Mental health inpatient experiences of song-writing: A qualitative study

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Mental health inpatient experiences of song-writing: A qualitative study

In plain language

This study explores the experience of engaging in song writing in mental health inpatient units through lyric analysis and qualitative interviews with people who engaged in song-writing during an admission. Themes identified from song lyrics were romantic love, spirituality, the meaning of life and illness. Themes identified from interview data related to the process of writing the song; the process of collaborating, the expression of emotion, music in hospital and the relationship of music to mental health. Findings highlight that song writing provides a collaborative activity in which participants with acute mental distress are able to express themselves and explore issues relevant to their illness and recovery. The study suggests that facilitated song-writing can provide an important creative therapeutic outlet contributing to recovery in mental health settings.


Abstract

While studies have highlighted song-writing as an enjoyable pastime for people experiencing mental illness, little is known about its benefits for recovery. This study explores consumer inpatient experiences of engaging in song-writing in mental health inpatient units through lyric analysis and qualitative interviews. Consumers in acute mental health units at a large metropolitan hospital took part in group song-writing activities over a 14-month period. Songs were written in partnership with the music therapist and the participants. In this study the same melodic structure was used for each group for consistency. One hundred songs were written by 110 participants and lyrics were collected with consent. Following purposive sampling, in-depth qualitative interviews were conducted with 11 participants. Thematic content analysis of the data was undertaken using an inductive approach. Themes identified from song lyrics were romantic love, spirituality, the meaning of life and illness. Themes identified from interview data related to the process of writing the song, the process of collaborating, the expression of emotion, music in hospital and the relationship of music to mental health. Findings highlight that song-writing provides a collaborative activity in which participants with acute mental distress are able to express themselves and explore issues relevant to their illness and recovery. Facilitated song-writing provides an important creative therapeutic outlet, contributing to recovery in mental health settings.


Citation

Hogan-Gibbons, C., Short, A. E., & Isobel, S. (2020). Mental health inpatient experiences of song-writing: A qualitative study. Australian Journal of Music Therapy. Advance online publication. Retrieved from https://www.austmta.org.au/journal/article/mental-health-inpatient-experiences-song-writing-qualitative-study


Date published: December 2020

"Dopamine, serotonin, noradrenaline flowing through my veins,     
Going to my brain, going to my brain,
Balancing, correcting everything to stop the pain.” (Participant Song 99)

Introduction

     The promotion of psychological well-being is central to music therapy, which uses social and relational capacities to promote interaction, communication and connection (McCaffrey, 2015). Music therapy focuses on the resources and strengths of participants; seeking to build their confidence and capacities. Music has a distinctive capacity for the promotion of self-organisation and self-regulation and mirrors all the capacities required for relating; including listening, responding, and initiation (McCaffrey et al., 2011). Importantly, these factors may also play a role in recovery from mental illness.

     Mental health services worldwide are moving towards recovery-oriented care. Recovery means gaining and retaining hope, understanding of one’s abilities and disabilities, engagement in an active life, personal autonomy, social identity, meaning and purpose in life, and a positive sense of self (Australian Government, 2010; Deegan, 1988). Personal recovery differs from clinical recovery, as it does not focus on symptom reduction but on discovering personal resources and satisfaction (Slade, 2009).  The central tenets of recovery share some of the core beliefs that inform music therapy (McCaffrey et al., 2011), including that central to personal well-being is the need for relating in meaningful contact with others (Odell-Miller, 1995). Music therapy may offer support as mental health services seek to reorient towards a recovery orientation by facilitating individuals’ personal journeys whilst at the same time fostering respectful, empathic relationships between service users and providers (McCaffrey et al., 2011). Song-writing may thus be an effective medium to assist with delivering recovery-oriented care.

     Song-writing in mental health units provides opportunities for the facilitated creation of lyrics to address the needs of the client (Baker & Wigram, 2005). Song-writing is “the process of creating, notating and/or recording lyrics and music by the client or the clients within a therapeutic relationship to address psychosocial, emotional, cognitive and communication needs of the client” (Baker & Wigram, 2005, p. 16). In mental health settings, consumers are often acutely unwell and at times, hospitalised involuntarily. In these circumstances, song-writing can be used to assess mental health, enhance quality of life, process understanding of illness, assist in coping, facilitate self-expression and identity formation, strengthen memories, enable interpersonal comm-unication and represent social, family and individual protective factors (O’Callaghan & Grocke, 2009).  Within a psycho-dynamic context it can also aim to “resolve unconscious inner conflicts, identify defence mechanisms, work through past relationships, integrate a fractured sense of self and help the song writer find meaning” (Baker, 2015, p. 196).

