The impact of relaxing music on prisoners' levels of anxiety and anger.

511587 research-article2013

IJOXXX10.1177/0306624X13511587International Journal of Offender Therapy and Comparative CriminologyBensimon et al.

Article

The Impact of Relaxing Music on Prisoners’ Levels of Anxiety and Anger

International Journal of Offender Therapy and Comparative Criminology 2015, Vol. 59(4) 406–423 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0306624X13511587 ijo.sagepub.com

Moshe Bensimon1, Tomer Einat1, and Avi Gilboa1*

Abstract Listening to relaxing music was found to reduce state anxiety and state anger among various populations. Nonetheless, the impact of relaxing music in prisons has not yet been studied. The current study examines the impact of relaxing music on levels of state anxiety and state anger among a random sample of 48 criminal prisoners. Main findings are as follows: (a) level of state anxiety decreased among the treatment group compared with the comparison group and (b) level of state anger decreased among the treatment group compared with the comparison group. Findings are discussed in light of other studies that have shown positive effects of exposure to relaxing music on levels of anxiety and anger among other populations. The final part of the study provides practical recommendations for prison administrators regarding implementation of programs of relaxing music in various prison facilities. Keywords prison, relaxing music, anxiety, anger, cultural sensitivity

Introduction Prison can be extremely stressful for inmates, be it for the composition of the inmate population who, for the most part, have already had a troubled life prior to incarceration, or the prison environment itself (Crewe, 2009). The majority of prisoners come from highly disadvantaged backgrounds (Walsh, 2006). Many are poor or homeless, undereducated or illiterate, and chronically underemployed or unemployed. Many are of poor physical and mental health and are addicted to alcohol or drugs (Borzycki & Baldry, 2003). Upon admission to prison, inmates face an anomic, violent, aggressive, *The

order of names is alphabetical. University, Ramat-Gan, Israel

1Bar-Ilan

Corresponding Author: Moshe Bensimon, Lecturer, Department of Criminology, Bar-Ilan University, Ramat-Gan, 5290002, Israel. Email: [email protected]

Downloaded from ijo.sagepub.com at The University of Hong Kong Libraries on May 9, 2015

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crowded, and noisy community (Crewe, 2011; Haney, 2006; Lawrence & Andrews, 2004; Wagner, McBride, & Crouse, 1999); various structural deprivations of freedom and deprivation of autonomy (Holman & Zeidenberg, 2006; Jewkes, 2005); and continuous humiliating trials that test their tolerance of pain, self-confidence, mental resilience, alertness, and intelligence (Castellano & Soderstrom, 1997). For these reasons, a number of studies have shown that inmates suffer from higher levels of mental and emotional distress (i.e., low self-esteem, loneliness, depression, stress, fear, anxiety, and anger) in comparison with the general population (Castellano & Soderstrom, 1997; Mills & Kroner, 2005), leading them to act out in ways that make them seem “less manageable and a greater risk to themselves and others” (Grisso, 2008, p. 151). These behaviors include, among others, increased drug abuse, self-harm, and suicide (Liebling, 2007; Palmer & Connelly, 2005). Understanding prisoners’ psychological and emotional distress and its effect on their maladaptive and criminal behaviors, particularly violent crimes in prison, are of paramount concern to correctional services (Buckaloo, Krug, & Nelson, 2009; Friedmann, Melnick, Jiang, & Hamilton, 2008; Van Harreveld, Van der Pligt, Claassen, & Van Dijk, 2007). Consequently, U.S. and European correctional services have proposed various coping measures to combat the high levels of stress and anger in prison (Cooper & Berwick, 2001; Howells, Heseltine, Sarre, Davey, & Day, 2004; Liebling & Maruna, 2005; Wagner et al., 1999) and heighten awareness of the outcomes that these emotions can generate (Howells, Watt, Hall, & Baldwin, 1997). Those coping measures include physical fitness (Hilyer & Mitchell, 1979), recreational activities (Baron & Richardson, 1994), and educational programs (Garland, 1996). However, although several studies have found that listening to relaxing music reduces state anxiety and state anger among various populations such as clinical and elderly populations (Gardiner, Furois, Tansley, & Morgan, 2000; Gerdner, 2000; Labbe´, Schmidt, Babin, & Pharr, 2007; Lou, 2001; Montello & Coons, 1998), the impact of relaxing music in the unusually stressful environment of the prison has been studied scarcely. These few studies examined music therapy effectiveness and not the impact of relaxing music on prisoners’ levels of anxiety and anger while being exposed to the music during daily activity in a non-music therapy setting. Therefore, the purpose of the current study is to examine the effect of relaxing music on prisoners’ self-reported levels of anxiety and anger, thus advancing empirical research and assisting correctional facilities in improving environmental climate for their inmates.

Anxiety and Anger Among Prisoners Theory and research on prisons and imprisonment have repetitively shown that prisons are traumatizing and extremely stressful places for inmates (e.g., Hulley, Liebling, & Crewe, 2011). Such physical and social environments have been found to be either causally or correlatively linked to high levels of mental and emotional disorders among prison inmates (e.g., James & Glaze, 2006). Surprisingly, despite the connection found between the environmental conditions in prisons and inmates’ emotional and psychological well-being and conduct (e.g., Fotiadou, Livaditis, Manou, Kaniotou, &


