Music as a method of coping with cancer: A qualitative study among cancer patients in Sweden

Abstract

Background: This study investigated patients’ understanding of the role of music in coping and in influencing their well-being. Methods: A qualitative study was conducted based on semi-structured interviews with 17 cancer patients. Participants were chosen from a group of patients who had listened to or played music as a means of coping with their illness. Results: The study shows the importance of considering the roles that different kinds of music play in coping with cancer. The music of nature, healing music, religious music and cheerful music each have different benefits for patients. Conclusions: A patient's situation and his or her individual characteristics determine the types of music that can act as a useful or harmful coping strategy. Therefore, it is essential to investigate the types of individual characteristics that can make listening to different kinds of music a helpful or harmful coping method.

Background

Some studies (Bradt, Dileo, Grocke, & Magill, 2011; Cassileth & Gubili, 2009; Daykin, McClean, & Blunt, 2007; Hart, 2009; Kaliyaperumal & Gowri Subash, 2010; Magill, 2009; Nainis et al., 2006; Sahler, Hunter, & Liesveld, 2003) have examined the effects that receptive interventions, such as listening to music, music and imagery, or a combination of music therapy interventions, have had on outcomes such as decreased pain and nausea, improved mood and improved quality of life among cancer patients.

Although several studies (Daykin et al., 2007; Hilliard, 2003; Olofsson & Fossum, 2009) have shown the benefits of music for promoting the well-being of cancer patients, few countries have integrated the utilization of music into healthcare. According to some researchers (e.g. Burns, Sledge, Fuller, Daggy, & Monahan, 2005), one possible reason for this could be that patients are not comfortable with participating in a music therapy intervention.

One area that must be investigated further is the role of music as a coping method when facing cancer from the patients’ perspective. The aim of the study upon which the present article is based was to understand patients’ own understandings of the role of music in coping. This study uses the following definition of coping:

Generally, coping is regarded as the means we use to combat or prevent stress. It can be defined as a process of managing the discrepancy between the demands of the situation and the available resources – a process that can alter the stressful problem or regulate the emotional response. (Ahmadi, 2006, p. 21)

Because I aimed to study the use of music as a coping method from the patient's perspective, the self-selection of the music was in focus in this study. Therefore, it was important for the study to gain knowledge about those kinds of music that patients themselves had experienced as a contributing factor in their struggle with their illness.

The study accomplished its aim by using a semi-structured interview technique for cancer patients who had used music to face the psychological and physical problems caused by cancer. It is hoped that this study will shed light on the importance of self-selected music for cancer patients.

Research Approach and Methodology

Semi-structured interviews were conducted with 17 cancer patients who had used (listened to or played) music as a means of coping with their illness. In order to recruit informants, I primarily used my established contacts with four cancer organizations in Sweden, which are among the most important patient organizations in this country. These are The Swedish Union for Ileostomy-, Colostomy- and Urostomy-Operated Persons (ILCO), The Leukemia Patients Organization (Bloodcancerförbundet) in Stockholm, The Prostate Cancer Brotherhood (Proliv) and the Breast Cancer National Organization (BRO). I also used the chat plaza and discussion forums provided by different cancer organizations, in this way expanding my recruitment domain as much as possible. In addition, the journals of certain cancer organizations, such as Proliv and the Breast Association in Stockholm, Amazona, were used in recruiting. Two of the above-mentioned organizations managed a meeting with their members at the time of their monthly gathering. At these meetings, I provided a thorough explanation of the study and its aims. The two other organizations published stories about my research in their monthly journals or newsletters and provided the readers with contact information.

These additional methods enabled me to recruit individuals who were not members of cancer organization associations, but who still visited and used these chat sites and discussion forums or read the journals targeting different cancer patients. Regarding the ethical considerations of dealing with a vulnerable group such as cancer patients, this approach was the most suitable for my research. Of the 35 persons who contacted me, I selected those who have used music not occasionally, but during or after their illness. Interviews were conducted in Swedish. The English citations presented here have all been translated from Swedish to English.

