Conclusions, Recommendations and References
Music in Mind has demonstrated the potential for young people with a wide range of mental health needs to benefit in multiple ways through engagement with interventions specifically targeted to bring together community arts practices and mental health provision.
Music in Mind sought inter-related outcome indicators from this work, allied with multiple aspects of health, wellbeing and musical engagement/development. The best practitioners and tutors recognised the need to plan for and recognise a wide range of approaches and outcomes, which led to some kind of ‘success’ in a given situation and at a particular time for a specific person or group.
The perceived personal and collective ‘developments’ reported through Music in Mind may be exclusively linked to the social and cultural milieu in which the interventions took place. However, there are also specific examples suggesting that, in some cases, the perceived positive benefits and developments have successfully transferred into other situations and been maintained in the longer term. For example, this is demonstrated through the progressive pathways to further and higher education beyond the participants’ time engaged in the projects, and although causation can only be surmised, the narratives taken from multiple perspectives suggest that participants think there is a positive link. There are also multiple instances of engagement with the programme helping young people to face issues and challenges in their lives and the ways in which the programme helped them to approach these.Identifying enabling factors and barriers
Music in Mind has provided a platform for Rhythmix and their NHS partners to identify and explore some of the barriers to initial and on-going engagement in this area of work. It has also provided many opportunities for them to work through, some of the challenges presented. It reports on many positive examples of young people engaging with the programme whilst also acknowledging the significant and multi-faceted barriers to engagement.
The approach to the programme aims to avoid the criticisms often levelled at arts evaluation in healthcare settings, dodging ‘magic bullets and quick solutions to complex problems’ (Daykin, 2012:73) by focussing on specific examples of success, enabling factors and barriers. This kind of practical, applied knowledge is crucial for future programme design; the evaluation seeks to identify and critique the emergent practices, offering a platform to share the learning with the wider sector to help to develop future thinking and reflexive practice.
The report and approach draws heavily on the importance of narrative, triangulated where possible, but also accepting the pitfalls of an over-reliance on this. However, with the attendance at projects not always being regular, and the focus on music making being central to the sessions, it is difficult to envisage how a more ‘positivist’ study, which may be preferred by some of the medical community, would benefit the young people involved and not impact negatively upon their reasons for engaging with the programme.Shared values, philosophies and priorities
The importance of shared values, iterative joint planning and supported delivery through proper partnerships between highly experienced, flexible and intuitive music tutors, and clinical /support staff who know the participants well and can provide sustained bespoke emotional, social and clinical support, are the foundation stones of successful projects. The outcomes of this programme appear to conform to ‘gestalt principles’, whereby the outcomes achieved from the most successful and collaborative Music in Mind projects are greater than the sum of the constituent parts contributed by the individual groups.Sustained funding and iterative programme development
Music in Mind has highlighted the need for sustained, long-term programmes providing on-going commitment for young people to be part of a project as and when they can manage, and with longer-term participation possible. Some young people need significant support to join and regularly attend groups. There is also evidence suggesting the continuity of provision may be important to help some young people transition between different stages of their clinical programme and between settings. In some of the examples cited in this report, it is speculated that there is a link between being able to signpost and scaffold transitions both clinically and musically, and some young people being more capable of adapting to new environments in positive ways. There is certainly much more work to be done in this area of research.
The funding of Music in Mind over this sustained length of time, along with the expectation of the ‘planning phase’ at the start of the programme, demonstrate Comic Relief’s understanding of the need for sustained support, investment and development as part of a longer term joined-up strategy between Rhythmix and CAMHS in order to develop and deliver meaningful and worthwhile programmes.Why is this work important?
Funding and resourcing for mental health services nationally and locally is overstretched, impeding the capacity for the NHS to provide timely support or early intervention for all young people in need of support. It is therefore unsurprising that collaborative approaches to using the arts to support a range of clinical and other outcomes, is not always given priority or the attention that it perhaps deserves. In many settings, the potential of the arts to support clinical outcomes and social inclusion are overlooked or undervalued, as happened in some of the Music in Mind projects when staffing levels became over-stretched and patient demand for services rose. This is particularly disappointing, given the growing body of evidence of the potential power of such programmes under the right conditions (e.g. Cayton, 2007; Secker et al., 2008; Hacking et al., 2008; Starikoff, 2008) and through this Music in Mind programme.
Much of the work in the Music in Mind programme has taken place in Tier 3 and Tier 4 settings, i.e. aimed at young people who already have serious mental health conditions requiring regular access to specialist multidisciplinary CAMHS teams. Tutors’ developing understanding of working with young people with a range of mental health needs could be invaluable at the earlier clinical stages and for those young people with less urgent and serious mental health needs, if such a collaborative programme with CAMHS staff could be facilitated.Why Music?