     Song-writing has been associated with improved psychological and emotional health, as well as clarifying thoughts and feelings and reducing negative emotions (Baker et al., 2008). Song-writing has been shown to improve mental wellbeing in people with acute mental illness (Silverman 2019a; Silverman 2019b) and assist in processing concerns for the world, the challenges of living with mental illness and recovery (Grocke et al., 2009). Song-writing can also assist people to regain hope, identity, social connection and empowerment through control (Kooji, 2009). While there is only a small field of evidence for song-writing for people with mental illness, the literature is suggestive that song-writing activities may enable deeper understanding of the issues individuals face in their mental health recovery.

     In mental health settings, Music Therapists use music and therapeutic skills to support people to participate in music experiences within the context of a therapeutic relationship  (Bibb et al., 2018). Tailored music-based interventions are developed to meet consumers’ self-determined objectives (Silverman, 2013). Music therapy can contribute to processes of empowerment, insight and change and is well suited to being used in settings where people may be reluctant to engage in treatment or experience disempowerment (Daveson, 2001). This is of direct relevance to mental health settings. While there is a growing field of evidence of the effects of music therapy on clinical outcomes (McCaffrey, 2018), sole focus on outcome measures can overlook the perspectives of people who may have valuable information to share about their personal experiences (Stickley, 2006). There are limited studies of the clients’ perspectives of music therapy or song-writing in acute mental health settings. Within a recovery orientation, providing opportunities to listen to and explore the experiences of people receiving care is paramount, and can help to balance the predominant focus in services upon clinical recovery (Hyde et al., 2015). In inpatient mental health settings in particular, many consumers may experience medically dominated approaches to care, with even the concept of recovery being reportedly co-opted by services (Beresford, 2015). Recovery-orientation requires a shift in traditionally-held practices, as it seeks to equalise power between clinicians and people receiving care (Schrank & Slade, 2007). The ongoing prioritising of listening to the voices of people receiving care, even when similar experiences have been reported previously, is critical to evaluation of mental health care (Isobel, 2019).

     Building on the existing research, this study aimed to identify what individuals in acute mental health units choose to write about in song-writing and explore how they experienced the process of song-writing, for the purposes of contributing to understanding of the role of music therapy in mental health settings. The study sought to contribute to evaluation of the local music therapy program as well as document and explore how the song-writing process may contribute to recovery using multiple sources of qualitative data. The study was guided by the research questions: ‘What do people in mental health units choose to write songs about?’ And ‘What is the experience of people in mental health units of participating in song-writing?’

Method

Design

     The study was a qualitative inquiry with multiple sources of data. Data were the lyrics from all songs written during the study period and the transcripts of semi-structured in-depth interviews conducted with participants from the song-writing groups.

Ethics approval

     Approval from the Concord Repatriation General Hospital Human Research Ethics Committee was gained for this study (CH62/6/2015-179).  All participants in each song-writing group held between February 2017 and April 2018 received written information about the study, including the use of the song lyrics as data, and gave written consent. No participant declined to consent. Potential participants in the interviews were given an additional information sheet and provided written consent.

Setting

     The study took place in a large metropolitan hospital in Sydney, Australia. A large mental health facility is attached to the main hospital and consists of a number of specialised units. A music therapist is employed part-time to provide music therapy programs in the mental health units. The current study included consumers who participated in the music therapy groups on two of the adult units, an acute and a sub-acute unit, both admitting 20 consumers. The units admit people between the ages of 16 and 65 who are experiencing acute relapse or onset of mental illness or disorder. The acute unit has an average length of stay of 18 days and the sub-acute unit has an average length of stay of 12 weeks. Additional demographics were not recorded to protect the privacy of participants and encourage participation.