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Xenitidis, 2006) and despite the connection found between the prisoners’ psychological well-being and maintaining order in prison (e.g., Felson, Silver, & Remster, 2012), very few studies examined the unique interrelations between the prison’s setting, inmates’ anxiety and anger, and inmates’ physical behavior. Instead, nearly all the studies in this field have only examined the relationship between prisoners’ behavior (personality disorders, antisocial, impulsive, violent, and aggressive behavior) and the degree of their adjustment to prison, not referring to prisoners’ levels of anxiety and anger as possible causes of negative behavior (Blevins, Listwan, Cullen, & Jonson, 2010; Buckaloo et al., 2009; Komarovskaya, Loper, & Warren, 2007; Novero, Loper, & Warren, 2011; Wagner et al., 1999). The following literature review relates to the little research that has focused on anxiety and anger among prison inmates. Anxiety has been marked as one of the emotional consequences of incarceration in Western countries. Lester, Hamilton-Kirkwood, and Jones (2003) examined anxiety and depression among 117 prison inmates in Her Majesty’s Prison in Cardiff. The findings showed high prevalence (42%) of self-reported anxiety scores among the research population. Of the inmates who exhibited anxiety levels above the normal range, 16% had severe scores and 19% had moderate scores. The research concluded that anxiety among prisoners is often not identified upon arrival, that subsequent inspections in prison are often poorly conducted, and that the mental health services that prisoners receive is often inferior to the treatment available to the general population. Dudeck et al. (2011) investigated the prevalence of trauma and mental distress in a sample of 1,055 male European long-term prisoners. The research revealed high scores of anxiety that differ fundamentally from those found in the general population. Anger has also been found to be a prevalent emotional response to incarceration. Wacquant (2002) and Gusten (1977) related to the high levels of noise in prison and measured, inter alia, their impact on inmates’ levels of anger. Wacquant ethnographically analyzed the Los Angeles County Men’s Jail and emphasized its “deafening and disorienting noise” (Wacquant, 2002, p. 373). Gusten empirically examined the levels of noise in several sections of the Manhattan House of Detention and their impact on inmates’ well-being. The research findings, which revealed high levels of noise between 74 and 94 dB, led Gusten to conclude that high levels of noise correlate to high levels of anger among incarcerated populations (Gusten, 1977). Finally, Lahm (2008) and Tartaro and Levy (2007), who analyzed inmate-on-inmate assaults, inmate-on-staff assaults, and overall levels of violence and misconduct in prison, and Chemtob, Novaco, Hamada, Gross, and Smith (1997) and Novaco and Chemtob (1998), who analyzed escalation of negative behaviors such as aggression and criminality in prison, found correlations between these behaviors and levels of anger.1

The Impact of Relaxing Music on Anxiety and Anger Music has been consistently found to reduce agitation, anxiety, anger, negative thoughts, and aggression among various populations such as students (Caspy, Peleg,


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Schlam, & Goldberg, 1988); demented patients (Bright, 1986); forensic psychiatry patients (Smeijsters & Cleven, 2006); preadolescents with emotional, learning, and behavioral disorders (Montello & Coons, 1998); and hospitalized patients (Richards, Johnoson, Sparks, & Emerson, 2007). However, different types of music have different effects on people. If the aim is to relieve anxiety and reduce anger, “relaxation music” should be used. Such music is characterized by steady, slow, repetitive, and flowing rhythms at a pace that is similar to the heart rate of a relaxed person (60 to 80 beats per minute). It consists predominantly of low tones and is not perceived as loud (50 to 65 dB; Bonny, 1986; Chlan, 1998; Staum & Brotons, 2000). Relaxing music is thought to decrease the activity of the sympathetic nervous system, resulting in dampening the arousability of the central nervous system (Everly & Benson, 1989). It exerts its relaxing effect by synchronizing body rhythms with those of the musical selection (Bonny, 1986; Bunt, 1994). This process presumes that two objects that vibrate at similar frequencies will tend to interact and synchronize with one another, thereby resonating at the same frequency (Bunt, 1994). Several studies have demonstrated this effect on various populations. For instance, Labbe´ et al. (2007) found that listening to relaxing music reduced state anxiety and state anger among college students after exposure to a stressor. Other studies found similar effects in clinical and elderly populations with behavioral or cognitive disorders (Gardiner et al., 2000; Gerdner, 2000; Lou, 2001; Montello & Coons, 1998). Nilsson (2008) reviewed 42 randomized control studies that examined the degree of stress and anxiety reduction through music intervention in a preoperative setting. This systematic review shows that music intervention can indeed reduce anxiety. Therefore, it seems that music may act as an anxiolytic treatment by which experiences of anxiety are prevented or reduced (Chikahisa, Sano, Kitaoka, Miyamoto, & Sei, 2007). Some studies that examine the effect of relaxing music also relate to the timing of the music intervention and the cultural compatibility between the music and its listeners. In a study with dementia patients, Goddaer and Abrahams (1994) suggested that the relaxing music put on during mealtimes dampened the noxious background noise which was bothering the patients and triggering agitated behaviors. Thus, music had a double function: It dampened background noise which had a negative effect, while at the same time provided an auditory stimulus which had a positive relaxing effect. Cultural compatibility between music and its listeners was also a factor that was found to be significant in using relaxing music to reduce stress (Nilsson, 2008). Music can be “relaxing” due to its physical attributes and yet fail to calm the listener merely because it represents a culture with which the listener is not acquainted or is even opposed to (Nilsson, 2008). Classical music, for instance, has many relaxing pieces, yet it might be intolerable for people from cultural backgrounds where Western culture is frowned upon. Surprisingly, despite the encouraging findings that relaxing music can be effectively used to reduce stress and anger in various populations, the impact of relaxing music on a highly stressed and angry population, namely, the incarcerated population, has not yet been studied. The special make-up of the incarcerated population and the


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closed and crowded living conditions in prison generate higher levels of stress and anger in comparison with the general population, invariably leading to violent and often deadly consequences. Therefore, examining the calming effect of relaxing music on prisoners may not necessarily yield similar promising results as those found in other populations. In addition, a positive effect of relaxing music on prisoners may prove to be beneficial to correctional facilities as it may serve as an inexpensive way to reduce stress and anger in prison in comparison with other treatments.

