juhendatud muusika

kuulamine 3) füsioloogilise ja emotsionaalse seisundi jälgimine (nt hingamise aeglustumine) 4)

refleksioon ja tähenduse loomine. ACTIVE MICRO-INTERVENTION (aktiivne variant)

struktuur: 1) emotsionaalse seisundi kaardistamine 2) aktiivne muusikaline tegevus (rütm,

improvisatsioon, hääl) 3) emotsioonide väljendamine ja reguleerimine 4) refleksioon.

2.3. Sihtrühm (vanuserühm jne): 15-64. Gruppide korral vanusepõhiselt 15–24, 25–44, 45–64.

2.4. Piirkond: Saaremaa, Rapla maakond

2.5. Formaat (individuaal, grupi, kombineeritud): nii individuaal kui grupp

2.6. Struktuur (seansside arv, ühe seansi kestus minutites, grupisekkumiste korral inimeste arv grupis):

Individuaalne 1–8 sessiooni; seansi pikkus 45-60 minutit. Grupisekkumise korral 4-8 sessiooni,

grupis kuni 12 osalejat ning sekkumise pikkus 90 minutit.

2.7. Vorm (kohapeal, veebis jne): kohapeal (individuaalne ja grupp), veebis (individuaalne)

2.8. Tõenduspõhisus (viidata uuringutele, rahvusvahelisele kasutusele; lisada viited või allikad): MTMI

on teaduspõhiselt arendatud ja ekspertide poolt valideeritud muusikateraapia lühisekkumine, mis

sisaldab struktureeritud receptive ja active sekkumist (de Witte et al., 2022). Sekkumine töötati välja

52 empiirilise uuringu analüüsi ning praktikute kogemuse põhjal ning valideeriti Delphi meetodil

16 eksperdi hinnangute kaudu. Tulemused näitavad olulist mõju stressi ja ärevuse vähendamisel.

Hinnates aktiivse variandi mõju depressioonile (Erkkilä et al., 2011) leiti depressiooni, ärevuse ja

stressi vähenemist. Sekkumise mõju põhineb: närvisüsteemi regulatsioonil (tempo, rütm);

2

emotsionaalsel väljendusel ja töötlemisel; terapeutilisel attunement’il (muusikaline kooskõla

spetsialisti ja kliendi vahel).

Meta-analüüsid ja süstemaatilised ülevaated näitavad, et muusikateraapia sekkumised vähendavad ärevust (SMD ≈ -0.36) ning parandavad emotsionaalset regulatsiooni ning on efektiivsed ka lühiformaadis sekkumistena sh Cochrane Collaboration (Bradt et al., 2016; de Witte et al., 2020; de Witte et al., 2022; Gold et al., 2009). Muusikateraapia sekkumised on seotud: kortisooli taseme vähenemisega; südamerütmi ja erutuse regulatsiooniga; emotsionaalse seisundi paranemisega. isegi üksikseansid võivad vähendada ärevust ja füsioloogilist stressi (de Witte et al., 2022). Lisaks näitavad meta-analüüsid, et muusikateraapia vähendab ärevust ja stressi, parandab emotsionaalset regulatsiooni ning on efektiivne ka lühiformaadis sekkumistena (Bradt et al., 2016; de Witte et al., 2020; de Witte et al., 2022; Gold et al., 2009; Lee et al., 2025). Muusikateraapia tõenduspõhisust on kirjeldatud ka Põld, Kleinberg et al. 2024 tuues välja, et muusikateraapia on depressiooniga noorukitel lastel tavaraviga võrreldes oluliselt efektiivsem.

2.9. Kinnitus sekkumise juhendi olemasolu kohta (lisada näidis või kirjeldus): MTMI protokoll on

kirjeldatud de Witte et al. 2022 ning lisatud ka taotlusele (Lisa 1)

2.10. Varasem rakendamine (rakendamise maht ja kestus): MTMI on rakendatud siiani

muusikaterapeutide poolt nii lühisekkumisena, sotsiaalses rehabilitatsioonis, tööalases

rehabilitatsioonis kui haiglaravis. Kuna eraldi ei ole mõõdetud sekkumise mahtu, siis seda välja

tuua on keeruline. Samas on nii sotsiaalses rehabilitatsioonis kui KOV vaimse tervise teenustena

loovteraapiad üheks enimkasutatud teenuseks, mistõttu võib väita, et sekkumist on rakendatud

olulises mahus.

2.11. Tagasiside kogumise viis: Eraldiseisvalt ei ole sekkumise osas tagasisidet kogutud vaid tulemusi

on mõõdetud kõigi kliendile võimaldatud sekkumiste kogumine. Edaspidi saab VIPS

rakendamisel mõju mõõtmisel kasutatakse EEK-2 või WHO-5 heaolu indeks (enne ja pärast).

Mõlemad hindamismeetodid on valideeritud ning sobilikud sihtgrupile (Allgaier et al, 2012;

Streimann et al. 2021).

3. Nimetus: Music-Based Relaxation Interventions

3.1. Lühikirjeldus (sh metoodiline alus): Music-Based Relaxation Interventions (MBRI) on

struktureeritud madala intensiivsusega sekkumine, mis ühendab muusika kuulamise (keskmiselt

tempoga 60-80bpm) ja lõõgastus- ja regulatsioonitehnikatega (nt hingamine, juhendatud

kujutluspildid või progressiivne lihaslõdvestus). Sekkumine sobib rakendamiseks lühiformaadis

ning sisaldab eesmärgistamist, füsioloogilise rahustamise faasi, muusikapõhist regulatsiooni (10–

20 min, tempo 60–80 bpm) ning refleksiooni. Protokoll põhineb meta-analüüsidel ja kontrollitud

uuringutel, mis näitavad, et muusikapõhised sekkumised vähendavad stressi ja ärevust ning

mõjutavad autonoomset närvisüsteemi.

3.2. Sihtrühm (vanuserühm jne): 15-64

3.3. Piirkond: Saaremaa, Rapla maakond

3.4. Formaat (individuaal, grupi, kombineeritud): individuaalne, grupp

3.5. Struktuur (seansside arv, ühe seansi kestus minutites, grupisekkumiste korral inimeste arv grupis):

6-10 korda sagedusega 1-2 korda nädalas, kestvus 30 minutit. Grupi puhul kestvus 60 minutit

ning grupis kuni 8 osalejat. Sekkumine on eelneval juhendamisel ka kliendi poolt iseseisvalt

rakendatav.