The number of informants was determined using “the point of saturation” principle; that is, the interview procedure was continued until no new themes emerged. When additional cases ceased to add new information, that meant the “saturation point” had been reached. The saturation point was reached at the fifteenth interview; two additional interviews were conducted afterward to ensure that no new themes appeared.

There are different opinions among scholars (Bowen, 2008; Charmaz, 2006; Ritchie, Lewis, & Elam, 2003) regarding the criteria for the saturation point. Those important criteria, as Mason (2010) mentioned, are: the heterogeneity of the population, the number of selection criteria, the extent to which “nesting” of criteria is needed, groups of special interest that require intensive study, multiple samples within one study, types of data collection methods used and the budget and resources available (Ritchie et al., 2003, p. 84), as well as the scope of the study, the nature of the topic, the quality of the data, the study design and the use of what Morse (2000, p. 4) calls “shadowed data”. Some researchers have gone a step further and maintained that the concept of saturation is inappropriate (Dey, 1999, p. 133). Without entering this discussion, I wish to draw attention to the point that conducting a study on the basis of a qualitative method means, among other things, using the researcher's personal judgment of the point of saturation. Although this judgment is usually based on certain scientific criteria, as mentioned above, it is the researcher who ultimately determines the size of the sample. Proceeding from the data the interviews provided, I realized after the fifteenth interview that the point of saturation had been reached; after the seventeenth interview, I decided to end the interviewing process.

The sample consisted of 17 cancer patients aged between 24 and 73 years of age (5 men and 12 women) who had used music (listened to or played music) as a means of coping with their illness.

I used the face-to-face interview method. Every interview was recorded and they took between 1 and 2.5 hours. The interviews were conducted mainly at the informants’ home and in a few cases at their workplace.

I used the basic idea of the grounded theory approach (Denzin & Lincoln, 1998; Glaser, 2005; Glaser & Strauss, 1967), which is to read (and re-read) a textual database and to find categories, concepts and properties. Accordingly, the present results have been developed inductively from a corpus of data during the process of conducting the research and not deductively on the basis of an existing theory.

When the tape-recorded and transcribed interviews were analyzed, certain themes and subthemes emerged. The first step was coding, thematizing and creating networks of different themes. I have used the Atlas Data Program, which is a qualitative data analysis management program. I have not used this program for analysis but for coding.

The next step was to return to the original interviews to check the inclusion of relevant information in the thematic condensation.

The analysis procedure described above continued until no new themes emerged, thus until additional cases ceased to add new information. The “saturation point” was reached after 15 interviews, although 2 additional interviews were conducted.

The last step was to establish the essential characteristics constituting the different ways in which music had played the role of a coping method for the interviewees.

The research study was approved by the regional ethics committee at Uppsala University.

During the preparation period, the researcher contacted the informants to explain the purpose, the study's aim and possible research process. Participants were informed that their privacy would be protected and that they could skip questions they did not wish to answer. Furthermore, the participants’ permission would be obtained before the recorder was turned on. The participants were given a letter of consent in which they were informed that the use of the collected data is purely for the purpose of the study and that the recordings would be destroyed at the end of the study. They were also informed of their right to withdraw at any time during the interview course. Furthermore, the interviewees were also told about the anonymity of their names and other identifiable traits.

Findings, Analysis and Discussion

As a qualitative inquiry, the study upon which this article is based aimed not to generalize the obtained results, but to shed light on how music can be used in coping. Music has been shown to play a significant role in the study participants’ ability to cope with cancer. In addressing the music that participants used as coping methods, the following terms (translation from the Swedish terms) were used, as these were terms the participants themselves had used:

• music of nature (“naturens musik”) – refers to the sounds of nature;

• healing music (“helande musik”) – refers to music that helps healing;

• religious music (“religiös musik”) – refers to music that invokes spiritual and religious feelings;

• cheerful music (“glädjande musik”) – refers to music that invokes feelings of happiness;

• hard and heavy music (“hard musik”) – refers to music such as heavy metal and hard rock.

