MUSICAL PATHWAYS IN RECOVERY

‘Music triggered a healing process from within me … I started singing for the
joy of singing myself … and it helped me carry my recovery beyond the state I
was in before I fell ill nine years ago … to a level of well-being that I haven’t had
perhaps for thirty years…’. This book explores the experiences of people who
took part in a vibrant musical community for people experiencing mental health
difficulties, SMART (St Mary Abbotts Rehabilitation and Training). Ansdell (a
music therapist/researcher) and DeNora (a music sociologist) describe their long-
term ethnographic work with this group, charting the creation and development of
a unique music project that won the 2008 Royal Society for Public Health Arts and
Health Award. Ansdell and DeNora track the ‘musical pathways’ of a series of key
people within SMART, focusing on changes in health and social status over time
in relation to their musical activity. The book includes the voices and perspectives
of project members and develops with them a new understanding of how music
promotes their health and wellbeing. A contemporary ecological understanding of
‘music and change’ is outlined, drawing on and further developing theory from
music sociology and Community Music Therapy. This innovative book will be
of interest to anyone working in the mental health field, but also music therapists,
sociologists, musicologists, music educators and ethnomusicologists. This volume
completes a three part ‘triptych’, alongside the other volumes, Music Asylums:
Wellbeing Through Music in Everyday Life, and How Music Helps: In Music
Therapy and Everyday Life.

Gary Ansdell is an experienced music therapist, trainer and researcher. He has

published widely in the fields of music, music therapy, and music and health/
wellbeing, and is co-editor, with the music sociologist Tia DeNora, of the Ashgate
series Music and Change: Ecological Perspectives.

Tia DeNora is Professor of Sociology of Music, in Sociology, Philosophy and

Anthropology at Exeter University, UK. She is the author of Music-in-Action,
Music in Everyday Life, After Adorno: Rethinking Music Sociology and Beethoven
and the Construction of Genius. She directs the SocArts Research Group at Exeter.

Sarah Wilson is an experienced music therapist who has worked in both medical
and non-medical mental health settings. She is currently music therapist and Music
Project Supervisor at SMART.
Musical Pathways in Recovery
Community Music Therapy and Mental Wellbeing

GARY ANSDELL
Nordoff Robbins and University of Exeter, UK

and

TIA DENORA
University of Exeter, UK

with

SARAH WILSON
Music Therapist & Music Project Supervisor, SMART
 Contents

List of Figures ix
Preface   xi

I Musical Pathways   1
II Continuous Outcomes   191
III Musical Recovery   213
Coda – Sarah Wilson 229

Appendix A: About Method: How We Wrote This Book   231

Appendix B: How We Negotiated the Ethics of this Project   237
Bibliography245
Index 251
24 Musical Pathways in Recovery

others. Paradoxically, as Mary’s mental health gets more stable her physical health
declines (perhaps with the impact of 30 years of antipsychotic medication?). She’s
unable to get to the group for three weeks, but decides to do some music therapy
at home for herself and Tim. She gets her guitar out (she’s not told us that she’s
taken this up again), and plays and sings Greensleeves. She leaves a message on
the hospital answerphone telling Sarah this. It turns out that this is the night she
dies. Sarah hears the message a day later. Tim confirms the guitar story.
We would like to say that this tale has something of a mythological resonance
for us: Orpheus and his lute – bringing a kind of musical enchantment into the
darkest corners. Mary and her guitar, reunited at the end. We know that probably
seems over-dramatic, but the facts of the case through the tracing of Mary’s
pathway show us precisely this trajectory: Mary, who in her darkest hours cast
aside music, then re-connects with music, literally embracing it – in the shape
of her guitar – in her final weeks of life. ‘Now farewell, adieu / To God I pray to
prosper thee / For I am still thy lover true / Come once again and love me’ runs the
final verse of Mary’s last song, Greensleeves.

7. Researching Musical Pathways

These three opening stories – Eloise’s, Barbara’s and Mary’s – are key examples
of what we’re calling ‘musical pathways’ in this book. These pathways are, we
will argue, the main significant outcome of how music helps people in this place,
through this project.
People in the SMART community varied in their attitude to our research.
We were scrupulous in regard to research ethics: consulting, informing, getting
consent and generally reassuring people. But some of the research participants
had previous uncomfortable experiences with medical research, and many of
the participants experienced variations in their mental conditions. And so, as we
described earlier (in ‘The ethical moment’) there were occasional troubles with
informed consent, when some participants sometimes felt unease or suspicion,
or simply forgot there was a research project, or what this project was about. On
the whole, however, SMART members were only too happy for us to take interest
in their passion for music and its helping effects, and they actively wanted us
to promote something which most found to be a good thing for SMART and its
community as a whole. The rhetoric of the evidence-based movement has filtered
down thoroughly now, so people know that without ‘the evidence’ current services
may be vulnerable, and new ones not commissioned.
The occasional person such as Roger had more specific advice to us about what
research should be in relation to the music project:
 Musical Pathways 25

Roger on research

The important thing about research … When I had a car and I used to work on it
myself … there’s the thing about doing everything in a rush … spark-plugs, points,
carburetor … and then you fix it … but sometimes you don’t know which bit you’ve
fixed! So when you want to replicate … to learn from failures, when things don’t go
right … So the music’s important because everybody has an emotional content … but
this needs ideally mixing with the intellectual content and working out why. I think
it’s a great shame that health, and mental health in particular … there’s a lot of talk
about preventative measures, and lots of talk about outcomes, measuring outcomes
… but they don’t really get measured when you look closely … But this does do a small
bit, this project …
And taking part itself is therapeutic! So there will be roughs and smooths … Because it
would be folly for us to presume that there’s knowledge out there, and we can obtain
it all … because there’s no such thing as obtaining all knowledge … life’s a quest … to
inquire and to fully, intelligently utilise what one’s learning whilst one’s learning it …
and that’s not always easy! Life often gets in the way!
Roger, interview (2012)

