Group singing fosters mental health and wellbeing: Findings from the East Kent "singing for health" network project

Abstract

Purpose
This paper aims to describe the development and evaluation of an innovative community singing initiative with mental health services users and supporters in East Kent, UK.

Design/methodology/approach
A network of seven singing groups was established between September 2009 and June 2010. The choirs met weekly in three terms with breaks for Christmas and Easter, and joined together for two public performances in February and June 2010. In total, 137 participants were involved in the evaluation processes over this period. Of these, 42 provided complete data on the CORE questionnaire, a widely used clinical measure of mental distress, at baseline and eight months later.

Findings
Clinically significant improvements were observed in response to the CORE. These changes, together with qualitative feedback from participants, demonstrate that group singing can have substantial benefits in aiding the recovery of people with a history of serious and enduring mental health problems. A limited body of research has also shown that singing can be helpful for people with existing mental and physical health problems.

Originality/value
The research finds marked improvements in mental wellbeing on a clinically validated measure for people with a range of enduring mental health issues participating in a network of small choirs. Qualitative evidence indicates that group singing can offer a wide range of emotional and social benefits for mental health service users.

Full text

Arts
Group singing fosters mental health and
wellbeing: findings from the East Kent
‘‘singing for health’’ network project
Stephen Clift and Ian Morrison
Abstract
Purpose – This paper aims to describe the development and evaluation of an innovative community
singing initiative with mental health services users and supporters in East Kent, UK.
Design/methodology/approach – A network of seven singing groups was established between
September 2009 and June 2010. The choirs met weekly in three terms with breaks for Christmas and Easter,
and joined together for two public performances in February and June 2010. In total, 137 participants were
involved in the evaluation processes over this period. Of these, 42 provided complete data on the CORE
questionnaire, a widely used clinical measure of mental distress, at baseline and eight months later.
Findings – Clinically significant improvements were observed in response to the CORE. These
changes, together with qualitative feedback from participants, demonstrate that group singing can have
substantial benefits in aiding the recovery of people with a history of serious and enduring mental health
problems. A limited body of research has also shown that singing can be helpful for people with existing
mental and physical health problems.
Originality/value – The research finds marked improvements in mental wellbeing on a clinically
validated measure for people with a range of enduring mental health issues participating in a network of
small choirs. Qualitative evidence indicates that group singing can offer a wide range of emotional and
social benefits for mental health service users.
Keywords Mental illness, Group singing, Recovery, Well being, Evaluation
Paper type Research paper
Background
This paper reports on the development and evaluation of an innovative community singing
project in which a network of small choirs for mental health service users and supporters was
established in East Kent in September 2009 and ran until June 2010. Inspiration for the
project came from a small choir established in September 2007 at the Mustard Seed Centre
in Canterbury (a day centre providing services of people in need of support). The choir was
set up in late 2007 up by Elle Caldon, a service user with training in music and singing, and
came to be known as the ‘‘Mustard Seed Singers’’ (Plate 1). An account of the development
of this choir, and two other mental health singing groups in other parts of England co-written
by service users, musicians and researchers has recently appeared in a fascinating volume
entitled Songs of Resilience (Clift et al., 2011).
The present authors joined the ‘‘Mustard Seed Singers’’ in early 2008, and over the year had
discussions with Elle, other members of the choir and local mental health professionals
about the idea of promoting similar choirs across East Kent. We were fortunate to obtain
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Stephen Clift is a Professor
of Health Education and
Research Director.
Ian Morrison is a Senior
Researcher both at the
Sidney De Haan Research
Centre for Arts and Health,
Canterbury Christ Church
University, Canterbury, UK.
Thanks are due to Canterbury
Christ Church University,
Eastern and Coastal Kent
Primary Care Trust, the Roger
De Haan Charitable Trust, and
the South East Coastal
Communities Project for
funding and support which
made the East Kent ‘‘singing for
health’’ project possible.

