The Case for Music – Supporting Clinical Outcomes
"You really have contributed so much to our therapeutic day program. Your skills with working with young people are great and the young people thoroughly enjoy this group. Rhythmix really does provide meaningful activity that the individual young people view as important. Rhythmix contributes to our therapeutic timetable by helping to engage the young people; its’ meaning creates an emotional response, helps motivate the young people, and relates to the young person's value system."Keli Horne, Day Service Lead, Chalkhill
I would say there has been a notable development in confidence and self- esteem for all of our young people who attended Music in Mind this term. The group were open, highly supportive of each other and reported finding it helpful to be able to join in a group where others could be understanding and non-judgmental to their specific needs. Rebecca Hempe, Targeted Youth Support Worker, East Sussex CAMHS
An ambition of Music in Mind was to facilitate "increased access to appropriate services for young people with mental health problems". Therefore the programme has mostly been delivered in venues where mental health services are regularly situated, and each programme has worked towards some kind of opportunity for young people to explore and verbalise their own thoughts and feelings (mostly through song and lyric writing). Most tutors have undertaken specific training on working with young people with mental health needs, and in most of the projects, at least some of the work has been co-delivered with support from professionals from CAMHS.
Overview of the focus of the case study
The case studies provide compelling evidence of some young people thriving through their time with the Music in Mind programme and beyond. From supporting engagement in formal education, to gaining friends, attending centres more regularly and accepting help, becoming more self-confident and using the narrative of song writing to express emotions and feelings and many more outcomes, Music in Mind has facilitated these. The relationships that young people have formed with each other, with the music tutors and with the support staff are the central pillars of this development.
There are many examples of partnerships and collaborations evident throughout Music in Mind – including some music tutors working with clinicians, nurses, occupational therapists, support staff, youth workers and other specialist staff at various points. Parents and families are another very important part of these partnerships, offering support to their children and each other, and also seeking support and advice from the specialist staff. Within the residential provision, the nature of the partnership between the music provision of statutory schooling and that provided within the Music in Mind project provides another key dimension.
Challenges with recording clinical outcomes
Arguably, many of the outcomes noted throughout these case studies could be considered to be ‘clinical’ since they note such factors as perceived rise in self-esteem, more self-confidence, working collaboratively with others and opening up about issues affecting young people involved in Music in Mind.
Some of the reported outcomes that appear to be related to clinical outcomes referred to short term changes. For example, one young person noted: “You can forget your problems when you’re playing music because you have to focus so much on what you’re doing”. This relates closely to clinical outcomes and perhaps contributes in the longer term, so is important in that sense.
Many of the young people involved in Music in Mind did not have the same level of contact with CAMHS and the projects consistently throughout the entire duration, because they were transferred to other parts of the service or discharged as would be expected in clinical programmes. An example is young people who spend a period of time as a residential patient at Chalkhill before being referred back to a more local Tier 3 community service. This is likely to be considered a clinically ‘successful’ outcome.
A perceived problem, though, is being able to say for sure that Music in Mind has contributed to this, and if so, the extent of the contribution. On the other hand, by triangulating the comments and hearing about the same events and incidences from multiple perspectives, the outcomes tell their own story through the narrative. Clinical outcomes, in the case of Music in Mind, could include all of the aforementioned outcomes and many more, including cases where young people mention that coming to the sessions was the hook into accessing the mental health support they needed.
There is no clearly defined definition or explanation of what ‘clinical outcomes’ are and what they look like; the perceptions and understanding of the term varied across the support staff and tutors. This is not suggesting that this is negative, but something that perhaps requires greater clarification in the future. However, there are emergent categories of outcomes across the data set (see below). It should be pointed out that there is a degree of overlap between these as to some extent they are reliant upon each other.
There are some examples of difficulties impacting upon young people’s ability to engage in the sessions for psychological reasons, particularly related to stress, anxiety and communication.
There are many reported incidences of social development, for example engaging in conversation with tutors and other young people when this was reported to be challenging, collaborating with others through musical processes and, in some cases, forming friendships which have continued outside of the group. As one young person said “I wasn’t going to join in but I’m glad I did, it was a laugh, I’ll definitely be back here next week”.
Emotional wellbeing, particularly coping with anxiety, stress and some of the physical issues related to emotional wellbeing (such as self-harm) were frequently noted, particularly when young people recognised for themselves that they were either doing something positive or feeling positive, or not doing something negative or having a negative outlook.
Lyric writing and song writing were mentioned many times as ways for participants to express their thoughts and feelings, and, in some cases, externalise matters that they had previously ‘bottled up’ (participant). The use of narrative in this way was reported to be very powerful for some young people, as both a vehicle for self-expression (on a range of topics) and with possible opportunities for engaging in some form of verbal communication around difficult topics such as bullying, bereavement, self-harm, negative thoughts and self-image.
