Health-promoting music

Hans Petter Solli leads the way from Reception at the Lovisenberg District Psychiatric Centre (LDPS) in Tøyen. Through a door and down the stairs to the basement, past shelves of correction fluid, virgin notebooks and stacks of coffee filters lies the music therapy room, which is Solli’s office. Against one wall is a piano, amplifiers are lined up in rows along the floor, and a drum kithas been set up in one corner. Room has also been made for guitars, percussion instruments and a small recording studio between the yellow-painted walls. For a music therapist who is also a drummer, is it tempting just to sit down and play a bit occasionally?

“I work with severely ill patients, and sometimes I need to chill out too. I don’t have a bad conscience if I sit down behind the drum kit in order to get my strength back after a session.”

Solli has taken a seat in one of the two chairs that, together with asmall round table, make up the seating group in the room. He’s at the initial stage of his post doctoral project “MusTCare: Implementing music therapyin an outreach mental health team”, in which he will be examining how music therapy for patients with severe mental illnesses and substance addiction can be implemented within a FACT team in the Gamle Oslo district.

FACT is short for Flexible Assertive Community Treatment – and is a model designed to provide holistic services to people with severe mental illness living in their own home. Solli tells me there are 15 FACT teams in Norway, and a further 18 are in the process of being set up. The model has also gained a footing internationally, in countries including Sweden, the Netherlands and the USA, and Solli is hoping that the research he is about to embark on will also assume relevance beyond Norway’s national borders.

“The FACT team’s work is based on a recovery-minded approach, which means taking an interest in how to give patients as good a life as possible despite their challenges. Some want to get stoned or drunk, and you have to accept that substance abuse is something they will carry on with. A fair amount of those who have psychoses must expect to live with the symptoms for the rest of their lives. So instead of just focusing on trying to put an end to the symptoms, we are more interested in giving them a good quality of life – work for social bonding, foster hope and offer meaningful activities that make life feel worth living.”

But the FACT team has a limited repertoire when it comes to how to help individual patients, according to Solli.

“Especially those who are unmotivated and have poor relational skills. Music therapy is a resource-oriented approach in which there is no great need to talk, and music is something that gets people excited, after all. Without music life becomes sad, many say. So too for us, and for many of my patients as well.”

The research project, which is subsidised by the Norwegian ExtraFoundation for Health and Rehabilitation through the Council for Mental Health, is affiliated with CREMAH – the Centre for Research in Music and Health at the Academy of Music. As part of the study, Solli is providing a music therapy service for 12-15 users in a 50-percent position over two years at the Gamle Oslo-based FACT. Using participatory observation and interviews with the patients, staff and managers, the aim is to gain a knowledge of the way music therapy can be implemented in the best way possible – a qualitative approach in the form of participatory applied research. Solli also has a competence group involved in the project, consisting of three people, all of whom have experience with psychosis, stimulants and music therapy. These people will be contributing to the study, among other things by coming up with suggestions for interview guides, analyses and ways of organising practice. The point is to shed light on the material from various angles and thus avoid blind spots.

“I’m biased in many ways, of course, as a music therapist, as an academic and as a healthcare professional. That’s why I’ve brought in people with experience of what I’m researching, to come up with suggestions, be critical and address any ethical concerns.”

The patients taking part in Solli’s study are some of the most severely mentally ill, and often refuse other assistance offered by the health services. Some have a keen interest in music,and many play instruments themselves. During the summer Solli starts a music group in the Grønland neighbourhood for those wishing to play with and meet others in the same boat, as a supplement – or an alternative – to individual therapy. As part of the FACT team, it is his job to work on an outreach basis, in the form of home visits, but eventually he hopes to be able to get the patients to meet him in the music room.

“I have a hypothesis that most people really want to get out of their homes, and that it’s good for those who spend a lot of time indoors alone. I envisage the first phase being to meet them at home, the second phase to meet them here in the music therapy room and in the group, and a third phase, if it transpires, to link them up to a music service in their part of town, whether it is the school of music and the arts, a music workshop or some other meeting place. I’ll be working with the very sickest people at a time when they most need help, but obviously I hope some will get better along the way, and that I can gradually usher them on to other services.”

The user at the centre

For 15 years Solli has been working as a music therapist at the Lovisenberg Diaconal Hospital, where he has been involved in creating three permanent positions for music therapists – two on general wards and one at LDPS, where he is currently employed. He is occupied with the user perspective in such therapy and has previously written a doctoral thesis at the Grieg Academy, where he interviewed patients with psychotic issues about their experience of music therapy on the locked psychiatric ward.