The role of religious music, cheerful music and hard and heavy music has already been noted (Ahmadi, 2009, 2011; Ahmadi & Norberg, 2010), albeit in different contexts than those addressed here. The current article presents the results of my study of the role that different types of music have played as coping methods. The English quotations presented here have all been translated from Swedish.

Music of Nature

In the study of the role of music in coping, several participants mentioned having used the music of nature as a coping method.

Katarina was 26 years old when she was diagnosed with blood cancer. She received one year of treatment, but her cancer returned for a second time after 1.5 years. As she explained, the diagnosis had a serious impact on her. She faced serious depression and music became her rescue, especially the music of nature, which made it easier for her to endure a range of treatments during her long illness. Katarina stressed that the music of nature was the most important coping method for her and explained its role as follows.

I had a very special experience just going out and standing and hear birds chirping and the wind in the trees; just getting a feeling of life. You get the feeling that you are one of many in a way, that there is something out there. For me, it has been a very important factor and even just water has had great significance too, and the chirping of birds. I feel, you see, every spring when the birds … when everything is waking up and so on, then it's there, that powerful feeling inside me, because there are so many associations with the time I was sick too, like it was just now in March-April when I had the transplant. I recovered at the same time as nature was waking up … If it hadn't been there then, it would have been much tougher, for sure.

As the above quotation shows, Katarina sought tranquility by listening to the music of nature and it became a coping method for her during her illness. The music of nature did not merely result in a tranquil environment. She mentioned that this music made her feel as though there was something out there; she felt something strong inside her. She said that she recovered at the same time as nature was waking up. Katarina is actually talking about a feeling of unity with nature.

The music of nature was also a coping method for Hedwig, who was diagnosed with breast cancer at the age of 47. She explained her view of nature and the importance of the music of nature in her coping with cancer as follows.

Yes, in fact it was always important to me that the music of nature was there … I listened right into my soul, every note right into the process of creation. You can say it like this, that the ability to be present in the here and now, in other words to live here and now, is a part of life's wisdom … The music of nature helped me feel myself present in the here and now, to be part of the great whole, nature, to be in the small particles that make up every flower. I was there right in the middle. The music of nature was not something I used for the purpose of healing, but for nature's life force.

As in Katarina's case, it seems as though the music of nature has given Hedwig a feeling of being one with nature. Hedwig has used music of nature as a coping method, a method that I refer to here as the “spiritual sanctification of nature”. In an earlier study I conducted with 51 cancer patients in Sweden concerning the use of religion and spirituality as a coping method with cancer (Ahmadi, 2006), several people who had been diagnosed with cancer used the “spiritual sanctification of nature” method.

As Zinnbauer, Pargament and Scott (1999, p. 911) point out, virtually any object can be perceived as divine-like in character. Such a search for the divine becomes more important when faced with a serious life problem. The process of sanctification occurs not only in relation to theistically oriented interpretations of various aspects of life, but also indirectly, which means that perceptions of divine character and significance can develop by investing objects with qualities associated with the divine (Pargament & Mahoney, 2005, p. 185). According to Pargament and Mahoney (2005, p. 185), these sacred qualities include attributes of transcendence (e.g. holy, heavenly), ultimate value and purpose (e.g. blessed, inspiring) and timelessness (e.g. everlasting, miraculous). The above examples show that both participants perceived a sacred value in nature.

One important factor in giving experiences of natural environments such a central role in coping is the prominent position that nature holds in Swedish ways of thinking and culture. According to The 1994 Study (Uddenberg, 1995, p. 27), based on a questionnaire survey among 973 Swedes between 20 and 69 years of age, 94% of respondents felt that “nature makes them feel relaxed and harmonious”. In the same study, 51% of respondents agreed that “human beings would feel much better if they were as natural as animals are”. An interesting point revealed through the EVSS (European Value System Study) was that Swedes are more ready than other European peoples to devote themselves to and spend money on environmental issues. Other studies, such as the Sifo study (Linden, 1994), the Uppsala Study of 1986 (Hamberg, 1994) and The 1994 Study (Uddenberg, 1995), all indicate that interest in nature and environmental questions is widespread among Swedes, especially among young people.