     Music therapists are qualified professionals. In Australia, to gain registration, music therapists need to complete a tertiary course in music therapy accredited by the Australian Music Therapy Association (AMTA). The music therapist in this study has a predominantly humanistic approach (Abrams, 2014) that prioritises the relationship between the inpatient and therapist, and views music as an opportunity for self-expression. The music therapist has over 20 years of experience in mental health, playing both piano and guitar.

Song-writing Groups

     As part of standard care, the music therapist (CHG) visits each unit once per week and invited any interested consumer to participate in a song-writing activity. The groups then occurred on the unit in a quiet space and lasted for approximately half an hour each. The groups were facilitated by the music therapist and at times a student music therapist assisted. During the group, the music therapist played her guitar and the group participants provided lyrics. A variety of songs can be commonly used, but for consistency in this study, the song ‘By the Waters of Babylon’ (Hayes, 1786) was used for each group. This melismatic song is easy to fit words to and has a slow rate of harmonic change. The melody and chords from the song were used as a framework for lyrics substitution. It is common for therapeutic song-writing in mental health units to involve the substituting of lyrics to existing songs, based on themes (Baker et al., 2008). Lyric substitution can provide a “safe structure” (Marom, 2004, p. 42) for spontaneous improvisation and expression of messages of and existential themes. Songs were written in one session. Groups comprised of 2-5 participants. The music therapist played the song on the guitar and sung the melody without lyrics. Then discussions about topics occurred, the music therapist asking the participants open-ended questions. Any member of the group could generate lyrics and a theme was agreed upon based on emerging ideas. The lyrics were written down as they occurred, and the music therapist sung the lyrics line-by-line, inviting the participants to join in if they desired. Editing suggestions by both group participants and the music therapist were made. When the song was complete, the group sung it through several times, with participants invited to join in or listen. Following the group, the music therapist typed up the lyrics and gave a copy to each group member. While this potentially limited the autonomy of the process, if participants preferred to write lyrics to another melody they would have been facilitated to do so with the music therapist outside of the study. This did not occur during the study.

Participants

     All consumers of the adult acute and sub-acute units were invited to participate in the song-writing activities as part of existing care. One hundred and twenty groups occurred with a total of 110 participants, most attending several times throughout their admission period. 

     Following the group, a purposive sample of participants were individually asked by the music therapist if they would be willing to be interviewed about the group. Purposive sampling was used for efficiency and validity (Rubin & Rubin, 1995). To minimise burden upon the consumers who were participating in the group as part of their admission, only those potential participants who had presented as actively engaged in the song-writing process and were therefore ‘information rich’ about the phenomena of interest (Sandelowski, 2000; Patton, 2001) were invited. This process was also guided by observations made by the music therapist about which consumers may be potentially available (i.e. not about to be discharged), articulate and reflective (Palinkas et al., 2015). If participants agreed, in the days following the group a clinician-researcher not involved in the music therapy program attended the unit, confirmed verbal consent, sought written consent and undertook the interview. Some potential participants had been discharged prior to interview and were not followed up. No participant withdrew consent between initial approach and the interview. The external researcher was used to ensure that participants had time to consider their involvement and to ensure their participation did not impact upon their future engagement in the music therapy program. 

     The semi-structured interviews occurred with individuals on the units. Questions were developed by the research team, based on the research question and related to experiences in the group and of song-writing, perceptions of the song and how they developed the lyrics. Questions included: Have you done song writing before? Did you enjoy the song writing? What are your thoughts about the song writing? Did you feel like the song captured how you were feeling at the time? These questions were used as a flexible guide from which a conversation about the song-writing process was developed and allowed aspects of the experience of song-writing to be raised and then explored in more depth.

     Interviews were audio-recorded and transcribed by a paid transcription company. The amount of interviews required for any qualitative study is difficult to determine and relies on researcher discretion and vigilance to the data (Rijnsoever, 2017). Rather than using a set number of participants or seeking data saturation, recruitment for this study was ceased based on ongoing discussion amongst the researchers about the data. This included reflection on the research questions to determine data adequacy (Kerr, Nixon & Wild 2010), that is, once enough data had been gathered to achieve the aim of the study. The intent of the interviews was to gather in-depth data to triangulate the lyric data, rather than to comprehensively explore all potential experiences of song-writing. A focus on the amount of participants, rather than the richness of individual data, can reinforce quantitative assumptions that “more is better” (Rijnsoever, 2017, p. 2). 

