Our need for relationships and belonging plays an important role in mental health (Baumeister & Leary, 1995). Social relationships can create a buffer to distress (Cohen & Wills, 1985) and are considered one of the key ingredients in mental health recovery (Bird et al, 2014; Leamy et al, 2011). Recent evidence shows that social identification with groups is beneficial for well-being (Greenaway et al, 2015) and the more social groups we feel we belong to, the better our mood (Cruwys et al, 2014). Luckily, it is possible to improve social identification, and an improved sense of connection can generalise to individuals outside of the perceived in-group, resulting in a better clinical outcome (Haslam et al, 2016; Meuret et al, 2016).

In general, self-stigma in mental illness can have a negative effect on social relationships, as it is associated with higher levels of social anxiety (Gerlinger et al, 2013; Pyle et al, 2015; Vrbova et al, 2017) and loneliness, and can be a barrier to social activity (Stain et al, 2012).

This is a real shame, since besides improving well-being, feeling one belongs to a valued group helps to protect against self-stigma (Rüsch et al, 2009).

I wonder: is it the stigma that is influencing the social network, or is it actually the other way around? And has the importance of valued connections so far been underrated in research on stigma and mental health?

Besides the general positive psychological effects of collective gatherings (Páez et al, 2015), inter-group contact can reduce prejudice (Pettigrew & Tropp, 2006). Furthermore, shared activities can enhance the experience of being immersed and absorbed in these activities, resulting in improved personal well-being as well as an increase in social cohesion (Zumeta et al, 2016).

The qualitative study discussed in this blog (Shakespeare & Whieldon, 2017) is about the effect of participation in an inclusive singing group on mental health and well-being. By offering an opportunity to bring people from different mental health backgrounds in touch with each other, the us/them dichotomy can be challenged. Taking part in a singing group can have a powerful effect on mental health.

Leisure activities in general (Davies et al, 2016), music (Even, 2013) and the use of arts (Sapouna & Pamer, 2016) have been proven to be beneficial for well-being and mental health, and especially group singing (e.g. Clift et al, 2010; Clift & Morrison, 2011; De Souza Cateano et al, 2017; Sanal & Gorsev, 2014;  Tavormina et al, 2014). Choir singing is even more effective than other hobbies like team sports (Stewart & Lonsdale, 2016), swimming (Valentine & Evans, 2001), or solo singing (Valentine & Evans, 2001; Stewart & Lonsdale, 2016).

Several theoretical rationales explain, when patched together, why group singing can be so beneficial. From a clinical psychology perspective, singing in a choir can be seen as a form of behavioural activation to improve low mood, exposure to reduce social anxiety, attentional bias modification to change patterns of rumination and worrying, cognitive training, and the mastery of new skills. The sense of concentration or absorption in an activity, called ‘flow’ (Csikszentmihályi, 1990), often occurs while singing, and is found to be related to social bonding (Keeler et al, 2015; Páez et al, 2015). A sense of flow goes together with improved well-being, heightened self-esteem (Robinson et al, 2012), higher levels of positive affect and lower levels of negative affect (Brom et al, 2014).

In general, emotions associated with music can be positive ones (Juslin & Laukka, 2004), and shared positive emotions have been found to improve the relationship with others (Taylor et al, 2017). Group singing has the added benefits of improving a sense of bonding (Chiu et al, 2016; Lamont et al, 2017; Parker, 2010; Stewart & Lonsdale, 2016) and these subjective changes are reflected by changes in oxytocin levels (Keeler et al., 2015; Schladt et al, 2017). Choir members socially identify with their group (Durrant, 2005). Moreover, choir participation increases the range of groups one feels one belongs to (so-called social identification) and this increase in social cohesion can even take place in larger choirs (Weinstein et al, 2015). All these ingredients make a singing group a great opportunity to improve well-being, mental health and social relationships.

So far, few studies have been done on the effect of singing together in people with different mental health backgrounds. The ones that did, found positive results in changing stigma and relationships, in group settings including Alzheimer’s patients and their families/carers and students (Beynon et al, 2016; Harris & Caporella, 2014) and in forensic psychiatric patients and community members (Mezey et al, 2015).

Methods

Recruited from 4 ongoing inclusive singing groups open to mental health service users as well as members of the general public, 14 women and 6 men were interviewed, of which 17 had experience with treatment for mental health difficulties. Six people identified as carers, 5 of them reported mental health problems as a result of this role, while 2 people reported medical conditions. In addition, focus groups were held with key organisers of the choirs, as well as with two voice coaches. Additional information came from participant observation over a 6-month period of the 4 singing groups, that were weekly attended by about 120 singers, though the total number of members was higher.

An emphasis was placed on enjoyment and the singing groups or workshops were intentionally not described as a choir to their participants so as to minimise pressure on performance. Rehearsals took place on a weekly basis, with no requirements regarding attendance. The singing repertoire consisted of uplifting music and there was no need to sight-read. Participation was free and included a social aspect as people could mingle over the breaks at rehearsal.

Results

In line with the literature and expectations, participants reported sustained or improved well-being and mental health as a result of taking part in the singing workshops. Effects were described as improved positive effects on mood, social anxiety, and functioning, a greater sense of confidence and improvements in social skills, as well as physical benefits.