As Roger says here, a lot of the focus in research on mental health is on

objective ‘outcomes’ and their quantitative assessment (think of RCTs, attitude
and depression scales, brain scans, hormone assays). These are generic measures,
designed to produce ‘generalisable’ (read ‘scientific’) results, to offer statistical
power and thus to provide a basis for large-scale healthcare funding and provision.
And yet, as Roger observes, outcomes ‘don’t really get measured when you look
closely’. We take this to mean that there is not a good enough ‘fit’ between what
counts as improvement or wellbeing from a 'patient’s' point of view and what
counts as improvement from the more ‘scientific’, and more impersonal, point
of view as assessed by standardized ‘measures’. In company with others, we
have discussed these issues in some detail in other writings (Ansdell et al. 2010;
Maratos et al. 2011; Ansdell and DeNora 2012; DeNora 2013a; 2013b; DeNora and
Ansdell 2014). We will not repeat those arguments here. What is more important
now in conveying how we researched this project is the question of how to find
‘fitting’ ways of describing what ‘outcomes’ might mean in more indigenous
terms, and how to ‘bespoke fit’ those concepts such that they are (a) intelligible
to both SMART members and to academic and health-professional readers and
(b) demonstrable through actual happenings and tales about those happenings at
SMART – there, then, over time and space. And, lastly, if wellbeing ‘outcomes’
are robust – beyond SMART – then we want to follow how they carry out, back
and into, members’ daily lives. And so we present and will use, as a way of gaining
purchase on the notion of ‘outcomes’ the term musical pathways. In recent years
‘pathways’ has become a buzz word in healthcare, where it is used to capture the
sense of movement, and different routes away from, the things that are linked with
26 Musical Pathways in Recovery

and taken to constitute illness, and toward those things associated with health and/
or wellbeing. There’s also a small history of talking about musical pathways:

Ruth Finnegan on ‘musical pathways’

The anthropologist Ruth Finnegan made a pioneering ethnography of the musical life
of a modern town, Milton Keynes, in her book The Hidden Musicians: Music making in
an English town (1989/2007). This is not just a study of music or musicians, but rather
explores the larger subject of how people move through an often-complicated range
of commitments, activities and territorial spaces of action. Among these are musical
pathways that, as Finnegan observes, may be far from ‘least important’:
‘ … pathways, then, are one of the ways in which people within an urban
environment organise their lives so as to manage, on the one hand, the heterogeneity
and multiplicity of relationships characteristic of many aspects of modern society,
and, on the other, that sense of both predictable familiarity and personally controlled
meaning that is also part of human life. In our culture there are many pathways that
people do, and must, follow – within employment, schooling, households, sport,
church, child-rearing. Within these many paths, who is to say that the pathways to do
with music are the least important, either for their participants or in the infinite mix
of crossways that make up an urban locality and, ultimately, our culture?’ (Finnegan
2007: 325)
What’s commonly lost in research on the ‘effects’ of music on people (for
good or ill) is how making music is usually part of a far broader ecology of action
and consequence. We’ve taken Finnegan’s lead (amongst others) in pursuing as
full a picture of the social ecology of SMART’s musical life as we can – tracing the
interweaving pathways and trails of musical people, musical things, and the musical
situations and events in and through which they converge, combust and transform.

By its very nature, music emerges from coordinated pathways. Music is made
by moving (bodies, instruments, the calibration of vocal chords and rhythmic
entrainment) and, acoustically speaking, by doing something that moves the air
(alternately compressing and expanding air in what we speak of as vibration).
Making music is also about moving through (from beginning to end of song,
phrase, note, passage). Whether fully improvised or guided by pre-composed texts,
music is made up of comings-in and goings-out: finding a place and lingering
in, then moving on and through (think of improvised jazz and the solo/chorus
choreography, or of singing in a choir and knowing when to start, move quickly,
slow down, or stop).
Similarly, to hear and participate in music is to hear tones in motion, as the
musicologist Victor Zuckerkandl (1956, 1973) so eloquently describes.9 These

9
 See also Ansdell (2014), Chapter 4.
 Musical Pathways 27

tones may also seem as if they have character and agency – they may strike us
as purposeful, dynamic, self-motivating. The sense we have of music in time
is – at its simplest – what is often termed the phenomenology of music. This
phenomenological sense is one of the things that distinguishes musical sounds
from sounds that just happen as a result of everyday physical events that take place
in time and space, that is the sounds that we discount as not ‘making musical time’
(e.g., the accidental sound of an object falling, but not necessarily the planned
sound of a bell or a train). While ‘music’ is also where we find it, in John Cage’s
sense, here we have in mind the kind of music that involves mutual coordination
in time and in ways that mark out a sense of event, duration and – as also, as we
will continue to describe throughout this book, 'musical space'.
Our aim, as will, we hope, become increasingly clear, is to add people and
situations to this picture so as to convert a traditional musical phenomenology
into an eco-phenomenology that can be seen to ‘fit’ and seen as ‘fitting’ the ways
that people – such as the members of the SMART Music project – account for
their experiences of and with music: that it motivates and quickens them; draws
them into places and occasions; helps them ‘get through’ situations; helps them
feel they belong somewhere (that they can ‘take their part’); softens the passage
into a social situation – or, alternatively, repels and redirects them (‘the music
pounding out of that clothes shop/bar tells me it’s not for me’). So music is
naturally associated with movement and action, with propulsion and attraction;
with finding a way in, through and out of physical, relational and social situations.
The point of an eco-phenomenology of musicking is to find a way to ‘fit’ the
‘inside’ and ‘outside’ of music together in ecologically valid ways, that is, in
ways that make sense and seem to explain what it is that music does, and thus,
how it is that music helps.
Thus the research agenda of this project, and our account of it in this book, is
not simply to report ‘what happened’ during the 10 years, but to try to understand
what exactly it is about music-in-action that can so powerfully accompany and
sometimes transform difficult lives. To understand it in this way means that we
have needed to follow it ‘on the ground’ and through time; that we have needed
to focus in two directions at once: down to the micro-detail of musical-social
moments, and then zooming up to see the broader picture developing over the
long time-span of 10 years – both for the organisation and place called SMART
and its links to the mental health arena, but also for the lives of its members.
Helping reconcile between these two foci is a mid-level or meso-level, where most
everyday social life takes place.
28 Musical Pathways in Recovery