Analysis

     Thematic content analysis (TCA) of both sources of data was undertaken. TCA is the most common form of analysis in qualitative research and a foundational approach to analysis of experiential data (Anderson, 2007). TCA is a process of “low hovering” over data (Anderson, 2007, p. 1), which allows for distillation of common themes from data while expressing the voices of participants and highlighting communality. TCA is generally used when describing or exploring a phenomenon, but where existing literature is limited (Hsieh & Shannon, 2005). The six phases of TCA are familiarisation, coding, generating themes, reviewing themes, defining and naming themes and writing up (Braun & Clarke, 2006). It emphasises pinpointing, examining and recording patterns (or themes) within data (Braun & Clarke, 2006). Researchers avoid pre-conceived categories and instead allow these to flow directly from the data (Hsieh & Shannon, 2005). Typed lyrics of songs and transcribed interviews were coded to answer the research questions. That is, sections of lyrics and transcripts were highlighted that linked to the themes of the songs or the descriptions of experiences or presented data ‘of interest’. Each highlighted section was identified as a code. All codes were then examined, discussed and collapsed into themes. For example, codes from the lyrics were sorted into tables in a word document that represented emerging categories of codes. These categories were identified as themes and named using exemplar codes. Following the development of themes, all data were re-examined to ensure the themes aligned with the raw data (Anderson, 2007). Both sources of data (the lyrics and the interview data) were examined separately. Members of the research team discussed all findings until consensus was reached.

Rigour and Reflexivity

     Rigour relates to the trustworthiness of the research process and findings (Morse, 2015). Methods to maintain rigour in this study included the use of multiple sources of data (Patton, 2015), the reflection on the songs and process with an external researcher after a few days had passed, ongoing reflection amongst the research team about emerging findings, professional transcription of the recorded data to ensure accuracy (Lincoln & Guba, 1986) and a systematic approach to the analysis of data. Member checking is commonly used to aid in trustworthiness of qualitative data, however, with participants who may be considered as marginalised or ‘vulnerable’, member checking should be used judiciously to reduce risk of harm or adverse power dynamics (Goldblatt et al., 2011; Candela, 2019). Therefore, to reduce burden during acute hospitalisation and support participant confidentiality, in this study, a decision was made to not ask participants to review their interview transcripts. However, the interviews themselves provided an opportunity for partial member checking of the song content and reflection upon the accuracy of the song theme. The dual use of both interview and song data also reduced the risk of researcher bias (Patton, 2015).

Results

Analysis of Songs

     A total of 100 songs were written and collected over the study period. The most prominent theme from analysis of the song lyrics was about romantic love, followed by themes about spirituality, the meaning of life and illness. Song themes are summarised in Table 1.

Analysis of Interviews

     Eleven interviews were conducted. No demographics were collected. Five themes were identified from the interview data. They were: 1) the process of writing the song (“It just emerged with the music” (P1)); 2) the collaborative process (“It was fun to do with someone else but I’d also like to do it my own way” (P1)); 3) the expression of emotions (“I found it a bit emotional actually” (P6)); 4) music in the hospital (“I think music helps a lot”); and 5) the relationship of song writing to mental health (“It takes your mind off illness”).

     Theme One: The Process of Writing the Song: “It Just Emerged With the Music” (P1). Participants described how they came up with the lyrics for their song. For many it just happened spontaneously in the process of the group; they did not plan what they were going to sing about and they were not sure how they had come up with the lyrics. “It just emerged with the music – it happened all of a sudden” (P1) described one participant or “It sort of just all flows out of me” (P7) said another. For others, the lyrics emerged from what was currently on their mind, often what they were experiencing in the hospital, things they were missing from home, people that were important to them or prominent feelings. One participant described that choosing a theme was easy. “I had it straight up. She was like what do you want to write about, I was like ‘loss’, just came out straight away” (P2). While another noted that once they thought of what they wanted to sing about, the words just naturally flowed from the tune: “I created a vision based on the tune and I then just spoke the words” (P1). Participants had not necessarily ever produced lyrics before, but many were surprised that it came easily to them in the process. As one participant said: “It’s like, wow, I found something that I could do that I didn’t know that I could do” (P8). Another participant who identified as always being creative suggested that the actual lyrics were less important than connecting with the song: “If you feel that you can’t write a song because you are not good with words, it doesn’t matter, as long as you come up with a tune, you let you emotions out, it doesn’t matter.  Like there are plenty of songs that are really popular that are really emotional and you read the lyrics and they make absolutely no sense” (P2).