“The value base and health-policy guidelines in the field of mental health and addiction currently emphasise the need to listen to patients. We’ve done that far too little in psychiatry in the past. To far too great an extent we have regarded ourselves as experts, showing how things are to be done. In recent years we have come to a much clearer realisation that the users have valid and important knowledge of what is useful.”

“The study will contribute fresh knowledge about the users’ own wishes and needs,”you write in the project description. What are you looking at that hasn’t been looked at before?

“Music therapy as an outreach service has not previously been studied to any great extent. There are few studies of patients with severe mental illness combined with addiction issues and living in their own homes. The FACT model is seen to be a working approach that leads to fewer admissions and less use of coercion; you retain the general overview and are able to help during critical phases. Looking at the implementation of music therapy in such a team, that’s the novel thing. We know that music therapy works — it’s recommended by the Directorate of Health and has knowledge-based therapy status — but we don’t know so much about the way music therapy services should be offered in different contexts. Little implementation research has been done in music therapy generally.”

Music therapy evolves in different ways, adapting to the user’s needs. Solli tells me he has one patient who often lies in bed in the supported accommodation he lives in while he listens to rap from a time when he was younger and felt better. On good days he writes his own raps, which Solli records with Garage Band software. Another patient often wants to watch old YouTube videos, allowing him to reminisce about his former life. The videos are a gateway to enabling him to jointly process experiences from his past and create new narratives.

“He won’t attend any other form of treatment, but this is the highlight of the week. He sits in that chair you’re sitting in now and isn’t the type to move much all week. But when 2Pac and California Love come on, he’s unable to sit still. I’ve learned loads of groovy dance moves from him!”

A third patient is a former guitar player who has played extensively in bands but has lost contact with friends and family since becoming ill. During the therapy sessions they work on melody writing. Here he can express what he struggles with in everyday life, and can write about how he would like life to be. They record some of the tunes in the little studio in the therapy room.

“Working out and mapping what we’re going to do together is not just an analytical phase but part of the therapy. When I meet a patient, it’s a meeting of two experts. I’m an expert in music therapy meeting a person who’s an expert in his life and his history. The aim is to bring about a state of equality. One of the patients I interviewed for my doctorate said there are so many people in psychiatry asking about all the difficult stuff, highlighting everything that doesn’t work. In the end she felt like an item of malfunctioning merchandise, whereas in music therapy she didn’t have that perception — there we take what resources we have and their life history as our basis and continue to build on that. That makes for a much more equal relationship –what they call a partnership relationship.”

The research is based on treatments adapted to the individual. Do you nevertheless envisage being able to extrapolate general guidelines from the work?

“The music therapy at FACT in Gamle Oslo is a specific context, of course, and not all experience from this place can be generalised. At the same time, it has many features in common with similar therapeutic offers elsewhere, and the patients I meet face many of the same health and social challenges. It will be perfectly possible to obtain useful knowledge that can be transferred; at the same time, it’s going to be important to work on individual plans for each individual patient throughout the project. It’s a paradox in a way, but the aim of the research is not to arrive at a stringent method or a manual offering an ideal working approach. It’s more about describing the framework and patient pathways,and perhaps also a basic value set outlining how music therapists ought to work. I hope the study will shed light on many important topics in a good way; but then, of course, more research is always going to be needed to elucidate other topics and contexts.”

More than music

Music is Solli’s tool, his way into therapy, but it is not only notes and sounds that are important to the users. At the summit meeting on music therapy in the field of mental health and addiction at the Academy of Music (NMH) before Christmas, Solli related how one of the patients participating in the research had suggested there should be coffee in the music therapy room in order to motivate him to bother taking a shower and going along to Solli’s office in Tøyen.

“So maybe I should buy an espresso machine, as part of the implementation strategy,” Solli then said.

Has there been a new coffee machine since we last spoke?

“I’ve bought one!”

Solli smiles contentedly behind his glasses.

“It’s all about motivating people to get treatment and be active. Many of the patients I work with have psychotic issues. For them the world is often a bit spooky; it’s easy to just withdraw from the world when you hear voices, maybe see things and have paranoid thoughts about the world not being a nice place. The health services often struggle to put in place good services, alliances and relations with these patients. But those of us in music therapy are known for being good at it.”