Swedes’ view of nature as a sacred and mysterious phenomenon and their strong tendency to visit natural environments, often experiencing a feeling of a unity with nature, presumably paves the way for the present participants “turning to nature and its music” as an essential way of coping with their stresses. This view of nature helps explain the importance of the music of nature as a coping method among some participants in the above-mentioned studies conducted among cancer patients in Sweden.

Healing Music

Some participants in the study of the role of music in coping expressed their belief in the healing function of music. Participants referred to healing music as relaxing music, which they feel is able to cure the body or has a psychological effect that helps them relax.

The present study found two patterns of using music as a healing method. Some believed that music directly impacted their body and helped cure them, while others regarded music as a means of helping them become enough strong to face the anxiety and stressors brought about by their illness. In other words, in the first pattern, music functions as a healing method that directly impacts the body's immune system and can therefore cure the illness. In the second pattern, the interviewee regards music as a healing source that helps the patient feel good and relax, which helps empower the body to fight the cancer.

Erik is a participant who represents the first pattern. Erik was 72 years old when he was diagnosed with prostate cancer. He responded to the question of whether healing music had an impact on his restored health as follows.

Yes, I absolutely believe that, and I think we can even influence our immune system negatively. I believe that we are created in such a wonderful way that we are influenced by goodness, joy, loveliness and the positive. When I listen to music that makes me calm and brings me a feeling of happiness, my cells react in a positive way … I am sure something makes that cancer cells die if stress in our body and mind disappear. Music is one of the ways that makes it possible. I know it seems stupid, but the world is full of unknown phenomena.

Susanne, another participant, regarded listening to healing music as a kind of therapy. Susanne was 54 years old when she was diagnosed with breast cancer. Like Erik, she believed in the impact of music on her immune system.

I think my immune system improves by my being well and then that I live well and everything. I believe too that intense experiences, nature, music and things like that influence my immune system … I think it [music] can build up my immune system so that I can resist and protect myself a little bit and my general well-being also.

Anna, who was diagnosed with breast cancer at the age of 56, represents the second pattern, emphasizing the psychological effects of music rather than its curing effect. She explains:

Music can't cure anyone at all, but through music we can go into our inner selves much more easily and there we can find an incredible number of resources for curing ourselves. Music is a tool, and a good one, which helps us get there, and healing music helps us see things differently sometimes.

The second pattern is also represented by Bo, who was diagnosed with blood cancer at the age of 54:

I think it really was a healing therapy because I've been able to work through the emotional issues later after the awakening, so I've changed quite a bit of my personality … I believe very much in a person's own will to do things. For example, I look at my will to survive; it has astonished everyone around me that I had that will to survive. That was the effect of the healing music. It has cured my soul, made me think differently; it has given me the strength to fight.

The above-mentioned participants, like others who used the healing music, noted that this music allowed them to reach a deeper world that was unknown to them – their inner world. It seems that the healing music functioned as a coping method for these participants; they all believed in the power of music to enhance the mind-body connection.

According to this view, our body responds to the way we think, feel and act. When we are stressed, anxious, or upset, our body tries to tell us that something is not right. Accordingly, those with good emotional health are aware of their feelings and behaviors and can cope with stress and problems. Those who have strong views on the body-mind connection suggest that poor emotional health can weaken the body's immune system, making us more likely to get sick during emotionally difficult times. Several scholarly works advocate this perspective on the relation of mind and body (see, for instance, DiGiacomo, 1992; Jacobs, 2001; Karren, Hafen, Frandsen, & Smith, 2006).

It should be mentioned here that, from a sociological point of view, the important point is not how the body–mind relation functions or if it is true that our psychological well-being impacts our physical one and to what extent. Instead, what is important is how interviewees’ belief in the body–mind relationship impacts their coping with their illness.