3.6. Vorm (kohapeal, veebis jne): kohapeal

3.7. Tõenduspõhisus (viidata uuringutele, rahvusvahelisele kasutusele; lisada viited või allikad: Meta-

analüüsid ja randomiseeritud uuringud näitavad ärevuse ja stressi vähenemist ning emotsionaalse

regulatsiooni paranemist (de Witte et al., 2020, Giordano et al, 2022, Nguyen et l., 2023,

Eckhouse et al. 2014, Chi et al., 2015, Bradt et al., 2013).

3

3.8. Kinnitus sekkumise juhendi olemasolu kohta (lisada näidis või kirjeldus): Lisatud fail – Lisa 3.

MBRI protokoll

3.9. Varasem rakendamine (rakendamise maht ja kestus): MBRI on rakendatud siiani

muusikaterapeutide poolt nii lühisekkumisena, sotsiaalses rehabilitatsioonis, tööalases

rehabilitatsioonis kui haiglaravis. Kuna eraldi ei ole mõõdetud sekkumise mahtu, siis seda välja

tuua on keeruline. Samas on nii sotsiaalses rehabilitatsioonis kui KOV vaimse tervise teenustena

loovteraapiad üheks enimkasutatud teenuseks, mistõttu võib väita, et sekkumist on rakendatud

olulises mahus.

3.10. Tagasiside kogumise viis: Eraldiseisvalt ei ole sekkumise osas tagasisidet kogutud vaid tulemusi

on mõõdetud kõigi kliendile võimaldatud sekkumiste kogumine. Edaspidi saab VIPS

rakendamisel mõju mõõtmisel kasutatakse EEK-2 või WHO-5 heaolu indeks (enne ja pärast).

Mõlemad hindamismeetodid on valideeritud ning sobilikud sihtgrupile (Allgaier et al, 2012;

Streimann et al. 2021).

4. Nimetus: Vibroakustilise teraapia

4.1. Lühikirjeldus (sh metoodiline alus): Vibroakustiline teraapia (VAT) on ravimeetod, mille puhul

kasutatakse madalasageduslikke siinushelisid vahemikus 30–120Hz kombineerituna muusikaga

(Rüütel, 1998a). Tänapäeval on madalsagedusega helivibratsiooniteraapia üks muusikateraapia

rakendusi, mida praktiseeritakse kogu maailmas. Rüütel (1998a) toob välja, et vibroakustilises

teraapias kasutatav muusika on reeglina mahe, improviseeritud ja ilma rõhutatud rütmita. VAT

sekkumise ajal kasutatakse juhendatud relaksatsiooni samaaegselt muusikaga. Kliinilises praktikas

ja teadusuuringutes kasutatakse tüüpprotokolli: Eesmärgistamine (2–5 min),

Lõõgastusinduktsioon (5–10 min), Muusikapõhine lõõgastus (15–25 min), Refleksioon (5–10

min)

4.2. Sihtrühm (vanuserühm jne): 15-64

4.3. Piirkond: Saaremaa, Rapla maakond

4.4. Formaat (individuaal, grupi, kombineeritud): individuaalne

4.5. Struktuur (seansside arv, ühe seansi kestus minutites, grupisekkumiste korral inimeste arv grupis):

8-10 korda sagedusega 1-2 korda nädalas, kestvus 45-60 minutit.

4.6. Vorm (kohapeal, veebis jne): kohapeal

4.7. Tõenduspõhisus (viidata uuringutele, rahvusvahelisele kasutusele; lisada viited või allikad:

Teadusuuringutes on tõendatud VAT sekkumiste abistavat mõju nii ühekordse sekkumise korral

(Kantor et al, 2022, Bergström-Isacsson et al, 2007) kui ka pikemate sekkumiste võimaldamisel

(Sigurdardóttir et al, 2019; Ahonen, Deek, Kroeker, 2012; Rogers et al, 2007; Leandertz et al,

2021, Skille ja Wigram, 1995; Rüütel ja Vinkel (2011). Bartel ja Mosabbir (2021) metanalüüs toob

ulatuslikult välja uurimistööde rohkuse helivibratsiooni kasutamisel füsioloogilisest,

neuroloogilisest ja biokeemilisest mõjust, sh 40Hz kasutamisest. Lõõgastustehnikad koos juhitud

kujutlustega on osutunud tõhusaks valu, ärevuse, depressiooni ja ravimite kasutamise

vähendamisel (Tusek et al, 1997) nii täiskasvanutel kui lastel (Álvarez-García ja Yaban, 2020) ning

seda eriti juhul, kui muusika ja juhitud kujutlust kasutatakse VAT sekkumise ajal (Alam et al,

2016). Sigurdardóttir et al (2019) uuringus oli 18 depressiivset klienti vanuses 18–70 a, kellele

võimaldati tavapärasele depressiooniravile lisaks 3–4 nädala jooksul kaheksa 20 minutilist VAT

seanssi koos muusikaga. Uuringus oli ka 20 liikmega kontrollgrupp, kes sai tavapärast

depressiooniravi. Tulemusena leiti, et võrreldes kontrollgrupiga oli VAT sekkumist saanud

patsientide depressioon vähenenud oluliselt rohkemal määral kui kontrollgrupis. Tegemist on ühe

kvaliteetseima uuringuga viimastel aastatel, mis valideerib VAT ravi depressiooniravis. Ahonen,

Deek, Kroeker (2012) viisid samuti läbi uuringu hindamaks VAT mõju stressi korral. 10

4

muusikavaldkonna üliõpilasega (vanuste vahemikkus ei ole esitatud) uuringus oli sekkumise

pikkuseks 30–60 minutit sõltuvalt osaleja vajadustest, sekkumiste arv oli 6–8 seanssi ning kasutati

sagedusi vahemikus 27–113Hz. Uuringu tulemusel nenditi, et sekkumisgrupil suurenes

subjektiivne heaolutunne (füüsiline ja emotsionaalne lõõgastus, vähenenud valu ja stress,

suurenenud emotsionaalne võimekus ja kontsentreerumine). Kantor et al (2022) uurisid

ühekordse VAT ja muusika sekkumise mõju 22 akuutsete stressinäitajatega ülikooli üliõpilasega,

vanuses 18–40. a. Kasutatud sagedus sekkumisgrupis oli 0–100Hz ning seansi pikkus kuni 50

minutit. Uuringus oli ka 28 osalejaga kontrollgrupp, kes kuulas sekkumisgrupiga sama muusikat

kuid ilma madalsagedusliku vibratsioonita. Stressinäitajatena kasutati pulsi sagedust, stressiga

seotud valu (hindamise mõõdik Visual analogue scales) ja lihaste lõdvestust. Selle pilootuuringu

tulemused näitasid, et madala sagedusega heli võib kasutada stressijuhtimise vahendina

hariduskeskkonnas, nt ülikoolis. Leiti, et madala sagedusega heli suurendab parasümpaatilise

närvisüsteemi aktiivsust ning toetab subjektiivse stressireaktsiooni ja lihaspingete leevendamist.

