INTRODUCTION
‘When the therapeutic value of music is understood and appreciated, it will be considered as necessary in the treatment of disease as air, water and food.’ (Vescelius, Reference Vescelius1918)
Music has been an important part of therapeutic activity for over two and a half thousand years (Horden, Reference Horden2000). The work of the Guild of St Cecilia in the late nineteenth century demonstrates this, one of the precepts of the Guild being that ‘Music has the power to affect patients in physical or emotional distress’ (Tyler, Reference Tyler2000). Formal music therapy currently holds that making music together creatively, particularly improvisation, is a prime agent of therapeutic change (Nordoff & Robbins, Reference Nordoff and Robbins2007; Andsell & Meehan, Reference Andsell and Meehan2010). Although there is an increasing evidence base to suggest that music therapy has clinical value (Tyler, Reference Tyler2000; Lloyd, Reference Lloyd2010) it is often expensive (Silverman, Reference Silverman2011) and requires highly trained individuals (British Association for Music Therapy, 2011). The primary attractor of the Lifemusic approach, from the point of view of a health service with a limited budget where careful choices about expenditure must be made, is that it provides instant access music making facilitated by lay people trained in the principles, and can therefore be provided ‘in-house’ at no extra cost, something that is becoming increasingly necessary in modern healthcare.
LIFEMUSIC
The Lifemusic method was developed as part of the Higher Education Funding Council for England (HEFCE)-funded South East Coastal Communities (SECC) project which ran from 2008–2011 (http://www.coastalcommunities.org.uk) and developed a range of social care and health initiatives within a consortium of nine universities spanning the South East Coast of England region. The remit of the project was to develop and ‘test run’ knowledge exchange projects designed to enhance well-being among disadvantaged communities along the South East coastal strip of the UK. One of the core principles of the project, inspired by the work of Bradford University's community engagement research team led by Jenny Pearce (Pearce et al. Reference Pearce, Pearson and Cameron2008), was to valorise and make use of knowledge generated by local communities and usually regarded as non-specialised or non-structured. From the outset of the project it was the accessibility of Lifemusic to non-trained, non-specialist musicians which lay at the core of the initiative. The contemporary world of music, culturally, socially and therapeutically has become largely the preserve of the specialist and musical skills are often restricted by those who possess them and those who train others (Rolsfjord, Reference Rolsfjord2010; Ruud, Reference Ruud2010). Lifemusic is explicitly non-elitist in this respect, based as it is upon four precepts: everyone is musical; there are no wrong notes; every sound has a meaning; music making is an act of trust (Paton, Reference Paton2011). Musical knowledge is therefore considered within this framework as a birthright, something we all possess regardless of background, training, social status or medical condition. By opening up musical practice in this way and by by-passing long-term professional training which often results in a rigid, over-theoretical, uncreative approach, it became possible to design a training programme which was open to professionals in other fields equipping them to set up and sustain musical activity within their own workplaces. During the course of the project and since, the training programme has therefore been able to cater for teachers, care workers, social work professionals, therapists from a variety of disciplines, counsellors, artists, nursing staff and mental health professionals.
RECOVERY
The concept of ‘recovery’ in mental health has been present in the literature from the 1980s (Deegan, Reference Deegan1988) representing the lived experience of rehabilitation and a move away from the idea of ‘cure’, to learning to live to the best of one's abilities with the difficulties present, be they physical or psychological. Higgins & McBennett (Reference Higgins and McBennett2007) stated that one theme of recovery is the reconstruction of a new sense of self by learning fresh perspectives about oneself and one's experiences of both the world and mental distress. McCaffrey et al. (Reference McCaffrey, Edwards and Fannon2011) explored the use of music therapy in recovery and found that music appears to be a supportive intervention that enables staff to meet clients at their level of functioning and build on strengths towards beneficial outcomes, an approach that supports some of the core principles of the recovery philosophy in mental health care. As Paton (Reference Paton2011) asserted, Lifemusic as a method provides the medium to allow those improvising to connect to time, each other and life as a whole, we can begin to see how participating patients may be able to move further along their own recovery paths by connecting once again to themselves, each other and indeed life itself. It was this belief that led to the commencement of the project described below.
THE PROJECT
The unit concerned was a 13-bed low secure forensic service that provided assessment, treatment, care and rehabilitation for individuals with a serious mental illness and associated challenging behaviour. The unit provided high quality, recovery-focused care for patients with mental health problems in a safe, secure and supportive environment. The predominant diagnoses of patients on the unit were paranoid schizophrenia and borderline personality disorder, with all patients experiencing some form of psychosis. Each patient presented with a unique and complex interaction of physical, psychological and social factors which led to their admission, including criminal justice convictions. The ethos of the unit was that patients who actively engage in their assessment and treatment are more likely to be successful in their recovery. Therefore we encouraged patients to become active partners in their treatment endeavouring to ensure the safety of all by addressing the offending or challenging behaviour of each patient as part of the treatment package. Lifemusic became part of that package in 2010.
