Effect of Music Breathing, a Programme Based on Mindful Breathing and Music Therapy for Promoting Sense of Coherence in Young People: A Randomized Controlled Trial
Phase: NA
Conditions: Sense of Coherence
Sponsor: Tung Wah College

Study Protocol 
 
Title: Effect of Music Breathing, a programme based on mindful breathing and 
music therapy for promoting sense of coherence in young people: A randomized 
controlled trial  
 
Document Date  
29/11/2022 
 

Effect of Music Breathing, a programme based on mindful breathing and music 
therapy for promoting sense of coherence in young people: A randomized 
controlled trial  
  
Introduction  
 
Stress arises when individuals perceive that they are powerless to cope with the 
demands placed on them (Lazarus, 1993). Chronic stress may lead to physiological (Pan 
et al., 2015) and psychological illnesses (Chernomas & Shapiro, 2013): adversely 
impacting interpersonal relationship and quality of life (Ribeiro et al., 2018). Young 
people are vulnerable to stressors associated with academic challenges, work and 
relationships (Sagy & Braun-Lewensohn, 2009; Ribeiro et al., 2018). Currently, these 
challenges have been exacerbated by the effects of the covid-19 pandemic, which has 
increased concerns associated with academic challenges, financial burdens, 
relationships and uncertainty about the future (CDC, 2020). Current research has found 
that young people’s mental well-being was adversely affected and perceived more 
stress as the pandemic took hold in 2020 (Tang et al. 2021; Anwer et al., 2021).  
Coping with this stressful event has never been so imperative in order to maintain a 
healthy mental state in young people.   
According to Lazarus and Folkman’s Stress, Appraisal, and Coping Theory (1984), 
the type of coping strategy is influenced by the evaluation of options for coping, 
referred to as ‘secondary appraisal’ (Lazarus & Folkman, 1984). Secondary appraisal 
involves evaluation of the personal resources or coping strategies that can be used to 
manage situations. Therefore, the results of secondary appraisal will determine the 
coping strategies in the form of behavioural actions, which in turn influence individuals’ 
emotional responses and mental well-being. Individuals with personal resources that 
can facilitate positive coping strategies and behaviours are therefore more adaptive to 
stressful situations. Sense of coherence (SOC) can be considered as a personal resource 
important to resolve stress and tension (Ängarne-Lindberg & Wadsby, 2011). SOC is 
defined as an enduring tendency individuals view life is comprehensible, manageable 
and meaningful (Antonovsky, 1993). It is a central component of the Salutogenic Model 
which plays a great emphasis on the role of personal resources and positive qualities in 
promoting well-being (Antonovsky, 1993). Therefore, a person with a strong SOC is 
more likely to perceive stressful situations less threatening and can mobilize resources 
that are available to promote well-being.  Further, Posadzki, and Glass (2009) argued 
that the sense of manageability and meaningfulness in SOC is corresponded to the 
behavioral and emotional components, respectively, of self-efficacy in Bandura’s Self-
Efficacy Theory (1977).  According to Bandura’s (1977), self-efficacy is the 
confidence in one’s ability to successfully complete a task. These two approaches 

reflect a common feature is that people who have strong beliefs in their capabilities to 
tackle life events as challenges rather than threats (Posadzki, & Glass, 2009). The 
stronger SOC may engender the individuals’ confidence to manage daily hassles, and 
hence increase the coping self-efficacy.  Coping self-efficacy can be termed as the 
confidence of an individual in their ability to effectively cope with the potential threats 
(Luzzo & McWhirter, 2001). SOC could be a component in the process of secondary 
appraisal that influences the coping options and enhances self-efficacy of coping in 
meeting the demands from the environments.  
To this end, SOC is therefore considered as a personal resource that can facilitate 
individuals to use resources available to manage stressful situations (Eriksson et al., 
2017) and promote resilience against adversities (Mayer, 2011).  In fact, previous 
studies with young people showed that SOC is associated with their quality of life, 
health behaviour, and mental health (Länsimies et al., 2017). It has been noted that SOC 
has a mediating effect between perceived stress and health status (Jeong & Koh, 2021), 
and a better SOC is associated with positive coping styles (Konaszewski et al., 2019). 
Furthermore, SOC and self-efficacy are closely related constructs in the context of self-
management of chronic disease (Hourzad et al., 2018). Therefore, young people with a 
strong SOC may be more likely to perceive stressful situations less threatening and can 
facilitate coping strategies to cope with stressors, and thus attain a better mental well-
being.  
 
The proposed intervention 
 
The proposed intervention, namely, music breathing (MB), was developed by Dag 
Körlin (co-investigator [Co-I] of the proposed study) as an adaptation of the Bonny 
Method of Guided Imagery and Music (GIM) (Bonny, 1975). As founded by Helen 
Bonny, GIM is an ‘in-depth approach to music psychotherapy in which specifically 
programmed classical music is used to generate a dynamic unfolding of inner 
experiences’ (Goldberg, 1995, p. 112). In GIM, music is used to evoke imagery and 
acts as a ‘container’ for the imagery experience. The therapist uses music with enough 
variability to stimulate flow and movement during the imagery experience, but avoids 
using excessive variability that would dysregulate the ANS. During the session, the 
therapist provides grounding and focus through an ongoing active dialogue with the 
client. The music used in GIM serves as a link between the self and the outer 
consciousness, and aspects of musical language, such as rhythm, melody and timbre, 
can enhance the feelings and imagery that arise from the unconscious self (Maack, 
2012). GIM could allow individual to get into their previous emotions that require 
further processing; accordingly, it can help people to reconnect the non-integrated self 
during deep music listening, as the inner resources become conscious (Goldberg, 1995). 