Religious Music

The study of the role of music in coping shows that some participants have used religious music as a coping method. Differences between the cases can be summed up by noting that religious music helped some accept their pain and misery and think of it as a test from God. They reported that this kind of music had a relaxing effect on them. For others, the music they listened to did not bring about any philosophical or theological thoughts. The religious music made them feel joy and tranquility by strengthening their faith, not just by causing an aphoristic accidental happiness.

This study has revealed four patterns in the use of religious music as a coping method. The first pattern was that religious music helped some participants overcome the depression caused by cancer. The religious music strengthened their faith and, in so doing, weakened the effects of their psychological reactions to having cancer. At the time of interview, Peter was 73 years old, newly diagnosed with prostate cancer and still under treatment. He said that he identified with a group of Swedish singers who had each suffered from one or several serious health problems. Their reflections on how illness had strengthened their identity as believers had caused him to see himself as a religious person with strong faith and that God was using his illness as a hardship to test his virtue, as per the Book of Job.

As Peter explained, religious music has helped him overcome the depression caused by cancer. He explains:

During my depression, I never lost the joy of God. I played a lot of music depending on my feelings and moods. I played a lot of Chopin, and religious music has had an enormous impact on my attitude.

He reported that he was a big fan of Einar Ekberg, who Peter felt was perhaps the most important cantor of the twentieth century. As Peter said:

He was a Christian personality, a very deep and warm one. He died at 50 of cancer. I have read a book on how his belief was impacted by cancer. He has the most fantastic songs with themes like heaven, eternal hope and what belief means. I have listened to such songs a lot especially during the period I used to take Casodex;¹ during this time I became more aware of the fact that it was not sure that I was gong to live the next year, that I was maybe at the last stage of my life. In this situation, I have entertained myself with such songs, which gave me new hope and new happiness; songs that have helped me find a new identity, to see myself not as a cancer patient but as a believer. I got two DVDs and a CD from the US with the title “Billy Gaither Homecoming”. When I listen to these songs, I am affirmed. This is exactly what I feel; it is exactly what I experience. These guys, who sing, all suffering from an illness, tell me about their belief and their hope, they look into my eyes directly and say “it is what you believe and it is the hope you have”. So it's clear that these songs have had a strong effect on me, they create a world where I am a believer, not a patient with the diagnosis, prostate cancer, I am Job and cancer is my test.

In summary, religious music has strengthened Peter's faith and helped him to cope with the psychological effects of cancer. This music has functioned as a coping strategy, which has helped him overcome the stress and fears caused by cancer.

The second pattern is where religious music is regarded as a spiritual experience – a key that opens the door to a room where the patient could contact God. Lars, who often used the music of J.S. Bach during his illness, explained that this music was like a spiritual experience. His case represents the second pattern. His explanation of the role of music was as follows.

Music primarily has a spiritual function. I began by listening to Bach's music because it sounds so lovely, it feels lovely and the melodies are beautiful and the harmonies are beautiful, that I think it is a spiritual experience of the soul … You see, if I want to get into a room, it's important I have a key … So you can say that a melody or music is the key … Getting into the room is the most important thing; it is in the room that I experience, it is in the room that I experience God.

The third pattern is when religious music, in combination with the patient's faith, is felt to have a strong healing function. This pattern is represented by the situation of Fredrik, a strongly religious person. Frederik emphasized that he was convinced that music could cure his illness, but not alone; he believed that music in combination with his faith has had a strong healing function. According to Frederik, getting cancer and defeating it is like coming back from a war:

Music in relation to my faith has this function. I believe it has a strong influence on my psyche, extremely positive. My psyche, of course, influences my body very much, psychosomatically through and through, so that my body profits from it, my immune system gets stronger from the positive forces working within me, those we are created by … You feel stronger, as if you have come back from a battle. You have come through a difficult trial.

