Centre for Psychotherapy
Belfast HSC Trust
BT8 8BH, Northern Ireland
McDougall I & McDonald J (2013) A Three Year Music Group for Young Men Recovering from Severe
Mental Illness in Northern Ireland. International Journal of Psychosocial Rehabilitation. Vol 18(1) 79-82
Objective: To describe the rationale, development, implementation and outcomes of a guitar group for young men with psychotic illnesses. Methods: In 2008 a guitar group aimed at young men with psychotic illness was developed by staff of the Rehabilitation and Recovery Team in Limavady, Northern Ireland and continued for 3 years. The group met on a weekly basis to play music together and provide a forum for informal discussion of the patients’ lives and mental health. After three years the men rated their health, mood, self-confidence, motivation, concentration and ability to translate any gains from the group to other aspects of life. Results: The group supported subjective and objective improvements in negative symptoms of Schizophrenia. Improvements in social functioning were observed, the group provided a novel way to engage young men with psychosis in mental health services and the young men wrote, recorded and performed their own music. The group provided a personal learning experience for the staff involved and anecdotal evidence of this is reported. Conclusions and Implications for Practice: This guitar group demonstrated that music is an excellent means to engage young men in services, can improve psychosocial functioning and provides further support for the mental health benefits of music. It challenges the traditional situation of psychiatric review being provided solely in an outpatient clinic.
There is a wide range of evidence for the use of music therapy in mental health problems (Nordoff Robbins, 2012) in particular psychosis (Silverman, 2003) and specifically as part of psychosocial rehabilitation in schizophrenia (Yang WY, Zheng L, Weng YZ, Zhang HY & Bio M 1998). Negative symptoms are difficult to treat pharmacologically, while the arts therapies are one of the few therapeutic interventions recommended in the NICE guidelines on Schizophrenia for negative symptoms (National Institute for Clinical Excellence, 2009).
The Limavady Rehab and Recovery team, located sixty miles from Belfast in the north west of Northern Ireland, has been part of the widespread changes in mental health care across Northern Ireland and the UK. Previously a generic adult community mental health service it now has a remit focusing on providing ongoing treatment and rehabilitation for those with severe mental illness. The team has an embedded ethos of providing holistic care, much of it coming from the staff’s natural abilities and enthusiasm for patient care. The guitar group arose from a number of unmet needs, including the limited availability of psychological therapies for patients undergoing rehabilitation from severe mental illness and difficulties in promoting the skills of patient’s despite a focus on recovery. Developing a means to address the difficulties of engaging young men within mental health services was also a high priority when developing the group.
To describe the development, implementation and the observable outcomes of a small guitar group for young men with psychotic illnesses. The objective of the group was to provide a form of psychological input for young men with psychosis that would be consistent with the spirit of recovery. By promoting these young men’s interest in music we hoped encourage their engagement with the service while maximizing the gains they could make in their recovery, using the available skills of the team members.
Staff from the team identified patients from their caseloads who played or were interested in music. Six patients were identified and invited to attend a weekly guitar group facilitated by the Team Manager and Specialist Trainee both of whom played guitar. Three of these men attended regularly, ranging in age from 22 – 35 years old and all had a diagnosis of a psychotic illness. The group took place on a weekly basis for ninety minutes, was informal and involved all of those attending playing music together. Time between playing music allowed conversation to develop. Vital to the group was the team Occupational Therapist who enthusiastically transported patients to the group and gave positive feedback.
The group continued in this format for three years. At the end of the three years, to capture whether the group was beneficial to their mental health and functional recovery, the men completed a self-report questionnaire to rate improvements in their health, mood, self-confidence, motivation, concentration and ability to translate any gains from the music group to other aspects of life.
All of the men rated mental health, mood, self-confidence, motivation and concentration as highly improved. All felt that they would be able to translate gains made in the guitar group to other aspects of their lives. Qualitatively they all identified the experience of getting together in a group to play music as the most enjoyable aspect of the group highlighting the importance of the focus remaining on a positive aspect of their lives.