Soomes asub meetodi arendamise eestvedaja (https://www.vibrac.fi/vibroacoustic-therapy/ )

ning Soomes rakendatakse VAT rehabilitatsioonis muusikateraapia teenuse raames. Teadustöid

on rohkelt kajastatud ka Next Wave Physio veebilehel.

4.8. Kinnitus sekkumise juhendi olemasolu kohta (lisada näidis või kirjeldus): VAT protsess on

kirjeldatud Rüütel et al (2004). Sekkumise protokoll lisatud failina – „Lisa 2. VAT seansi

struktuur_TLÜ VAT laboris“ ning Lisa 4 – VAT protokoll, Skille-Wigram mudel.

4.9. Varasem rakendamine (rakendamise maht ja kestus): VAT on rakendatud siiani

muusikaterapeutide poolt nii lühisekkumisena, sotsiaalses rehabilitatsioonis kui haiglaravis.

4.10. Tagasiside kogumise viis: mõju mõõtmisel kasutatakse EEK-2, ESDS-6, NRS. Mõõtmisvahendid

on toodud kompaktsena Rüütel 2002; Rüütel et al, 2004; Viil. S., 2023.

5. Kavandatud maht

5.1. Seansside koguarv toetusperioodil: 789

5.2. Teenusesaajate arv: 155 (95 individuaalselt ja 60 gruppides)

5.3. Keskmine seansside arv ühe teenusesaaja kohta: 5,1

5.4. Maht piirkondade kaupa: Saaremaal 35 individuaalselt ja 20 grupis, Raplamaal 60

individuaalselt ja 40 grupis

5.5. Sihtrühmani jõudmise ja suunamise kanalid: sotsiaalmeedia, KOV teavituskanalid (KOV ajaleht,

osavaldade ajalehed Saaremaal), Raplamaal Raplamaa Sõnumite podcast, perearstid ja

sotsiaaltöötajad

6. Meeskond ja rakendusvõimekus

6.1. Spetsialistide arv (vähemalt 5, lisada viie inimese info allolevasse tabelisse):

Ees- ja perekonnanimi Haridus (eriala, kraad) Lepingu (nt töö-, töövõtu- või käsundusleping) sõlmimise kuupäev

Siiri Viil Terviseteaduste magister, loovteraapia kutse 7, pereterapeut, kogemusnõustaja

10.2019

Kaili Inno Terviseteaduste magister, loovteraapia kutse 7, pereterapeut, suprviisor

1.7.2025

Kadi Uibo Muusikapedagoogika magister, muusikaterapeut

28.6.2025

Epp Sussen Terviseteaduste magister, loovteraapia kutse 7

15.12.2023

5

Liisi-Katarina Verk Lõpetamas Tallinna Ülikoolis sotsiaalse rehabilitatsiooni BA, varasem kogemus sotsiaaltöötajana ning juhtumikorraldajana

12.3.2026

Ave Verk Sotsiaalpedagoogika magister, pereterapeut (superviseeritav)

1.7.2025

Laima Parik Psühholoogia magister, loovterapeut 1.7.2025

6.2. Spetsialistide kvalifikatsioon: spetsialistid, kes muusikateraapia sekkumisi rakendavad on kõik

asjakohase baasharidusega ning kogemustega vaimse tervise valdkonnas. Kõik töötavad

igapäevaselt klientidega.

6.3. Superviisorite arv ja kvalifikatsioon: Superviisor Kaili Inno (loovterapeut kutse 7)

6.4. Supervisiooni sagedus ja korraldus: grupi supervisioonina vähemalt kord kvartalis. Individuaalse

supervisioonina vastavalt vajadusele.

6.5. Riskijuhtimise plaan: Keskus on tegutsenud aastaid ning meie meeskond on laiem kui taotluses

välja toodud. Seega on risk, et teenuseosutajal tekib personali puudus, väike. Seadmed VAT

osutamiseks on olemas ning vajadusel on olemas võimekus ka soetada seadmeid juurde. Samuti

on muusikateraapiliste lühisekkumiste osutamiseks vajalikud töövahendid olemas. Ruumid on

keskusel olemas nii Raplas kui Saaremaal (Orissaares ja Kuressaares). Teenuse järjepidevuse

tagamiseks on keskusel piisaval arvul spetsialiste, kes on kvalifitseeritud teenuseid osutama.

Teenuse kättesaadavuse osas informatsiooni jagamisel kasutatakse kohalikke tervishoiu- ja

sotsiaalvõrgustikke, sotsiaalmeediat, haridusvaldkonna asutusi, valdkonnas elanikke koondavaid

MTÜsid. Samuti on mõlemas piirkonnas TERVIK ettevalmistuseks loodud koostöömudelid,

mille kaudu informatsiooni teenuse olemasolust on võimalik jagada.

6.6. Kinnitus metoodika kasutusõiguse kohta: Kinnitame õigust metoodikaid rakendada. Spetsialistid

on väljaõppe läbinud

7. Ühe seansi maksumuse ja kulude põhjendus

7.1. Ühe seansi maksumus (koos seansi formaadiga, kui sama taotlus/VIPS sisaldab erinevaid

formaate): MTMI 45-60min 90eur; grupp 90 min 200eur. MBRI 30 min 60eur; grupp 60

minutit 170eur. VAT 60min 70eur

7.2. Keskmine kulu ühe teenusesaaja kohta: 403,55 eur

7.3. Seansi maksumuse struktuur – esitada kulude jaotus, sh tööjõukulud, supervisioon, koolitus,

koordineerimine, litsentsi- ja platvormikulud ning kaudsed kulud (kuni 7% taotletava toetuse

üldmahust):

üldkulud (ruumid, vahendid, taristukulud) 28,24

spetsialisti tööjõukulud 262,24

supervisioonifond 40,34

REHA litsensikulu 4,8

koordineerimine 67,82

kokku 1 teenusesaaja keskmine kulu 403,44

8. Koolitustegevused (vajaduse korral)

8.1. Koolituste kirjeldus ja maht (tundides):

8.2. Koolitatavate spetsialistide arv:

8.3. Koolitatavate superviisorite arv:

8.4. Seos kavandatud rakendamisega ja proportsionaalsuse põhjendus:

8.5. Koolituskulude kogusumma (eurodes) ja osakaal toetuse eelarvest (%):

6

9. Selgitus, kuidas kavandatav tegevus aitab tervikuna suurendada VIPS-i rakendamise võimekust Eestis

(nt spetsialistide ettevalmistus, sekkumise kättesaadavus, rakendamise maht või organisatsiooniline

suutlikkus).