funding from the Eastern and Coastal Kent Primary Care Trust and the South East Coastal
Communities Project (a Higher Education Funding Council England initiative) to do this. The
‘‘Mustard Seed Singers’’ played a key role in setting up the project, by giving performances
and running workshops in community venues providing support for mental health service
users. Practical assistance was also provided by East Kent health professionals in
occupational therapy and mental health promotion services, and staff of mental health day
services. A total of seven new choirs were established and these met for weekly rehearsals in
community centres for three terms under the direction of facilitators who received training
and support as part of the project. A common repertoire was agreed and songs were
learned by ear and sung without accompaniment. This approach made it possible to bring
the choirs together as a large chorus for public performances in February 2010 at the Astor
Theatre in Deal and in June 2010 at the Granville Theatre in Ramsgate (Plate 2).
Plate 1 The Mustard Seed Singers
Plate 2 The East Kent ‘‘Singing for Health’’ Chorus at the Granville Theatre
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The project was closely monitored and evaluated following the procedures described below
and some of the findings from this evaluation are reported here. In addition, a short film was
created based on the June 2010 performance. This paper should be read in conjunction with
this film, which communicates more graphically than any academic report, what was
achieved and the impact the project undoubtedly had on participants’ sense of mental
wellbeing and social inclusion (www.youtube.com/watch?v¼MIsoii8pxO4).
Research on singing, wellbeing and health
Systematic reviews of research on singing and wellbeing (Clift et al., 2008, 2010) have
revealed a relatively small and varied corpus of research. Of the studies reviewed, a number
stand out as particularly relevant to the question of whether group singing has a potential
role in aiding the recovery and social inclusion of people with mental health needs. Bailey
and Davidson (2002) have shown considerable wellbeing benefits from choral singing for a
small sample of homeless men and replicated these findings in further studies of singers in
choirs in disadvantaged and privileged communities. Two quasi-experimental studies have
also reported positive health impacts from group singing for elderly people using
standardised measures and objective indicators of wellbeing and health. Houston
et al.(1998) report improvements in levels of anxiety and depression in nursing home
residents, following a four-week programme of singing, and Cohen et al. (2006) found
improvements in both mental and physical health in a group of elderly people participating in
a community choir for one year.
Clift et al. (2010) report the largest study on choral singing and wellbeing undertaken to date.
Their cross-national survey took the WHO’s definition of health[1] as a starting point and
utilised the short form of the WHO quality of life questionnaire (WHOQOL-BREF)[2] to gather
data on 1,124 choral singers drawn from choirs in Australia, England and Germany. In
addition, singers completed a specially constructed 12-item ‘‘effects of choral singing
scale’’ and gave written accounts of the effects of choral singing on wellbeing and health in
response to open questions.
Clift et al. (2010) and Clift and Hancox (2010) examined written accounts of the effects of choral
singing on wellbeing given by participants with relatively low psychological wellbeing as
assessed by the WHOQOL-BREF, and high scores on the singing scale indicating a
strong-perceived impact of singing on a sense of personal wellbeing. A total of four categories
of significant personal and health challenges were disclosed by members of this group:
enduring mental health problems, family/relationship problems, physical health challenges and
recent bereavement, and in all cases, singing provided support in coping with such challenges.
To date, however, no research has examined the value of group singing for the recovery and
social inclusion of people with a history of serious and enduring mental health issues. The
project reported on here was an attempt to establish and evaluate a network of singing
groups using a validated and widely employed clinical assessment tool. To the best of the
authors’ knowledge, this project is unique and nothing like it has been attempted elsewhere.
Method
A multi-method, longitudinal, observational design was adopted to monitor and evaluate this
initiative. Ethical approval was given by Canterbury Christ Church University. Participants
were invited to participate in the evaluation in November 2009 and completed
questionnaires towards the end of each term. They were also asked over the course of
the project to provide qualitative feedback on their experiences. The present paper focuses
on changes over an eight month period from the end of terms one to three.
