"I Have Found My Voice": A Music Therapy Group in a HSE Unit
Introduction
This article describes how music therapy was experienced by adults in a Health Services Executive (HSE) Acute Adult Psychiatric Unit in Ireland. The role of music therapy within the unit and how it has become an integral part of the patients' weekly therapeutic program will be examined. This will be reflected in case examples that have arisen within the work. Pseudonyms have been used to maintain anonymity and protect confidentiality. Themes will be reviewed that have emerged within the work such as: developing social skills; enhancing awareness of self and others; realising potential; finding hope and meaning unique to the outcomes of music therapy; reigniting a desire to learn an instrument; facilitating the exploration of feelings and desires, and providing motivation. These themes illustrate how music therapy can address a range of psycho-social needs and contribute to patients' holistic care and the quality of the environment.
Setting
The Acute Psychiatric Unit is located on the lower ground floor of Cavan General Hospital and can cater for 25 in-patients in the catchment area of Cavan and Monaghan. Individuals who come to the unit present with severe and enduring mental health problems, often as a result of early and severe attachment difficulties. This is communicated through self-harm, suicidal behaviour, and unstable relationships with others. The music therapist uses the occupational therapist’s room to run the music therapy group. Sometimes, by arrangement, members of the team join the group for educational or observational reasons, including students on placement. There is a range of modalities within the multidisciplinary team, including psychiatrists, psychologists, psychiatric nurses, an occupational therapist, a social worker, and an art facilitator. Members of the MDT have recognised the higher levels of attendance for music therapy, particularly in those patients who have demonstrated lower attendance rates in concurrent interventions. This highlights the unique element the music offers to patients and the importance of providing a range of therapies and interventions to meet varied needs.
Music Therapy
The starting point for this paper was a desire within the multidisciplinary team to highlight the music therapy work, as part of the weekly therapeutic program at Cavan General Hospital. Music Therapy focuses on fostering a space where the patient's unconscious processes can be explored and expressed in a safe and non-judgemental environment. Music therapy is unique in that it offers music, a non-verbal medium to express and connect in an indirect way. This can be useful in providing insight into the individual's inner world. In the area of psychiatric care, the relationship between the internal and external is an integral part of a holistic approach to healthcare.
Music Therapy involves rigorous training at Masters level in order to become highly qualified and trained in using musical interventions to support therapeutic outcomes. Odell defines music therapy as “the use of music to allow an alternative means of communication and expression where words are not necessarily the most effective way to fulfill therapeutic aims for the client” (1988, p.52). The Irish Association of Creative Arts Therapists (IACAT) is the accrediting body for Creative Arts Therapists in Ireland. They define music therapy as an “evidence-based profession where the planned and creative use of music-based interventions by an IACAT-accredited music therapist supports people to improve, restore or maintain health, functioning and well-being” (2021). The musical space is essentially an opportunity to hear one's emotional state back. It has the ability to help visualise and make sense of one's thoughts and how we relate to the world around us. Nieman states that “music faces us with the realisation that there are two worlds; the inner and the outer. The inner is often noncommunicable ... music is a bridge for us by which we can reach this inner world” (Priestley, 1975).
Engaging in active music-making provides insight into developing awareness into the self and with others, in particular reflecting on emotional issues. It is a space that enables the patient to transfer their negative energy and turn it into something creative, which then provides space for verbal reflection.
In this setting, verbal dialogue plays an important role in helping to understand and reflect on the musical experience. The music therapist draws upon the mentalization based treatment model (MBT) to support patients in verbal discussion (Bateman & Fonagy, 2006). “Mentalization, or better mentalizing, is the process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes” (Bateman & Fonagy, 2010, p. 11). Music has the ability to access both the implicit (body language and unconscious material) and explicit (words, narratives) levels of communication. Drawing upon the MBT model can help patients understand their mental state, thus enhancing mentalizing. This will be reflected in the case studies discussed below.
With these components in mind, I present a dialogical view of the dynamics I believe are most significant within the music therapy group. "The Quartet" exhibits four key elements of the group: the group members, the music therapist, the verbal dialogue, and the music.
Figure 1: Diagram. The Quartet
This diagram demonstrates the music as the core element of the therapeutic frame, therefore, placing it in the centre of the quartet. It is within the music and the client's relation to the music itself that acts as the focus of the therapeutic process. The verbal discussion provides an opportunity to clarify, encourage communication, reflect and process the musical experience. Lindblad groups the purpose of verbal dialogue under three areas of focus: to establish trust between client and therapist; to deepen the experience of the present moment; and to clarify some aspect of the client’s life story (Lindblad, 2016).
Musical Processes
Due to the nature of the client group and the presence of psychotic symptoms, recording sessions were deemed unsuitable. It was felt that attempts to do so may fuel feelings of paranoia and heighten existing anxiety. For the purpose of this paper, the music therapist will provide her own creative responses to the musical processes of the case reflections being presented. These audios are not intended to portray the patient's musical responses but solely to help illustrate the work being discussed.