The fourth pattern is when religious music has a deep impact on a participant's general attitudes toward life. It gives some participants a feeling of having been reborn. The fourth pattern is represented in the case of Gunhild, who was 45 when she was diagnosed with breast cancer. Gunhild believed in God, but said that she was not a practicing Christian. Concerning the role of music in coping with cancer, she said:

During this depression, I never lost my joy in God. And it was a little of that that I wanted to break through to with religious music … I listen to the songs sometimes … it's not euphoric emotion; the opposite in fact. It's based on firm ground and that ground is what God's word, the Bible, taught me, my being in God Jesus Christ, and it is a reality for me … This rebirth, that is reality for me.

Like Peter, Lars and Fredrik, Gunhild has used religious music as a coping method. The religious music that the others listened to helped them accept the pain and misery caused by cancer as a test from God or as a battle, which enabled them to endure their problems. Religious music has a relaxing effect on them. In the case of Gunhild, by strengthening her faith, the religious music has made her feel joy; not, as she explained, as an aphoristic accidental happiness, but something more profound.

Cheerful Music

Christine was diagnosed with breast cancer at the age of 62. She seemed extremely cheerful during the interview. She explained that music has always been a part of her life because she was brought up in a family with a strong tradition of playing music. She pointed out that she has always sung to herself because music has always helped her live in a dream world where she has been able to do what she wished. She explained that she still loved to sing the songs of Pippi Longstocking (Pippi Långstrump in Swedish), the fictional character in a series of children's books created by Swedish author Astrid Lindgren. Pippi is very unconventional, assertive, rich and extraordinarily strong, able to lift a horse with only one arm. She frequently mocks and dupes the adults she encounters, an attitude likely to appeal to young readers. However, Pippi usually reserves her worst behavior for the most pompous and condescending of adults.²

Christine explained that cheerful songs like Pippi's made her feel strong and healthy. In her interview, Christine referred to Pippi and the music of the dramatization of the Pippi books for television. This music, along with other “cheerful music,” made Christine feel as though nothing could stand in the way of her happiness:

But I can do this only when singing … This has helped me a lot, especially when I went through my chemotropic treatment and felt awful. I sang all the time during this period. This helped me overcome my fear and not think about death. I sang songs that made me happy. They were joyful; some of them were dance music songs, like samba. I could see myself on the dance floor, dancing and dancing. You know, it is magic; you put on a CD and it lets you be whoever you wish.

Christine explained that she felt a discrepancy between others’ understanding of her as an ailing middle-aged women and her own understanding of herself as a “happy girl,” a “Pippi Longstocking” who was able to do whatever she wished. According to Christine, this discrepancy was overcome by the world created in the “cheerful” music.

Another interviewee, Elisabeth, a 55-year-old woman who had diagnosed with breast cancer one year before the interview, explained that she used the cheerful music – in her case classic rock and pop songs – as a coping method. She explained that such music brought her back to a world in which she was a young woman in love. She stressed that this imaginary picture had, throughout the whole period of the treatment and long after it, contributed tremendously to her fight against her illness. She said:

I was shocked and very sad. I used to listen to music when I drove to work but not intensively. One of my colleges told me that listening to music had helped her when she lost her husband. I began to listen to rock music which I loved and then it became more and more, especially after operation. I bought a MP3 and day and night had it with me. It was fantastic to listen to love songs, to be young again and be in love, an imaginary world, an imaginary man, an imaginary love. I enjoyed the rock and pop music like ABBA; they made me feel that 11 am someone else, not a middle-aged woman with one breast, but a young beautiful happy woman; music became my rescue.

The music that Christine and Elisabeth listened to or sang has functioned as a coping method that has helped them change their situation in a more positive direction. Music may become a means of masking the psychological problems that cancer patients usually face. Putting on the mask of Pippi Longstocking has helped Christine identify with someone who is not only not sick, but also stronger than others; this has made her feel happy and healthy and helped her overcome the depression brought about by cancer. In the same way, putting the mask of a young woman in love in an imaginary world made it possible for Elisabeth to cope with her illness.

Hard and Heavy Music

This study revealed that hard and heavy music can have three functions: as a source of meaning, as a source of tranquility, and as a source of expressing a sense of “self.

