Music Therapy Group with Institutionalized Psychiatric Adults: The Third Way. A Pilot Study

Music Therapy is The Third Way’, said Helen, 19 years old, with schizophrenia. When she came for music therapy she was at a catatonic state; she could say only one word at a time with the exact flat tone of voice. Soon we discovered that when singing she could say all the words. She felt that it was the most important clinical intervention she received among psychiatric care with medication and verbal psychotherapy. She claimed that through music therapy she experienced a significant decrease of the symptoms. She reached the functioning state of being, namely FA-fonie (FA-voice, in [2,3]. The structure of the human psyche contains three dimensions: The Real, the Imaginary and the Symbolic. In the case of a psychotic structure of the human psyche the dimension of the Symbolic is excluded, as well as the big Other-A [2]. Music in a safe therapeutic relationship can allow entrance to the Symbolic order. Inspired by Helen, I conducted a pilot study over a period of 8 months, to investigate the contribution of Music Therapy to the psychosocial growth toward FA-fonie of 20 institutionalized psychiatric adults, average age of 45 years old, 15 men and 5 women. The institution provided safety but not a life with meaning or freedom in expression.

The environment of the institution was impersonal. The 20 residents faced a situation of absolute emptiness. They were mentally and physically exhausted. Their imagination and even their memory was gone. Everyone shared the common feeling of isolation. They seemed apathetic and withdrawn to their own world. An electric piano was situated in the central hall, as well as some percussive instruments in a closet. The music therapist took care of the instruments and conducted 25 open music therapy groups, as well as two community music therapy performances with a professional choir invited to join the performances of the residents. In the process of 25 open music therapy group sessions, the institutionalized psychiatric adults started from the phallic state (F-Φ) they were at. The therapist used clinical improvisation with voice and instruments, popular songs that were chosen by each resident, song writing, as well as activities with musical stories created and organized by the residents. As the residents were provided with the safe space in the music therapy group, their unique Voice (Fonie-Voice) emerged. They expressed and shared their needs, their dreams, they found meaning in their lives and moved ‘from sensorial playing to music making’ [4]. As they connected and meaningfully interacted with each other they entered the Symbolic order (FA: is a symbol for the pitch of F) [5]. Eventually, they experienced functioning moments in life (-f,-φ: symbol for the normal neurotic) with significant decrease of the psychotic symptoms, reaching the healthy state of FA-fonie/FAvoice (Figure 1).

Figure 1:The scheme of FA-fonie (FA-voice) with explanations. S: Symbolic, I: Imaginary, R: Real, A; the big Other.

The staff of the psychiatric institution answered 5 questionnaires with open-ended questions. Phenomenological hermeneutic design was adopted. Data analysis was guided by Diekelmann et al. [1] seven stages process of phenomenological technique. Triangulation techniques were used to ascertain the credibility and trustworthiness of findings. Researcher triangulation was performed through the independent data analysis of each interview by three researchers, who reached consensus over the identified categories.

a. Each interview transcript is read to gain an overall understanding.
b. Implicit and explicit meanings are identified, and similar themes are extracted from all transcripts.
c. One or more ‘relational theme(s)’ that cut(s) across all texts is identified.
d. Excerpts are extracted to support the identified theme(s). e. All transcripts are re-read to confirm developing themes and sub-themes.
f. Α constitutive pattern is identified, which demonstrates the interrelationship among themes across all texts.
g. Α written report contains the main findings, which are supported by the participants’ quotes. The discovery of a constitutive pattern reflects the highest level of hermeneutic analysis

5 Hyper Themes were found, and 13 Sub Themes derived from the Hyper Themes:

1^st Hyper theme: Mood changes

The withdrawal and heavy mood of the residents (due to the illness and institutionalization), through the music therapy sessions moved to joy, enthusiasm, and motivation.

Sub theme 1:Joy and enthusiasm enhanced motivation and active participation in the group:
i. “They all participated, they were happy and anticipated the session.”
ii. “It seemed that the music therapy group had a positive effect in their mood.”

Sub theme 2:Spontaneity and humor:
i. “After the music therapy session, the residents are more alive, they have positive energy and humor.”
ii. “I am very impressed when I see them tease each other and play like little children do during the music therapy session.”