Group Work
The efficacy of working in groups has been well documented within psychological and therapeutic work with clients. Fitzpatrick (2016) talks about how "we are relational beings and grow through connection with others" (2016). According to Bowlby (1989), one of our principal drives is to form attachments. Maslow (1954) and Glasser (1998) talk of our need to belong and to form relationships. Being in a group brings a sense of belonging, provides an opportunity to learn from others, gain more insight into their presenting problems, and form attachments and relationships within it.
Approach to Group
Due to the short stay and nature of the setting, the music therapy group is offered as ‘open’. This allows inpatients to join the session without having expectations to attend from week to week. This, in turn, means that the group can encompass new members from week to week. Admissions on average can last from as short as five days up to 20 weeks. Getting the balance between welcoming newcomers as well as progressing with the work with long-term patients attending each week can present its own challenges. However, I have witnessed that it also can often provide long-term patients with a sense of purpose and meaning when they find themselves able to come forward and offer reassurance and guidance to new members joining the group.
My approach is not based on one theoretical framework but provides a client led space bringing focus on the here and now; engaging in active music making, using improvisation as the focus. Engaging in group musical improvisation allows for thoughts and feelings, both conscious and unconscious, to become audible. The way in which patients improvise and connect with others in the music enables the music therapist to further understand the inner world of the patient. My role is to help bring shape and structure to the music and acknowledge the patients’ state of mind through musical improvisational techniques. With this client group and the style of the group, I have found providing a time frame helpful in maintaining boundaries. Dynamics within the group can change from week to week depending on patient presentations, meaning therapist direction and activity structure has been found more helpful in supporting patient engagement.
The use of pre-composed songs is also heavily used in the group. They can often flare up memories, and encourage individuals to reflect on their personal life experiences. Patients often like to share a song that has particular meaning to them, for example, "The Long and Winding Road" by the Beatles was once shared by a patient. Through verbal dialogue and drawing upon the MBT model, the therapist was able to help the patient link the lyrics of the song to their own journey of feeling stuck and questioning aspects of their own life. Song discussions can often help to reveal moods and lead to themes for musical improvisations. I have found that titled improvisations can often help patients to reflect and make sense of their current mental state. Bruscia writes that “titled improvisations are referential in nature in that the music symbolises something outside of the self” (Brusica, 1987).
Making music with others who are experiencing similar difficulties can help individuals feel supported and connected.
A wide variety of instruments, both tuned and untuned percussion, guitars, and a piano are available, all of which are set up for the music therapy group each week. It is common for patients who come to the group to hold no musical knowledge or training. This can often invite feelings of being overwhelmed or intimidated by the instruments and musical space. For this reason, the group often calls for more therapist direction and the session may start with a guided improvisation. This can assist in easing feelings of uncertainty, help patients feel supported, and avoid possible withdrawal from the group. Patients then often feel more able and confident to engage in a free musical improvisation which is client led and supported by the therapist, usually on harmonic accompaniment. “Improvisation is any combination of sounds created within a framework of beginning and ending …. in an environment of trust and support established to meet the needs of the client” (Wigram, 2004).
Case One
Paula (pseudonym) was a well known patient to the unit, having had several previous admissions. She came to the unit with dysthymia symptoms and presented with emotional dysregulation. Paula came to the group every week and would be tearful and present with a low mood. She shared feelings of uncertainty around how the group would be helpful. She expressed "wanting to just shake out of it", revealing feelings of frustration of her ongoing mental health struggles. Feelings of isolation and loneliness were heightened through COVID-19 restrictions. This feeling was ever-present in the group by all, as thoughts were shared on missing family and friends and the challenges the restrictions brought in everyone's lives. I shared my own personal feelings of relief and joy to be back facilitating the group again, being with people once again, and sharing something unique together. Albeit along with this feeling of relief and joy came a settling period of working face to face again, a somewhat similar feeling to Paula's uncertainty of the group itself. The discussion developed into familiar feelings of frustration on mental health struggles, which further influenced the theme of our next improvisation.
I suggest engaging in free improvisation, focusing on this presence of the frustrations voiced. Paula suggests the theme "finding freedom", and one by one the group members choose an instrument. The improvisation begins in a minor tonality, expressing a solemn and slow-moving pace reflecting this feeling of being held captive. Quite soon into the improvisation, Paula begins to use her voice, singing freely and improvising around the group's music. The therapist supports and holds the group's music on harmonic accompaniment. Paula uses her voice to engage in surprisingly playful and spirited melodies. This was in contrast to the feelings expressed beforehand. When the music comes to an end it feels important to acknowledge Paula's ability to engage in the vocal play. Paula shares her surprise, saying “I have found my voice!" This statement, and the power that music can present in helping people connect and be creative when everything else feels closed and inaccessible, resonates with me. When encouraged to reflect on the frustrations expressed, Paula was able to link her music directly to her feelings. The space allowed her to externalise and transfer her difficult feelings and turn them into something creative and magical. She further revealed how she had struggled to engage meaningfully in other groups, verifying the accessible nature of the music.