Muusikateraapia lühisekkumiste laiem rakendamine loob laialdasemad võimalused klienditele, kellel on

raskendatud verbaalne eneseanalüüs või väljendus. Samuti toovad loovteraapia meetodid nähtavale

alateadvusest selle, mida inimene ise ei oska sõnastada. Piisava ja asjakohase täiendõppe korral on

võimalik neid sekkumisi laiapõhjaliselt rakendada alates koolieelsetest lasteasutustest kuni elukaare

lõpufaasis olevatele inimestele. Eeldus väljaõppe läbimiseks on varasem muusikaga kokkupuude (nt

muusikaõpetajad, laste muusikakoolis käimine, individuaalne pilliõpe vms). Perspektiivis näeme 2027

koolitusprogrammi koostamist ja väljeõppe võimaluse pakkumist spetsialistide väljaõppeks mahus 50-

60h sh praktika, mille järel on võimalik taotluses toodud sekkumisi uutel spetsialistidel rakendada.

Õppekava eelnõu on meil koostamisel ning pädevused koolitust läbi viia olemas sh koolitustegevuse

kogemus. Leiame, et muusikateraapia lühisekkumiste kättesaadavuse suurendamisel vähendab see

ühiskonnas uskumust, et ainult kliiniline psühholoog ja psühhiaater on mõjusad vaimse tervise

abivahendid ning keskendumine kahele piirkonnale, mis ei ole nn keskused, tooma kvaliteetsed teenused

elanikkonnale kogukonnas kättesaadavaks laiendades sellega elanikkonna ja sihtrühmade kaetust vaimse

tervise teenustega.

VAT – lühisekkumisena rakendatav kogu elukaare ulatuses ning selle lühisekkumisena rakendamiseks

on uutele spetsialistidele vajalik VAT väljaõpe kättesaadav VIBRAC I mooduli veebikoolitusena1 või

Eestis kohapealse koolitusena (koolitaja pädevus Ivar Vinkel’l). Vajalikud seadmed on võimalik

ühekordse ostuga hankida ning nende hinnaskaala on erinev vastavalt sekkumise pakkuja võimalustele.

Seadmete osas on olemas nii väikesed kaasaskantavad seadme, kaasaskantavad madratsid kuni püsival

asukohaga voodid. Nt Next Wave Physio (Soome tootja), Multivib (Norra tootja), Vibracare. Üheks

võimaluseks on VAT rakendada ka koolides ja lasteaedades, kus on loodud eraldi sensoorsed ja/või

nn rahunemistoad. Seega perspektiivis spetsialistide ettevalmistuse korraldus on lihtne ja ei ole kulukas

ning sekkumine saab olla kättesaadav nii kogukonna teenusena kui haridus- ja sotsiaalasutustes

kohapeal.

Kinnitused Kinnitan, et esitatud andmed on õiged ning vastan määruses sätestatud nõuetele. Kinnitan, et taotluses esitatud kulude katteks ei ole saadud ega taotleta toetust Euroopa Liidu fondidest, riigieelarvest ega muudest avaliku sektori vahenditest. /digitaalselt allkirjastatud/ Siiri Viil Viited

• Alam, M., Roongpisuthipong, W., Kim. N. A., Goyal. A., Swary. J. H., Brindise, R. T., Iyengar.S., Pace, N., West. D. P., Polavarapu, M. & Yoo. S. (2016). Utility of recorded guided imagery and relaxing music in reducing patient pain and anxiety, and surgeon anxiety, during cutaneous surgical procedures: A single-blinded randomized controlled trial. Journal of the American Academy of Dermatology, 75(3), 585–589. https://doi.org/10.1016/j.jaad.2016.02.1143

• Ahonen H. , Deek, P., & Kroeker, J. (2012). Low frequency sound treatment promoting physical and emotional relaxation qualitative study. International Journal of Psychosocial Rehabilitation. International Journal of Psychosocial Rehabilitation, 17(1), 45–58 Rogers et al, 2007;

1 https://www.vibrac.fi/vibrac-webinar-level-i/ Koolitus sisaldab baasteadmisi madalsagedusliku heli kasutamisest, VAT lähenemistest, meetoditest, sagedustest, terapeutilise suhte loomisest, keha tajust, muusika kasutamisest, tulemuste hindamisest, terapeudi vastutusest ning kasutatavate seadmete ja juhtumite näidetest.

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• Álvarez-García, C. & Yaban, Z.S. (2020). The effects of preoperative guided imagery interventions on preoperative anxiety and postoperative pain: A meta-analysis. Complementary Therapies in Clinical Practice, 38, 101077. https://doi.org/10.1016/j.ctcp.2019.101077

• Bartel, L., Mosabbir, A. (2021). Possible Mechanisms for the Effects of Sound Vibration on Human Health. Healthcare (Basel). 18;9(5), 597. https://doi.org/10.3390/healthcare9050597

• Bergström-Isacsson, M., Julu, P.O.O. & Witt-Engerström, I. (2007). Autonomic Responses to Music and Vibroacoustic Therapy in Rett Syndrome. Nordic Journal of Music Therapy, 16(1), 42–59. https://doi.org/10.1080/08098130709478172

• Bradt, J., Dileo, C., Magill, L., & Teague, A. (2016). Music interventions for improving psychological and physical outcomes in cancer patients. Cochrane Database of Systematic Reviews, (8), CD006911. https://doi.org/10.1002/14651858.CD006911.pub3

• Bradt, J., Dileo, C., & Potvin, N. (2013). Music interventions for improving psychological and physical outcomes. Cochrane Database of Systematic Reviews.