Music in Prison Review of music therapy literature reveals that the majority of articles focus on the work of music therapists in forensic psychiatry, and only infrequent reference has been made to music therapy programs conducted within correctional facilities (Daveson & Edwards, 2001; Hoskyns, 1995). In 1979, Wardle portrayed the use of different method variations with women inmates residing in the psychiatric wing of a female prison. These methods included vocal and instrumental singing and playing, song selection, and improvisation. Ten years later, Thaut (1989) evaluated self-perceived changes in states of relaxation, mood/emotion, and thought/insight in 50 psychiatric prisoner-patients pre- and postmusic therapy. His study was conducted over a 3-month period with eight different groups of patients, with each group participating in three different treatment modalities: group music therapy, instrumental group improvisation, and music and relaxation. The findings of the research revealed significant (p < .05) change in self-perceived ratings across all scales before versus after music therapy. The magnitude of change differed significantly (p < .05) between scales. All eight groups showed similar responses, and the different treatment modalities did not significantly influence the results. In a later study, Thaut (1992) emphasized that reducing anxiety, stress, hostility, and combativeness were important goals for music therapists who work in the correctional field. He underlined that when facilitating music therapy with imprisoned people who have a psychiatric diagnosis, a means of creating and sustaining emotional and motivational ties with reality could be achieved. Finally, he encouraged the idea of using music that reflects the participant’s personal preferences for musical styles and songs. In 1994, Loth conducted a study investigating various aspects of work in a mediumsecure unit situated within a general psychiatric hospital. Her study provided information concerning the lives of individuals that access correctional facilities and insight into intra- and inter-personal dynamics and interactions that occur and combine during a music therapy program. Hoskyns (1995) examined the viewpoints of adult offenders accessing music therapy in Day Training Centers, analyzed observers’ perspectives when assessing and rating music therapy through the use of video material, and explored her own point of view as a therapist in relation to casework and developing theory. The researcher proposed that music therapy may change individuals’ self-perception and that such a


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change may positively affect these individuals’ adaptation and respond to his or her environment Finally, Daveson and Edwards (2001) investigated the role of music therapy for five women prisoners housed in minimum-, medium-, and maximum-security quarters in one women correctional facility. Analysis of the surveys that evaluated inmates’ self-report measures revealed that music therapy assisted the participants in achieving increased levels of relaxation, a reduction in stress, and an increase in self-expression. In addition, vocal recreation (i.e., singing of familiar songs) and listening to songs being sung assisted in relaxation. Finally, singing, writing songs, song parody, and listening to songs being sung were all identified by the participants as assisting in the reduction of stress and levels of anger and frustration.

The Aim of the Current Study This research examines the effect of relaxing music on male prisoners’ self-reported levels of anxiety and anger in a non-music therapy setting. The study uses relaxing musical selections that take into consideration the ethnic differences within the inmate population. This is in line with Nilsson’s (2008) recommendation that research that attempts to evaluate the effect of music on different populations should be tailored to their ethnicity. Specifically, two sub-questions and hypotheses are raised: A. Would adult male prisoners who are exposed to relaxing music in prison report significantly lower anxiety values in comparison to adult male prisoners who are not exposed to such music? Based on the above-mentioned literature that has studied the impact of relaxing music on levels of anxiety among various populations, we hypothesize that exposure of adult male inmates to relaxing music in prison will provide significantly lower anxiety values in comparison to adult male prisoners who are not exposed to such music. B. Would adult male prisoners who are exposed to relaxing music in prison report significantly lower anger values in comparison to adult male prisoners who are not exposed to such music? Based on the above-mentioned literature that shows that relaxing music reduces levels of anger among various populations, we hypothesize that exposure of adult male inmates to relaxing music in prison will provide significantly lower anger values in comparison with adult male prisoners who are not exposed to such music.

Method Participants Forty-eight male adult prisoners from the Ela medium-security prison facility in Israel took part in this study. Of the prison wings, two were chosen for the study since they both house prisoners sentenced to a maximum of 7 years. They share the following


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Table 1. Demographic Data—Comparison Between Treatment and Comparison Groups.

No. of participants Age Prison sentence Time served Cultural background Immigration Religion

Religiosity

Treatment group (Wing 1)

Comparison group (Wing 2)

Statistical comparison

24 29.8 (SD = 6.8) 20.3 (SD = 12.6) 16.8 (SD = 11.8)

24 31.1 (SD = 9.2) 18.8 (SD = 12.1) 15.3 (SD = 9.8)

t(42) = 0.51, p > .05 t(35) = 0.71, p > .05 t(32) = 0.71, p > .05

5 immigrants 19 non-immigrants 8 Jews 14 Muslims 2 Christians 5 religious 16 non-religious

3 immigrants 21 non-immigrants 12 Jews 9 Muslims 0 Christians 4 religious 16 non-religious

χ2(1) = 0.45, p > .05 χ2(2) = 3.7, p > .05

χ2(1) = 0.01, p > .05

Note. Demographic questions were not fully answered by participants, hence the different degrees of freedom for different demographic variables.

criteria: average length of imprisonment, criminal background, number of inmates per wing (n = 100), number of inmates per cell (n = 2), and identical daily routine. Furthermore, it should be emphasized that the distribution of prisoners between these two wings by the Israel Prison Service (IPS) is absolutely random. Twenty-four prisoners were chosen from Wing 1 and 24 prisoners from Wing 2. Since both wings housed similar populations and were exactly the same architecturally, we designated arbitrarily Wing 1 to be the experimental group and Wing 2 to be the control group for this study. Table 1 shows the similarity of these wings regarding various demographic variables. In both wings, the participants’ age, prison sentence, and prison time served were not statistically different. In addition, prisoners in both wings were similar in their cultural composition: a majority of non-immigrants (79% in Wing 1 and 88% in Wing 2), a mixture of Jews (33% vs. 57%) and Muslims (58% vs. 43%), a low percentage of Christians (8% vs. 0%), and a minority of strictly observant religious prisoners (24% vs. 20%). Table 1 also shows that prisoners in both sections were sentenced to a similar length of prison sentence (M = 20.3 months for the treatment group vs. M = 18.8 months for the comparison group) and that they served a similar length of prison sentence (M = 16.8 months for the treatment group vs. M = 15.3 months for the comparison group).