Sub theme 3:Change to positive mood:
i. “After the session you worked on the grief issues, due to the sudden loss of his partner, who was also herself a resident here, Th. seems to be able to deal with it incredibly well.”
ii. “And about M. who died, although the residents denied any participation, once they wrote a song about loss and grief for M., they were ready and happy to sing also Christmas songs.”
iii. “G., who was recently admitted at the unit, for the first time, had a nice and quiet night sleep. This is happening only the nights after the music therapy group sessions.”

2^nd Hyper theme: Creativity

Instead of passivity and lack of interest for any activity or other person, in music therapy sessions the innate ability for creativity was awakened. Inspiration and realization of unique ideas and activities took place. Sublimation of heavy feelings into music creativity facilitated the entrance to the symbolic order.

Sub theme 1:Improvisation:
i. “The fact that they take music instruments, and they improvise with meaning is beyond my expectations. Even with their voices they create such an atmosphere that helps me understand exactly what is happening to them. This is not happening when they talk. (I can’t understand what’s happening to them through their talking.)”
ii. “This activity helps them come into a meaningful contact on one hand with an external special therapist who motivates them creatively and on the other hand with their own creative abilities that were inactive over the years.”
iii. “The contact with the music instrument did not function only as a means for expression; it encouraged a deeper function in forming meaningful relationships, of which these people are deprived.”

Sub theme 2:

i. “I am impressed by the ability of N. to write verses. I am enthusiastic about the group’s collaboration in composing music on his verses and I was deeply moved when I heard the complete song performed by them during the Christmas event.”
ii. “I’ve seen them participate with a lot of care, when they were creating the song for M. who died suddenly. M. was admitted at the hospital, but we were all expecting her to get well and come back to the residency. Each one of the group members at his/her turn had something very important to say. I am amazed.”

3^rd Hyper theme: Self-expression

Instead of lack of expression or stereotyped activities, in music therapy sessions, meaningful self-expression through music improvisation and song writing was enhanced. The residents took advantage of the vast reservoir for verbal and non-verbal ways of self-expression, offered by music. They functioned beyond the limitations of institutionalization and the mental illness at appropriate timing and with the appropriate emotions.

Sub theme 1:Expression through music instruments:
First time experience: “P.’s expressivity, left me speechless, considering that he touched the harmonica for the first time in his life. I was not impressed though by the fact that he chose the harmonica to play. It was as if he were transferring his usual obsessive-compulsive hands movement to his mouth-which he did every time he thought that people were not looking at him- into a socially acceptable activity. That could be like an act of sublimation.” Meaningful experience: “I was impressed by the musician Θ., who brought his best guitar and played in front of everybody… usually he played his guitar alone, without any meaning…. compulsively.” Connection with happy past: “X., who chose the little recorder from the very first time, had no intention to let it go until the very end of the sessions. He was totally identified with it, and he was extremely happy that he found the shepherd in himself, who he used to be when he was young, as he kept telling us over and over.” Working on a happier future: “N. found his happy place in life through music therapy. He has started taking piano lessons. Now, as he says, his life has a meaning.”

Sub theme 2:Expression through body movement-Obvious decrease of the body symptoms of psychosis:
i. “When they dance and move in the music therapy group, they seem so very rhythmical and coordinated, that one could say that the mental illness did not touch them. I don’t see them move so well anywhere else.”
ii. “I am very surprised to see that, during the music therapy group, all the stereotyped movements along with the aphonic cries/ screams and the uncontrolled salivation stop.”

Sub theme 3:Expression of painful emotions (verbally and non-verbally):
i. “I see them express their inner pain, open up and share their guts, while sublimating all those heavy emotions into music. If I were not a witness of their experiences, I could have never believed it.”
ii. “Even M. observed and told X. that he plays without any feeling. And X. heard her, and he started playing so beautifully and expressively as if he woke up from lethargy.”

Sub theme 4:Expression of happy feelings (verbally and nonverbally):
i. “I liked to observe how they could change their mood to a happy one, how easily they were following orders and how freely they were expressing themselves.”
ii. “Only in music therapy I see them all in a state of euphoria, discovering more and more ways to express their happiness.”
iii. “Very rarely I see them to express positive emotions. Their smiles along with their happiness make me forget that we actually are at the institution.”

4^th Hyper theme: Socialization

Instead of withdrawal and, often, the complete lack of any communication with the big Other (A), the residents, through the music experiences, kept the boundaries, followed orders, waited patiently for their turn, collaborated meaningfully with important others and had the feeling of belonging to this group.

The image of the mental illness symptoms was significantly reduced.