Their participation in the singing group provided group members with a sense of social engagement, belonging, safety and support. They felt they were able to have fun, express themselves and communicate in a safe environment, and claimed to benefit from the structure that attending the rehearsals gave them. They referred to the singing group as different from choirs or other group settings and especially valued the inclusive nature and accepting atmosphere, social equality, and absence of a formal therapy or need to speak about their condition. The authors included quotes from participants and organisers, which reflected a renewed sense of self-identity, an increased ‘togetherness’ as well as changes in social identification as a member of the singing group.

Support was offered on a formal and informal basis to those who needed it, but the responsibility of caring for group members was carried by the group as a whole. Friendships were formed between group members of different mental health backgrounds, and the group offered an opportunity to educate members without lived experience of mental illness about mental ill health, thus reducing stigma.

The ability for members to help out with the organisation of the rehearsals improved individual skills, group role-identity and a sense of self-efficacy and empowerment in some of the members but also had a positive effect on group cohesion. For some, improved social engagement transferred to situations outside of the choir.

Conclusions

Participation in a singing group led to improved mental health, well-being, and social relationships as well as positive changes in self- and social identity, increased empowerment and connectedness with others.

Strengths and limitations

The study discussed in this blog is a great example of a hobby with intentional benefits, the most obvious strengths being the effect of singing together and the set-up of inclusion and equality between group members from different mental health backgrounds.

The qualitative nature of the study ensured that themes that were important to the participants were brought to light, including detailed information from participants that couldn’t be captured by questionnaires.

Some limitations of the study are the self-selection of participants, and the ratio of participants with and without a history of service use. The missed opportunity to hear from individuals who did not volunteer for the interviews could mean that potential adverse effects may not have been captured.

In addition, as the aim was to evaluate this inclusive program, it is crucial to hear from more participants without a history of mental ill health about their experiences with the singing group, in particular related to connectedness and social identity. People in the general public see others with an obvious mental illness as different from themselves (Corrigan et al, 2015); usually lack of knowledge (Hawke, 2014) or lack of familiarity (Aromaa et al, 2011; Boyd et al, 2010; Svensson & Hansson, 2016) result in a wish to withdraw from them. It would be interesting to investigate if a project like this could bring about any changes in these processes and in public stigma.

Unfortunately, no information was given about the ratio of participants who were service users versus non-service users in the 4 singing groups. A good balance of different mental health backgrounds would optimise the opportunities for changes in social identification processes.

From a stigma reduction point of view, more concrete information on changes in social identification would be beneficial, as this has the potential to reduce the dichotomy between service users and non-service users.

Reading this piece led me to contemplate the implications of not calling the singing group a choir. The policy (designed not to put pressure on participants) can give them space to focus on the singing together, and benefits have been proven to be greater when individuals place less pressure on themselves (Grape, 2003). However, not every choir is solely focused on musical perfection or performing for an audience and, if applicable, calling a choir a choir may improve the sense of empowerment.

The songs used in the groups were described as uplifting. Though this seemed to have had an immediate positive effect, a greater variety of songs might have been even more beneficial. When considering singing for self-expression and the expression of emotions, a broader range would potentially cover more sides of participants’ experiences and possibly be cathartic in some cases.

Note from the author

My own background in singing started not many years ago. I had always hesitated to sing as I thought I wasn’t any good. Fortunately, at some point my desire to sing won out over self-criticism and I joined a choir, blushing and sweating my way through the first couple of rehearsals. It was a good thing that because of my background as a therapist I knew that anxiety can be a natural response to new situations, and that exposure is the way to get through it. So I hung in there, and the tension I felt while singing dissipated. My advice to readers: 1) Never think you can’t sing: you can learn a lot! 2) Don’t let an initial sense of discomfort keep you from doing something you might enjoy.

When I moved to the UK 5 years ago, joining a large choir greatly helped me in finding my feet and integrating in Scottish society. I can testify first-hand that singing in a choir builds friendships and connectedness, increases social identification (I now love veggie Haggis) and is a fun and exciting way to spend your free time.

My inspiration to found HarmonyChoir came from a combination of my own experiences of being in a choir, and because of discussions I had with service users about how much they benefited from their musical and singing activities. I heard their stories about feeling like an outsider to society, and about anxiety, loneliness and stigma, and wondered if an inclusive choir setting would be able to help make changes in this.

More and more evidence points to the power of building communities to improve mental health and reduce stigma. Further research is needed into the effects of similar low-cost, cross-disciplinary, art-based initiatives. These can be extremely effective in targeting social psychological processes that influence well-being and mental health.

Conflicts of interest

The author of this blog, Liesbeth Tip, is a Clinical Psychologist, PhD student at the University of Edinburgh and founder of HarmonyChoir. She started this not-for-profit community choir as a research project at the University of Edinburgh (funded by the Innovation Initiative Grant, Edinburgh Fund), to study the effects of singing in an inclusive choir on mental health, and mental health stigma (article in preparation). By popular demand, the choir is still ongoing.

The University of Edinburgh now offers a Master’s programme in ‘Health Humanities and Arts’.

Primary paper

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