Tools State-Trait Anxiety Inventory (STAI). The STAI (Spielberger, 1983) is a 40-item selfreport questionnaire that measures anxiety. Twenty of the 40 items ask the respondents to rate how their feelings are “at the moment”; these items make up the State Anxiety Scale. The other 20 items ask the respondents to rate how they “generally” feel; these items make up the Trait Anxiety Scale. The state anxiety items are measured on a Likert scale of values from 1 to 4, where 1 indicates “not at all” and 4 indicates “very


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much.” The trait anxiety items are measured on a similar 4-point Likert scale of values from 1 to 4, where 1 indicates “almost never” and 4 indicates “almost always.” High scores indicate greater levels of anxiety for both scales. Spielberger (1983) reported test-retest stability of trait anxiety among male and female college students over a 104day period to be .73 and .77, respectively. In this study, the Hebrew version of STAI was used for the participants’ convenience. The Hebrew version of the STAI shows high Cronbach’s internal consistency coefficients: α = .90 for men and women (Teichman & Malinek, 1985). The same level of internal reliability was found in the current sample (α = .90). State-Trait Anger Expression Inventory (STAXI). The STAXI (Spielberger, 1988) is a 44-item, self-report instrument comprised of three subscales. The first subscale consists of 10 items that relate to state anger (the emotional intensity of anger in a specific situation). The second subscale consists of 10 items that relate to trait-anger (the individual’s disposition to experience anger habitually). The third subscale consists of 24 items that relate to the form of expressing anger (anger extroversion, anger introversion, and anger control). The anger levels were measured on a Likert scale of values from 1 to 4, where 1 indicated “almost never” and 4 indicated “almost always,” with higher scores indicating greater rates of anger. Cronbach’s alphas in various samples ranged from 0.81 to 0.91 (Spielberger, 1988). In this study, the Hebrew version of STAXI was used for the participants’ convenience. The internal reliability of the Hebrew versions of State Anger, Trait Anger, and Anger Expression scales were found to be .91, .65, and .71, respectively (Zamir-Katzir, 2002). Similar levels of reliability were found in the current sample as well: Cronbach’s αs were .92, .78, and .68 respectively. Personal Background Questionnaire. This questionnaire consists of demographic questions, including age, religion, criminal history, incarceration history, length of prison sentence, and length of time served. Musical background. Selection of the musical pieces was done according to the following criteria: (1) tempo of 60 to 80 beats per minute, (2) loudness of 50 dB to 60 dB, and (3) the music was in cultural accordance with the participants’ background. To achieve this, we conducted a pre-test in which we exposed 63 prisoners from a similar cultural background but from a different prison facility to 1-min musical excerpts taken from nine CDs, each representing a different type of relaxing music (see the appendix for details). To avoid order effect, four different random sequences were used. After listening to each excerpt, the prisoners were asked to rate its ability to calm people down on a scale where 1 indicates “not at all” and 7 indicates “very much.” The five excerpts whose scores were higher than the median score (X > 4) were determined to be “relaxing,” and musical pieces from the CDs from which the excerpts were taken were then used in the study. Cultural accordance between the participants’ background and the musical contents of the CDs were guaranteed because the cultural background of the pre-test prisoners and the participants was similar.


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Procedure and Research Design An approval to conduct the research at the “Ela” prison was received from the Research Authority of IPS, the Israeli Police and Prison Service Ombudsman, and the Ethics Review Board of the Department of Criminology at Bar-Ilan University. Following this approval, the researchers met with the prison warden at the prison facility. During this initial meeting, the researchers described the type and purpose of the project and requested the warden’s assistance in choosing the two most appropriate prison wings for the study (i.e., as similar as possible in architecture, number of inmates, types of offenses, and length of imprisonment). The researchers received full cooperation from the warden and then met with the officers of the two wings that were designated for the study. Over the course of the following week, two researchers met with all the Israeli Prison Service officers working in the two chosen prison wings at the prison facility, explained the nature and objectives of the study, and requested their assistance. In the week that followed, a third researcher, together with Bar-Ilan University’s music department technician and the head of the “Ela” Prison logistic department, prepared and installed all the relevant musical equipment in Wing 1. At that stage, participants were not apprised of the aim of the research in order to avoid bias. Upon filling out the questionnaires, they were told that the aim of the research was to examine their feelings in prison. The aim of the study was only revealed after its completion. The design of the study was quasi-experimental. The treatment group (Wing 1) was exposed to three consecutive weeks of music while the comparison group (Wing 2) was not exposed to music. Measurements were taken at four different time-points: a baseline measurement was taken one week prior to the 3-week exposure to music, two measurements were taken during the 3-week exposure to music (one at the end of the first week and one at the end of the third week), and one post-manipulation measurement was taken 1 week following the 3-week exposure to music. Each measurement included the state anxiety questionnaire and the state anger questionnaire. The questionnaires were distributed while the music was playing. In the baseline measurement, prisoners also answered the trait-anxiety and the trait-anger questionnaires and the personal background questionnaire. Translators from Hebrew to Arabic, Russian, and English assisted whenever needed. The process of filling in the questionnaires lasted 30 min in the baseline measurement and 10 min in the following three measurements. During the three weeks of exposure to music, music was played on a daily basis. Six CDs were compiled, each designated for 1 day of the week (not including Saturday, a holyday for religious Jews in which music is not played). The music in each day was played in a different order. Music was played on a Sony CDP-315, with an amplifier of the model 3240PE Integrated Amplifier (NAD Electronics), and two Sony loudspeakers. Music interventions were delivered using loudspeakers that were suspended from the ceiling above the guard’s position at 2.5 meters height. In Nilsson’s (2008) extensive review of randomized control studies on stress and anxiety, it was suggested that music be played for durations of at least 30 min at a time. Accordingly, a 45-min disk was played from beginning to end three times a day at the public area of the wing: during breakfast (08:00-08:45), lunch (13:00-13:45), and


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Table 2. Trait Anxiety and Trait Anger of Treatment Group Compared With Comparison Group.