Table 1. Song Themes

     Theme Two: The Process of Collaborating: “It Was Fun to Do With Someone Else but I’d Also Like to Do it My Own Way(P1). Most participants liked collaborating with other people to develop the song as it helped them think of different ideas or just created more of a sense of connection. People described “bouncing ideas off each other” (P8), “give and take” (P7), “compromising” (P7), “two heads are better than one” (P7) and “witnessing the creative process” (P8). Not all participants enjoyed the group dynamic, however, as one participant found that it could be challenging if other group members had different expectations for the shared song or if they were generally disruptive. Creating a song with other people was seen as fun but more benefit was sometimes gained if they could control the lyrics and content. For example, one participant stated: “It was fun to do with someone else but I’d also like to do it my own way” (P1). For a few participants, the task was a solo one when there were not enough people interested in joining the group. Some liked this opportunity while others described writing by themselves as confronting and there was more pressure to come up with ideas when it was just you. However, the benefits were described as getting “more ownership of anything that is created” (P8). Creating in a group made some people nervous initially although they felt increasingly comfortable. One participant reflected: “I was thinking am I ready to go to like a really personal level and what if people laugh at my ideas or they think that it is a bit silly, but I thought you know what, why not, just go for it, you’ve just got to talk yourself through that initial trepidation I suppose. I got there in the end” (P3).

     Theme Three: The Expression of Emotion: “I Found it a Bit Emotional Actually” (P6). Many participants described that the outcome of the group was satisfying for example, “[It was] quite fulfilling actually in the end” (P6) and they were positive about the experience: “I think that it was a really good session” (P7). The experience of song-writing provided an important creative outlet for emotions. Emotions that were not able to expressed elsewhere were able to be expressed through the song. One participant detailed:

"Like if you’ve got your emotions bottled up, which I usually do, song-writing, poetry, drawing, painting all of that, is a very good outlet for it. I struggle with showing my emotions to people and I don’t often get a chance to sort of lay all my problems out on a table, so creative arts is a great way to do that." (P2)

     Participants described that they were surprised by how emotional the experience was both during the process and at the end when they heard their song. For example:

"It was a bit interesting, like when she sung it back, it was kind of really heartfelt, like it kind of – you know you had that feeling inside and it’s only until you hear someone else singing them outside, like yeah, that’s how it really does feel." (P3)

For some participants, the song stayed in their mind and they thought about it over the next few days. It had given them an outlet for expressing feelings and it was a way of engaging in a therapeutic interaction in a different way. “I think it was a really great chance to go and have that safe space where you could talk about things in a different forum” (P3).

     Theme Four: Music in Hospital: “I Think Music Helps a Lot” (P5). Most participants described that they were missing music during their hospital stay. The units had one small radio but for many participants they were used to having more music in their everyday lives and for many it was this that encouraged them to join the group. One participant described joining the group by accident after hearing the music: “I was actually sitting out in the garden behind us and I heard the guitar going, and so I just walked in, because I love listening to music(P6). For others, the choice was more purposeful because they wanted access to music: “Well we’ve got the little radio here, but I mean I listen to music all the time, I listen to it in the car, and I listen to it at home” (P6). While participants described varying styles of music they enjoyed including rap, jazz, folk and classical, many shared descriptions of music having a role in managing their mental health. Music was used as a distraction from their mental health symptoms such as auditory hallucinations, an outlet for energy, a way to settle to sleep, a tool for reducing distress or a way to relax. As one participant described:

"There hasn’t been a lot of musical stuff and that’s really hard for me because music is a very big part of my life.  Waking up without having music playing around me is very uncomfortable…not having that much access to music here is – like it’s making me really agitated." (P2)

     Music also passed the time with one participant describing his portable music device as his “knight in shining armour” (P7) who saved him from boredom and difficult thoughts.  While most participants were attracted by opportunity to engage with music, for one the group was just a way to engage in any form of distraction from the boredom of hospital: “So, you know, any kind of opportunity to do something, just – like now for instance, it’s going to take half an hour, so it’s half an hour closer to dinner time” (P6).