• Chi, G. C. H., et al. (2015). Effects of music relaxation on anxiety: A randomized controlled trial. Journal of Research in Nursing, 20, 129–144.

• Eckhouse, D. R., et al. (2014). Effects of music and relaxation interventions on anxiety: A randomized controlled trial. Orthopaedic Nursing, 33, 342–351.

• de Witte, M., Spruit, A., van Hooren, S., Moonen, X., & Stams, G. J. J. M. (2020). Effects of music interventions on stress-related outcomes: A systematic review and two meta-analyses. Health Psychology Review, 14(2), 294–324. https://doi.org/10.1080/17437199.2019.1627897

• de Witte, M., Pinho, A. S., Stams, G. J. J. M., Moonen, X., Bos, A. E. R., & van Hooren, S. (2022). Development of a music therapy micro-intervention for stress reduction. The Arts in Psychotherapy, 77, 101873. https://doi.org/10.1016/j.aip.2021.101873

• de Witte, M., Pinho, A. d. S., Stams, G.-J., Moonen, X., Bos, A. E. R., & van Hooren, S. (2022). Music therapy for stress reduction: A systematic review and meta-analysis. Health Psychology Review, 16(1), 134–159. https://doi.org/10.1080/17437199.2020.1846580

• Erkkilä, J., Punkanen, M., Fachner, J., Ala-Ruona, E., Pöntiö, I., Tervaniemi, M., Vanhala, M., & Gold, C. (2011). Individual music therapy for depression: Randomised controlled trial. The British Journal of Psychiatry, 199(2), 132–139. https://doi.org/10.1192/bjp.bp.110.085431

• Giordano F, Losurdo A, Quaranta VN, Campobasso N, Daleno A, Carpagnano E, Gesualdo L, Moschetta A, Brienza N. Effect of single session receptive music therapy on anxiety and vital parameters in hospitalized Covid-19 patients: a randomized controlled trial. Sci Rep. 2022 Feb 24;12(1):3154. DOI: 10.1038/s41598-022-07085-8

• Gold, C., Solli, H. P., Krüger, V., & Lie, S. A. (2009). Dose–response relationship in music therapy for people with serious mental disorders: Systematic review and meta-analysis. Clinical Psychology Review, 29(3), 193–207. https://doi.org/10.1016/j.cpr.2009.01.001

• Kantor, J., Vilímek, Z., Vítězník, M., Smrčka, P., Campbell, E. A, Bucharová, M., Grohmannová, J., Špinarová, G., Janíčková, K., Du, J., Li, J., Janátová, M., Regec, V., Krahulcová, K. & Kantorová, L. (2022). Effect of low frequency sound vibration on acute stress response in university students-Pilot randomized controlled trial. Frontiers in Psychology. Oct 13:980756. doi:10.3389/fpsyg.2022.980756

• Leandertz, M., Joukainen, J., Pesonen, T. & Ala-Ruona, E. (2021). Psychotherapeutically Oriented Vibroacoustic Therapy for Functional Neurological Disorder: A pilot study. Music & Medicine. 13(1), 20–30. DOI: https://doi-org.ezproxy.tlu.ee/10.47513/mmd.v13i1.754

• Lee YJ, Kim SJ, Yoon J, Lee JH. Music therapy for patients with depression: systematic review and meta-analysis of randomised controlled trials. BJPsych Open. 2025 Sep 9;11(5):e201. doi: 10.1192/bjo.2025.10822

• Nguyen, T. K., Hoang, H., Bui, Q. V., & Chan, C. W. H. (2023). Effects of music intervention combined with progressive muscle relaxation on anxiety, depression, stress, and quality of life: A randomized controlled trial. PLOS ONE.

• Põld M, Kleinberg A, Koiduaru K, Jürisson M. (2024). Loovteraapiad laste ja noorukite psüühikahäirete ravis: tervisetehnoloogiate hindamise raport TTH69. Tartu: Tartu Ülikooli peremeditsiini ja rahvatervishoiu instituut. ISBN 978-9985-4-1427-9

• Rüütel, E. (1998a). Vibroakustiline teraapia: Teoreetilised lähtekohad ja rakendusvõimalused. Tallinna Pedagoogikaülikool.

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• Rüütel, E., Ratnik, M., Tamm, E. & Zilensk, H. (2004). The experience of vibroacoustic therapy in the therapeutic intervention of adolescent girls. Nordic Journal of Music Therapy, 13(1): 33–46 https://doi.org/10.1080/08098130409478096

• Rüütel, E. (2002). The psychophysiological effects of music and vibroacoustic stimulation. Nordic Journal of Music Therapy, 11(1), 16–26. https://doi.org/10.1080/08098130209478039

• Rüütel, E. ja Vinkel, I. (2011). Vibro-acoustic therapy – research at Tallinn University. Miroslav, P (toim.). Art and science in life potential development, 42−44. Croatian Assosation for Sophrology, Creative Therapies and Arts-Expressive Therapies; University of Zagreb.

• Sigurdardóttir, G. A., Nielsen, P. M., Rønager, J. & Wang, A. G. (2019). A pilot study on high amplitude low frequency–music impulse stimulation as an add-on treatment for depression. Brain Behavior. 9(10):e01399. doi: 10.1002/brb3.1399

• Skille, O. & Wigram, T. (1995). The effects of music, vocalization and vibration on brain and muscle tissue: Studies in vibroacoustic therapy. In T. Wigram, B. Saperston, & R. West (Eds.), The art & science of music therapy: A handbook. Chur, Switzerland: Harwood Academic Publishers.

• Tusek, D., Church, J. M. & Fazio, V. W. (1997) Guided imagery as a coping strategy for perioperative patients. AORN Journal. 66(4), 644–649. https://doi.org/10.1016/S0001-2092(06)62917-7

• Viil, S (2023), Vibroakustilise teraapia sekkumistulemuste püsivus gümnaasiumiõpilaste depressiooni, ärevuse ja vaimse kurnatuse sümptomaatikas. Tallinna Ülikool https://www.etera.ee/s/44SmWN5Kmy

Supportive Counseling kui madala intensiivsusega sekkumine

Lühikirjeldus

Supportive counseling on madala intensiivsusega psühholoogiline sekkumine, mis põhineb

aktiivsel kuulamisel, empaatilisel suhtlemisel ja emotsionaalsel toetamisel.