Attending to the meso-level

The ‘meso’ is a term used to describe the middle level of social action. It is offered
in contrast to ‘micro’ (face to face and individual action) and ‘macro’ (large-scale
institutions, trends and patterns). It highlights how social change and social stability
happen ‘in action’ and in ways that involve and draw together groups of people,
practices (conventions, operations, activities with histories of use) and things. It
permits focus on what sociologists call, ‘interaction orders’ or local realms of action
that produce time-after-time forms of stable, concerted action and experience. The
interaction order is the place of mutual and entwined forms of collaboration and
the place where identities emerge, firm up, are challenged and change. The meso
level is, in the words of sociologist and ethnographer Gary Alan Fine, ‘where the
action is’ (Fine 2010). And thus it is the place where it is possible to see cultural forms
(music) getting into action and experience, mediating social relations and creating
coordinated pathways of various kinds.

8. Furnishing and Re-furnishing the Musical-Social Space of SMART

An example of thinking about the meso-level of the project is our continuing

interest in the space of SMART. We’ve already described the basics of the layout
in Section 4 above. We’ll now go one stage further by describing this context
in terms of the metaphor of ‘furnishing’ and ‘re-furnishing’. This goes beyond
talking about the physical layout in objective terms; rather it looks at how the
space becomes configured and reconfigured through collaborative social action.

***

Having committed himself to the experiment of putting a music (therapy) group in

the cafe space at SMART Gary’s first thought is to disturb the usual everyday life
of the cafe as little as possible. On Thursday afternoons between 2–4pm the space
will be configured a little differently at one end than usual (the piano turned round,
a front row with instruments turned to face the piano, a microphone and amp to the
left of the piano, a few more rows of tables furnished with small instruments and
songbooks), but no more than this. People who don’t want to join in can still sit at the
back of the cafe, and around the sides, and look and listen from a distance. This way,
there is spatial ambiguity, or rather, it’s possible to be both ‘in’ and ‘out’ of the
musical space, to belong to the space (inhabit it) in different ways – most notably, as
a musical participant or cafe patron. The space affords, in other words, different ways
of belonging and with these, different levels of musical investment. If music seems to
be asking too much, one can ‘just sit and drink tea’ (it is, after all, still open as a cafe!).
In the early months of the group we experiment with different ways of setting
out the space. Some configurations work, some don’t; it certainly doesn’t work
when the music configuration dominates the cafe space too much, converts it into a
760455
book-review2018
BJM0010.1177/1359457518760455British Journal of Music TherapyBook Reviews

Book Reviews
British Journal of Music Therapy

Book Reviews 2018, Vol. 32(1) 38­–45

[Link]/home/bjm

Gary Ansdell, Tia DeNora and Sarah Wilson, Musical Pathways in Recovery: Community Music Therapy
and Mental Wellbeing. Routledge: London; New York, 2016; 263 pp.: ISBN: 9781409434160, £36.99
(paperback), £110 (hardback), £27.99 (eBook)

Reviewed by: Max Ryz

The recovery model within mental health care is increasingly being adopted and advocated by health professionals and
policy-makers alike. As an alternative to the medical model, ‘recovery’ emphasises the importance of leading fulfilled lives
beyond the restraints of symptomology. This book is therefore timely and relevant as it illustrates and indeed advocates a
community/resource-oriented approach, mirroring core aspects of the recovery model. The final in a series described as a
‘triptych’, Musical Pathways in Recovery follows on from DeNora’s Musical Asylums (2013) and Ansdell’s How Music
Helps (2014).
At its centre, this book revolves around ‘SMART Music’ – a pioneering and award-winning community music therapy/
open mic group with its accompanying ethnographic research. The main base of the project is a café within ‘SMART’ – a
charity set up to help form a bridge between the hospital and the community ([Link]). Here, Ansdell
and DeNora join forces, collaborating within SMART Music itself in participatory researcher roles as well as in co-
authoring this book, which charts 10 years of the project – an impressive feat!
The three-part structure of the book is unorthodox, the first being very large and comprising of 45 smaller sections. The
following two parts are significantly smaller and have an organising feel, which helps to digest the somewhat hefty initial
meal. The book draws to a close with a brief ‘Coda’ from SMART’s current music therapist Sarah Wilson, who features
regularly throughout the book, followed by two helpful appendices which share processes behind the writing, research
methods and ethics involved.
The book opens with a vivid scene, following a service user from the nearby mental health unit into SMART Music.
This sets the tone and central theme that runs throughout the whole book – people following music and music following
people.
Part 1, ‘Musical Pathways’, is the main meat of the book, which is immersed in the action of SMART Music. The
researching emerges alongside the birth and growth of the project, the data of which are skilfully woven throughout.
This largely consists of vignettes, interviews and field notes organised in a lively format that playfully interacts with the
authors’ own thoughts and influences from the world of community music therapy, ethnomusicology and sociology. The
research arm of the project is not kept in the background or treated as an add-on but actively and openly acknowledged
within the book (p. 7). This is akin to the values of the ethnographic approach embedded within the project: ‘… research
with people, and not “on” them … from our staying immersed long term in this musical community’ (preface xi).
Accompanying the first 6 months of the project, sections 1–15 cover a wide range of themes, which touch on many
areas of music therapy practice. There is an exploration into the project’s place, space and developing layouts and how
this flexibly evolves with the people and ‘ecology’ of the setting. Peoples’ uses of and attachments to their instruments
are considered, examining changes that occur and what these symbolise in terms of specific relationships to music, health
and illness. Ideas about the varying and complex levels of ‘ritual and performance’ are also considered in connection to
musical experience and social events (p. 55). Following sections include a fascinating study into the use of repertoire and
songs – the explicit musical focus of SMART Music.
All of these themes are tied together throughout a text, which continually shifts between a micro and macro lens on
musical relating – from the minutia moments within individuals’ expression to the group/ensemble experience and its
peripheral ‘para’ and ‘extra-musical’ phenomena. I feel this does well to reflect the multilayered complexity of what
the authors describe as a ‘musical ecology’ (p. 41). Music moving through space and people in this way exemplifies the
‘Ripple Effect’ as theorised in Community Music Therapy (p. 151). This is further demonstrated, giving examples of dif-
ferent musical ‘work’ in varying formats and situations. Here, the project becomes more expansive, developing offshoots
in the form of other groups and public performances as well as having an advocating function for both service users and
SMART as an organisation. The associated psychological and social impact on individuals and their community alike is
discussed through a music therapy/sociological frame.
So there is certainly a lot to keep you busy with jam-packed descriptions from the many fruits of the project. The
absence of chapters took some getting used to, and combined with the increasing length of transcriptions and vignettes
 Book Reviews 39