Main outcome measure: CORE questionnaire
The CORE questionnaire[3] is widely used in clinical practice to assess the outcomes of
counselling and psychotherapy. It consists of 34 statements describing feelings and behaviours
related to mental distress, and respondents are asked to indicate how often they have felt or
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behaved that way over the previous week on a five-point scale (Table II). The questionnaire is
scored by calculating the mean item rating and multiplying by ten, giving a scale from zero to 40 –
the CORE outcome measure (CORE-OM). A high score indicates mental distress. Sets of items
within the questionnaire relate to overall ‘‘subjective wellbeing’’, psychological ‘‘problems’’, daily
‘‘functioning’’ and ‘‘risk’’ to self and others and sub-scale scores can be derived, but should be
treated with caution (Lyne et al., 2006). The CORE-OM has excellent reliability and validity, and a
score of 10 has been established as a clinical cut-off point. Individuals scoring below 10 are
relatively ‘‘well’’ and those scoring ten or above are ‘‘unwell’’. In addition, a change of five points
represents a reliable movement towards deterioration or improvements in wellbeing, and a
movement of five points over the cut-off value of 10 represents a change that is both reliable and
clinically significant (Connell et al., 2007; Gray and Mellor-Clark, 2007).
Analysis
Given the non-normal distribution of item and summated scores on the CORE, Wilcoxon
signed rank tests were used to assess changes, with an alpha value of 0.05. The null
hypothesis was that no change will be observed in CORE-OM, sub-scales and individual
item responses over a period of eight months of engagement in choral singing.
Results
The sample
Over the course of the first year, 137 people participated in the monitoring process and gave
feedback in the form of completed questionnaires and qualitative comments. Of these,
42 provided sufficiently complete data on the CORE towards the end of the first and third
terms (November 2009 and June 2010). This numerical difference is accounted for by the
following factors: people joining the project in terms two and three; people leaving the
project in term one; absence from sessions when questionnaires were distributed and
participants leaving items in the questionnaire unanswered.
The sample includes 31 females and 11 males. The average age of the total sample is 59.6
(SD ¼ 14.2), range 27-81 years, with no significant difference in age between men and women.
Changes in CORE-OM and sub-scales scores
Over the period of eight months the CORE-OM shows a high test-retest Spearman
correlation of 0.75 ( p , 0.001, one-tailed) supporting the reliability of the scale. Table I
reports the means for the CORE-OM and its component scales (wellbeing, problems,
functioning and risk) for November 2009 and June 2010, together with Wilcoxon Z-values.
There is clear evidence of a marked reduction in CORE values over a period of eight months.
The change seen for CORE-OM represents a moderate ‘‘effect size’’ of 0.44.
Changes for individual items on the CORE questionnaire
In order to appreciate more clearly the character of reported mental distress, and the precise
nature of the changes observed over eight months, it is illuminating to consider responses to
Table I CORE-OM and sub-scale means (standard deviation) for November 2009 and June 2010
November 2009 June 2010 n Z
a
p
b
CORE-OM 9.43 (6.58) 6.85 (5.26) 42 2 3.47 0.001
Wellbeing 1.33 (0.88) 0.96 (0.74) 42 2 2.95 0.003
Problems 1.11 (0.87) 0.80 (0.65) 42 2 2.78 0.005
Functioning 1.03 (0.71) 0.74 (0.61) 42 2 3.00 0.003
Risk 0.19 (0.45) 0.15 (0.26) 42 2 0.24 ns
Notes:
a
Based on Wilcoxon signed ranked test;
b
p-values are two-tailed
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individual items on the CORE questionnaire. Means for each item for November 2009 and
June 2010 are given in Table II, together with Wilcoxon Z-values.
Individual patt erns of change over eight months
The data reported in Tables I and II are of interest in assessing the mean effects of
choral singing on wellbeing, but it is of greater interest to consider the changes observed for
each individual in the sample. Figure 1 shows the paired scores for each participant over
the eight months period of the evaluation. The horizontal and vertical dashed lines
represent the clinical cut-off value of 10; the solid diagonal line represents no change
and the upper and lower dashed lines indicate clinically significant deterioration and
improvement, respectively. The most striking pattern in these data is a general improvement
in CORE-OM scores, with 11 of the 42 participants showing a clinically significant
improvement.