Paula revealed how engaging with the musical instruments helped her to realise her potential, express herself, and feel motivated.
A nursing student was present for the session. As the group ended, the nursing student voiced her personal surprise at Paula's musical expression, remarking how different she was outside of the group.
Audio A - I have found my voice!
Here the therapist creates her own creative response from the session, solely for the purpose of demonstration.
Case Two
Jade (pseudonym) is a well known young woman to the unit. Jade has a diagnosis of schizoaffective disorder and comes from a disordered family unit. Jade came to the unit in her most recent admission, presenting as chaotic and disoriented. She struggled with managing her emotions and experienced feelings of paranoia. She would come to the group engaging in the music with disorder and chaos. She would often project these strong feelings, criticising the group and me and leaving no space for fellow members to join the musical space. She would often leave the room for several minutes, sometimes returning, sometimes not. Her presentation was reflected in her musical communications, which was that of suddenness and aggression. She would react in a dismissive and confrontational manner to the therapist when the therapist made attempts to help her understand her behaviour. It felt important to acknowledge and interpret her behaviour without pushing her away and letting her intimidate the group. This provided a space for Jade to feel listened to, as well as continuing the session for the group. The music presented as unstructured, lacking direction - the tonality leaps from one to the next reflecting the heightened state Jade would present with.
Audio B - I’m listening and we’re here
Here the therapist creates her own creative response from the session, solely for the purpose of demonstration. Here the therapist is reflecting on her struggle to allow Jade to feel listened to whilst finding the balance of holding the group.
As the sessions progressed, Jade became more settled and reactive within the group. She was now linking her previous music with strained relations within her family and her ongoing struggles with her mental health. Her role became meaningful as she developed into a mentor within the sessions, encouraging new members to engage. Her music became interactive and communicative. She openly revealed how the music "brought her elsewhere" and provided her with a space to "sing things". The engagement with the instruments reignited a desire in her to learn an instrument and incorporate music into her life. Jade talked about having hope while recognising the power of the music in helping her take her negative energy and turn it into something "beautiful and extraordinary". She talked of how she could hear and visualise her thoughts and feelings by physically interacting with the instruments. The music now has direction and structure, reflecting on the awareness and acceptance she is now experiencing.
Jade is connecting meaningfully with her music and instruments and those around her. She is more respectful and is open to sharing and connecting.
Audio C - Together we play
The therapist creates her own creative response from the session, which reflects a group that is creating together.
Conclusion
As a music therapist working within psychiatry, I have come to recognise when there is a need for greater musical containment when patients are more unwell and actively psychotic. The nature of the work has highlighted the importance of leaving space for verbal dialogue so as to facilitate some reflection of the music where possible. The recurring themes which emerged throughout the work validate the need for the consistency and predictability of the group within the weekly therapeutic program in the unit. The case studies highlight the benefits of music therapy within an acute psychiatric unit, as demonstrated by the following themes: developing social skills; enhancing self-awareness and awareness of others; realising potential; finding hope and meaning unique to the outcomes of music therapy; reigniting a desire to learn an instrument; facilitating the exploration of feelings and desires, and providing motivation.
I will finish this paper with a quote from clinical psychologist Tony Bates when he speaks about finding hope through times of uncertainty. This statement captures the true essence and value of the creative arts therapies when talking about acknowledging pain and trauma:
“I think when we accept vulnerability …. engage with it ... find strength through creativity ... and do something with it … then we are on the way to living a full and happy life” (Bates, 2021).
References
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Bates, T. (2021) On Dealing with Uncertainty. Brendan O'Connor; Apple Podcasts. Available: https://podcasts.apple.com/gb/podcast/dr-tony-bates-on-dealing-with-uncertainty/id1495 060929?i=1000525333994 [accessed 24 June 2021).
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Edel Loughran
Edel Loughran is an IACAT registered Music Therapist based in Co. Monaghan. She holds a BA (Music and Irish) and an MA in Music Therapy. She is the owner and founder of Music Therapy NEtwork serving North East Ireland. She works at HSE facilities as well as private organisations providing music therapy across the lifespan to individuals and groups. Her passion lies within the field of mental health. Edel first set up the music therapy group in the acute psychiatric unit at Cavan General Hospital in 2017 on a pilot basis for twelve weeks and is since an ongoing part of the weekly therapeutic program. Edel employs psychodynamic theory in her work as a music therapist. She draws upon the mentalization based treatment model (MBT) acquired from her training and work experience within the NHS in London, to help individuals understand and challenge unhealthy thinking patterns and behaviour. Edel is currently setting up a music therapy community group within the Cavan/Monaghan service to provide greater emotional support to service users as a link from the hospital to the community.