     Theme Five: Relationship to Mental Health: “It Takes Your Mind Off Illness” (P8). Participants spoke about their mental health experiences, diagnoses and the relationship to their creativity. Participating in the group had reminded some of their previous creative endeavours and inspired them to try to get back to them. For example, a participant stated: “And I think that’s what I'm actually going to do when I leave here, like look at writing lyrics for rap songs” (P7). Some participants felt that the medication they were prescribed was impeding their capacity to think creatively. Yet one participant described that the medication allowed him to be creative by reducing his distracting psychotic symptoms: “The psychotic elements come through when I am not on the medication. When I'm on my medication it sort of levels it out and allows me still to be creative, to a point” (P7). Participants reflected on the opportunity the group gave to express their feelings about being in hospital through song, whether they be good or bad: “One was more about being the angst of being trapped in here, but the other one was more about having a positive view of the diagnosis” (P8). One participant noted that the song had helped her to process the diagnosis she had recently been given. Whereas for others, the song-writing gave them a chance to think about something else besides their illness.

     The Inter-Relationship of Themes from Interviews With Songs. The themes from the songs and interviews were synchronous. For example, the interview theme of ‘expression of emotion’ was also noted in songs that were written about romantic love, hurt, pain love lost and grief. As Participant 2 said, “You let emotions out”. Grief over a deceased father was expressed by Participant 84: “I lost my dad 6 weeks ago, I miss him so”. The interview theme of ‘music in the hospital’ explored how many inpatients were missing listening to and playing music. The song-writing activity offered them an opportunity to engage with music. Music was reported to distract them from their mental illness, yet the song-writing allowed them to also express their emotions directly related to it. The interview themes highlighted a ‘relationship of song-writing to mental health’. Several song themes were directly about treatment experiences such as the use of medications: “They gave us drugs to take it away, but that just made us lonely” (P53, S48). Participants also wrote specifically about their symptoms and mental state: “One thousand thoughts running through my mind” (S83, P94).

Discussion

     The participants in this study engaged in song-writing on the mental health inpatient units for different reasons including boredom, being attracted to the sound of music, or after encouragement from staff. Whatever their impetus, the songs they then produced explored deep and existential topics related to love, loss and disconnection; spirituality and making sense of life on a higher level; the meaning of their lives through reflecting on their pasts and future; as well as the experiences of health and illness including being confined in hospital. The themes of the songs indicate the potential role the song-writing activity may have played in aiding with the expression and articulation of experiences directly relevant to mental health recovery. The process of engaging with music on the inpatient unit allowed them to express emotions and thoughts that they may not have otherwise verbalised or been given opportunities to express. When reflecting upon the songs, the accuracy and depth of their expressed emotion and cognitions often surprised the participants, suggesting that song-writing may aid in articulating personal experiences that could be then woven into wider care planning and treatment. The findings of this study highlight that consumers in mental health units benefit from the opportunity to collaborate with others, express their emotions, and engage with music through the unique process of facilitated song-writing. The process of song-writing was new to most participants in this study but they were surprised with the ease in which they could develop lyrics. The findings contribute to the evidence base that song-writing in acute mental health units can be a feasible and therapeutic activity. 

     The participants in this study reported benefited from collaborating in the process of song-writing and sharing emotional experiences with others. Listening to and performing music are connective experiences, which often involve empathic and relational processes (Cox, 2017). Music therapy is known to provide a unique opportunity for people who may be otherwise reluctant to engage in interactive and relational therapeutic approaches (McCaffrey et al., 2011). Collaboration with others plays an important role in supporting interaction and communication (McCaffrey,2015) with song-writing being known to facilitate collaboration (O’Callaghan & Grocke, 2009; Wigram & Baker, 2005) in a way that is enjoyable (Grocke et al., 2009). For consumers in mental health units, group song-writing provides an opportunity to foster connection and enhance collaboration. During periods of hospitalisation in mental health units, connection with other consumers often plays an underreported role in recovery (Isobel, 2019).