towards the latter of part 1, I found myself having to pop up for air! Perhaps the odd transcription could have been left out
or shortened as sometimes they repeated prior comments or covered the same points.
Just before part 1 draws to a close, there is some much welcome re-orientation in the form of existential questions
regarding our profession, within a thought-provoking section titled the ‘Therapy of Non-Therapy’ (p. 178). This explores
the way that SMART Music is viewed as a non-traditional looking therapy, juxtaposed with psychodynamic music therapy
and the medical model. There is also some contemplation of the way in which music therapy and therapists are perceived
by other professionals, service users and funders, which prepares the ground for the following two final parts of the book.
Part 2 ‘Continuous Outcomes’ and part 3 ‘Musical Recovery’ refer back to the project and gather together findings
where explicit links are made between SMART Music and the recovery model. There is a wrestling with the notion of out-
come measures, where a persuasive argument is made for the need to develop bespoke outcomes using ‘naturalistic data’,
which record music therapy phenomena within the environment in which it occurs. This is certainly of pertinence within
our field, where we increasingly face demands to provide ‘evidence’ within a standardised reductionist framework in order
to keep funding and services afloat. Refreshingly, Ansdell and DeNora offer an antidote within their research stance, tak-
ing into account the rich varying shades and overtones of meaning, ‘to experience and conceptualise the holistic, dynamic
and continuous coming-into-being of an effect’ (p. 211).
Psychodynamic music therapy does make the odd fleeting appearance within this book, but I felt this only functioned
to draw distinctions. For example, in part 3, the authors state that our profession needs to recover a ‘musical core’, both in
our practice and in our description of what we do. They suggest that this is akin to Nordoff Robbins Community/Recourse-
oriented approaches (p. 224). While I agree with this in some part, I perceived a value judgement placed on socially
oriented approaches fitting better with what music does. Some assumptions are made in describing a psychotherapeutic
approach, which are somewhat stereotypical – not taking nuanced ways of working into account.
Transference-informed music therapy too must ultimately have music at its core for its sense of professional validity
and identity. Working in this way has its losses and limitations, but this is also true of the authors’ advocated approach,
which I suggest as a music therapist regularly using both approaches myself. On the whole, this could have been given
more space, although the authors acknowledge some of the struggles within the project as well as reflecting on some
service users’ ambivalent attachments to music making. Perhaps they could have gone one stage further, for example,
examining the pros and cons of flexible fluid boundaries and the particular sorts of compliancy and tendencies that are
associated with a more socially focused way of working.
Despite this, and discourses aside, there is so much to gain from reading Musical Pathways in Recovery, which has
broad appeal, whatever your therapeutic ‘persuasion’! SMART Music is a real success in many ways, as is this book,
which exemplifies and parallels the changing aspirations within mental health care. This is one for the bookshelf. Full of
knowledge, humanity and heart, it illustrates the musical pathways taken by those in need while beautifully demonstrating
creative, flexible and meaningfully therapeutic ways of working with music, people and their communities.

References
Ansdell G (2014) How Music Helps: In Music Therapy and Everyday Life. Farnham: Ashgate.
DeNora T (2013) Music Asylums: Wellbeing through Music in Everyday Life. Farhnam: Ashgate.