Meaning

One of the problems many young cancer patients face is losing the dreams they had for their future regarding matters such as family life, education and career. They may feel as though cancer has taken their dreams from them and, in so doing, their reason for living as they knew it.

This music has helped some participants realize that their dreams about their life were illusory, that life is full of unexpected events and that there is a lot of injustice and suffering in the world. Thinking in this way can help them to relax.

The case of Helen, who was diagnosed with breast cancer at 23, illustrates this function of hard and heavy music. As she explained, she felt alone and angry; cancer had robbed her of all her dreams and hopes. As a teenager, she had listened to hard and heavy music, but at the time she got cancer, she had not listened to this kind of music for some time. After treatment, she started listening to heavy metal music again.

Helen explained that this music helped her realize that her dreams about her life and the world were illusory, that life was not as just and sacred as she had once believed, that the world was full of injustice, and that people everywhere suffered from injustice, prejudice and discrimination. She explained that she began to understand that human life had no special meaning. This new outlook helped her stop regarding cancer as a “murderer” that had killed her life and her dreams. She explained:

I was very sad, but more than that, I was angry; I went around and asked why this had happened to me. Everything was okay before the cancer; I had a boyfriend, had started studying and was having a pretty good time. Before cancer, I had many plans. I was so depressed that I couldn't do anything. I bought some CDs and listened to them all the time; they were all heavy metal music, one was called “I Hate Therefore I Am,” another was “Children of Bodom”. These helped me see my life and my situation differently. I began to realize that it is no problem that I no longer have any dreams, ambition, and goals; that it was even good that I didn't see any special meaning to my life… This music gave me a new goal: to be goalless, to be different from ordinary people who stress themselves to death in order to reach a goal and again find another one to run after.

In Helen's case, finding a meaning in life meant finding her place in the world. The heavy metal music has helped her regulate her relationships with the people around her.

Tranquility

The experiences of some participants show that hard and heavy music can act as a positive coping strategy that helps them deal with the negative emotions caused by cancer. The study shows that, as expressed by Hargreaves, Miell and MacDonald (2002), hard and heavy music has functioned as a means of regulating mood.

Sara's experiences provide an excellent example of how hard and heavy music can act as a positive coping strategy. She was eight years of age when she got cancer. At around nine years of age, the cancerous tumor was removed, but this resulted in a visible handicap. During the entire treatment period and afterwards, she behaved not as a child but as an adult, trying to handle things in a calm and rational manner. Sara hid her sadness, fear and anger throughout her childhood. It was when she was being treated for depression that music became a way for her to cope with her feelings:

I was in a psychiatric clinic … I bought a CD-Walkman and walked around with it and listened to music … In certain periods, I listened a lot to punk rock; it was a way to be angry, to release all the feelings. You make the feeling more intense with the music, it is like it creates a resonance between the feelings and the music you hear, something like interplay between feelings and the music and it became easier to bear the feeling. Afterwards you feel kind of calm.

This quotation shows that hard and heavy music can have a harmonizing and relaxing effect, despite the fact that it is loud and abrasive and that its lyrics do not describe the beautiful side of humanity or depict any hope or a positive future for individuals or the world.

Hard and heavy music creates an imaginary world in which the patient can live far from the real one.

Source of Expressing a Sense of “Self”

Hard and heavy music may not only help a cancer patient get rid of his or her anger. It may also create an imaginary world in which the patient has a new identity. In such a case, the patient actually lives in two worlds: the real one, where (s) he is a humble cancer patient, and an invented one, where she/he is an aggressive person who destroys everything. The calmness comes afterwards.

One of the important effects of hard and heavy music seems to be providing an alternative avenue for self-expression for young people facing a life crisis. The study shows that, for some participants, hard and heavy music has functioned as a means of establishing and developing an individual sense of identity.

For Sara and Helen, hard and heavy music played the role of a coping method by opening the door to a world in which they could be themselves and could express their forbidden feelings. The music helped them achieve tranquility.