 
Although GIM was developed mainly for people with traumatic stress and ANS 
dysregulation, MB can be used by people without dysregulation, including those 
experiencing adjustment disorders and developmental crises and those seeking self-
actualisation. The aim of MB is to help the person to learn affect regulation through 
breathing while listening to selected pieces of music (Körlin, 2019b).  
 
Exposure to a threat or stress is known to arouse the autonomic system. Stress 
reduction involves the parasympathetic system, which cooperates with the sympathetic 
system to regulate arousal and autonomic activity. These two systems converge in the 
right medial orbitofrontal cortex (mPFC) to coordinate cognitive functions, including 
perception, decision making and emotional regulation via the lateral-, dorsal-ventral 
and vertical integration of whole-brain functions. Through breathing exercises, MB 
emphasises the vertical integration of the ANS, which coordinates the orbitofrontal 
region to facilitate emotional regulation of the limbic system and regulation of the ANS 
in the brain stem (Körlin, 2019a, 2019b). 
 
During MB, forceful music can be used because the window of tolerance (WoT) 
increases when using meditative breathing. WoT refers to the zone in which one’s 
nervous system can regulate and handle stressors in life (Siegel, 1999a). Each person is 
assumed to have a WoT that enables them to process and control their thoughts, 
emotions and images. This concept of the WoT is crucial for managing the stages of 
MB, namely the grounding, modulation and working stages (Körlin, 2008). The 
selection of music depends on the stage experienced by the individual and involves 
matching two dimensions: 1) the state of arousal and level of intensity, and 2) the degree 
of harmonic modulation and other musical transformations. The guiding principle is to 
identify the musical arousal level that the client can tolerate without dysregulation. Any 
changes in the harmonic progression and rhythmic variations may lead to emotional 
modulation. Music that is highly repetitive in terms of the melody, harmony, rhythm or 
other music elements tends to hold arousal at a steady level. In other words, the aim of 
MB is to initially stabilise the client in a comfortable zone of arousal, and then to 
explore different qualities and degrees of modulation. The selected music must be 
maintained with a steady rhythm and tempo it attunes with the breath (Körlin, 2019a, 
2019b). 
 
Dag Körlin, the Co-I of proposed study, has applied MB to clients with adjustment 
disorders and prolonged grief, and to those seeking self-actualisation. The initial 
findings from nine case studies demonstrated that patients with PTSD experienced 
reductions in depression–anxiety symptoms and stress levels after 15–20 weekly 
sessions (Körlin, 2019b). Körlin (2019b) also reported that MB yielded clinically 
significant reductions in chronic dissociative symptoms such as flashbacks, anxiety and 
fear. 

 
During MB, the level of emotional response can be regulated by intentionally 
controlling breathing during periods of silence and listening to music. Breathing acts 
like a ‘volume knob’ to regulate the level of arousal and quality of consciousness. By 
varying the depth and pace of breathing, one can control arousal from moment to 
moment. Through breathing, the autonomic functions can be regulated. Based on the 
above theoretical discussions, we hypothesise that a programme, namely, music 
breathing (MB), can reduce stress, foster the self-regulation of emotions and facilitate 
the development of awareness and personal strength, as a result, leading to improved 
emotional well-being.   
 
Based on the above theoretical discussions, we hypothesise that the MB programme 
can facilitate the promotion of SOC leading to better coping, reduced stress and better 
mental well-being.  Fig. 1 shows the conceptual framework of the study. In the 
proposed study, the efficacy of a music breathing programme (MB) will be tested using 
a randomised controlled trial design. The hypotheses of the proposed study are as 
follows: 
H1: People who receive the MB programme will have better SOC, emotion regulation, 
coping self-efficacy and mindfulness than those receiving the control condition. 
H2: People who receive the MB programme will have reduced stress-related symptoms 
and better physiological outcome, i.e., salivary cortisol levels than those receiving 
the control condition. 
H3: People who receive the MB programme will have better mental well-being than 
those receiving the control condition. 
H4: There is an association between SOC, coping self-efficacy, emotion regulation and 
mindfulness. 
Study design. We will conduct a two-arm, parallel randomised controlled trial (RCT) 
to evaluate the effects of the MB programme. Randomisation involving computer-
generated two-digit random numbers (even and odd) (Excel 2007, Microsoft, Redmond, 
WA, USA) will be used to allocate participants in sequence to either the intervention 
group or control group in a 1:1 ratio after they have provided consent to participate. 
The allocation will be blinded to the participants and the data analyst. The random 
allocation will be conducted by a research assistant who will not be involved in the 
intervention and data analysis. Participants in the experimental arm will receive a 6-
week MB programme. Participants in the control arm will receive a 6-week placebo 
control programme and will be blinded to the study details. Data will be collected from 
both groups at three time points: before-intervention (T0), after-intervention (week 6; 
T1) and 1-month follow-up (week 10; T2), except the salivary cortisol levels which will 
be assessed at T0 and T1. Figure 2 depicts the flow of the study. 
Subject recruitment. The participants will be recruited from universities and district 