Table II CORE item means (SD) for November 2009 and June 2010 (following the order in the questionnaire)
Items November 2009 June 2010 N
a
Z
b
p
c
1. I have felt terribly alone and isolated (F)
d
0.93 (1.17) 0.63 (0.99) 41 2 2.00 0.049
2. I have felt tense, anxious or nervous (P) 1.29 (1.21) 0.83 (1.05) 41 2 2.82 0.005
3. I have felt I have someone to turn to for support when
needed (F) 1.63 (1.55) 1.41 (1.50) 41 2 1.01 ns
4. I have felt OK about myself (W) 1.64 (1.50) 1.26 (1.48) 42 2 1.23 ns
5. I have felt totally lacking in energy and enthusiasm (P) 1.24 (1.24) 1.00 (1.03) 41 2 1.09 ns
6. I have been physically violent to others (R) 0.02 (0.15) 0.00 (0.00) 42 2 1.00 ns
7. I have felt able to cope when things go wrong (F) 1.20 (1.40) 1.00 (1.38) 41 2 0.78 ns
8. I have been troubled by aches and pains (P) 1.46 (1.23) 1.44 (1.10) 41 2 0.06 ns
9. I have thought of hurting myself (R) 0.36 (0.96) 0.17 (0.49) 42 2 1.29 ns
10. Talking to people has felt too much for me (F) 0.81 (1.04) 0.60 (0.99) 42 2 1.88 ns
11. Tension and anxiety have prevented me doing important
things (P) 0.83 (1.10) 0.52 (1.07) 42 2 1.39 ns
12. I have been happy with things I have done (F) 1.31 (1.30) 0.76 (1.23) 42 2 2.12 0.03
13. I have been disturbed by unwanted thoughts and
feelings (P) 1.02 (1.09) 0.64 (0.98) 42 2 2.86 0.004
14. I have felt like crying (W) 1.24 (1.12) 0.86 (0.90) 42 2 2.34 0.019
15. I have felt panic or terror (P) 0.61 (1.02) 0.41 (0.87) 41 2 1.10 ns
16. I have made plans to end my life (R) 0.12 (0.50) 0.07 (0.46) 42 2 0.54 ns
17. I have felt overwhelmed by my problems (W) 0.88 (1.13) 0.64 (1.10) 42 2 1.80 ns
18. I have had difficulty going to sleep or staying asleep (P) 1.27 (1.30) 1.00 (1.16) 41 2 1.58 ns
19. I have felt warmth or affection for someone (F) 0.98 (1.20) 0.86 (1.28) 42 2 0.83 ns
20. My problems have been impossible to put to one side (P) 1.12 (1.17) 0.88 (1.14) 41 2 1.60 ns
21. I have been able to do most things I needed to (F) 0.83 (1.29) 0.60 (1.13) 42 2 1.04 ns
22. I have threatened or intimidated by another person (R) 0.14 (0.42) 0.14 (0.47) 42 2 0.06 ns
23. I have felt despairing or hopeless (P) 0.81 (1.17) 0.50 (0.86) 42 2 3.13 0.002
24. I have thought it would be better if I were dead (R) 0.33 (0.82) 0.24 (0.69) 42 2 0.95 ns
25. I have felt criticised by other people (F) 1.17 (1.15) 0.60 (0.86) 42 2 2.61 0.009
26. I have thought I have no friends (F) 0.59 (1.00) 0.37 (0.77) 41 2 1.71 ns
27. I have felt unhappy (P) 1.26 (1.19) 0.88 (0.83) 42 2 2.37 0.018
28. Unwanted memories have been distressing me (P) 1.19 (1.15) 0.64 (0.98) 42 2 2.82 0.005
29. I have been irritable with other people (F) 1.00 (1.01) 0.74 (0.77) 42 2 1.67 ns
30. I have thought I am to blame for my problems (P) 1.21 (1.16) 0.93 (1.11) 42 2 1.90 ns
31. I have felt optimistic about my future (W) 1.57 (1.40) 1.10 (1.25) 42 2 2.15 0.031
32. I have achieved things I wanted to (F) 1.32 (1.13) 0.95 (1.00) 41 2 1.98 0.048
33. I have felt humiliated or shamed by other people (F) 0.64 (0.91) 0.24 (0.53) 42 2 2.83 0.005
34. I have hurt myself physically (R) 0.17 (0.70) 0.31 (1.05) 42 2 0.69 ns
Notes:
a
N varies due to missing values for some items;
b
based on Wilcoxon signed ranked test;
c
p-values are two-tailed;
d
initials indicate
the sub-scale: W, wellbeing; P, problems; F, functioning; R, risk
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Discussion
The sample
The sex and age characteristics of the 42 participants – 26 per cent men and 74 per cent of
women, with an overall average age of 59.6 – is remarkably similar to the findings from the
large-scale cross-national survey of choral singers reported by Clift and Hancox (2010). The
age range is also very wide, from late 20s to early 80s; which means that the choirs span
three or four generations and can be considered strongly ‘‘inter-generational’’ in character.