Reviewer biography
Max Ryz studied Contemporary Composition at Trinity College of Music and went on to train as a music therapist at the Nordoff
Robbins Music Therapy Centre, London. He currently works as a music therapist, clinical supervisor and educator within adult mental
health at Central North West London NHS Trust and in private practice.
© The Author(s) 2018
Reprints and permissions:
[Link]/[Link]
DOI: 10.1177/1359457518760455

Philip Neilson, Robert King and Felicity Baker (eds) Creative Arts in Counseling and Mental Health.
SAGE Publishing: Thousand Oaks, CA, 2016; 208 pp.: ISBN 9781483302850

Reviewed by: Rowan Armes, Melanie Beer, Alison Ramm

Overview
The scope of this new book is ambitious, and gives an impressive account of creative arts initiatives in mental health care
in Australia. With 12 authors and three editors, the overall impression is of energy and variety tightly packed into a modest
208 pages. The authors acknowledge that they are a ‘diverse group of people’, including therapists, people with experience

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 The Arts in Psychotherapy 38 (2011) 185–189

Contents lists available at ScienceDirect

The Arts in Psychotherapy

Is there a role for music therapy in the recovery approach in mental health?
Tríona McCaffrey, MA MT, BA a,∗ , Jane Edwards, PhD, RMT a,1 ,
Dominic Fannon, MD, MMSc, MSc (CBT), MRCPsych b,2
a
Music & Health Research Group, Irish World Academy of Music and Dance, University of Limerick, Ireland
b
Recovery Team, Mayo Mental Health Services, Castlebar, Co Mayo, Ireland

a r t i c l e i n f o a b s t r a c t

Keywords: The recovery approach in mental health care emphasises the importance of the service user leading a
Music therapy fulfilling, meaningful life beyond the limitations of illness or symptomatology. This approach to care
Mental health is increasingly included as a central part of mental health policy and service provision in a number of
Recovery
countries including the UK and Ireland, to address the needs of people who have severe and enduring
mental disorders. It is an autonomous, holistic and empowering way of working with individuals as
they journey towards healing. Fundamental to this model is the relationship fostered between service
users and health professionals. The recovery philosophy of care mirrors some of the core principles of
music therapy, including the importance of the therapeutic relationship and the possibilities for change
and growth within this. This paper explores the congruence between music therapy and the recovery
approach by providing: (1) An overview of current published evidence for music therapy in mental health
care. (2) A discussion of this psycho-social creative arts therapy intervention within the specialized area
of recovery in psychiatry, and (3) case vignettes to illustrate the application of this philosophy in music
therapy work within a recovery service.
© 2011 Elsevier Inc. All rights reserved.

Introduction Music therapy: the evidence

Recent and emerging discussion of the recovery approach has The growing evidence base for music therapy in mental health
been welcomed within the music therapy literature (Chhina, 2004; care supports the development of the profession in modern day
Grocke, Bloch, & Castle, 2008; Kooij, 2009). This parallels an mental health services. A review of controlled studies concluded
increase in support for the practice of recovery in mental health that music therapy is “a structured interaction that patients are
care from the service user, carer and service provider community able to use to participate successfully, manage some of their symp-
worldwide as promoted by the International Initiative for Mental toms, and express feelings relating to their experiences” (Edwards,
Health Leadership (IIMHL, 2010). 2006, p. 33). Lin et al. (2011) reviewed almost 100 studies of music
According to the American Music Therapy Association (AMTA, therapy and mental health and concluded that
2010) almost 19% of members practise in the area of mental health.
. . . music as used by music therapists results in clinical improve-
This is similar to figures produced by the Association of Professional
ment. We found no demonstrable evidence that simply listening
Music Therapists (APMT) in the UK, where mental health related
to music had the same type of result. Therefore, it may be that
work accounts for the employment context of approximately 17% of
a purposeful and professional design for delivering music, cou-
members surveyed (2009). Given the substantial number of music
pled with other factors (such as actually making music as part
therapists practising within this area it is timely to reflect upon the
of therapy, or the interaction with a therapist), will potentiate
opportunities for the music therapy profession to develop greater
the therapeutic effectiveness of music
expertise within the specialist area of mental health recovery.
(p. 43).
Music therapy is a proven beneficial intervention for people
with enduring mental illness which may bring about improvements
in social functioning, global state and mental state (Grocke et al.,
∗ Corresponding author. Tel.: +353 61 234358; fax: +353 61 202589. 2008). A systematic review of music therapy studies with patients
E-mail addresses: [Link]@[Link] (T. McCaffrey), [Link]@[Link] (J. who have schizophrenia or schizophrenia-like illnesses concluded
Edwards), [Link]@[Link] (D. Fannon).
1
that the music therapy intervention, in addition to standard care,
Tel.: +353 61 213122.
2
Tel.: +353 94 9049112. could improve patient’s global state (Gold, Heldal, Dahle, & Wigram,

0197-4556/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/[Link].2011.04.006
186 T. McCaffrey et al. / The Arts in Psychotherapy 38 (2011) 185–189

2005). Research into music therapy with mental health service cultivating the positive elements of a person’s life—such as his
users has demonstrated improved symptom scores among those or her assets, aspirations, hopes, and interests. (p. 151)
randomised to music therapy, especially in general symptoms of
The recovery approach in mental health maps onto a wider
schizophrenia (Talwar et al., 2006).
perspective in mental health services that has proposed the inclu-
The effectiveness of music therapy to reduce negative symp-
sion of service user voices in reviews of existing programmes and
toms of schizophrenia has been examined. A randomized control
approaches as well as future decision making in policy areas. In
trial showed music therapy increased patients’ ability to converse
Australia for example, an existing policy that standardized outcome
with others, reduced their social isolation, and increased their level
measures should be used across all mental health services nation-
of interest in external events (Tang, Yao, & Zheng, 1994). The guide-
ally has been criticised for its failure to include services user voices
lines of the National Institute for Clinical of Excellence (NICE) in
in the evaluation process. Happell (2008) provided an opportu-
the United Kingdom in relation to the treatment of schizophrenia
nity for some of these voices to be heard through conducting focus
stated that arts therapies are “the only interventions both psycho-
groups with 16 service users and reporting these outcomes. The
logical and pharmacological, to demonstrate consistent efficacy in
study explored multiple perspectives in addressing the meaning of
the reduction of negative symptoms” and recommends that con-
recovery, and highlighted the core concept of hope that recovery
sideration be given to offering arts therapies to assist in promoting
endorses. As described by one respondent -
recovery (NICE, 2009, p. 205).
The increasing evidence of the benefits of music therapy that I think they [services] should have a belief in optimum recov-
these outcome studies have provided is a driving force for develop- ery. I mean, they should look for the best possible outcome
ing music therapy services in the mental health sector. However, (participant response - Happell, 2008).
the psychodynamic and process oriented aspects of music therapy
At the same time the central concept of hope has required
including its unique employment of arts based non-verbal media
broader elaboration. As Geoff Shepherd and colleagues noted:
to process experiences and feelings can be overlooked when priv-
ileging outcome-based studies that focus on symptom reduction. This need not mean that in recovery services everyone must
Further exploration of an holistic approach to service development always remain ‘hopeful’ even in the face of what seem to be
and evaluation is needed across many areas of mental health pro- insurmountable practical problems. While it is true that recov-
vision (Hewitt, 2007). ery approaches do generally believe that the individual’s hopes
and dreams are often more important than professional judge-
ments about what is ‘realistic’, they do not encourage naïve
unrealism (Shepherd et al., 2008, p. 3).
The recovery approach