Another aspect of emotional wellbeing mentioned by some participants and support staff was a feeling of belonging and development of coping strategies. For example, a participant in the East Sussex CAMHS project stated after a performance: "It gave me a strategy. A way to cope. When things are difficult you feel so alone but this group helped me see that there were people around me. It's one of the best things I have ever done".
Another participant stated: "It pushed me out of my comfort zone and helped me felt part of the group and that's important to me”. This suggests that feeling secure is an essential part of the safety net needed for young people to take creative and personal risks.
The most commonly expressed response to the question "what would you tell someone else about the music sessions?" related to enjoyment and having fun with other people, although this was sometimes caveated with comments about how it was "scary at first’.
Some of the song writing sessions provided opportunities for particular issues to be explored and strategies developed. For example, bullying came up as a recurrent theme.
Personal psychological benefitsPerceived higher levels of self-esteem and self-confidence were often noted as observed outcomes by support staff and young people. This related to the confidence to play instruments, and to do things in front of other people (e.g. contributing to discussion, playing, making musical suggestions and performing). Many instances of perceived higher levels of self-confidence and self-esteem transferring to other situations beyond the projects are noted, with some young people giving credit to their feelings of wellbeing from the projects as responsible for this. Improved aspects of resilience were noted by tutors, support staff and young people. However, resilience is a difficult term to define and the references to it were often implicit, with the exception of "sticking at something" or "not giving up", which were frequently mentioned.
Accessing support / AttendanceThere are examples given by support staff of young people seeking advice and support in the sessions, using the opportunities to engage more informally with staff from CAMHS to ask questions. Some participants reportedly attended sessions more regularly during the music projects, implying that these young people valued the music sessions. However, some young people found regular or initial attendance difficult. This sometimes meant that it was difficult for them to feel confident to attend a session when they had been missing previously. Tutors also noted the disruption to groups with irregular attendance and some musical challenges related to creating safe spaces for risk taking with small groups.
Disclosure and TrustIssues of trust came up through the sessions – trusting oneself and the judgements made, building trust with support workers, with tutors and other young people. There are a few specific examples of trust growing over time and the impact upon creative processes and outputs, levels of engagement and more open communication. There are multiple examples of disclosure about things relating to young people’s lives and thoughts, particularly through the narrative of the lyrics. It is clearly very important that a support worker is always available to support emergent thoughts, feelings and emotions. Some support staff mentioned that working with young people in a different environment to that where they usually saw them (e.g. in a 1:1 situation) facilitated opportunities to see how young people responded in different situations and also to develop relationships and build trust.
Defining terminology and outcomesThroughout Music in Mind, a number of terms are used where the definition is either contested or perceived differently by different stakeholders. Future projects should attempt, where possible, to clarify definitions of terms through discussion and considering different perspectives. Given the interest in clinical outcomes, discussion around how best to appropriately record and report specific outcomes would be beneficial, particularly because the kinds of ‘evidence’ expected by some medical professionals extends beyond the types of evidence recorded here.
Programme designProgrammes are designed flexibly to work with a bespoke group of young people, moving between learning instruments to playing covers of chosen songs and more creative and self expressive aspects of music making. This model is important to the programme because it provides a structure in which trust and relationships are built and young people’s own thoughts, feelings, emotions and voices can be heard. Lyric writing and rapping also provided a safe and supportive way for young people to express themselves and sometimes the topics they chose opened the door for discussion with the support and clinical staff and were a stepping stone towards finding individual and collective strategies for the future. However, without the support of specialised staff, it is an unrealistic and inappropriate expectation that a music tutor on their own will always be able to provide this support and guidance. Whilst it was sometimes challenging to get young people to attend additional sessions in the school holidays, there were some examples of the music project drawing young people into the centre. This provided access to professional help in tackling issues such as bullying on an individual basis through both the music and working with clinical staff at the centre - which had, in one instance, become more of a need due to a young person’s anxiety building over transition periods such as the summer holiday.
The importance of clinical supportHaving someone with a clinical background in the sessions and who knows the young people, is extremely important to be able to nurture and note behaviours. For example, there was a young woman in an East Sussex project with an acute eating disorder who the support worker noted ate an apple in the session, having not eaten in front of people for a considerable amount of time. The support worker was able to follow this up positively with the young person involved; the music tutor alone would not have been aware of the significance of this. As noted throughout the report, the need to have clinical/ support staff working alongside young people to support their mental health needs and wellbeing is important in every session. Without this, the opportunities to offer support and guidance are significantly diminished and the sessions may lead to unintended detrimental outcomes.