The initial proposal, that was funded via the National Association of Psychiatric Intensive Care Units and Low Secure Units (NAPICU), was to purchase ten sessions of facilitated Lifemusic for the patients, which would be carried out concurrently with three members of staff training to become Lifemusic facilitators. It was anticipated that the benefits of this proposal could be to:
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• Provide Lifemusic sessions beyond the life of the project
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• Aid expression of emotion in a non-threatening way
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• Enhance personal development
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• Encourage group interaction
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• Enhance listening skills
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• Boost confidence, well-being and self-esteem for all involved
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• Reduce challenging behaviour
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• Provide enjoyment and fun.
A typical session lasted forty five minutes. Initially these had been an hour long, but this proved to be too long for patients so they requested a reduction in time period. The initial ten sessions were facilitated by the second author, with support from ward staff and subsequent sessions were carried out by two ward staff, who were trained facilitators. Membership varied from week to week and usually included one member of support staff in case of challenging behaviour. Once the group had commenced then membership was closed for that day. Each session generally comprised an introductory exercise followed by a main improvisational piece and a wind down. There was some discussion at pertinent points during the session as the music making dictated. No spectators were allowed in sessions, anyone present had to take part including staff members. The average number of patient attendees at each group was five and two patients attended all the sessions provided.
Staff training was carried out at Chichester University for three members of staff who were selected due to interest and discussion. They were the unit clinical manager/matron, a staff nurse and a senior administrator. The staff nurse was allowed to attend the training as part of their work time, the clinical manager opted to attend in her own time and the senior administrator had to attend in her own time for training but, having been trained, was allowed to facilitate sessions as part of her work time.
The training programme itself was a 36 hour course run weekly over 12 weeks. The approach was mostly experiential with time set aside for reflective commentary and discussion. The central aim of the training was to equip people to facilitate practical music workshops using the Lifemusic method based upon the four elements of participation, improvisation, communication and trust. Improvisation, despite being the primary musical act, is largely neglected in conventional professional training but is of course at the heart of music therapy practice (Bruscia, Reference Bruscia1987; Ruud, Reference Ruud1998; Wigram, Reference Wigram2004). Lifemusic provides so-called ‘holding forms’ for group improvisation (Witkin, Reference Witkin1974), essentially patterns and interactive games which are easy to learn but which provide anchors for often extended creative playing using the voice together with the kind of ‘instant access’ instruments, mainly tuned and un-tuned percussion, familiar to anyone who has worked in music therapy situations.
In addition to the musical techniques explored, each training group provided an experiential model for those forms of dynamic interaction well documented in group theory (Yalom & Leszcz, Reference Yalom and Leszcz2008). Music seems to amplify and enhance these interactions since creative music making in groups appears to open up pathways of empathic and dynamic feeling which often surprise those participating. An improvisation might seem to be merely a fun thing to do or a way of letting off steam but when studied in greater depth it can be viewed as a unique and complex interaction which brings people into contact at a non-verbal, affective, even perhaps archetypal level (Paton, Reference Paton2011). This aspect of group attunement received emphasis and provided a focus for the training, serving as a valuable model for subsequent clinical practice.
OUTPUTS
Post session feedback was gathered following each session; this information was sought either by questionnaire or verbally from patients and staff who took part. Their main reported points are presented in Box 1.
Common themes from narrative reports
Patient reports
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• All reported feeling more relaxed after a session
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• Saw the sessions as either a ‘quite’ or ‘very’ relevant rehab. activity
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• Most reported feeling happier after a session
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• All would recommend the sessions to other patients.
Staff reports
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• Increased understanding of group dynamics
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• Observing patients develop in listening and confidence
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• Noted even those who were very unwell could take part successfully
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• Improved interpersonal relationships between staff/patient attendees outside of the group.
Behavioural changes were also measured using observation by staff of behaviour of patients on days following the Lifemusic sessions and the following four were noted:
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1. Less pro re nata (prn; on request, as required) medication was requested by patients who had attended the session in the day following.
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2. There were no episodes of challenging behaviour in those who attended the group for at least 48 hours following sessions.
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3. Behaviour in group changed in those who attended regularly.
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4. Behaviour outside group changed positively in the two members who attended every group (see discussion below).
Whilst it is acknowledged that there are other factors that could have influenced these changes they represented a noticeable change in behaviour during the project and as such were deemed interesting.