Described as an idea “whose time has come” (Shepherd,

Music therapy and the recovery model
Boardman, & Slade, 2008, p. 1) the recovery approach in mental
health has become an underpinning feature of mental health pol-
The NICE recommendations in relation to arts therapies offer
icy and service in a number of countries (Shepherd et al., 2008).
an incentive for further reflection upon the applicability of music
Based on principles that place the service user and their lived expe-
therapy within the recovery model of care. Recovery acknowledges
rience at the heart of decision making about treatment and care,
that each person’s journey to wellness is unique and individual.
the recovery approach emphasises hope, meaningful activity and
By actively participating in treatment goals and plans people can
empowerment (Lloyd, Waghorn, & Williams, 2008; Shepherd et al.,
assume a fulfilled life even when faced with the challenges of
2008). “Belief that there is hope for a better life is a large part of the
mental illness. Recovery promotes hope, positive self-image and
recovery orientation” (Lloyd et al., 2008, p. 325). Recovery responds
identity, trust in self, meaning, relationships, personal resourceful-
to and includes service user perspectives on the value of hope and
ness, confidence, control and above all else it emphasizes that the
positive expectations as described by a service user attending a
voices of people with mental illness are to be heard and respected
focus group evaluating perspectives in mental health provision:
(Mental Health Commission, 2007).
. . . it’s almost as if you’ve got to fight against the system to strug- These central tenets of recovery share some of the core beliefs
gle to survive and put your point across: ‘And this is what’s that inform and support the work of music therapists worldwide.
happening to me, do you understand me? do you know what Qualified music therapy practitioners work from the principle
I’m doing? do you know what I’m talking about?.. A person’s got that central to personal well-being is the need for relating in
to work through emotion. They’ve got to work through stress. meaningful contact with others (Odell-Miller, 1995). Therefore it
They’ve got to be able to work through voices and things that is timely to consider the possibilities the recovery model offers
are disturbing and destructive to their lives within music therapy practices internationally. Music therapy can
(participant response – Happell, 2008) support the call of modern mental health services to reorient
towards a more person centred way of working by facilitating
The recovery approach can be distinguished from what is
individuals’ personal journeys whilst at the same time foster-
described as clinical recovery “which implicitly assumes that, in
ing respectful, empathic relationships between service users and
the majority of cases, correct assessment and optimal treatment are
providers (American Psychiatric Association, 2005; Department of
sufficient to achieve full symptom remission. This, in turn, enables
Health and Children, 2006; Mental Health Commission, 2007).
people to return, mostly without further assistance, to premorbid
Grocke et al. (2008) have suggested that music therapy is
levels of community functioning.” (Lloyd et al., 2008 p. 322). The
“closely aligned to the recovery model of psychiatric care” in that its
recovery approach recognises that much more than clinical symp-
emphasis is on “strengths and resources” (p. 444). Common theo-
tom management or reduction is needed in supporting optimal care
retical ground between recovery and music therapy can be found in
objectives for individuals. As Davidson, Shahar, Lawless, Sells, and
descriptions of resource-oriented music therapy (Rolvsjord, 2010).
Tondora (2006) suggest, recovery is positioned
This approach in music therapy focuses on “the clients resources,
. . .in contrast to the traditional deficit-based model derived strengths and potentials, rather than primarily on problems and
from the clinical discipline of psychopathology, recovery- conflicts, and emphasises collaboration and equal relationships”
oriented care is described as eliciting, fleshing out, and (Gold et al., 2005b). Schwabe (2005) described resource-oriented
 T. McCaffrey et al. / The Arts in Psychotherapy 38 (2011) 185–189 187