centres through emails, social media, leaflets and posters. Inclusion criteria: young 
people (aged 18 to 30); moderate level of stress (Perceived Stress Scale (PSS-10) score 
>14-26/40); a liking for music. Exclusion criteria: participants diagnosed with an acute 
mental problem; participants under the influence of drugs that affect the nervous system; 
having previous experience with imagery evoked by music and meditations where 
music is played.   
Sample size. The estimated sample size has been calculated using the statistical package 
G*Power 3.1.9.4 (version 2019) for a multivariate analysis of variance (MANOVA) 
according to the effect size (Cohen’s d) (between 0.43 and 0.59) of anxiety in previous 
study on group music-guided imagery (Torres et al., 2018). When converting to a 
repeated measure (Cohen’s f), the effect size is considered moderate (f = 0.25), with a 
type I error rate of 5% (2-sided) and assuming a correlation of 0.5 between repeated 
measures. To achieve 90% power to measure outcome three times in two groups, 232 
subjects (n=116 per group) will be required (Cohen, 1988). Assuming a 20% attrition 
rate (Porter et al., 2012), the trial will require at least 145 participants starting in each 
arm. We target to complete the recruitment process within 20 weeks; therefore, an 
average rate of recruitment about 14 subjects per week is anticipated. It might be 
possible to shorten the recruitment period if the threat posed by the pandemic weakens. 
Experimental group. The experimental group will receive the MB programme in 6 
weekly sessions (each session lasts 2 hrs in a group of 6 participants) delivered in a 
confined and quiet room on the campus, plus a session of home practice on a weekly 
basis. The study intervention will be delivered by a certified music therapist who has 
been trained by the Co-I, Dag Körlin. At the beginning of the first session, information 
on the concept of mindfulness will be delivered. The MB will comprise three 
components, including therapist-guided meditative breathing, breathing with music 
listening, drawing a mental image of the breathing practice with a circle as a reference 
and sharing and processing of the experience (Körlin, 2019). The detail of the study 
intervention is presented in Table 1. Home practice will be carried out according to a 
weekly schedule during the 6-week intervention; the participants will record the 
frequency and duration of home practice: mindful breathing, music listening and 
drawing images. In the orientation during the first week, the participants will be asked 
to work out a plan for implementing home practice and to complete an online schedule 
during the subsequent weeks. To increase the compliance rate, they will also receive 
reminders to perform their home practice via WhatsApp messages or email. The 
research team will monitor the participants’ progress, provide motivation and 
encouragement to continue the home practice. 
Control group.  

Participants (6-8 participants per group) will receive a 30-minute Mental Health 
Education Programme (MHE) in the first meeting (week 1) and second meeting (week 
6). The content of the MHE is adopted from the Student Health Service, Department of 
Health, HKSAR. The MHE is comprised of the following topics:   
What is Stress? 
https://www.studenthealth.gov.hk/english/health/health_ph/health_ph_stress.html); 
Tips on Being Joyful 
(https://www.chp.gov.hk/archive/joyful/en/contentsab5e.html?id=40); 
Breathing Exercise practice 
(https://www.studenthealth.gov.hk/english/emotional_health_tips/eht_re/eht_re.html); 
and  
Music listening.  
A take home kit which consists of the fact sheet information of the health talk and the 
video link of the breathing exercise and musical pieces will be provided to the 
participants after the first meeting. They are instructed to practice the breathing 
exercise and listening to the musical pieces at home. A weekly reminder via 
WhatsApp message and email will be sent to the participants to enhance their 
compliance.  In the second meeting, participants will receive the revision talk about 
on the MHE and share their experience in stress management with the group 
members.   
 
Treatment Fidelity. To ensure treatment fidelity, the certified music therapist will have 
at least 25 hours of MB programme training; the implementation of the intervention 
will be supervised by Dag Körlin, the Co-I. The group sessions will be audio-taped with 
the consent of the participants, and the recordings will be given to the supervisor for 
quality monitoring. Written session reports will be provided and regular meetings via 
Zoom (i.e., three supervisions in the first group, and then two supervisions in the 
subsequent groups) will be arranged for maintaining the quality of the intervention. The 
research team will discuss any issues that may arise regarding the study protocol to 
ensure the quality and consistency of study intervention via regular face-to-face or 
online meetings.  
Measures. Primary and secondary measures will be collected at before-intervention 
(T0), after-intervention (week 6; T1) and 1-month follow-up (week 10, T2) via a self-
administered questionnaire. The salivary cortisol levels will be collected at T1.  
Primary outcome 
Sense of coherence. The 13-item Chinese version of the Sense of Coherence Scale (C‐
SOC‐13) (Ding et al., 2012) will be used to measure the comprehensibility, 
manageability and meaningfulness of the participants’ lives (Antonovsky, 1993). This 