Trait anxiety Trait anger—general Trait anger—habitual Trait anger—extroversion Trait anger—introversion Trait anger—control

Treatment group (Wing 1)

Comparison group (Wing 2)

Statistical comparison

2.24 (SD = 0.44) 2.25 (SD = 0.41) 2.17 (SD = 0.24) 2.00 (SD = 0.42) 2.20 (SD = 0.48) 2.30 (SD = 0.62)

2.19 (SD = 0.60) 2.08 (SD = 0.60) 2.06 (SD = 0.39) 1.89 (SD = 0.51) 2.22 (SD = 0.42) 2.06 (SD = 0.69)

t(46) = 0.34, p > .05 t(47) = 1.16, p > .05 t(47) = 1.21, p > .05 t(47) = 0.78, p > .05 t(47) = −0.15, p > .05 t(47) = 1.28, p > .05

dinner (17:00-17:45) hours. Thus, throughout the experiment, prisoners were exposed to 45 (minutes) × 3 (times a day) × 18 (days in three weeks) minutes of relaxing music (=40.5 hr). The comparison group was not exposed to music during that period but answered the same questionnaires at the same time points as the prisoners in the treatment group. Confidentiality of the participants was ensured, and all participants signed an official informed consent form. This agreement included a statement from the participants declaring their voluntary agreement to participate in the study and acknowledging that they may withdraw from the study at any time.

Results Treatment and comparison groups were first compared regarding their trait measures. As can be seen in Table 2, there were no significant differences between the two groups at baseline on all trait measures, namely trait anxiety, and four sub-measures of trait anger (habitual anger expression, anger control, anger extroversion, and anger introversion). Therefore, further comparison between the groups was possible. In addition, state variables were used as covariates in further analyses. Trait anxiety served as a covariate when comparing the two groups on their state anxiety and the four submeasures of trait anger served as covariates when comparing the two groups regarding state anger. Little’s missing completely at random (MCAR) test revealed that there were no significant differences between participants who had missing data and those who did not, χ2(13) = 12.62, p > .05, indicating that data were MCAR. Missing data were, therefore, imputed, using SPSS’s expectation maximization (EM) option. Table 3 shows the changes from the baseline measurement for each of the following measurements: 1 week into manipulation, 3 weeks into manipulation, and 1 week following manipulation. Change was calculated for each participant by subtracting each of the measurements from the baseline. Change of state anxiety measurements was compared between treatment and comparison groups using ANCOVA entering trait anxiety as a covariate. Change of state anger measurements was compared between treatment and comparison groups using ANCOVA, entering the four submeasures of trait anger (anger—habitual, anger—extroversion, anger—introversion,


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and anger—control) as covariates. As can be seen, state anxiety measurements changed substantially from baseline for the treatment group but not for the comparison group after 1 week of manipulation. The change was maintained at 3 weeks into manipulation and remained substantial and significantly different from the comparison group 1 week following manipulation, when music was not played to the participants. State anger measurements decreased moderately from baseline for treatment group but not for comparison group. The difference between the groups was not significant 1 week into manipulation but was significant 3 weeks into manipulation. Upon elimination of the music at the end of the manipulation, the effect on the state of anger that had been achieved 3 weeks into manipulation, rescinded.

Discussion The goal of the present study was to examine the effect of relaxing music on prisoners’ self-reported levels of anxiety (Hypothesis 1) and anger (Hypothesis 2). Changes from baseline for state anxiety and state anger were measured 1 week into manipulation, 3 weeks into manipulation, and 1 week following manipulation. Findings regarding state anxiety are in line with our first hypothesis. State anxiety measurements changed substantially from baseline for treatment group but not for comparison group. This is in line with former studies showing a decrease in anxiety following exposure to relaxing music, for example, in hospitalized patients in perioperative settings (Nilsson, 2008; Smolen, Topp, & Singer, 2002), in staff members and residents from a chemical dependency/alcoholism unit (Hammer, 1996), and in college students (Labbe´ et al., 2007). The effect of the music on the prisoners did not fade out as time passed and remained substantial and significantly different from the comparison group even 1 week following manipulation, when music was no longer played to the prisoners. This indicates a possible carryover effect of the calming music on the prisoners’ state of anxiety. Hence, whereas past studies measured the effect of music on anxiety only immediately following the end of the music exposure (e.g., Haun, Mainous, & Looney, 2001; Labbe´ et al., 2007), the current study is, to our best knowledge, the first to measure state anxiety 1 week following manipulation. This indicates that music may have a longer lasting effect on decreasing state anxiety than what was previously found. However, additional research is required to substantiate this assumption with other populations. Findings regarding state anger are generally in line with our second hypothesis, which is in accordance with other studies showing a decrease in anger following exposure to relaxing music, for example, in people with dementia (Gardiner et al., 2000; Gerdner, 2000; Lou, 2001); in preadolescents with emotional, learning, and behavioral disorders (Montello & Coons, 1998); in forensic psychiatric patients (Smeijsters & Cleven, 2006); and in college students (Labbe´ et al., 2007). However, the change of state anger in our research was moderate. There was a decrease in state anger among prisoners in the treatment group but less so in the comparison group. The difference


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M (SD)

1.90 (0.62) −0.41

2.49 (1, 36)a .12 1.87 (0.58) 1.60 (0.47)

−0.24 −0.57

M (SD)

−0.31 [−0.44, −0.18]

p

−0.06 −0.50

ANCOVA (df)

−0.16 [−0.28, −0.04] 10.74*** (1, 44) .002 2.19 (0.55) 2.18 (0.38)

Mean difference (95% CI)

Change from baseline mean ANCOVA (df) p

M (SD)

−0.40 [−0.56, −0.24]

4.22* (1, 36)a

.047 2.02 (0.76) 1.82 (0.54)

−0.27 [−0.42, −0.12] 11.60*** (1, 44) .001 2.38 (0.63) 2.34 (0.44)


3 weeks into manipulation

−0.08 −0.35

0.13 −0.34

Change from baseline mean

ANCOVA (df)

p

−0.21 [−0.44, 0.01]

1.46 (1, 36) .23

−0.11 [−0.26, 0.04] 11.71*** (1, 44) .001


1 week follow-up

aSix participants, three from the treatment group and three from the comparison group, were excluded from the state-anger analyses due to their response set bias (they answered 1 = almost never, to all questions). *p < .05. **p < .01. ***p < .001.

Treatment

State anxiety Comparison 2.28 (0.66) 0.03 Treatment 2.34 (0.47) −0.34 State anger Comparison 1.76 (0.57) −0.20

Outcome

Change from baseline mean

1 week into manipulation

Table 3. State-Anxiety and State-Anger Measurement Changes From Baseline to 1 Week Into Manipulation, 3 Weeks into Manipulation, and 1 Week Following Manipulation for Treatment and Comparison Groups.