psychotherapy in music therapy as an approach in which healthy the Range (1870). When asked what she liked about the song she
resources are emphasised and rediscovered through active and pondered over the words “where seldom is heard a discouraging
reflective listening in music therapy. Rolvsjord (2010) proposed word and the skies are not cloudy all day”. These words re-echoed
that resource oriented music therapy facilitates empowerment, and and yet contrasted to her earlier description of having a dark cloud
she distinguishes it from medical or psychoanalytical discourse. over her in opposed to the blue skies described in this song. She
This also parallels the goals of the recovery approach that simply requested the song Eileen McManus (n.d.) about a young woman
following the status quo is not enough to ensure quality care (Borg who leaves Ireland to work abroad. The girl featured in the song
& Kristiansen, 2004). reminded Ann of herself as a young woman leaving her home in
In the related area of arts activities in mental health, recovery Ireland to seek a better life in the USA.
has been presented as facilitated through participation in art mak- At review it was noted that Ann was arriving early and
ing describing it as a strengths based approach (Van Lith, Fenner, keeping all her scheduled appointments. This was a marked
& Schofield, 2010). The association of strengths based approaches improvement in attendance and social functioning which was also
with the recovery model is a recurring theme (Davidson et al., 2006; evidenced in her participation to other classes at the day cen-
Grocke et al., 2008). tre. Ann remarked that she was “getting things done” for herself
Having considered the framework for music therapy within and her mood stabilised with tearful episodes being rare. Sub-
recovery, the following case reports illustrate the approach of a sequent sessions introduced her to instrumental improvisation
music therapist establishing her practice as a member of a recov- in order to involve her in a success orientated task. Her playing
ery team in a mental health service. These cases exemplify how on the xylophone was timid and barely audible yet she giggled
music therapy can realise some of the central themes of recovery as she randomly hit notes across the full range of the instru-
by responding to the individual wishes and requests of people with ment. Question-answer like play placed more demands on her
enduring mental illness in a way that realises their personal choices, initiation of and responses to music and gradually Ann’s musical
strengths and potentials so that they can reclaim control over their responses held more decisive and assertive qualities about them
lives. These stories reveal “willingness and ability to shape services until she built up her confidence to perform a duet rendition of
to the needs and preferences of each individual service user”, qual- one of her favourite songs, Country Roads (1971). A re-emerging
ities that are essential to recovery-orientated model of care (Borg theme in music therapy sessions for Ann has been “being able
& Kristiansen, 2004, p. 493). to”.

Case report 1
Case report 2
‘Ann’ was a 66-year-old female with a long history of depres-
sion and marked anxiety stemming back over the past forty years. ‘Kevin’ was 40 years old and had a diagnosis of paranoid
She was introduced to music therapy over two years ago when schizophrenia. He first presented to mental health services at 24
she would occasionally attend a weekly open group in her local years of age and since then has had seven recurrent admissions
day centre. Her attendance was sporadic and her engagement was with severe episodes of self-harm behaviour and pronounced cycles
passive expressing her wish to “just listen”. Ann often became of depression, mania and aggression. He resided in a high sup-
emotionally overwhelmed and tearful during songs of a sentimen- port continuing care unit for people with severe and enduring
tal manner, sometimes causing her to leave the room and not mental health needs. Kevin was referred to music therapy for emo-
return. tional expression by his psychiatrist after having psychotic episodes
Ann informed her key-worker that she was no longer going where he engaged in serious self-injurious behaviour and physical
to attend the day centre as it was too difficult for her, so a harm towards others.
subsequent case review was scheduled with the view to look- Kevin’s first session started with a discussion around his musical
ing at other ways Ann could be reengaged in a meaningful likes and dislikes. He mainly replied to questions in a monosyllabic
therapeutic program. It was agreed that Ann be referred to manner and appeared ambivalent to the process at hand until he
individual music therapy in an effort re-engage her whilst specif- made a reference to his interest in sport and Ireland’s defeat in a
ically addressing her poor perception of self and limited social recent rugby match. I offered a musical response to his statement by
functioning. playing Ireland’s Call (1995) on the xylophone. With some encour-
During music therapy assessment Ann expressed her pes- agement Kevin reached for a percussion instrument and began to
simistic view of life describing herself as being shadowed by “a sound it resulting in a joint improvisation of the famous sport-
dark cloud” and having a constant feeling of unhappiness. She ing anthem. This was the first of many ‘real’ musical encounters
declined to play an instrument and doubted her ability to do so in Kevin’s treatment.
insisting that I play instead as she stated that I was “better at it”. In session four song composition was introduced to Kevin.
She lacked motivation and answered questions in a monosyllabic He asked how this could be achieved so I explained that a first
fashion. Ann found it difficult to make song choices, often request- step could be to choose a style of music he would like to use. He
ing that I make them for her instead, something that I avoided hesitated initially and then said that he liked reggae, particularly
doing by offering her encouragement and support to make them Bob Marley. I began to gently hum and strum the chords of the
for herself. Once again she expressed her wish to “just listen” to song No woman no cry (1974). Kevin nodded in agreement and
music yet, whilst listening to songs she made subtle and feeble said that that was the style he wanted. Deciding the lyrics was
responses by gently moving her lips in synchrony to lyrics with- somewhat more difficult so I made the suggestion of re-writing
out vocalising. This indicated Ann’s self-doubt and lack of belief the original lyrics of the selected song whilst keeping the original
in her abilities whilst also hinting to me that she had potential to melody. Once again I strummed the song’s chordal pattern as
assume more active participation and control over her environ- Kevin made suggestions of lyrics similar to the original rhythmic
ment. pattern. After approximately 10 min Kevin had written a song.
Initial sessions with Ann addressed her lack of self-confidence
The sun is shining today
by supporting her to make choices and to foster communication Yet in my heart I’m grey
through discussion of themes as they arose in her selected lyrics. The sun is shining today
One song choice that Ann frequently made was that of Home on Yet in my heart I’m grey
188 T. McCaffrey et al. / The Arts in Psychotherapy 38 (2011) 185–189