Sub theme 1:Feeling of belonging:
i. “I saw them becoming in a group and with great pleasure; this is happening only in music therapy.”
ii. “Even A. and N. say that after the music therapy group, they feel alive, and they all agree that only in these sessions they feel as a group.” iii. “They can never be a group or have any group spirit at any other activity offered.”

Sub theme 2:Boundaries:
i. “…at those moments where they played solo-tutti, the soloist seemed to lead the rest of the group members with a strong feeling of responsibility and obvious pleasure. All the other members followed the soloist with a first-time seen respect.”
ii. “I’ve seen S. accepting and following easily all the rules for the first time in her life. And she kept doing it in every music therapy group session. Only here I see her waiting quietly for her turn.”

Sub theme 3:Collaboration and meaningful interaction (verbally and non-verbally) among the residents, the residents and the staff, the residents and the outside visiting groups. Inclusion versus Institutionalization.

i. “To see the patients express themselves and interact in appropriate ways while someone is playing, was a very beautiful and rejuvenating experience.”
ii. “In duetti, I had the feeling that they respected each other, as they shared important parts of themselves.”
iii. “I’ve witnessed a huge progress concerning their issues of withdrawal, boundaries, limits, collaboration and functionality among them and with the staff. They also communicated freely with the whole group of the choir that came and sang at the Christmas event.”
iv. “A. regained enough social skills that she effectively used them also in her personal relationships outside the music therapy sessions.

5^th Hyper theme: Special changes in particular residents

Some of the residents showed exceptional changes concerning all the previous hyper-themes.

Sub theme 1

a. P.: He found a way to use his hands creatively (instead of putting them in his mouth), by choosing to play the harmonica.
b. Th.: A musician with obsessive-compulsive way of playing, was able to deal with the ordeal caused by the sudden death of his partner and played his best guitar expressively even at the last event, open to a wide audience.
c. A.: Now, she can communicate appropriately and nicely with other people.
d. X.: He connected with the shepherd he used to be when he was a little boy.
e. S.: Now, she accepts rules and follows orders with pleasure, even outside the sessions.
f. Aρ.: Now. he likes to participate in group activities and feels proud to be a member of the group.

a. No permission to videotape the sessions.
b. Time and energy consuming to receive approval for the clinical work, the research and the publication by the Ethics committee.
c. Ignorance or blurred ideas about music therapy by the helping staff in the beginning.
d. Very limited instruments offered.
e. Personal funding.

Through music therapy - the exploration of the musical/ creative self, self-expression in the group and interaction within the Symbolic order- all participants identified with their uniqueness and got engaged in meaningful relationships. Evidence showed an essential reduction of the image of the symptoms concerning institutionalization and psychotic withdrawal, leading to social inclusion and to the state of FA-fonie. As the third way, music therapy introduces a new humanism that is human protective beyond human centered, because the residents experienced the appropriate safety to live a meaningful life with empathy and freedom. Music therapy as the third way offered psychiatric patients a new sense of humanism: from human centered to human protective of essential values:
A. Feel safe.
B. Sense of personal value/feelings of pride.
C. Live a life with meaning, empathy and freedom.
D. Feeling of belonging.
E. Feel creative and functioning.
F. Act and interact with others appropriately.
G. Social inclusion.

The psychiatric residents said about the music therapy group and the community music therapy performances:
a. “It helps me sleep easier at nights”.
b. “It’s the first time we became friends”.
c. “First time we belong to a group”.
d. “We found our Voices and became one”.
e. “We feel free”.
f. “It’s Power of God”.

1. Diekelmann N, Allen D, Tanner C (1989) The NLN criteria for appraisal of baccalaureate programs: A critical hermeneutic analysis. New York, US.
2. Psaltopoulou D (2022) From the aphonic voice of autism to the FA-fonie (FA-Voice) in music therapy-case study. Adv Complement Altern Med 7(4): 698-706.
3. Psaltopoulou D, Rousaki A (2020) Music therapy in adult psychiatric unit: The third way. Proceedings of the 16^th WFMT world congress of music therapy. Today pp.96-97.
4. Backer DJ (2004) Music and psychosis. The transition from sensorial play to musical form by psychotic patients in a music therapeutic process, dissertation. Aalborg University, Denmark.
5. Psaltopoulou D (2015) Music therapy: The third way. In: Kallipos, Athens (Eds.), Electronic Academic E-books, Greece.