Much is written about the ‘power of music’ in education, learning and to promote or enhance wellbeing (e.g. Hallam, 2015). In answering the question ‘why music?’, MacDonald, Kreutz and Mitchell (2012: 7-9) suggest a variety of reasons why music could be connected to producing positive benefits in healthcare and wellbeing settings. They conclude that music is: ‘ubiquitous, emotional, engaging, distracting, physical, ambiguous, social, communicative’ and that it ‘affects behaviour and identities’. From the perspective of the findings reported through Music in Mind, there is little to disagree with in this categorisation (apart from noting the significant relational inter-dependence of some of these) and much evidence that all of these factors were prevalent and important to some young people at some points.
Perhaps what is understated in MacDonald et al.’s (2012) list is the power of music as a potential lever between resistance and acceptance. For some of the young people engaged in Music in Mind, it is music that hooked them in, and in the case of these mental health programmes, this may mean that by using music as the facilitator, participants may be more engaged with and open to accessing the clinical programmes and specialist support.
Programmes such as Music in Mind could be considered to be set up with the explicit underpinning of MacDonald’s (2013:page) ‘conceptual framework for health and wellbeing’, where the inter-related factors of ‘community music’ ‘everyday uses of music’, ‘music therapy’ (which is related to ‘music medicine’) and ‘music education’ all interplay; it is clearly Music in Mind is synergous with all of these to a greater or lesser extent. Likewise, the work has some clear links with Andsell’s (2015) conceptual model related to music in everyday life and its relationship to the emerging field of community music therapy. Andsell suggests that musical worlds, experiences, personhood, relationship, community and transcendence all interplay in dynamic ways.
Research and applied practice is still grappling to fully answer the question ‘why music’ but the outcomes from Music in Mind show that ‘making music well’ (a term coined by Finney, 2016, to describe the purpose of music education) was an important aspect for participants. The breadth of this term ‘making music well’ also links well with the ‘potential outcomes of music education’ suggested by Hargreaves, Marshall and North (2003:160) in which socio-cultural, personal and musical-artistic outcomes, all relating to self-identity, are surmised to be possible outcomes and of which there are multiple examples evident in this programme. The adherence to music as something to ‘learn/develop’ and not just as ‘participation’ was important to many of the young people engaged in Music in Mind – they cared about the quality of what they produced, and whilst the social aspect of participation was important, it was often mentioned in the context of producing something musical together.
The role of learning / education is therefore an important factor that needs to be considered in the planning of future programmes.
We should not ignore the importance of music to some young people. As engaged listeners, to those penning their own tracks, honing their practical and creative skills in many ways, it is, for some young people with mental health needs, a perceived lifeline, a fundamental part of who they are, or as was said more than once in the project “Music quite literally is my life”. Not every young person with mental health needs will find that music is the ‘hook’ to help them to seek and accept help, but for some, under the right circumstances, music can help them to take steps towards improved mental health and wellbeing.The support labyrinth
Music in Mind has highlighted the need for support not just for the young people who access the CAMHS services, but those who support them. Talking to parents highlighted some of the significant issues faced by families, carers and friends, particularly around the anxiety and stress of wanting to keep their family safe and do everything in their power to make them well. They discussed the stigma of mental health, the feelings of isolation and not knowing where to get dedicated help and support. In one of the Music in Mind projects, some parents appreciated the company of other parents whilst the music sessions were taking place, exchanging information and feeling the relief of talking to others in a similar situation. Parents suggest that opportunities for specialists to work with parents and carers could run alongside the sessions to provide an education, information and support programme for young people’s personal support networks; however, given the significant financial and staffing challenges for front-line mental health support, the additional cost and time this would involve needs to be carefully planned for in future funding applications if this is to become a reality.The importance of professional development
Programmes such as this rely on the availability and future professional development of a growing body of highly skilled music tutors. Tutors working with young people with a variety of mental health needs require flexible musical skills to be able to adapt to the needs and wants of the young people, coupled with the experience and person-skills to be able to work effectively with this young people with a wide range of needs and interests, recognising and working with the challenges that this presents. Tutors also need to collaborate effectively with medical and clinical professionals, sharing core values and philosophies about the approaches to work, and recognising the importance of the work and the seriousness with which mental health needs must be considered. Mutual respect and understanding from the musical and clinical side is therefore imperative.
From the findings of this evaluation, it is clear that there are a small number of highly specialised Rhythmix tutors who take an inquiry-based approach to their work, reflecting upon their impact as ‘the new health musicians’, the term coined by Ruud (2013: 87) to describe those with the ‘necessary musical and performative skills, the methodological equipment and the theoretical familiarity, and, not least, the personal, ethical and political values to best carry out these health-musicking projects.’ To be clear, there is a distinction between ‘new health musicians’, and music therapists - highly trained and specialised practitioners who use evidence-based practices to work towards therapeutic goals through developing a musical and therapeutic relationship. Both can make important contributions to working with people with mental health needs, but the input of specialist staff from a clinical background is crucial when music tutors work with young people with mental health needs. The challenge going forward is to utilise and further develop the skills of all practitioners effectively and collaboratively in order to benefit clinical outcomes and musical engagement; without the clinical support and targeted aims, such programmes run the significant risk of diminishing the impact on health and wellbeing through becoming ‘just another music project’.Bringing it all together
The final word about these projects comes from Rivkah Cummerson, Youth Engagement and Participation Manager for CAMHS NHS Sussex Partnership. Her words succinctly sum up what young people and CAMHS want and gain from programmes such as Music in Mind and the importance CAMHS places upon such a bespoke collaboration. There is much to learn and continue to unearth about the barriers to participation and effective practice for young people with mental health needs, and there is also much to celebrate.