In my youth my life goes by favourite tunes to learn and acknowledged that he wasn’t attending
And so I lay down and sigh for lessons but rather he wished to do something to help himself.
Things are looking better
Then it begins to rain
Joe tended to approach playing in a complex manner and was
No more sunshine for us most self-critical of his musical contributions. This only increased
his anxiety and hurried his eager nature to strive but in many
After singing his song Kevin told me that it was during his late ways set him up for failure rather than success. It also warranted
teens that he began to have mental health difficulties which were my sometimes harsh honesty with him when he chose musi-
particularly pronounced as he began his studies at university. He cal material that was overly intricate and ambitious. Treatment
expressed remorse and sadness about how his actions affected oth- focused foremost on Joe’s wish to build a musical repertoire on
ers around him at this time and described the resulting losses which piano accordion but also upon self-regulation of anxiety through
he experienced. play.
A number of months into his music therapy program Kevin Sessions began by Joe making a song selection which featured
experienced further psychotic episodes accompanied by self-harm simple I-IV-V chord patterns which he could play on bass along-
behaviour and he required acute care. Sessions were postponed side my singing and slow vamping accompaniment on keyboard
and resumed two months later. Using musical interactions such in order to emphasise metre. This was a way of grounding and
as song selection, song singing and improvisation stimulated stabilising the music to help regulate pulse and breathing so that
discussion and expression of feelings with Kevin being able to Joe’s initial anxiety was curbed after entering the building. He com-
communicate how he felt during his psychotic episodes. He spoke mented that this was an enjoyable exercise to begin with which
of his experience of fleeting thoughts and apparent distortion of helped to settle him into sessions and resulted in a satisfactory
reality. For example he had heard people around him refer to musical experience.
“May day” which he interpreted to be a sign of distress when in By breaking suitable tunes into simple parts and separating left
fact it was in reference to the first day of the month of May, a and right hand play Joe was able to improve his musicianship and
day of religious significance in the Roman Catholic calendar. His acknowledge the gains himself. After his fifth session when he
insight improved with greater awareness of the consequences of managed to play both the melody and bass accompaniment of the
his actions towards others when he had become violent. He also popular Irish piece called Sally Gardens (1889) he once again said
articulated his fear of meeting people he once knew and their that music makes him feel good about himself.
attitude towards him as a result of his mental illness. From the onset of the program Joe began to play the accordion
Kevin had told me that he had attended piano lessons dur- at home of his own accord. To help him self-regulate his anxiety
ing childhood but had not played to this standard in many years. independently whilst also developing his music skills he was given
Despite his difficulties in concentration he sometimes played the a CD featuring recordings of pieces with emphasised metre which
keyboard for short periods. Two months after his music therapy he could play along with. Joe reported that this helped him and
program was resumed he arrived to a session suggesting he play added that he was occasionally able to build up the confidence to
the keyboard and skilfully performed the introduction of the Led play for his house mates. After three months Joe had built a reper-
Zeppelin song Stairway to Heaven (1971). He proudly informed me toire, from memory, of four traditional Irish pieces which he could
this was something he had been working on for a while and had successfully play from beginning to end.
learned by ear. This marked a point in therapy where he captured Joe’s self-direction in his treatment highlights how an individ-
a more active role and has since brought in recorded songs for me ual’s motivation and interest can develop when they are central
to listen to and help him arrange for keyboard. By reawakening to their own care-planning process. This is fundamental to the
his musicality Kevin has been able demonstrate self-determination. recovery philosophy of care. In music therapy he has achieved and
These outcomes underline the importance of finding and maintain- governed his ambition to learn a new skill whilst being empowered
ing hope, re-establishing a positive identity, building a meaningful to help himself.
life and taking responsibility and control during the personal jour-
ney of recovery (Shepherd, Boardman, & Slade, 2007).
Discussion
Case report 3
Music therapy is uniquely placed to provide opportunities for
‘Joe’ self-referred to music therapy because he wanted to learn a clients who have difficulties in participating in therapeutic ser-
new skill to improve his self-confidence. During his first session he vices and who find general social relating challenging. The review
described his experience of living with psychosis and social anxiety of studies pertaining to people who have severe and enduring men-
and when asked how he envisaged music therapy to help him he tal illnesses recorded a “negligible” attrition level for participants
exclaimed “music makes me feel good”. The following outlines the (Grocke et al., 2008, p. 444). In the experience of the authors, clients
initial three months of weekly sessions. attending music therapy services do so regularly, and note that
Joe purchased a piano accordion and clearly expressed his wish self-care frequently improves, with clients “dressing up” for ses-
to be able to play this instrument. In anticipation of sessions he had sions (Tommy Hayes, personal communication, 2008). Therefore,
independently learned part of one tune. He had attended a music these aspects of potential benefits including self-care and economic
skills group in the past as part of a previous treatment program. impact might be given consideration as a parameter for evaluation
Now being part of any group made him nervous and he had minimal in future studies.
social involvement. His fear precipitated sensory hallucinations Music therapy focuses on the resources and strengths of clients;
whereby he believed that he omitted an unpleasant body odour gently and gradually building their confidence and capacities
which others could smell. His anxiety upon meeting new social sit- through regular supportive sessions over time. Whilst music mak-
uations and entering the building where sessions took place was ing requires a unique kind of mental organisation that is difficult
evident and Joe often complained of stomach pains in the sessions’ to account in simple terms, it is important to consider music’s
opening moments. This translated into his playing which displayed distinctive capacity for the promotion of self-organisation and
considerable music skill but was unstable in metre, phrasing and self-regulation. In conjunction with another person, playing music
dynamics leaving Joe dissatisfied with the final musical product. together mirrors all the capacities for relating that verbal interac-
Notwithstanding this Joe eagerly continued to bring some of his tion requires; including listening, responding, and initiation.
 T. McCaffrey et al. / The Arts in Psychotherapy 38 (2011) 185–189 189

The case reports presented here provide support for the appli- Department of Health and Children, Ireland (2006). A vision for
cability of music therapy within the recovery approach. Processes change: Report on the expert group on mental health policy.
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Conclusion apy in the care of the severely mentally ill? Australasian Psychiatry, 16,
442–445.
Happell, B. (2008). Determining the effectiveness of mental health services from a
Three individuals with an enduring mental illness are described consumer perspective: Part 2: Barriers to recovery and principles for evaluation.
attending their first music therapy sessions, finding ways to build International Journal of Mental Health Nursing, 17, 123–130, doi: 10.1111/j.1447-
0349.2008.00520.x.
on their capacities through music, demonstrating new skills, and
Hewitt, J. (2007). Critical evaluation of the use of research tools in evaluating qual-
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