The choirs were also very socially diverse, in terms of educational levels, literacy and
employment history, although information on these characteristics was not formally
gathered.
Changes in CORE-OM and sub-scales scores
Table I shows that a statistically significant improvement in CORE-OM scores occurred over
this period with an effect size of 0.44, which is generally considered to be ‘‘moderate’’. It
should be remembered, however, that the sample considered here is very diverse. It
includes not only people with current mental health issues, but also individuals in recovery
from previous serious periods of mental ill-health, some friends/family supporters and also
one mental health promotion specialist, all of whom gave CORE-OM scores below the
clinical cut-off point. An effect size of 0.44, for the sample as a whole, therefore, almost
certainly underestimates the strength of the impact of group singing for people above the
clinical cut-off point.
Statistically significant changes are also found for three sub-scales within the CORE
questionnaire: wellbeing, problems and functioning, suggesting that group singing helps to
create movement and improvements in all three areas equally. The risk scale, however,
showed no change, but this is clearly due to the fact that risk scores were very low. Although
we know that a few individuals who were part of the project did have a history of self-harming
Figure 1 Individual CORE-OM scores in November 2009 and June 2010 (n ¼ 42)
0.00 5.00 10.00 15.00 20.00
CORE-OM November 2009
CORE-OM June 2010
25.00 30.00
30.00
20.00
10.00
0.00
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behaviour, and there was at least one person who, during the course of the evaluation was
seriously suicidal, very few people reported any risk behaviours or feelings towards
themselves or others.
Changes for individual items on the CORE questionnaire
In total, 11 out of 34 items show significant changes indicating that participants have
responded to the CORE questionnaire in a discriminating way with positive changes on
some items, but no significant change on others. Not surprisingly, given the lack of change
on the risk sub-scale, none of the risk items show significant changes. There are, however,
striking improvements on five ‘‘functioning’’ items. Three indicate improved relationships
with others: ‘‘I have felt terribly alone and isolated’’, ‘‘I have felt humiliated or shamed by
other people’’ and ‘‘I have felt criticised by other people’’; and two suggest a greater sense
of accomplishment: ‘‘I have been happy with things I have done’’ and ‘‘I have achieved
things I wanted to’’. These items are interesting in pointing to social acceptance and
achievement as central resources offered by participation in choral singing. Five ‘‘problem’’
items and two ‘‘wellbeing’’ items also show significant changes. Three of the problem items
vary in intensity, but all point towards an improved sense of emotional wellbeing: ‘‘I have felt
despairing or hopeless’’, ‘‘I have felt tense, anxious or nervous’’, and ‘‘I have felt unhappy’’;
and this is supported by a positive change in one of the wellbeing items: ‘‘I have felt like
crying’’. Two further problem items are interesting in suggesting that participants were
less-troubled by negative thoughts and feelings: ‘‘I have been disturbed by unwanted
thoughts and feelings’’ and ‘‘unwanted memories have been distressing me’’, which
suggests that participation in choral singing may have helped to provide a different focus for
attention and provided distraction from otherwise troubling ideas (Clift and Hancox, 2010).
Finally, one wellbeing item shows an improved sense of future-orientation: ‘‘I have felt
optimistic about my future’’.
Individual patt erns of change
Figure 1 shows a general improvement in CORE-OM scores on an individual level, with 11
out of 42 participants showing a clinically significant improvement. This indicates that for
those individuals who engaged in the project over the course of a year, the intervention was
invariably positive (i.e. singing does no harm). However, this effect may be exaggerated
given that people who left may well have been those who did not gain benefits. Efforts were
made to contact people who joined the project and then stopped coming, but resource
constraints meant that detailed follow up was not possible. The upper right-hand quadrant of
the graph is of interest here as out of the five individuals, only one shows a clinically
significant improvement, although they remain above the clinical cut-off point. The remaining
four appear to be remarkably stable in their levels of mental distress, and it is clear that the
choral project served to maintain their involvement despite a lack of apparent improvements
in measured wellbeing.
