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Karaoke Therapy in the Rehabilitation of Mental Patients
C M Leung, G Lee, B Cheung, E Kwong, Y K Wing, C S Kan, J Lau

INTRODUCTION

Karaoke, which literally means ‘without an orchestra’ is a form of entertainment first launched in Japan in the sixties. People sing with the microphone in unison with the music video in which the lyrics of a popular song are highlighted against a background of sceneries. The singing is then mixed with the background music by the ‘Karaoke’ device, producing a live, concert-like output. Either video cassette tape or laser disc can be used and the latest models of laser disc player are usually equipped with built-in karaoke function. Apart from providing background music, karaoke utilising laser discs also permits duo singing supported by the original professional singers. The commercial version of the device installed at karaoke lounges differs from the domestic version by its multiple terminals which operate through central control, allowing customers to sing in their sound-proof rooms. With karaoke, even the shy and socially inhibited, a characteristic of Asians like Chinese and Japanese, may became less restrained and join in with the singing. In the past ten years, the popularity of karaoke has grown rapidly, spreading across different cultures and social classes, including that of the West. It has established itself as a popular form of entertainment especially for informal social gatherings resulting in a rapid growth of karaoke lounges and associated industries in major Asian cities.

It is commonly observed that karaoke singing tends to bolster self image, decrease stage anxiety and encourage social interaction especially for anxiety prone persons. In our department at the Prince of Wales Hospital, karaoke has been used to provide an outlet for relaxation and fun for in and day patients since 1990. The use of music in the treatment of diseases of the mind and the body has been practiced since ancient times and has gained wide acceptance as a form of adjunct treatment in various fields of modern medicine(1-4). In view of the popularity of karaoke and its unique features as distinct from simple singing per se, we have ventured to look into its potential benefits for mental patients. In this paper, we describe a double blind study on the efficacy of karaoke against simple singing. Our experience with the therapy is also summarised.

METHOD

Subjects were day patients of the psychiatric rehabilitation centre at the Prince of Wales Hospital, a teaching hospital in Hong Kong. Only those who satisfied the following criteria were included in the present study: age between 17 and 50 years; a diagnosis of chronic schizophrenia according to DSMIIIR; stable mental state with remission of active positive symptoms for at least three months, and the ability to read and sing. Only schizophrenic patients were chosen as they formed the bulk of our clients at the centre. Exclusion criteria included negative attitude towards singing, organic brain damage and extreme mutism. Patients were then matched according to sex, age and duration of illness. They were randomly assigned to the karaoke and non-karaoke groups. Informed consent was obtained. Contracts were made with participants to complete the program and abstain from practising karaoke or group singing outside the training sessions.

An occupational therapist (GL) conducted all the training sessions. The index (karaoke) group sang karaoke while the controlled (non-karaoke) group practised simple singing. Each session lasted about forty-five minutes and there were two sessions a week. The songs and schedules were the same for both groups with both duos and solos performances before fellow patients at the rehabilitation centre.

RESULTS

A total of four matched pairs were recruited. All were males as no female patient met the admission criteria. There was no sign of relapse or change in medication during the study period. The mean age was 30.3 (sd 4.8) with a mean neuroleptics dosage of 431 mg (sd 573 mg) chlorpromazine equivalent. The mean duration of illness was 8.8 years (sd 7.2). The intra-class correlation coefficients for the test-retest reliability was good for the AAS (0.95) and acceptable for IA (0.78) and ISE (0.68).

No significant difference within the 2 groups was observed across all rating scales. Though improvement was found in all items of the modified NOSIE for both the karaoke and non-karaoke groups at the end of the sixth week, none reached statistical significance. The treatment difference between the 2 groups was found to be significant in 2 areas. Firstly, the karaoke group scored higher with the ‘Starts up a conversation with others’ of the modified NOSIE at the sixth week compared to the controlled group. Secondly, the karaoke group had increased score with Audience Anxiety while there was a decrease with the controlled group at the third week.

Hypothesis on the mechanism of karaoke

Karaoke singing could be envisaged as a form of behavioural therapy with elements of feedback, relaxation, assertiveness and social skill training. It excels simple singing in several aspects. With modern technology, the breath-holding audio-visual effect of karaoke serves as a powerful reinforcement for participants. The use of laser discs, Dolby system and surround sound stir up the atmosphere with surrealistic and hypnotizing effects. With lyrics shown on the video, even new songs can be mastered easily, camouflaging one’s inadequacy. This bears special importance in a Chinese society where there is social pressure to abide by the rules of propriety (shou li)(9) and where sanction against performing or showing off in public for fear of, among many other things, losing face (diao mian zi), prevail(10). Furthermore, while karaoke offers good chance for practising visual motor co-ordination (reading, listening and singing), it also provides the rare and excellent opportunity for projection and identification with one’s idols - favourite singers or actors. Besides, one also finds the occasion extremely relaxing by ventilating grievances that are often themes of pop songs. Finally, holding the microphone symbolises power and control, offering a sense of security. Psychodynamically, it satisfies phallic superiority in males and neutralises penis envy in females.

Directions for future research

Though having gained worldwide acceptance as a popular form of entertainment, karaoke has remained essentially an Asian product. To gain formal recognition as a form of behavioural therapy, more stringent research is required. The characteristics of clients benefiting most from the therapy, relative importance of various therapeutic components, optimal frequency of training sessions and duration of treatment remain to be sorted out. Long-term follow-up could establish any long- lasting therapeutic effects. Finally, we need cross-cultural studies to confirm its efficacy in other cultures. With further research and elaboration of the training technique, karaoke may serve a dual function of entertainment and treatment for mental patients in the future.

Correspondence to:
Dr C M Leung