scale is scored on a 7-point semantic scale with two anchoring phrases, ranging from 1 
(very poor) to 7 (very strong). The higher mean score represents a greater sense of 
coherence. The original SOC-13 was shown to have high internal consistency 
(Cronbach’s α = .74 – .91) (Antonovsky, 1993). 
Secondary outcomes 
Coping self-efficacy. The Coping Self-Efficacy Scale (CSES) is used to measure a 
person’s confidence in their ability to cope effectively with stress (Chesney et al. 2006). 
It is a 13-item scale with three subscales: (1) use problem-focused coping, (2) stop 
unpleasant emotions, and (3) seek support from friends and family. The CSES has 
strong reliability (α = 0.79–0.92) and concurrent validity. It is rated on an 11-point scale 
on which the participant believes they could perform the behaviour. The anchor points 
range from 0 (cannot do at all), to 10 (certain can do). Higher scores indicate higher 
levels of coping self-efficacy.  
Emotion regulation. The Difficulties in Emotion Regulation Scale (DERS) is used to 
assess the ability to regulate emotions (Gratz & Roemer, 2004). It contains a total scale 
score (36 items) and six factors including nonacceptance of emotional response, 
difficulties in engaging in goal-directed activity, impulse control difficulties, lack of 
emotional awareness, limited access to emotion regulation strategies, and lack of 
emotional clarity. Items are measured on a 5-point Likert-type scale from 1 (almost 
never) to 5 (almost always), with higher values indicating difficulty in emotion 
regulation. 
Mindfulness. The 15-item Mindful Attention Awareness Scale (MAAS) (Chinese 
version) will be used to assess attentiveness to and awareness of experiences in the 
present moment (Deng et al., 2012). This scale is scored from 0 (almost always) to 6 
(almost never); a higher mean score reflects a higher level of mindfulness. The internal 
consistency of the scale is good (coefficient of reliability > .82).  
Depression, anxiety and stress. The 21-item Depression Anxiety Stress Scales (DASS-
21) (Chinese version) comprise 21 statements on three components: (a) depression, (b) 
anxiety and (c) stress (Lovibond & Lovibond, 1995). The scales are scored using a 4-
point Likert scale with response options from 0 (does not apply to me at all) to 3 (applies 
to me very much, or most of the time). The internal consistency has been demonstrated 
to be good (Cronbach’s  values: Depression = .88, Anxiety = .75, and Stress = .81). 
Subjective general well-being. The 24-item BBC Subjective Well-being Scale (BBC-
SWB) will be used to measure the participants’ subjective experiences of general well-
being (Pontin et al., 2013). It measures three components: psychological well-being, 
physical health and well-being and relationships with good internal consistency 
(Cronbach’s α = .94) and concurrent validity (r = .640 -  .80) (Pontin et al., 2013). The 
scale is scored using a 5-point Likert-scale. 

Salivary cortisol: Salivary cortisol levels (sCort) will be used as a biomarker of 
psychological stress. sCort is considered a reliable measure of hypothalamus pituitary 
adrenal axis (HPAA) adaptation to stress and correlates well with plasma cortisol (Nater 
et al., 2013). Average sCort levels in healthy subjects are 5.52 - 28.92 nM/l in the 
morning; 1.10 - 11.32 nM/l in the afternoon (Bozovic et al., 2013). sCort is stable for 
several days, non-invasive and easily obtained without adding stress to subjects 
(Bozovic et al., 2013), and so is suitable for this study in which the participants are 
required to provide multiple samples at home. Samples will be collected from saliva 
using Cortisol Salivary Test kits and analysed using a commercially available enzyme-
linked immunoassay (eNano Health). Participants will be asked to provide 2 samples: 
0700–0800 h and 1600–1700 h to avoid meals within 60 min of providing each sample 
and to avoid caffeine-containing food and drink during the two days of sampling. 
Participants will be instructed to keep the samples in an envelope and send to the 
laboratory for analysis. 
Demographic information. A self-developed questionnaire will be used to collect 
demographic information about the participants, including age, gender, educational 
level, religious beliefs and practices, socioeconomic status and coping behaviour. The 
latter will be assessed using the Brief Cope Inventory (COPE) (Carver, 1997). 
Statistical analysis. The statistical analysis will be performed in accordance with the 
study design, RCT with an intention-to-treat analysis using SPSS, Version 26. The 
baseline characteristics of the participants in the two arms will be compared to identify 
any clinically meaningful differences at baseline and at each time point using Chi-
square test (for nominal data), Mann-Witney U test (for ordinal or non-normality data) 
or t-test (for normality data). Any variables considered to be significantly different will 
be further evaluated (e.g., included as covariates in the statistical analyses) and adjusted 
to account for their potential confounding effects on the outcomes. To measure both the 
primary and secondary outcomes, we will obtain repeated measures of multiple 
outcomes in the two groups, and the data will be analysed using a multivariate approach, 
such as a MANCOVA or Generalized Estimating Equation (GEE), with adjustment of 
the baseline outcome variables to test for between-group differences. Correlation 
analyses will be performed to determine the relationships among the dependent 
variables. Regression analyses and ANOVA will be conducted to assess significant 
differences in the effects of the demographic variables on each outcome variable.  
Repeated measures of ANOVA will be performed to explore the levels of sCort 
differing within subjects and between groups; between the two sampling days (day) and 
across the five sampling times (time). Path analyses will be conducted to test the 
mediating effects between stress-related symptoms and personal strength and emotional 
regulation. Sub-group analyses will be conducted according to categorisations such as 