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between the two groups was not significant 1 week into manipulation but was 3 weeks into manipulation. State-anger-reduction effects of music were not only slow to show an effect but were also quick to fade out as suggested by the fact that there was no evident change 1 week following manipulation. Why there should be differences in the impact of music on prisoners’ state anxiety and not on prisoners’ state anger is an intriguing question that awaits further investigation. A similar discrepancy was found in Labbe´ et al.’s (2007) research, which too found that non-selected music had a better impact on college students’ (N = 56) state anxiety in comparison to their state anger. A partial explanation to this difference is that anger, unlike anxiety, is reduced if there is a perception of control and a perceived ability to overcome a stressor (e.g., Smith, Adelman, Nelson, & Taylor, 1988). Regarding the current findings, it may be that the music became familiar and expected only by the third week of exposure. Only then could the participants have perceived control over the situation and used the music to combat their anger levels. In conclusion, this study does not merely add evidence to the claim that relaxing music alleviates anxiety and anger in different settings and with various populations. The unique contribution of this study is that relaxing music can actually affect one of the most problematic and tenuous environments that society has constructed, namely, the prison. Moreover, this is the first study showing that this effect can last 1 week post-music in decreasing state anxiety. These findings are very encouraging in that they can help maximize the efforts to enable a calmer atmosphere in the violent and tensed environment of the prison. We believe that adding music to the prisoners’ auditory space can improve prison atmosphere and assist prison administrators in maintaining order. Relaxing music can be used as an audio-anxiolytic tool and an integral part of the multimodal regimen of inmates. Therefore, relaxing music in prisons should be considered by jail policy makers. It is an inexpensive technique that does not require extra staff members or expensive equipment. There are, however, some pitfalls that should be addressed and further researched before using relaxing music effectively in prisons. First and most important is the process of choosing the playlist. This must be done with great caution so as to avoid choosing music that might be perceived offensive or terribly “bad” by inmates, thus causing resistance to the music, and subsequently, a rise in anxiety and anger levels. In the present research, the process of choosing the playlist was systematic and required a separate sample of prisoners. We believe that skipping this phase might have resulted in a problematic playlist that would have in turn shown no effect or even a negative effect on anxiety and anger levels. The second possible pitfall is connected to the first but specifically refers to the cultural issue. Relaxing music is not relaxing only due to tempo and intensity but also due to its cultural implications. Therefore, the cultural background of the prisoners must be determined, and the choice of music must be oriented to that background. In the current study, participants came from three different cultural backgrounds, and the music that we chose was acceptable to all of them. Third, it is important to be attuned to the most suitable length of time in which music is played to prisoners and to its most suitable timing. Too much exposure to music may


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be perceived as a nuisance and cause a negative counter-effect while too little exposure to music may not be noticed. In the present study, music was played three times a day, 45 min each time. The results seem to indicate that a good balance between too much and too little music was achieved. However, this still awaits a systematic examination. Timing is also crucial. There are times in the prison schedule when relaxing music is fitting as background music while there are times when music can interfere with important activities (e.g., watching TV and speaking on the phone). In the current study, some participants complained that there were times when the music interfered with such activities. Further research is, therefore, recommended in order to determine appropriate and inappropriate times for implementing the relaxing music procedure. Further research can address the limitations of the present study that needs replication and validation. We suggest to examine state anxiety and state anger with a larger sample and with varied sub-populations in prisons (e.g., women prisoners and highsecurity prisoners); employ a larger playlist to enable a more varied musical experience; administer measurements not only while the music is being played but also one hour later in order to check short-term effects; and try to minimize the number of measurement items to simplify the procedure (e.g., reduce state anxiety questionnaire to six items, see Marteau & Bekker, 1992). In addition, the impact of relaxing music should also be investigated 1 month or even longer following manipulation to check longer term effects. Finally, a qualitative research should conduct interviews with inmates to more deeply understand the experience of being exposed to relaxing music on a daily basis in prison.

Appendix List of CDs Played in the Pre-Test 1. Hussan, Z. (1987). Making music. On Making music [CD]. Germany: ECM Records. 2. Winter, P. (1988). For the beauty of the world. On Wolf eyes [CD]. Omaha: American Gramophone Records. 3. Jenkins, K. (1999). Adiemus. On Adiemus—songs of sanctuary [CD]. London: Virgin Records. 4. Turkish meditations music. From the Internet: http://www.youtube.com/watch ?v=0AQ1EbFme4k&feature=fvsr 5. Ajad, S. A. (1994). Reiki music vol. 2. [CD]. Austria: High Tide Srl. 6. Elbaz, A. (1992). Heart to heart talk with birds. On Shoshanat HaRuchot (Compass Rose) [CD]. Israel: N.M.C. Music. 7. Dalacija (Ansnble Dalacija—Dalmatian songs). 8. Ryan, R. (1991). Shepherd Moons. On Enya—Shepherd Moons [CD]. Israel: C.D.I. 9. Kedem Band. (1999). Shabbat Chatan (Bridegroom’s Saturday). Jerusalem: Creative Audio. Note. CDs in bold were chosen to be used in the experiment.


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Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

Note 1. Nonetheless, it should be stated that anger often leads to various forms of behavior that may assist individuals in letting off steam. Thus, for example, aggressive behavior may actually help inmates in defending themselves against psychological harm and preserving their self-esteem (Day, Howells, & Casey, 2003).