Supportive counseling sekkumine põhineb mitte-direktiivse toetava nõustamise (non-directive

supportive therapy) mudelil, mille keskmes on aktiivne kuulamine, peegeldamine ja emotsionaalne

valideerimine. Sekkumine on sobiv kerge kuni mõõduka psühholoogilise distressi (nt ärevus,

stress, depressiivsed sümptomid) leevendamiseks ning on struktureeritud lühiformaadis (1–6

sessiooni) rakendatav kogukonna- ja esmatasandi teenustes. Sekkumisel on selgelt kirjeldatud

struktuur ja korduvad komponendid, mida rakendatakse kindlas järjekorras.

Sekkumise protokoll (35–50 min sessioon)

1. Avamine ja kontakti loomine (5 min)

- turvalise keskkonna loomine

- avatud küsimuste kasutamine

2. Probleemi eksploratsioon (15–20 min)

- aktiivne kuulamine

- peegeldamine (sisu ja emotsioonide tasandil)

3. Emotsionaalne tugi (10–15 min)

- valideerimine

- normaliseerimine

- empaatia

4. Kokkuvõte ja sulgemine (5–10 min)

- põhipunktide kokkuvõte

- lihtsad toimetuleku sammud

Rakendatavad tehnikad

- aktiivne kuulamine (active listening)

- peegeldamine (reflection)

- valideerimine (validation)

- normaliseerimine (normalization)

- toetav tagasiside (encouragement)

Tõenduspõhisus

Sekkumise efektiivsust toetavad meta-analüüsid, mis näitavad, et mitte-direktiivne supportive

therapy on efektiivne kerge kuni mõõduka depressiooni korral ning avaldavad olulist mõju

depressiooni ja psühholoogilise distressi vähendamisel (Cuijpers et al., 2012; Wampold & Imel,

2015).

Supportive counseling aktiveerib “common factors” mehhanismid, milleks on terapeutiline

suhe, empaatia, kuulamine, mis omakorda on olulised sekkumise mõju ennustajad (Bruce

Wampold & Imel, 2015)

Viited

• Cuijpers, P., Driessen, E., Hollon, S. D., van Oppen, P., Barth, J., & Andersson, G.

(2012). The efficacy of non-directive supportive therapy for adult depression: A meta-

analysis. Clinical Psychology Review, 32(4), 280–291.

https://doi.org/10.1016/j.cpr.2012.01.003

• Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence

for what makes psychotherapy work (2nd ed.). Routledge.

• Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality

change. Journal of Consulting Psychology, 21(2), 95–103.

https://doi.org/10.1037/h0045357

1

Sotsiaalministri 17.03.2026 määrus nr 1.2-2/27-1

„Väheintensiivsete psühholoogiliste sekkumiste

rakendamise toetus“ Lisa 1

Taotlusvorm

1. Taotleja andmed

1.1. Asutuse/ettevõtte nimetus: Ojaveere Nõustamine OÜ

1.2. Registrikood: 14576910

1.3. Postiaadress: Rapla maakond, Rapla vald, Rapla linn, Tallinna mnt 22, 79512

1.4. Arvelduskonto (IBAN): EE972200221070258412

1.5. Esindaja nimi ja ametikoht: Siiri Viil, juhatuse liige

1.6. Kontaktisiku andmed (nimi, e-post, telefon): Siiri Viil [email protected] 55 155 78

1.7. Taotletav toetuse kogusumma (käibemaksuta): 22 500 eur

1.8. Projekti elluviimise periood: 1.6-31.12.2026

Kui taotlus sisaldab mitut VIPS-sekkumist, esitatakse allolev info iga sekkumise kohta eraldi (vajaduse korral dubleerides vastavad väljad).

2. VIPS-i kirjeldus:

2.1. Nimetus: Supportive counceling (Kogukonna psühholoogiline lühinõustamine)

2.2. Lühikirjeldus (sh metoodiline alus): Supportive counseling on madala intensiivsusega

struktureeritud psühholoogiline sekkumine, mis põhineb aktiivsel kuulamisel,

peegeldamisel ja emotsionaalsel valideerimisel. Sekkumine järgib struktureeritud

sessioonimudelit, mis hõlmab probleemi uurimist, empaatilist peegeldamist ja toetavat

kokkuvõtet (Cuijpers et al., 2012; Wampold & Imel, 2015). Sekkumise eesmärk on

parandada kliendi emotsionaalset heaolu, toetada toimetulekuoskusi ning pakkuda turvalist

ruumi kogemuste jagamiseks. Erinevalt kõrgema intensiivsusega psühhoteraapiatest ei

keskendu supportive counseling sügavale psühhodünaamilisele analüüsile ega keerukatele

kognitiivsetele tehnikatele, vaid emotsionaalsele kohalolule ja toetavale suhtele. Empaatial

ja reflektiivsel kuulamisel põhinev lähenemine toetab emotsionaalset regulatsiooni ja

enesemõistmist ning tugevdab sekkumise mõju. Sekkumine on sobiv kerge kuni mõõduka

psühholoogilise distressi (nt ärevus, stress, depressiivsed sümptomid) leevendamiseks ning

rakendatav lühiformaadis (1–6 sessiooni) kogukonna- ja esmatasandi teenustes. Supportive

counseling on mitte-direktiivne, emotsionaalset tuge pakkuv sekkumine, mis keskendub a)

aktiivsele kuulamisele, b) emotsioonide valideerimisele c) toimetuleku toetamisele.

Uuringutes on toodud korduv selge sessiooni struktuur ja komponendid.

2.3. Sihtrühm (vanuserühm jne): 15-64. Gruppide korral vanusepõhiselt 15–24, 25–44, 45–

64.

2.4. Piirkond: Saaremaa, Rapla maakond

2.5. Formaat (individuaal, grupi, kombineeritud): nii individuaalne

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2.6. Struktuur (seansside arv, ühe seansi kestus minutites, grupisekkumiste korral inimeste arv

grupis): individuaalse kohtumise pikkus 30-60 minutit. Tegemist võib olla ühekordse

sekkumise või pikemaajalise (kuni 6 kohtumist).