gender, coping style and religion.  
Ethical considerations. Ethical clearance will be sought prior to the study from the 
study institution. Consent will be obtained and anonymity ensured to protect privacy. 
Participants will receive study information and have autonomy to withdraw from the 
study at any time.  
Significance of the study. The call to investigate effective strategies for stress 
management and improved mental well-being among young people has been prominent 
in this decade, particularly during the global pandemic period. The findings from the 
proposed study are expected to provide support for the potential benefits of a therapy 
option that integrates mindful breathing and music therapy with the intent to engender 
SOC in coping with stress in young people. The results will add knowledge of SOC to 
the stress and coping process and support the advancement of stress reduction-related 
knowledge. The findings will advance the level of professional knowledge, thus 
supporting researchers, health care professionals and policymakers who plan, 
implement and evaluate public health services and improve teaching and learning. 
While the MB programme requires professionally trained music therapists for delivery, 
the skills can be learned and practised by the participants. This therapy option provides 
an opportunity for young people to learn the techniques and benefit from the long-term 
effect of this intervention. In the long run, young people will have improved ability to 
cope with stressors in their everyday lives and will experience fewer psychological 
burdens and better health. Furthermore, in an era where the headlines seem dominated 
by war, plague and global warming, acquiring a coping skill that can be self-practised 
echoes the social distancing and reduce the demand for healthcare services. For young 
people, improved mental well-being can facilitate a healthy transition into adulthood 
and should yield promising results throughout their lives. These individuals are key 
contributors to the workforce and will contribute to economic growth and a positive 
societal environment. 
 
References 
Antonovsky, A. (1979). Health, stress, and coping. New perspectives on mental and 
physical well-being, 12-37. 
Antonovsky, A. (1990). Pathways leading to successful coping and health. 
Antonovsky, A. (1993). The structure and properties of the Sense of Coherence Scale. 
Soc Sci Med, 36(6), 725-733) 
Antonovsky, A. (1996). The salutogenic model as a theory to guide health 
promotion. Health promotion international, 11(1), 11-18.  
Ängarne-Lindberg,T. & Wadsby,M.(2011).Sense of Coherence in Young Adults With 
and Without 
Experience of Parental 
Divorce in Childhood. J 
Divorce 
Remarriage,52(5),309–321. 
Anwer, S., Li, H., Antwi-Afari, M. F., Shaphe, M. A., Alghadir, A., & Wong, A. Y. 
(2021). Evaluation of sleep habits, generalized anxiety, perceived stress, and research 
outputs among postgraduate research students in hong kong during the coronavirus 

(COVID-19) pandemic. Journal of Multidisciplinary Healthcare, 14, 3135. 
Bandura, A. (1977). Self-efficacy: toward a unifying theory of behavioral 
change. Psychological review, 84(2), 191. 
Bonny, H. (1975). Music and consciousness. Journal of Music Therapy, 12(3), 121-135 
Bozovic, D., Racic, M., & Ivkovic, N. (2013). Salivary cortisol levels as a biological 
marker of stress reaction. Med Arch, 67(5), 374-377. 
Brabant, Olivier, & Erkkilä, Jaakko. (2018). Enhancing improvisational music therapy 
through the addition of resonance frequency breathing: Common findings of three 
single-case experimental studies. Music Therapy Perspectives, 36(2), 224–233.  
Carver, C. S.  (1997).  You want to measure coping but your protocol’s too 
long:  Consider the Brief COPE. International Journal of Behavioral Medicine, 4, 92-
100 
CDC. 
(2020). 
How 
COVID-19 
spreads. 
Retrieved 
from 
https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-
spreads.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%
2F2019-ncov%2Fprepare%2Ftransmission.html.  
Chernomas, W. M., & Shapiro, C. (2013). Stress, depression, and anxiety among 
undergraduate nursing students. International journal of nursing education scholarship, 
10(1), 255-266. 
Chesney, M. A., Neilands, T. B., Chambers, D. B., Taylor, J. M., & Folkman, S. (2006). 
A validity and reliability study of the coping self‐efficacy scale. British journal of 
health psychology, 11(3), 421-437.  
Cho, H., Ryu, S., Noh, J., & Lee, J. (2016). The effectiveness of daily mindful breathing 
practices on test anxiety of students. PloS one, 11(10), e0164822. 
Cohen, J. (1988). Power analysis for the behavioral sciences. L Erlbaum, Hillsdale. 
de Witte M, Pinho A da S, Stams G-J, Moonen X, Bos AER, van Hooren S. (2020). 
Music therapy for stress reduction: a systematic review and meta-analysis. Health 
Psychology Review. November 2020:1-26. doi:10.1080/17437199. 1846580  
Deng, Y. Q., Li, S., Tang, Y. Y., Zhu, L. H., Ryan, R., & Brown, K. (2012). Psychometric 
properties of the Chinese translation of the mindful attention awareness scale 
(MAAS). Mindfulness, 3(1), 10-14.  
Ding, Y., Bao, L. P., Xu, H., Hu, Y., & Hallberg, I. R. (2012). Psychometric properties 
of the Chinese version of Sense of Coherence Scale in women with cervical 
cancer. Psycho‐Oncology, 21(11), 1205-1214. 
Eckhardt, K. J., & Dinsmore, J. A. (2012). Mindful music listening as a potential 
treatment for depression.J. Creat. Ment. Health, 7, 175–186.  
Eriksson, M. (2017). The sense of coherence in the salutogenic model of health. The 
handbook of salutogenesis, 91-96.  
Feldman, G., Greeson, J., & Senville, J. (2010). Differential effects of mindful 
breathing, progressive muscle relaxation, and loving-kindness meditation on 
decentering and negative reactions to repetitive thoughts. Behaviour research and 
therapy, 48(10), 1002-1011.  
Forsberg, K. A., Björkman, T., Sandman, P. O., & Sandlund, M. (2010). Influence of a 
lifestyle intervention among persons with a psychiatric disability: A cluster 
randomised controlled trail on symptoms, quality of life and sense of 
coherence. Journal of clinical nursing, 19(11‐12), 1519-1528.  
Gratz,K.L.& Roemer,L.(2004).Multidimensional assessment of emotion regulation and 
dysregulation:Development,factor structure, and initial validation of the difficulties in 
emotion 
regulation 
scale. Journal 
of 
psychopathology 
and 
behav 
assessment,26(1),41-54. 
Gross, J. J., & Thompson, R. A. (2007). Emotion regulation: conceptual foundations. 
In J. J. Gross (Ed.), Handbook of emotion regulation (pp. 3–27). New York: Guilford. 
Hillecke, T., Nickel, A., & Bolay, H. V. (2005). Scientific perspectives on music 
therapy. Ann NY Acad Sci, 1060(1), 271-282. 
Hourzad, A., Pouladi, S., Ostovar, A., & Ravanipour, M. (2018). The effects of an 
empowering self-management model on self-efficacy and sense of coherence among 
retired elderly with chronic diseases: a randomized controlled trial. Clinical 
interventions in aging, 13, 2215. 