"Since 2008, CAMHS in East Sussex have been working with in partnership with Rhythmix to provide music based group work for young people aged 12+ accessing our Tier 3 Specialist CAMHS Service. The purpose of the sessions is to provide much needed peer support and interaction, a chance to reflect on mental health issues and to enjoy learning or improving an existing musical skill within a space that is safe to bring both personal issues and frailties to.
Without the partnership, we would not be able to offer this creative means of communicating personal stories and thoughts on mental health. Rhythmix provides a unique service to CAMHS by linking us with musicians who are extremely skilled in communicating both their skills and passion for music, whilst containing high levels of anxiety and being able to let young people reach their potential even under difficult circumstances. I am amazed at how relaxing the sessions are even when young people have never played before.
The work undertaken with Rhythmix is highly valued by the young people that take part. We receive a great deal of feedback in CAMHS that young people want to engage in positive activities that feel safe (in this context, understand their mental health issues and support them to move beyond them) and support them to make social connections. Not only but young people also consistently ask for creative approaches to understanding mental health distress to be offered alongside talking therapies. Working with Rhythmix helps us to meet this demand."
- Rivkah Cummerson, Youth Engagement and Participation Manager at East Sussex CAMHS, Sussex NHS Foundation Partnerships Trust
Developing and maintaining strong collaborative working models
Work with organisations and teams where there is commitment to collaborative working and in which young people can be supported to thrive musically and feel supported to access the specialist support for their mental health needs. Organisational and practitioner values and priorities need to align. Specialist support must be integral to the initial and on-going planning and delivery in order to properly support young people to be creative and take risks; without adequate support, approaches used by the creative arts could be dangerous for young people with mental health needs.
Find the ‘right’ people to work with – this includes the choice of music tutors and the CAMHS staff. On-going engagement and leadership of the same people is important in many ways, and this means finding the ‘right’ people to work with and not just the one who can be spared. If the music tutors and the support/clinical staff in each centre recognise and value the possibilities, then all organisations must do what they can to ensure the programmes fulfil their potential and are not ‘just a music project.’Funding the scaffolding as well as the delivery
Funding bodies and partners need to be made aware of the importance of planning and funding the scaffolding supporting programmes designed to bring together mental health and wellbeing and the creative arts in cohesive and worthwhile ways. This includes the need to provide access to projects (e.g. transport and someone to help and encourage young people to attend sessions on a regular basis), support within the projects, particularly emotional and clinical support, and support to transition in and out of projects, including appropriate signposting and availability of further opportunities in communities. Supporting families and carers through creating a network to meet and speak together and education/signposting to run alongside music and wellbeing programmes should also be considered.
There are still many young people with mental health needs who are unaware of the possibilities available to participate in programmes such as Music in Mind, and others who are unsure or nervous about what they are signing up for or the potential value. Future programmes of work needs to consider ways in which the young people already involved can help grow participation, for example through making a film of their experiences (being mindful of ethical guidelines on identifying vulnerable young subjects). Additionally, the requirements for safe yet authentic creative music making spaces in a wider range of centres which young people with mental health needs often access needs further consideration.Professional development
There is a recognised need to widen the pool of experienced and dedicated music tutors that encourage and enable young people with mental health needs to thrive in a range of situations within and beyond projects. Finding people with appropriate work and musical experience and a track record of successfully engaging a wide range of people from different backgrounds and in different situations, as well as being flexible musicians seems imperative.
Develop and find funding for an apprenticeship/mentoring programme using experienced tutors with an interest in developing other people, as well as the time and interpersonal skills to successfully commit in order to professionally develop new tutors.
Professional development should be more joined-up and needs led, encouraging interaction and engagement beyond one-off, individual courses. In future projects, it is recommended that all tutors should be contracted on the understanding that they should be willing to take an inquiry-based approach to work and be willing to share their reflections and actions. Those who do this really well currently could share their practice with others.
Professional development should also consider involving professionals including clinical and support staff alongside the music tutors, enabling them to share perspectives, expertise, insights and challenges. However, this needs to be either funded from within a project or fully organised by the services such as CAMHS in order make this available for all staff.Consolidating and developing the knowledge of the wider sector
Rhythmix and other organisations/funders with an interest in working with people mental health needs should work together to synthesise and share what is already known about enabling factors and barriers when working with this particular client group in order to co-produce some guidelines for excellence. Interest in wellbeing is growing and there is a need for more inquiry-based practice to develop alongside this, providing a more rigorous evidence base upon which to develop further funding and practice. There is a degree of cross-over and synergy with other areas of wellbeing and working with other specific client groups; the next stage is to recognise the commonalities when working with other client groups and to consider the uniqueness of working with people with mental health needs.