     Engagement with song-writing allowed the participants in this study to express, and reflect upon, emotions related to their mental health as well as their wider experiences of self and being. The benefits of emotional expression and addressing psycho-social issues through song-writing has also been noted in previous studies (Baker & Wigram, 2005; Baker et al., 2008;). Improvisation of song lyrics may facilitate a unique process of expression (Marom, 2004). Certainly, the songs analysed in this study had many expressive components to them. Participants described that the lyrics often ‘flowed out’ of them without conscious processing, or as one participant said “I created a vision based on the tune and I then just spoke the words” (P1). Creativity is partly a conscious activity, and partly an unconscious intuitive function (Moses, 2010). Creative approaches to therapy, such as song-writing, may facilitate access to emotions not consciously accessible through traditional means (Chong, 2015). The music itself was also important. Participants described how important music was in many of their lives and how they missed it during hospitalisation. Music has been linked to the expression of emotion since ancient times, with more recent neurobiological imaging showing how music can activate regions of the brain linked to emotion (Nizamie & Tikka, 2014 ). Music has also been linked to cognitive processing (Rickard et al., 2005) and the release of endorphins and neurotransmitters implicated in mental ill-health such as dopamine (Boso et al., 2006). These findings, alongside those of the current study, are suggestive of a need for more opportunities for mental health consumers to engage with music in both structured and unstructured ways.

     Songs about health and illness allowed participants an opportunity to reflect on the experiences of being hospitalised, with lyrics and interviews also addressing issues directly related to mental illness, such as diagnoses and the effects of medication. A few described how their mental health affected their ability to engage with music or how music helped soothe their symptoms, but no direct symptom benefits were attributed to the group. Similarly, previous works have identified that although music therapy is usually well liked, it can be difficult to ascertain the particular aspects of the music therapy process that benefit individuals (Hibben, 1999; McCaffrey, 2018). While it may be difficult to link music to clinical recovery (such as symptom alleviation), the role of music in personal recovery seems more clear. The participants in this study used the song-writing activity to articulate experiences directly linked to connection, identity and meaning which are key components of personal recovery.

     This study has shown that song-writing in mental health settings may provide an emotional outlet that allows for processing of experiences and reflection. The experiences of the participants had significant overlap with the desired aims of a recovery orientation. These included supporting participants to focus on their own resources and strengths, considering their own meaning within life and experience, while connecting with others and promoting hope. Participants valued the opportunity to express their thoughts and feelings within the guided structure of a song and benefited through emotional release, a shared experience of validation and an enjoyable and occupying activity. Music therapy in inpatient settings may be hard to evaluate in relation to clinical outcomes, but individual experiences highlight the potential role it may play in personal recovery from mental distress. A recovery orientation in mental health also emphasises the need for inclusion of service user voices in any evaluation of current approaches, as well as future decision making (McCaffrey et al., 2011). As such, the voices of inpatients, such as those included in this study, reflecting upon their experiences of participating in song-writing provide an important contribution to the emerging evidence base of music therapy in mental health settings.

     Future songwriting studies could attempt to measure the relationship between participation and self-perceived recovery and clinical outcomes. Another perspective could also be gained from replicating this songwriting study with consumers in community mental health settings or using a variety of songs to enhance expression of lyrics.

Limitations

     While the findings of this study are suggestive of benefits of music therapy in acute mental health units, they may not be applicable to all settings. All groups occurred with a single therapist within one hospital and it is not possible to identify what influence this had on the songs produced as well as the experience of the group. The use of purposive sampling and the leading nature of the questions may have led to a bias towards positive experiences being vocalised. Other less engaged participants may have had different experiences not reported here. As is always the case, decisions about data analysis are made by the researchers and influenced by a number of conscious and unconscious factors. As such, while a rigorous approach to analysis was used, other researchers may have identified different findings from the same data.

Conclusion

     In this study, song-writing in acute mental health units provided an enjoyable collaborative activity in which participants were able to express themselves about issues important to them, including those related to their health, experiences of hospitalisation and reflections on wider meanings of personal existence. Songs were written about love, spirituality, the meaning of life and illness experiences, facilitating safe expressions of grief, loss, hope and frustration. Facilitated song-writing provides a creative and therapeutic outlet which may contribute to recovery in mental health settings.

References

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