References Baron, R. A., & Richardson, D. R. (1994). Human aggression (2nd ed.). New York, NY: Plenum. Blevins, K. R., Listwan, S. J., Cullen, F. T., & Jonson, C. L. (2010). A general strain theory of prison violence and misconduct: An integrated model of inmate behavior. Journal of Contemporary Criminal Justice, 26, 148-166. Bonny, H. (1986). Music and healing. Music Therapy, 6, 3-12. Borzycki, M., & Baldry, E. (2003). Promoting integration: The provision of prisoner postrelease service. Canberra, Australia: Australian Institute of Criminology. Bright, R. (1986). The use of music therapy and activities with demented patients who are deemed “difficult to manage.” The elderly uncooperative patient [Special issue]. Clinical Gerontologist, 6, 131-144. Buckaloo, B. J., Krug, K., & Nelson, K. (2009). Exercise and the low security inmate: Changes in depression, stress, and anxiety. The Prison Journal, 89, 328-343. Bunt, L. (1994). Music therapy: An art beyond words. London, England: Routledge. Caspy, T., Peleg, E., Schlam, D., & Goldberg, J. (1988). Sedative and stimulative music effects: Differential effects on performance impairment following frustration. Motivation and Emotion, 12, 123-138. Castellano, T. C., & Soderstrom, I. R. (1997). Self-esteem, depression and anxiety evidenced by a prison inmate sample: Interrelationships and consequences for prison programming. The Prison Journal, 77, 259-280. Chemtob, C. M., Novaco, R. W., Hamada, R. S., Gross, D. M., & Smith, G. A. (1997). Anger regulation deficits in combat-related post-traumatic stress disorder. Journal of Traumatic Stress, 10, 17-36. Chikahisa, S., Sano, A., Kitaoka, K., Miyamoto, K. I., & Sei, H. (2007). Anxiolytic effect of music depends on ovarian steroid in female mice. Behavioural Brain Research, 179, 50-59. Chlan, L. (1998). Effectiveness of a music therapy intervention on relaxation and anxiety for patients receiving ventilatory assistance. Heart and Lung, 27, 169-176. Cooper, C., & Berwick, S. (2001). Factors affecting psychological well-being of three groups of suicide prone prisoners. Current Psychology, 20, 169-182.


421

Bensimon et al.

Crewe, B. (2009). Power, adaptation, and the social world of an English prison. Oxford, UK: Oxford University Press. Crewe, B. (2011). Depth, weight, tightness: Revisiting the pains of imprisonment. Punishment and Society, 13, 509-529. Daveson, B. A., & Edwards, J. (2001). A descriptive study exploring the role of music therapy in prisons. The Arts in Psychotherapy, 28, 137-141. Day, A., Howells, K., & Casey, S. (2003). The rehabilitation of indigenous prisoners: An Australian perspective. Journal of Ethnicity in Criminal Justice, 1, 115-133. Dudeck, M., Drenkhahn, K., Spitzer, C., Barnow, S., Kopp, D., Kuwert, P., . . .Dünkel, F. (2011). Traumatization and mental distress in long-term prisoners in Europe. Punishment & Society, 13, 403-423. Everly, G., & Benson, H. (1989). Disorders of arousal and the relaxation response: Speculations on the nature and treatment of stress-related diseases. International Journal of Psychosomatics, 36, 15-21. Felson, R., Silver, E., & Remster, B. (2012). Mental disorder and offending in prison. Criminal Justice and Behavior, 39, 125-143. Fotiadou, M., Livaditis, M., Manou, I., Kaniotou, E., & Xenitidis, K. (2006). Prevalence of mental disorders and deliberate self-harm in Greek male prisoners. International Journal of Law and Psychiatry, 29, 68-73. Friedmann, P. D., Melnick, G., Jiang, L., & Hamilton, Z. (2008). Violent and disruptive behavior among drug-involved prisoners: Relationship with psychiatric symptoms. Behavioral Sciences and the Law, 26, 389-401. Gardiner, J. C., Furois, M., Tansley, D. P., & Morgan, B. (2000). Music therapy and reading as intervention strategies for disruptive behavior in Dementia. Clinical Gerontologist, 22, 31-46. Garland, D. (1996). The limits of the sovereign state. British Journal of Criminology, 36, 445-471. Gerdner, L. (2000). Music, art, and recreational therapies in the treatment of behavioral and psychological symptoms of dementia. International Psychogeriatrics, 12, 359-366. Goddaer, J., & Abraham, I. L. (1994). Effects of relaxing music on agitation during meals among nursing home residents with severe cognitive impairment. Archives of Psychiatric Nursing, 8, 150-158. Grisso, T. (2008). Adolescent offenders with mental disorders. The Future of Children, 18, 143-164. Gusten, R. (1977). Noise in jails: The constitutional issues. Washington, DC: National Clearinghouse for Criminal Justice Planning. Hammer, S. E. (1996). The effects of guided imagery through music on state and trait anxiety. Journal of Music Therapy, 33, 47-70. Haney, C. (2006). The wages of prison overcrowding: Harmful psychological consequences and dysfunctional correctional reactions. Journal of Law and Policy, 22, 265-293. Haun, M., Mainous, R. O., & Looney, S. W. (2001). Effect of music on anxiety of women awaiting breast biopsy. Behavioral Medicine, 27, 127-132. Hilyer, J., & Mitchell, W. (1979). Effect of systematic physical fitness training combined with counseling on the self-concept of college students. Journal of Counseling Psychology, 26, 427-436. Holman, B., & Zeidenberg, J. (2006). The dangers of detention: The impact of incarcerating youth in detention and other secure facilities. Justice Policy Institute. Available from http:// www.justicepolicy.org.