Personal accounts of involvement and its effects
At three points during the project, members of choirs were asked to provide written
feedback about the effects of their involvement in group singing. These accounts provide
invaluable personal testimonies, which often provide insights into the ways in which singing
can be beneficial on an individual level given each person’s unique experiences,
circumstances and problems. The accounts given here are from individuals in three groups
that can be found in Figure 1: those who have scores below 10 on both occasions –
‘‘well-well’’; those who score above 10 initially and below 10 on follow-up – ‘‘unwell-well’’,
and those whose scores remain above 10 – ‘‘unwell-unwell’’. The change in CORE-OM
scores is given below each account.
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Well-well
Karen was relatively ‘‘well’’ on both occasions of assessment with CORE, but clearly
identified herself as having an on-going mental difficulty:
I have bipolar disorder [. . .] When I am depressed, singing in the group and coming together with
other people lifts my mood and gives me something positive and productive to focus on.
When I am manic, singing is something I can channel my extra energy into and express my
enthusiasm for life through. The choir provides structure and purpose in an otherwise sometimes
empty life [. . .] The group reminds me that there are many people with difficulties of one kind or
another. We can understand each other’s problems and support one another (Karen, 30,
CORE-OM scores 9 to 4).
Unwell-well
Elisabeth, also with bipolar disorder shows a clear movement from being above the clinical
cut-off point to being below it:
It helps me to structure my week, to have something to keep going for. I enjoy meeting all types of
people. It has been very good to meet new people who have experiences similar to my own.
If I feel I might have a panic attack, I know how to breathe properly which helps. I would have very
little reason to leave the house if I wasn’t doing choirs (Elisabeth, 27, CORE-OM 28 to 9).
Unwell-unwell
Margaret provides invaluable insights into how the singing project managed to maintain her
engagement despite on-going difficulties with depression:
Music is a very important therapeutic and enjoyment factor in my life. The singing group has
meant that I have been actively involved for once rather than in the audience and it’s been a
valuable experience. I find any group situation hard and testing. To share and experience music
with a group has enabled me to overcome some of the barriers I would usually feel. I have
managed to attend singing on several occasions when feeling extremely stressed. I found to my
surprise and delight that it did indeed not only provide a distraction but transformed my mood. I
have been reminded that I am often my own worst enemy and refuse to do things through fear of
failure (Margaret, 53, CORE-OM 24 to 27).
Limitations of the evaluation and further research directions
The most obvious limitation of the evaluation reported here is that it is uncontrolled, and
further research is warranted to compare involvement in group singing with other forms of
social intervention and usual treatment controls. In addition, we were not in a position to
consider medical histories and the extent to which participants were currently on medication
or in receipt of counselling or psychotherapy. Clearly, there is a need to investigate the
relative merits of social interventions of this kind compared with the use of anti-depressants
and psychological therapies.
The future of the ‘‘singing for health’’ network
The Primary Care Trust was approached early in 2010 with a request to continue to support
the network for a further year, but they were unable to do so, given their financial situation.
Fortunately, the Roger De Haan Charitable Trust agreed in September 2010 to provide
funding to allow the network to restart in September 2010 and to run until July 2011, when a
public performance event will take place. We expect the choirs to grow in size with new
members, and we will continue to monitor and evaluate the project closely.
Notes
1. ‘‘Health is a state of complete physical, mental and social wellbeing and not merely the absence of
disease or infirmity’’ WHO (1946).
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2. The WHOQOL-BREF is the short form of a quality of life questionnaire constructed by the World
Health Organization Quality of Life project on the basis of a large-scale international collaborative
project (www.who.int/substance_abuse/research_tools/whoqolbref/en/).
3. See www.coreims.co.uk/index.php for details of the development and use of the CORE
questionnaire in clinical services.
References
Bailey, B.A. and Davidson, J.W. (2002), ‘‘Adaptive characteristics of group singing: perceptions from
members of a choir for homeless men’’, Musicae Scientiae, Vol. 6 No. 2, pp. 221-56.