Sara explained the use of hard and a heavy music as follows:

The aggressiveness was good because everything felt so unfair; children are not supposed to think about death. Music is so alive, and it has so much comfort in it. I listened to aggressive music during the time I felt angry, and it was good, it was pleasant to show your feelings through the music. I got cancer when I was eight years old and I've got a handicap because of it. I showed myself as a good and calm child during the sickness, then as a teenager I tried to be like everyone else, pretended to be strong. But then suddenly it was enough. The music helped me for a while to show my anger and dissatisfaction, my real self.

As Sara's explanation of her childhood indicates, she has not yet found an opportunity to develop her self-identity, as her role as a sick child has taken over all other roles and identities she had or could have. The hard and heavy music became her coping method, a resource that helped her become strong enough to act against the sick role, which she felt had been ascribed to her for several years. She stressed that her handicap meant that the way others viewed her, as a sick person, did not cease, even after she had survived the cancer.

Helen explained that her self-image, as well as the picture others had of her, changed rapidly after the cancer diagnosis. Helen stressed that it was difficult to handle this change; the hard and heavy music she listened to during her illness was her rescue, because she pretended to be the person these songs addressed. She had the feeling that a new person was growing within her. She said that this music caused her anger, which had long been hidden, to resurface:

Many people around me cared about my body, but not my soul. I was the center of attention, but no one could see my real self. I should control my feelings; this was an unacceptable expectation from a young person.

Sara and Helen felt that other people perceived them as sick people. They understood this role as ascribing to them certain characteristics, such as dependency and obligatory acceptance of one's own situation. This understanding and evaluation of others’ view of their self gave rise to negative feelings, such as shame and humiliation, but also anger and resistance. It was within such circumstances that hard and heavy music came into the picture. Hard and heavy music helped them handle the conflict between their self-image as a “normal” person and the looking-glass self, which ascribed to them the sick role. Using the imaginary world that this music had created for them, they were then able to “come out” and express their “ideal self,” the self they wanted others to perceive.

It seems as though the hard and heavy music that Sara and Helen listened to did not become a means of masking their situation, but rather a means of preparing for a normal life, especially when they put the treatment period behind them and began to return to everyday life.

Summary and Further Remarks

The study shows the impact of using music as a coping method when facing serious life crises, such as being struck by cancer. Using the interviewees’ own words with regard to coping methods, it is possible to reach the following conclusions.

The music of nature gives a feeling of belonging to an immense whole – a feeling of the unity of existence. This feeling helps cancer patients see their problems as a natural part of life.

Healing music enhances the mind/body connection and enables patients to get in touch with their inner world.

Religious music and cheerful music can help patients achieve a balance in their inner feelings.

Hard and heavy music can help young cancer patients rid themselves of their anger and reconstruct their self-image. In such cases, the patient lives in an imaginary world in which he or she is a mean, aggressive person who destroys everything (Ahmadi, 2009, 2011; Ahmadi & Norberg, 2010).

Coping has an individual character (Ahmadi, 2006, p. 27; Pargament, 1997, p. 87), and the same applies to music. Certain music, such as hard and heavy music, may be useful for some individuals (Ahmadi, 2009; Arnett, 1996; Deyhle, 1998) and harmful for others, depending on the situation. Certain music can function positively as coping method and some negatively (for more discussion about positive and negative coping method, see Pargament, 1997). For instance, the strengthen of a faith by religious music can make that a person views her/his illness as a punishment for her/his sins and feels guilty (negative coping). For someone else, a strengthening of faith can bring about tranquility (positive coping) by making her/him see her/his illness as a test from God. Therefore, it is important to study what types of individual characteristics can make listening to different kinds of music either helpful or harmful.

As the study shows, regardless of whether the music is the music of nature, healing music, religious, “cheerful” or hard and heavy, it has played an important role as a coping method for informants diagnosed with cancer. By creating a new self-image, a new identity, music helped them identify with a situation different than the one in which they found themselves. Given the important role music has played in coping with cancer in the present cases, it is essential that cancer therapists and caregivers turn more of their attention to music. Furthermore, the significant role of art, especially music in health-related issues, must be recognized and more studies conducted in the research area of art and health.