Jensen, J. F., Egerod, I., Bestle, M. H., Christensen, D. F., Elklit, A., Hansen, R. L., ... 
& Overgaard, D. (2016). A recovery program to improve quality of life, sense of 
coherence and psychological health in ICU survivors: a multicenter randomized 
controlled trial, the RAPIT study. Intensive care medicine, 42(11), 1733-1743.  
Jeong, Y. J., & Koh, C. K. (2021). Female nursing graduate students’ stress and health: 
the mediating effects of sense of coherence and social support. BMC nursing, 20(1), 
1-7. 
Jerath, R., Crawford, M. W., Barnes, V. A., & Harden, K. (2015).Self-regulation of 
breathing as a primary treatment for anxiety. Appl Psychophysiol Biofeedback., 40(2), 
107-115. 
Kekäläinen, T., Kokko, K., Sipilä, S., & Walker, S. (2018). Effects of a 9-month 
resistance training intervention on quality of life, sense of coherence, and depressive 
symptoms in older adults: randomized controlled trial. Quality of life research, 27(2), 
455-465.  
Konaszewski, Karol, Kolemba, Marcin, & Niesiobędzka, Małgorzata. (2019). 
Resilience, sense of coherence and self-efficacy as predictors of stress coping style 
among university students. Current Psychology (New Brunswick, N.J.), 40(8), 4052-
4062. 
Körlin, D. (2008). Music Breathing Breath Grounding and Modulation Of The Bonny 
Method Of Guided Imagery And Music (BMGIM). J of the Association for Music & 
Imagery, 11.  
Körlin, D. (2019). Music Breathing. In K. E. Bruscia & D. E. Grocke: GIM the Bonny 
Method and Beyond, second edition. Gilsum:NH. Barcelona Publishers. 
Körlin,D.& Wrangsjö, B (2002).A neuropsychological theory of traumatic imagery in 
the Bonny Method of Guided Imagery and Music (BMGIM). In K. E. Bruscia & D. 
E. Grocke (Eds.), Guided Imagery and Music: The Bonny Method and Beyond. 
Gilsum, NH: Barcelona Publishers. 
Korsakova-Kreyn, M., & Dowling, W. J. (2014). Emotional processing in music: Study 
in affective responses to tonal modulation in controlled harmonic progressions and 
real music. Psychomusicology: Music, Mind, and Brain, 24(1), 4. 
Kwok, S. Y. (2019). Integrating positive psychology and elements of music therapy to 
alleviate adolescent anxiety. Research on Social Work Practice, 29(6), 663-676. 
Länsimies, H., Pietilä, A. M., Hietasola‐Husu, S., & Kangasniemi, M. (2017). A 
systematic review of adolescents’ sense of coherence and health. Scandinavian 
journal of caring sciences, 31(4), 651-661.  
Lazarus, R. S. (1993). Coping theory and research: Past, present, and future. 
Lazarus,R.S.,&Folkman,S.(1984). Stress,appraisal, and coping. NY. Springer 
publishing co. 
Liu,H., Gao, X., & Hou,Y.(2019).Effects of mindfulness-based stress reduction 
combined with music therapy on pain, anxiety, and sleep quality in patients with 
osteosarcoma. Braz J Psychiatry,41,540-5. 
Loo, L. M., Prince, J. B., & Correia, H. M. (2020). Exploring mindfulness attentional 
skills acquisition, psychological and physiological functioning and well-being: Using 
mindful breathing or mindful listening in a nonclinical sample. PsychoMcol, 30(3), 
103.  
Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: 
Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck 
Depression and Anxiety Inventories. Behaviour research and therapy, 33(3), 335-343. 
Luzzo,D.A.,&McWhirter,E.H.(2001).Sex and ethnic differences in the perception of 
educational and career‐related barriers and levels of coping efficacy. J Couns 
Dev,79(1),61-67.  
McKinney, C. H, & Honig, T. J. (2017). Health Outcomes of a Series of Bonny Method 
of Guided Imagery and Music Sessions: A Systematic Review. J. Music Ther., 54(1), 
1-34.  
Miranda, D. (2019). A Review of Research on Music and Coping in 
Adolescence. Psychomusicology, 29(1), 1–9. https://doi.org/10.1037/pmu0000229 
Moore, K. S. (2013). A systematic review on the neural effects of music on emotion 
regulation: implications for music therapy practice. Journal of music therapy, 50(3), 