2.7. Vorm (kohapeal, veebis jne): kohapeal ja veebis

2.8. Tõenduspõhisus (viidata uuringutele, rahvusvahelisele kasutusele; lisada viited või allikad):

Juhendatud sekkumised (st sekkumised, kus osalejat toetab juhendaja või nõustaja) on

osutunud oluliselt efektiivsemaks kui täielikult iseseisvad eneseabivormid, näidates

suuremat mõju sümptomite vähenemisele ning paremat sekkumises püsimist (Baumeister

et al., 2014). Madala lävega kogukonnakeskustes pakutav psühholoogiline lühinõustamine

ja aktiivne kuulamine on kooskõlas rahvusvaheliselt tunnustatud low-intensity psychological

interventions mudeliga, mille efektiivsust toetavad arvukad randomiseeritud

kontrolluuringud ja süstemaatilised ülevaated. Eriti tugev tõendus on kognitiiv-

käitumuslikel ja juhendatud eneseabi sekkumistel, mis on efektiivsed kerge kuni mõõduka

depressiooni ja ärevuse vähendamisel. Aktiivne kuulamine ja empaatiline suhtlus on nende

sekkumiste keskne komponent, toimides terapeutilise liidu ja muutuse mehhanismina.

Meta-analüütilised uuringud on ka näidanud, et terapeutiline liit, empaatia ja valideerimine

on olulised ennustajad positiivsetele ravitulemustele sõltumata konkreetsest

teraapiameetodist (Wampold & Imel, 2015). Supportive counseling põhineb teaduskirjanduses

kirjeldatud ja manualiseeritud lähenemistel, sh Brief Supportive Psychotherapy (BSP),

mida on kasutatud randomiseeritud uuringutes ning mille keskmes on empaatia, aktiivne

kuulamine ja fookus emotsioonidel (Markowitz, 2022). Madala intensiivsusega

sekkumistes täidab aktiivne kuulamine mitut funktsiooni: loob turvalise ja toetava

keskkonna, suurendab osaleja motivatsiooni ja kaasatust, toetab eneserefleksiooni ja

probleemilahendust. Seetõttu on aktiivne kuulamine käsitletav mitte üksnes toetava

elemendina, vaid olulise toimemehhanismina, mille kaudu sekkumine avaldab mõju. Mõju:

1) kognitiivsete mustrite muutus (nt mõttemustrite muutmine); 2) Käitumuslik

aktivatsioon (rohkem tegevust → parem meeleolu); 3) sotsiaalse toe ja kuuluvustunde kasv;

4) Enesetõhususe kasv (inimene õpib ise toime tulema). Tõenduspõhisus näitab, et sellised

mitte-direktiivsed sekkumised on efektiivsed kerge kuni mõõduka distressi vähendamisel

(Cuijpers et al., 2012; Wampold & Imel, 2015).

2.9. Kinnitus sekkumise juhendi olemasolu kohta (lisada näidis või kirjeldus): Sekkumise

protokoll lisatud failina – Lisa 1 Supportive counceling protokoll. Samuti rakendame

vajadusel täiendava materjalina Tervisekassa töövihikuid (depressioon, unevihik (sh

noorte unevihik), ärevus jt).

2.10. Varasem rakendamine (rakendamise kirjeldus, maht ja kestus): Oleme sekkumist

kasutanud mitme aasta vältel erinevate spetsialistide poolt klientidega, kes ei vaja

psühhoteraapiat. Samuti noorte nõustamisel. Näeme, et sageli on piisavalt abistav see, kui

klient saab väljendada enda mõtteid ja tundeid ning teda kuulatakse ja peegeldatakse (ei

rakendata suhtlemistõkkeid) ning läbi turvalise keskkonna ja toetuse leiab inimene ise

lahendused või ressursi. On hulk sihtgruppe, keda veebipõhised sekkumised ei toeta, kuna

nad ei kasuta neid ega ka hakka kasutama. Meie kogemusel on äärmiselt oluline, et

kogukonnapõhises madala lävendiga vaimse tervise keskustes on elanikul võimalus tulla ja

saada kohest abi. Meie keskusesse on selliselt tulnud emotsionaalselt madalseisus olevad

inimesed, sõprade poolt kohale toodud suitsiidsete mõtetega inimesed, noorukid, kes

kogevad üksildust jne. Sealjuures erinevates vanusegruppides. Senise kogemuse baasil

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oleme näinud teadusuuringutes toodud psühholoogilise nõustamise kohest mõju ning

näeme vajadust seda püsivalt pakkuda.

2.11. Tagasiside kogumise viis: seni läbi keskuse rahulolu uuringu, mis ei ole sekkumise

põhine. Iga spetsialist on kliendiga kohtumiste lõppedes suuliselt teinud kokkuvõtte

eesmärkide saavutamisest või enesetunde muutusest.

3. Kavandatud maht

3.1. Seansside koguarv toetusperioodil: 250

3.2. Teenusesaajate arv: 50

3.3. Keskmine seansside arv ühe teenusesaaja kohta: 5

3.4. Maht maakondade kaupa: Raplamaal 30 ja Saaremaal 20 inimest

3.5. Sihtrühmani jõudmise ja suunamise kanalid: sotsiaalmeedia, KOV teavituskanalid (KOV

ajaleht, osavaldade ajalehed Saaremaal), Raplamaal Raplamaa Sõnumite podcast,

perearstid ja sotsiaaltöötajad

4. Meeskond ja rakendusvõimekus

4.1. Spetsialistide koguarv (vähemalt 5, lisada viie inimese info allolevasse tabelisse):

Ees- ja perekonnanimi Haridus (eriala, kraad) Lepingu (nt töö-, töövõtu- või käsundusleping) sõlmimise kuupäev

Siiri Viil Terviseteaduste magister, loovteraapia kutse 7, pereterapeut, kogemusnõustaja

10.2019

Kaili Inno Terviseteaduste magister, loovteraapia kutse 7, pereterapeut, superviisor

1.7.2025

Marianne Mändmets-Tuvikene

sotsiaalpedagoogika ja lastekaitse magister, pereterapeut (superviseeritav)

27.4.2023

Epp Sussen Terviseteaduste magister, loovteraapia kutse 7

15.12.2023

Liisi-Katarina Verk Lõpetamas Tallinna Ülikoolis sotsiaalse rehabilitatsiooni BA, varasem kogemus sotsiaaltöötajana ning juhtumikorraldajana

12.3.2026

Ave Verk Sotsiaalpedagoogika magister, pereterapeut (superviseeritav)

1.7.2025

Laima Parik Psühholoogia magister, loovterapeut 1.7.2025

Greta Vaus Usuteaduste magister, meditsiiniõde 16.4.2024

1.1. Spetsialistide kvalifikatsioon: spetsialistid, kes muusikateraapia sekkumisi rakendavad on

kõik asjakohase baasharidusega ning kogemustega vaimse tervise valdkonnas. Kõik

töötavad igapäevaselt klientidega.