All of the men who attended remained symptomatically well during the three years. None required hospital admission or crisis intervention and one of the men had a reduction in medication. Staff members and key workers noted objective improvements in negative symptoms of schizophrenia including motivation, concentration and problem solving skills across the three years the group ran. The evidence for this was seen in the group through the men’s attendance, ability to play, write and record music together. The group provided a regular social outlet and a medium for expression of emotions through writing music. The men’s self confidence grew and was demonstrated through their developing ability to perform their music live to an audience.
Other gains are more difficult to define and relate to the use of the music group as a setting for delivering mental health care. From a psychotherapeutic perspective the music allowed a different way to engage patients, not always talking but still accessing emotions. The means of provision of care for these patient’s mental was dramatically changed from a traditional patient-doctor or patient-nurse interaction to an informal, more relaxed situation. This allowed for more natural conversations regarding their experiences of mental health services, their symptoms and truthful opinions of their treatment.
Anecdotal accounts (see Appendix A) of their experiences as patients illustrated for clinicians the realities of mental illness in ways that are difficult to access in a formal clinic setting. These patient’s descriptions of the effects of mental illness and its treatment gave the staff a learning experience that textbooks can never provide.
With sessions lasting ninety minutes, time pressures were reduced and the informal setting allowed for open and spontaneous discussions of delusions, hospital admissions, encounters with staff and the nature of mental illness. Schizophrenia was reframed as something patients have suffered from in the past and can move on from, rather than something they “have”. The men also provided mutual support for each other through discussions on mental health, sexuality, substance misuse and caring for relatives.
In the second year, the group took to composing and recording songs, often working out complimentary guitar, bass and vocal parts. Songwriting is a complex process that requires use of higher executive brain functioning known to be impaired in psychosis (Kelly C, Sharkey V, Morrison G, Allardyce J &McCreadie RG 2000). It requires multi-tasking, hand eye co-ordination and an ability to understand language in lateral, abstract and metaphorical ways raising its potential as a helpful tool in rehabilitation. The positive reinforcement of patient skills is an integral aspect of the recovery model and the group provided this by enabling new skills to be learnt and praise of current skills to be given.
The content of the songs composed were very personal and highlighted some of the inherent difficulties of suffering from a psychotic illness and the challenges of recovery when peers have moved on with careers, relationships and education. The group took to performing their compositions live, most significantly in front of the staff at the local in-patient unit. All of the men had spent significant amounts of time in the unit while very unwell so to return while thriving was an important milestone.
The men also began to arrange to meet outside of the weekly group to play and compose music, a marked shift from having previously been socially isolated. When the disparity between symptomatic and functional recovery is considered (Oorschot et al 2012) this is perhaps the most significant development, with regular social activity providing an important protective factor against relapse.
Conclusions and Implications for Practice
The majority of the men in this group achieved symptomatic remission on a combination of medications with a number prescribed Clozapine. Functional recovery was more difficult requiring intensive input over a period of a number of years, which included a number of other psychosocial interventions. This music group was an intervention that ran for three years at no extra expense in a time of financial hardship and demonstrated lasting mental health benefits to the patients attending.
The success of this group highlights again the positive mental health benefits of music based psychological interventions (Ulrich, Houtmans& Gold 2007, Talwar et al 2006, Ekkila et al 2011, Yang W-Y et al 1998) and is in line with the NICE Guidelines for Management of Schizophrenia which advocate for arts therapies as an adjunct to medical treatment (National Institute for Clinical Excellence, 2009).
Clear strengths of this music group as an intervention include it arising from listening to the interests of the service users, it was driven by providing clinically for a number of unmet needs and it created an atmosphere that allowed the development of conversations with patients that would not be possible in a traditional doctor-patient setting. While the absence of quantitative analysis could be considered a weakness, a study design incorporating quantitative analysis would not have allowed for the personal, individual encounters that we have observed to occur. It is these close encounters with our patient’s lives that here has allowed us the opportunity to both provide a recovery-focused treatment while also developing a deeper understanding of how patients experience their psychotic illness and treatment.
This intervention would not have been possible were it not taking place in an environment and culture that was supportive of a holistic, creative forward thinking approach to patient care. The authors would like to thank the men who attended the group and the staff of Limavady Rehabilitation and Recovery Team for their enthusiasm and encouragement with this project.
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