198-242.  
Nammontri, O., Robinson, P. G., & Baker, S. R. (2013). Enhancing oral health via sense 
of coherence: a cluster-randomized trial. Journal of dental research, 92(1), 26-31.  
Nater, U. M., Skoluda, N., & Strahler, J. (2013). Biomarkers of stress in behavioural 
medicine. Current opinion in psychiatry, 26(5), 440-445. 
Pan, Y., Cai, W., Cheng, Q., Dong, W., An, T., and Yan, J. (2015). Association between 
anxiety and hypertension: a systematic review and meta-analysis of epidemiological 
studies. Neuropsychiatr. Dis. Treat. 11, 1121–1130. doi: 10.2147/NDT.S77710 
Pérez Lloret, S., Diez, J. J., Domé, M. N., Alvarez Delvenne, A., Braidot, N., Cardinali, 
D. P., & Vigo, E.(2014). Effects of different" relaxing" music styles on the autonomic 
nervous system. 
Pontin, E., Schwannauer, M., Tai, S., & Kinderman, P. (2013). A UK validation of a 
general measure of subjective well-being: the modified BBC subjective well-being 
scale (BBC-SWB). Health and Quality of Life Outcomes, 11(1), 1-9. 
Porter, S., Holmes, V., McLaughlin, K., Lynn, F., Cardwell, C., Braiden, J., Doran, J. 
& Rogan, S. (2012). Music in mind, a randomized controlled trial of music therapy 
for 
young 
people 
with 
behavioural 
and 
emotional 
problems: 
study 
protocol. J. Adv. Nurs., 68(10), 2349-2358. 
Posadzki, P., & Glass, N. (2009). Self-efficacy and the sense of coherence: narrative 
review and a conceptual synthesis. TheScientificWorldJOURNAL, 9, 924-933. 
Raglio, A., & Oasi, O. (2015). Music and health: what interventions for what 
results? Front. Psychol., 6, 230. 
Ribeiro, Í. J., Pereira, R., Freire, I. V., de Oliveira, B. G., Casotti, C. A., & Boery, E. N. 
(2018). Stress and quality of life among university students: A systematic literature 
review. Health Professions Education, 4(2), 70-77.  
Saarikallio, S., & Erkkilä, J. (2007). The role of music in adolescents’ mood regulation. 
Psychology of Music, 35, 88–109.  
Sagy, S.,& Braun-Lewensohn,O.(2009). Adolescents under rocket fire: when are 
coping resources significant in reducing emotional distress?.Global Health Promotion, 
16(4),5-15. 
Seppälä, E. M., Nitschke, J. B., Tudorascu, D. L., Hayes, A., Goldstein, M.R. Nguyen, 
D.TH, Perlman, D. & Davidson, R. J. (2014). Breathing‐based meditation decreases 
posttraumatic stress disorder symptoms in US Military veterans: A RCT longitudinal 
study. J. Trauma. Stress, 27(4), 397-405. 
Siegel, DJ. (1999). The developing mind. New York: Guilford Press; 394p. 
Siegel, DJ. (2001). Toward an interpersonal neurobiology of the developing mind: 
Attachment relationships, "mindsight" and neural integration. Infant Mental Health 
22, 67-94.  
Siegel, DJ. (2006). An interpersonal neurobiology approach to psychotherapy. 
Psychiatr Ann. 36: 248-256. 
Siegel, D.J. (2007). Reflections on the mindful brain. The Mindful Brain: Reflection 
and Attunement in the Cultivation of Well-Being, 17(3), 166-168. 
Siegel, DJ. (2010). Mindsight: The new science of personal transformation. NY: 
Bantam Books. 
Siegel, D.J. (2019). The mind in psychotherapy: An interpersonal neurobiology 
framework for understanding and cultivating mental health. Psychology and 
Psychotherapy, 92(2), 224–237. https://doi.org/10.1111/papt.12228 
Segal, Z. V., Williams, J. M. G., & Teasdale, J. (2002). Mindfulness cognitive therapy 
for depression. A new approach to preventing relapse. New York: Guilford.  
Stegemann, T., Geretsegger, M., Phan Quoc, E., Riedl, H., & Smetana, M. (2019). 
Music therapy and other music-based interventions in pediatric health care: An 
overview. Medicines, 6(1), 25.  
Super, S., Wagemakers, M. A., Picavet, H. S., Verkooijen, K. T., & Koelen, M. A. (2016). 
Strengthening sense of coherence: Opportunities for theory building in health 
promotion. 
Health 
Promotion 
Interventions, 
31(4), 
869–878. 
doi:10.1093/heapro/dav071 
Tang, A.C.Y., Kwong, E.W.Y., Chen, L.Y., & Cheng, W.L.S. (2021). Associations 
between demographic characteristics, perceived threat, perceived stress, coping 

responses and adherence to COVID-19 Prevention Measures among Healthcare 
Students in China: A Cross-Sectional Survey with Implications for the Control of 
COVID-19. Journal of Advanced Nursing doi: http://doi.org/10.1111/jan.14889 
Torres, E., Pedersen, I. N., & Pérez-Fernández, J. I. (2018). Randomized trial of a group 
music and imagery method for women with fibromyalgia. J of Music Therapy, 55(2), 
186-220. 
Zaccaro, A., Piarulli, A., Laurino, M., Garbella, E., Menicucci, D., Neri, B., & 
Gemignani, A. (2018). How breath-control can change your life: a systematic review 
on psycho-physiological correlates of slow breathing. Frontiers in human 
neuroscience, 12, 353. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
            