Clift, S. and Hancox, G. (2010), ‘‘The significance of choral singing for sustaining psychological
wellbeing: findings from a survey of choristers in England, Australia and Germany’’, Music Performance
Research, Vol. 3 No. 1, pp. 79-96, available at: http://mpr-online.net/
Clift, S., Hancox, G., Staricoff, R. and Whitmore, C. (2008), Singing and Health: A Systematic Mapping
and Review of Non-clinical Research, Canterbury Christ Church University, Canterbury.
Clift, S., Morrison, I., Vella-Burrows, T. and Hancox, G. (2011), ‘‘Singing for mental health and wellbeing:
community initiatives in England’’, in Brader, A. (Ed.), Songs of Resilience, Cambridge Scholars Press,
Cambridge.
Clift, S., Hancox, G., Morrison, I., Hess, B., Kreutz, G. and Stewart, D. (2010), ‘‘Choral singing and
psychological wellbeing: quantitative and qualitative findings from English choirs in a cross-national
survey’’, Journal of Applied Arts and Health, Vol. 1 No. 1, pp. 19-34.
Cohen, G.D., Perlstein, S., Chapline, J., Kelly, J., Firth, K.M. and Simmoens, S. (2006), ‘‘The impact of
professionally conducted cultural programs on the physical health, mental health, and social functioning
of older adults’’, The Gerontologist, Vol. 46 No. 6, pp. 726-34.
Connell, J., Barkham, M., Stiles, W.B., Twigg, E., Singleton, N., Evans, O. and Miles, J.N. (2007),
‘‘Distribution of CORE-OM scores in a general population, clinical cut-off points, and comparison with
the CIS-R’’, British Journal of Psychiatry, Vol. 190 No. 1, pp. 69-74.
Gray, P. and Mellor-Clark, J. (Eds) (2007), CORE: A Decade of Development, CORE IMS, Rugby,
available at: www.coreims.co.uk/index.php
Houston, D.M., McKee, K.J., Carroll, L. and Marsh, H. (1998), ‘‘Using humour to promote psychological
wellbeing in residential homes for older people’’, Aging and Mental Health, Vol. 2 No. 4, pp. 328-32.
Lyne, K.J., Barrett, P., Evans, C. and Barkham, M. (2006), ‘‘Dimensions of variation on the CORE-OM’’,
British Journal of Clinical Psychology, Vol. 45 No. 2, pp. 185-203.
WHO (1946), Preamble to the Constitution of the World Health Organization as adopted by the International
Health Conference, New York, NY, 19-22 June, 1946; Signed on 22 July 1946 by the Representatives of
61 States (Official Records of the World Health Organization, No. 2, p. 100) and Entered into Force on 7 April
1948, World Health Organization, Geneva.
Further reading
Bailey, B.A. and Davidson, J.W. (2005), ‘‘Effects of group singing and performance for marginalized and
middle-class singers’’, Psychology of Music, Vol. 33 No. 3, pp. 269-303.
Barkham, M., Culverwell, A., Spindler, K., Twigg, E. and Connell, J. (2005), ‘‘The CORE-OM in an older
adult population: psychometric status, acceptability, and feasibility’’, Ageing and Mental Health, Vol. 9,
pp. 235-45.
Cheung, K., Oemar, M., Oppe, M. and Rabin, R. (2010), User Guide: Basic Information on How to Use
the EQ-5D, Version 3, The EuroQol Group, Rotterdam, available at: www.euroqol.org/
Clift, S. (2010), ‘‘Singing for health: a musical remedy’’, British Journal of Wellbeing, Vol. 1 No. 6,
pp. 19-21.
Clift, S., Nicols, J., Raisbeck, M., Whitmore, C. and Morrison, I. (2010), ‘‘Group singing, wellbeing and
health: a systematic mapping of research’’, UNESCO Journal, Vol. 2 No. 1, pp. 1-25, available at: www.
abp.unimelb.edu.au/unesco/ejournal/
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About the authors
Stephen Clift is a Professor of Health Education and Research Director at the Sidney
De Haan Research Centre for Arts and Health, Canterbury Christ Church University.
Stephen Clift is the corresponding author and can be contacted at: stephen.clift@canter-
bury.ac.uk
Ian Morrison is a Senior Researcher at the Sidney De Haan Research Centre for Arts and
Health, Canterbury Christ Church University.
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