422


Hoskyns, S. L. (1995). The use of simple ratings scales to assess changes in activity during group music therapy. In A. Gilroy & C. Lee (Eds.), Art and music: Therapy and research (pp. 138-151). London, England: Routledge. Howells, K., Heseltine, K., Sarre, R., Davey, L., & Day, A. (2004). Correctional offender rehabilitation programs: The national picture in Australia. Canberra, Australia: Criminology Research Council. Retrieved from http://www.criminologyresearchcouncil.gov.au/ reports/200203-04.html Howells, K., Watt, B., Hall, G., & Baldwin, S. (1997). Developing programs for violent offenders. Legal and Criminological Psychology, 2, 117-128. Hulley, S., Liebling, A., & Crewe, B. (2011). Respect in prison: Prisoners’ experiences of respect in public and private sector prisons. Criminology and Criminal Justice, 12, 3-23. James, D., & Glaze, L. (2006). Mental health problems of prison and jail inmates. Bureau of justice statistics. Washington, DC: US Department of Justice. Jewkes, Y. (2005). Men behind bars: “Doing” masculinity as an adaptation to imprisonment. Men and Masculinities Journal, 8, 44-63. Komarovskaya, I., Loper, A., & Warren, J. (2007). The role of impulsivity in antisocial and violent behavior and personality disorders among incarcerated women. Criminal Justice and Behavior, 34, 1499-1515. Labbe´, E., Schmidt, N., Babin, J., & Pharr, M. (2007). Coping with stress: The effectiveness of different types of music. Applied Psychophysiology and Biofeedback, 32, 163-168. Lahm, K. F. (2008). Inmate-on-inmate assault: A multilevel examination of prison violence. Criminal Justice and Behavior, 35, 120-137. Lawrence, C., & Andrews, K. (2004). The influence of perceived prison crowding on male inmates’ perception of aggressive events. Aggressive Behavior, 30, 273-283. Lester, C., Hamilton-Kirkwood, L., & Jones, N. K. (2003). Health indicators in a prison population: Asking prisoners. Health Education Journal, 62, 341-349. Liebling, A. (2007). Prison suicide and its prevention. In Y. Jewkes (Ed.), Handbook on prisons (pp. 423-446). Cullompton, UK: Willan. Liebling, A., & Maruna, S. (Eds.). (2005). The effects of imprisonment. Portland, OR: Willan Publishing. Loth, H. (1994). Music therapy and forensic psychiatry—choice, denial and the law. Journal of British Music Therapy, 8, 10-18. Lou, M. F. (2001). The use of music to decrease agitated behaviour of the demented elderly: The state of the science. Scandinavian Journal of Caring Sciences, 15, 165-173. Marteau, T. M., & Bekker, H. (1992). The development of a six-item short-form of the State Scale of the Spielberger State—Trait Anxiety Inventory (STAI). British Journal of Clinical Psychology, 31, 301-306. Mills, J. F., & Kroner, D. G. (2005). Screening for suicide risk factors in prison inmates: Evaluating the efficiency of the depression, hopelessness and suicide screening form (DHS). Legal and Criminological Psychology, 10, 1-12. Montello, L. M., & Coons, E. E. (1998). Effects of active versus passive group music therapy on preadolescents with emotional, learning, and behavioral disorders. Journal of Music Therapy, 35, 49-67. Nilsson, U. (2008). The anxiety- and pain-reducing effects of music interventions: A systematic review. Association of PeriOperative Registered Nurses Journal, 87, 780-807. Novaco, R. W., & Chemtob, C. M. (1998). Anger and trauma: Conceptualization, assessment, and treatment. In V. M. Follette, J. I. Ruzek, & F. R. Abueg (Eds.), Cognitive-behavioral therapies for trauma (pp. 162-190). New York, NY: Guilford Press.


423

Bensimon et al.

Novero, C., Loper, A., & Warren, J. (2011). Second-generation prisoners: Adjustment patterns for inmates with a history of parental incarceration. Criminal Justice and Behavior, 38, 761-778. Palmer, E. J., & Connelly, R. (2005). Depression, hopelessness and suicide ideation among vulnerable prisoners. Criminal Behavior and Mental Health, 15, 164-170. Richards, T., Johnoson, J., Sparks, A., & Emerson, H. (2007). The effect of music therapy on patients’ perception and manifestation of pain, anxiety, and patient satisfaction. Medsurg Nursing, 16, 7-13. Smeijsters, H., & Cleven, G. (2006). The treatment of aggression using arts therapies in forensic psychiatry: Results of a qualitative inquiry. The Arts in Psychotherapy, 33, 37-58. Smith, D. C., Adelman, H. S., Nelson, P., & Taylor, L. (1988). Anger perceived and control school behavior among students with learning problems. Journal of Child Psychology and Psychiatry, 29, 517-522. Smolen, D., Topp, R., & Singer, L. (2002). The effect of self-selected music during colonoscopy on anxiety, heart rate, and blood pressure. Applied Nursing Research, 15, 126-136. Spielberger, C. D. (1983). Manual for the State-Trait Anxiety Inventory: STAI. Palo Alto, CA: Consulting Psychologists Press. Spielberger, C. D. (1988). Manual for the State-Trait Anger Expression Inventory (STAXI). Odessa, FL: Psychological Assessment Resources. Staum, M. J., & Brotons, M. (2000). The effect of music amplitude on the relaxation response. Journal of Music Therapy, 37, 22-39. Tartaro, C., & Levy, M. (2007). Density, inmate assaults, and direct supervision jails. Criminal Justice Policy Review, 18, 395-417. Teichman, Y., & Malinek, H. (1985). State-Trait Anxiety Questionnaire, translation and modification to Hebrew. Tel Aviv, Israel: Department of Psychology, Tel Aviv University. Thaut, M. H. (1989). The influence of music therapy interventions on self-rated changes in relaxation, affect, and thought in psychiatric prisoner-patients. Journal of Music Therapy, 26, 155-166. Thaut, M. H. (1992). Music therapy in correctional psychiatry. In W. Davies, K. Gfeller, & M. Thaut (Eds.), An introduction to music therapy: Theory and practice (pp. 273-284). Dubuque, IA: William C. Brown Publishers. Van Harreveld, F., Van der Pligt, J., Claassen, L., & Van Dijk, W. W. (2007). Inmate emotion coping and psychological and physical well-being: The use of crying over spilled milk. Criminal Justice and Behavior, 34, 697-708. Wacquant, L. (2002). The curious eclipse of prison ethnography in the age of mass incarceration. Ethnography, 3, 371-397. Wagner, M., McBride, R. E., & Crouse, S. F. (1999). The effects of weight-training exercise on aggression variables in adult male inmates. The Prison Journal, 79, 72-89. Walsh, T. (2006). Is corrections correcting? An examination of prisoner rehabilitation policy and practice in Queensland. Australian and New-Zealand Journal of Criminology, 39, 109-133. Wardle, M. (1979). Music therapy in a women’s prison. Part 1: The old prison. British Journal of Music Therapy, 10, 11-14. Zamir-Katzir, A. (2002). Adolescents who murder: A character profile and risk factors of violence directed outward in comparison to property offenders (in Hebrew, English abstract) (Unpublished master’s thesis). Bar-Ilan University, Ramat Gan, Israel.


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