 
                     
 
 
            
 
    
 
 
   
 
 
 
 
 
 
 
          
      
Fig. 1   Conceptual Framework of the study 
 
Music 
Breathing 
Programme 
Sense of Coherence  
Depression, anxiety, 
and stress 
 
Salivary cortisol level 
 
Mental well-being 
Coping self-efficacy 
Emotion regulation 
Mindfulness 
Theory of Stress, Appraisal, and Coping 
Framework of interpersonal neurobiology 
   
Music therapy 
Mindful breathing 
 
 
 
 
 
 
 
 
Analyzed (n=   
) 
Excluded from analysis, give reasons (n=  ) 
Follow-Up 
at week 7 
Allocation  
Enrollment 
Excluded (n=  ): 
Not meeting inclusion criteria (n=  ) 
Declined to participate n=   
)   
Other reasons (n=   
) 
Allocate to MB group (n=  ): 
Received allocated MB intervention 
(n=   
) 
Did not receive allocated MB 
intervention, give reasons (n=   
) 
 
Allocate to control group (n=   
): 
Received allocated intervention (n=  ) 
Did not receive allocated intervention, give 
reasons (n=  ) 
 
Lost to follow-up, give reasons (n=   
) 
Discontinued intervention, give 
reasons (n=    
) 
Analysis  
Lost to follow-up, give reasons (n=   
) 
Discontinued intervention, give reasons 
(n=   
) 
 
Recruitment of subjects 
Excluded (n=  ): 
Not consenting to trial (n=  ) 
Other reasons (n=No of refusal) 
Figure 2. Study flow diagram  
Participants invited to participate (n=   ) 
Randomized (n=   
) 
Analyzed (n=   
) 
Excluded from analysis, give reasons 
(n=    
) 
 

Table 1. Study intervention   
Session  
Activities (2 hours) 
Weekly home exercise 
 
1 
a) 
Concept of mindfulness  
b) 
Discovery breathing 
c) 
Draw the mental image of the practice of discovery breathing 
d) 
Triangular breathing   
e) 
Silent Breathing (SB)  
f) 
Draw the mental image of the practice of SB 
g) 
Debriefing 
- 
Share and process the experience  
- 
5-min practice  
- 
Practise triangular 
breathing and SB 
and draw the mental 
image of the 
practice of SB. 
 
2 
a) 
Sharing and debriefing of the mental image drawn at home  
b) 
SB practice and drawing to the mental image of SB practice & 
debriefing  
c) 
Music Breathing (MB)  
d) 
Draw the mental image of MB with debriefing  
e) 
Debriefing 
- 
Share and process the experience 
- 
8-min practice 
- 
Practise SB, MB 
(Use music in the 2nd 
session) and the 
mental image of the 
practice of MB 
 
3 
a) 
Sharing and debriefing of the mental image drawn at home  
b) 
SB practice and drawing to the mental image of SB practice & 
debriefing  
c) 
Music Breathing (MB) 
d) 
Draw the mental image of MB with debriefing  
e) 
Debriefing 
- 
Share and process the experience 
- 
11-min practice  
- 
Practise SB, MB 
(Use music in 
present and previous 
sessions), and draw 
the mental image of 
the practice of MB  
4 
a) 
Sharing and debriefing of the mental image drawn at home  
b) 
Music Breathing (MB) 
c) 
Draw the mental image of MB with debriefing  
d) 
30-second Music listening with breathing 
e) 
Discourse on the effects of each piece of music on self 
f) 
Debriefing 
- 
Share and process the experience 
- 
14-min practice 
- 
Practise SB, MB 
(Use music in 
present and previous 
sessions), and draw 
the mental image of 
the practice of MB 
5 
a) 
Sharing and debriefing of the mental image drawn at home  
b) 
Music Breathing (MB) 
- 
Perform breathing with listening to music pieces selected by 
therapist from the pre-arranged list  
c) 
Draw the mental image of MB with debriefing  
d) 
30-second Music listening  
e) 
Debriefing 
- 
Share and process the experience 
- 
17-min practice 
- 
Practise SB, MB (Use 
music in present and 
previous sessions), and 
draw the mental image 
of the practice of MB 
6 
a) 
Sharing and debriefing of the mental image drawn at home  
b) 
Music Breathing (MB) 
c) 
Draw the mental image of MB with debriefing  
d) 
Movement to the music 
e) 
Debriefing   
- 
Share and process the experience 
f) 
Closing activities/ritual 
  
- 
20-min practice 
- 
Practise SB, MB (Use 
music in present and 
previous sessions), and 
draw the mental image 
of the practice of MB