1.2. Superviisorite arv ja kvalifikatsioon: Superviisor Kaili Inno (loovterapeut kutse 7)

1.3. Supervisiooni sagedus ja korraldus: grupi supervisioonina vähemalt kord kvartalis.

Individuaalse supervisioonina vastavalt vajadusele.

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1.4. Riskijuhtimise plaan: Keskus on tegutsenud aastaid ning meie meeskond on laiem kui

taotluses välja toodud. Seega on risk, et teenuseosutajal tekib personali puudus, väike.

Seadmed VAT osutamiseks on olemas ning vajadusel on olemas võimekus ka soetada

seadmeid juurde. Samuti on muusikateraapiliste lühisekkumiste osutamiseks vajalikud

töövahendid olemas. Ruumid on keskusel olemas nii Raplas kui Saaremaal (Orissaares ja

Kuressaares). Teenuse järjepidevuse tagamiseks on keskusel piisaval arvul spetsialiste, kes

on kvalifitseeritud teenuseid osutama. Teenuse kättesaadavuse osas informatsiooni

jagamisel kasutatakse kohalikke tervishoiu- ja sotsiaalvõrgustikke, sotsiaalmeediat,

haridusvaldkonna asutusi, valdkonnas elanikke koondavaid MTÜsid. Samuti on mõlemas

piirkonnas TERVIK ettevalmistuseks loodud koostöömudelid, mille kaudu

informatsiooni teenuse olemasolust on võimalik jagada.

1.5. Kinnitus metoodika kasutusõiguse kohta: Kinnitame õigust metoodikaid rakendada.

Spetsialistid on väljaõppe läbinud

2. Ühe seansi maksumuse ja kulude põhjendus

2.1. Ühe seansi maksumus (koos seansi formaadiga, kui sama taotlus/VIPS sisaldab erinevaid

formaate): 90eur

2.2. Keskmine kulu ühe teenusesaaja kohta: 450eur

2.3. Seansi maksumuse struktuur – esitada kulude jaotus, sh tööjõukulud, supervisioon,

koolitus, koordineerimine, litsentsi- ja platvormikulud ning kaudsed kulud (kuni 7%

taotletava toetuse üldmahust):

üldkulud (ruumid, vahendid, taristukulud) 31,5

spetsialisti tööjõukulud 292,5

supervisioonifond 45

REHA litsentsikulu 3

koordineerimine 78

kokku 1 teenusesaaja keskmine kulu 450,00

3. Koolitustegevused (vajaduse korral)

3.1. Koolituste kirjeldus ja maht (tundides):

3.2. Koolitatavate spetsialistide arv:

3.3. Koolitatavate superviisorite arv:

3.4. Seos kavandatud rakendamisega ja proportsionaalsuse põhjendus:

3.5. Koolituskulude kogusumma (eurodes) ja osakaal toetuse eelarvest (%):

4. Selgitus, kuidas kavandatav tegevus aitab tervikuna suurendada VIPS-i rakendamise

võimekust Eestis (nt spetsialistide ettevalmistus, sekkumise kättesaadavus, rakendamise maht

või organisatsiooniline suutlikkus).

Saaremaa piirkonnas ei ole vaimse tervise tugi KOV ja riiklike teenustega kaetud mujal kui ainult

Kuressaares. Ka haridusvõrgu tugiteenused on tsentraliseeritud ning kättesaadavad vaid Kuressaares.

Seetõttu on oluline osa hajaasustusega piirkonnast selline, kus kogu elanikkonnal elukaare ulatuses ei

ole vaimse tervise abi kättesaadav. Meie keskus osutab teenuseid Ida-Saaremaal ning vajadus teenuste

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järele on suur. Kuna aga Saaremaa on palgavaesuse osas Valga järel teisel kohal, siis elanikel teenuste

eest ise tasumiseks ressurssi ei ole. Raplamaal on küll teenuste kättesaadavus Tallinna lähedusest

tulenevalt parem, kuid potentsiaali astmelise abi mudeli I ja II astme rakendamisel meditsiinisüsteemi

koormuse vähendamisel on oluline. Raplas piloteeritakse ka perearstiteenuse osas pilootmudelit

Confidoga, kus inimestel puudub võimalus saada kontakti oma perearstiga või rääkida telefonitsi enda

pereõega. See on viinud esmatasandi terviseteenused inimestest veel kaugemale ning tekitab tunde, et

kellegagi ei ole võimalik rääkida. Seetõttu on äärmiselt oluline võimaldada antud perearstiteenuse

mudeliga piirkonnas VIPSe, kus on võimalik inimesel kellegagi päriselt rääkida. Psühholoogilise

lühinõustamise kättesaadavuse suurendamisel vähendab see ka ühiskonnas laiemalt uskumust, et ainult

kliiniline psühholoog ja psühhiaater on mõjusad vaimse tervise abivahendid ning keskendumine kahele

piirkonnale, mis ei ole nn keskused, tooma kvaliteetsed teenused elanikkonnale kogukonnas

kättesaadavaks laiendades sellega elanikkonna ja sihtrühmade kaetust vaimse tervise teenustega.

Kinnitused Kinnitan, et esitatud andmed on õiged ning vastan määruses sätestatud nõuetele. Kinnitan, et taotluses esitatud kulude katteks ei ole saadud ega taotleta toetust Euroopa Liidu fondidest, riigieelarvest ega muudest avaliku sektori vahenditest. /allkirjastatud digitaalselt/ Siiri Viil Viited

• Baumeister, H., Reichler, L., Munzinger, M., & Lin, J. (2014). The impact of guidance on

Internet-based mental health interventions — A systematic review. Internet Interventions, 1(4),

205–215.

• Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes

psychotherapy work. Routledge.

• Winston, A., Rosenthal, R. N., & Pinsker, H. (2004). Learning supportive psychotherapy: An

illustrated guide. American Psychiatric Publishing.

• Cuijpers, P., Driessen, E., Hollon, S. D., van Oppen, P., Barth, J., & Andersson, G. (2012).

The efficacy of non-directive supportive therapy for adult depression: A meta-analysis.

Clinical Psychology Review, 32(4), 280–291.