DISCUSSION
Nordoff & Robbins (Reference Nordoff and Robbins2007) stated the premise that there is an innate responsiveness to music that continues in us despite many profound handicaps. This was supported by the observation of staff that even those with the most profound psychotic symptoms were able to remain engaged and improvise with others for some, if not all, of the sessions they took part in. In some cases, even a fifteen minute participation represented a connection with others that had been impossible to facilitate by more traditional means until that point. Gouk (Reference Gouk2000) stated that music, mainly singing, dancing and playing instruments, is essential for community and bodily health, an assertion that was clearly borne out by the changes in behaviour noted in the two individuals that attended each group. In one case the patient concerned was very uncertain of the process at the beginning but grew in confidence as the sessions progressed. This confidence was shown by increased participation in the groups themselves, by increasing levels of communication, particularly that initiated by them, and ultimately by the patient agreeing to co-facilitate sessions on another ward for other patients. Here the patients’ interpersonal skills and personal development showed clear evidence of positive change. This supports the findings of two pilot studies reported by Silverman (Reference Silverman2011) assessing the effect of music therapy on the proactive coping skills of psychiatric inpatients. The other consistent attender was well known to have a very short attention span and to be challenging in behaviour on a regular basis, primarily via intimidation and sheer physical presence. This patient was initially very dominant in the group and tended to focus inward however, over time, they became able to listen to others demonstrated by clear musical conversations and found a role in being the person to welcome to group those patients who may not have attended before. In this case the patient showed a clear reduction of challenging behaviour, the skills that were being developed in listening during the group began to translate into their daily life and they began to demonstrate appropriate leadership skills that did not rely on bullying. This echoes the outcomes Meekums & Daniel (Reference Meekums and Daniel2011) found from a literature synthesis of arts use in offender care, that arts and arts therapies were generally found to be associated with improvements in arousal levels, emotional literacy and quality of life.
Some unexpected outcomes for this project revolved around the impact that the sessions had on staff. As noted in Box 1, staff reported seeing patients develop their listening skills and confidence levels along with seeing patients they had previously, due particularly to severity of psychotic symptoms, found very difficult to connect with in any therapeutic manner. Both these aspects appeared to contribute to an increase in staff belief that these patients could indeed achieve some aspects of recovery; a phenomenon noted by Forchuk et al. (Reference Forchuk, Jewell, Tweedell and Steinnagel2003) in their exploration of perceived staff role changes during the process of their patients recovery from psychosis. This served to improve staff ability to foster more hope for that person's future, an aspect of the recovery model that is intrinsic to its success (Deegan, Reference Deegan1988). Additionally, the relationships between staff and patients who attended the groups were reported as being improved. One staff member suggested this might be due to the fact that, during the Lifemusic sessions, all took part on an equal footing thus hierarchy was not an issue, in fact, as previously stated, over time one patient took on a leadership role within the group thus arguably raising his status above that of the staff. This finding supports the assertion of Gold et al. (Reference Gold, Rolvsjord, Aaro, Aarre, Tjemsland and Stige2005) that the use of music in recovery emphasises collaboration and equal relationships.
Following the end of the project the sessions were continued until the closure of the unit, however the sessions were offered on the rehabilitation ward at the same hospital for some time following this. There were other outputs that could be attributed to the influence of Lifemusic on the patients which were increasing requests for musical activities such as: music appreciation, karaoke and organ music with patient accompaniment. Other activities have also emerged, a session provided for a team working away day for senior staff of the unit proved very productive as did sessions for a patient led conference held as part of the local World Mental Health Day celebrations in 2011. The method clearly has some sustainability potential as there are still planned sessions happening for nursing students. The Lifemusic project itself has continued to expand and the training programme which now runs twice a year over four weekends has to date trained over 100 practitioners. The principle of inclusivity remains at the heart of the training which enables this form of music making to reach into a wide variety of communities and clinical practice (e.g. drug and alcohol abuse counselling, neuro-disability rehabilitation, mental health, learning disability groups, hospice care, older people, younger people, team building sessions etc.). The most recent project applies the approach purely vocally and a pilot ‘Singing for Health’ project, a collaboration between the University of Chichester and a local GP practice has attracted over 180 people over an 18-month period providing valuable data for further research and evaluation.
CONCLUSION AND RECOMMENDATION
In times of financial constraint it is often arts related activity that is the first to go in healthcare despite the clear benefits to patient care. Further exploration of this topic is recommended particularly in view of the requirement for meaningful activity (National Institute for Health and Care Excellence, 2011) on inpatient units, and the potential that music has to improve the therapeutic relationship (Gold et al. Reference Gold, Rolvsjord, Aaro, Aarre, Tjemsland and Stige2005). Friedson (Reference Friedson2000) and Kramer (Reference Kramer2000) describe embodied knowledge as being the only viable way of grasping the connection between healing and music. As this tacit knowledge is difficult to quantify perhaps this goes some way to explaining how, in our health service increasingly focussed on quantity, it is difficult to clearly justify and evidence the vast benefits of the arts in healthcare. For the future the requirement of measuring, in tangible rather than anecdotal ways, the beneficial effects of the arts in healthcare is essential if the arts are ever to fulfil their potential in the reciprocal healing of both patients and services.
Acknowledgements
The low secure unit project was supported by NAPICU via Dragon's Den funding. The development of the Lifemusic method was supported by the HEFCE-funded South East Coastal Communities (SECC) project.
