Pointers for working with adolescents in a medium secure mental health unit
This blog outlines a few pointers for creative music making in a secure mental health unit setting based on the Royal Philharmonic Orchestra's (RPO) recent project in partnership with the Musical Inclusion Programme Team at Northamptonshire Music Education Hub (NMEH) at St Andrew’s Healthcare, a medium secure mental health unit in Northampton.
St Andrew’s Healthcare is a charity that runs four hospitals, of which Northampton is their main site. St Andrew’s Healthcare works with residential service users, all of whom present different levels and complexities of needs.
Service users can range from those born with learning difficulties to those who have incurred brain injuries and need specialist rehabilitation. Service users often come to St Andrew’s from a range of backgrounds and include sufferers of substance addiction and those who have been detained under the mental health act, some of whom have a history of criminal or violent behaviour.
Therapy at St Andrew’s Healthcare focuses on Cognitive Behavioural Therapy (CBT), which recognises each service user’s individual needs and creates a unique set of recovery goals to meet them.
The project, led by RPO Workshop Leader Sigrun Saevarsdottir-Griffiths, took place over three days in April 2015 at the St Andrew’s Healthcare site in Northampton. Supported by three RPO musicians, one NMEH Musical Inclusion Programme tutor, a music psychologist and a team of nurses, music specialists, teachers and occupational therapists from the Malcolm Arnold House, the project aimed to improve the wellbeing of patients from two treatment pathways through devising their own musical pieces.
The first all-male group were generally at the older end of the 13-19 age bracket. Amongst the group were a number of very confident young men who wrote and composed their own music, some of whom already participate in the Malcolm Arnold House band.
The needs of the second group were more profound with fewer participants able to communicate competently in addition to more complex autistic, stress and anxiety needs.
The project culminated in an internal showcase concert for other service users and hospital staff representatives. The performance was a huge success leaving participants with a heightened sense of achievement and aspiration.
Here are a few key points of learning which we would like to share with you following the time we spent with the young people from Malcolm Arnold House. These may come in useful for you if you undertake projects in a secure mental health setting.
Avoid delays on arrival
For the safety of all involved including staff, visitors and patients alike, security surrounding access to the ward is tight.
It is likely that your team will not have visited the hospital before and will need to do a number of identity checks before they can enter the ward. This takes time, especially if the ward reception has limited resources. To avoid delays to the start of your first session ensure that:
- Musicians know what items must be kept in lockers. This will usually include general items such as keys, phones and medication but may also include instrument accessories including guitar leads, reed knives and spare strings.
- The delivery team arrive with plenty of time prior to the start of each session. We integrated 30 minutes into the musicians’ call times for this; however, on the first day 45 minutes would have been more realistic, especially as we were clashing with the arrival of staff at the start of the working day.
Attention and anxiety
Expect attention spans to dwindle by the end of each session. During our first day debrief we raised the fact that the afternoon group struggled to hold their attention through to the end of the session at 4.00pm. Staff members were continually asked at what time the session was due to finish. Patients presenting with autism are generally very set to their daily routine and many have countdown clocks which enable them to gauge their progress through an activity.
The use of conventional icebreakers may be intimidating to some patients with shy or anxious dispositions. In our first session with the neuro-pathway we went round the circle asking patients to say their name, if they played an instrument and what their favourite song was. At the end of this exercise, it was reported that some patients found this hard as it was difficult for them to talk in front of groups, and responding to the question on-the-spot caused them unnecessary stress and tension.
To help overcome these obstacles:
- Ask a member of pastoral staff to outline the structure of the session at the start of each workshop giving the group clear timings and expectations.
- We added a very short afternoon break to the session on the second day at 3.15pm. This gave the group time to relax, and in which to have a drink and biscuit. When they returned, they were in higher spirits and able to work through to 4.00pm.
- Encourage your workshop leader to use a nonverbal or impersonal icebreaker such as a clapping or movement game before name introductions. This will engage everyone at the very start and avoid participants getting too nervous about responding to questions before having any trust or relationship with the workshop leader.
Graded Exposure
Initially we experienced a number of participants coming into the session and walking straight back out after seeing the circle of chairs laid out. Don’t let this put you off, it’s not personal, some patients just find it difficult to participate in large groups. This is why we would recommend a Graded Exposure approach.
With some patients this might need to start before the project begins. Talk with your host organisation and be clear about what they need to prime the young people to expect in the first session. This could include:
- Where it will take place
- The names of the visiting practitioners
- The structure of the creative work
With some patients, getting them into the workshop room is relatively easy however getting them to participate and use their talent is more challenging. Over the three day project we worked with one female participant in particular who suffered with severe anxiety and found participating in large group activities quite daunting. To ensure she participated in the final performance outcome, we graded her exposure to performing through the following small steps:
- Worked in a small group to write song lyrics and create a melody
- Listened to the workshop leader sing the song back to the group
- Sang the song with workshop leader, a friend and a support worker in private
- Sang behind the band alongside workshop leader, friend and support worker
- Sang with all of the above to empty chairs
- Sang with all of the above to up to ten participants and support staff in dress rehearsal
- Sang in performance to an audience of staff and guests from the hospital
Expect the unexpected
The nature of the service users on a mental health ward is generally unpredictable. Expect incidents to occur at very little warning. If a participant does present a danger to themselves or others:
- Stop
- Stay calm
- Say nothing
- Try not to look shocked no matter what they are doing
- Most importantly let the host staff contain the incident through their own method and procedure
- Do not intervene yourself
- Continue exactly where you left off with no reference to the incident
You will never be left alone with the patients so it is highly unlikely that you will ever be called upon to deal with violent or aggressive participants.
Ensure that your piece doesn’t rely on particular parts to work
Patients may be extracted from sessions at short notice for many reasons, including appointments, hearings or self-exclusion. It can be infuriating if you have spent considerable time with the group developing solo lines to find that in fact that person will not be in your performance.
- Avoid creating a piece which relies on individual parts; try your best to have parts doubled in a number of instruments.
External agencies get a privileged view point
Finally, remember that as an external practitioner or agency you are getting the privilege of coming into the setting with no prior knowledge or expectation of the young people you will be working with.
Having no pre-existing expectation of levels of ability or mental health profile enabled us to work with each young person as an individual, asking them to achieve against our standards, setting the bar higher than the internal expectations of hospital practitioners for such a short period of time.
Working alongside St Andrews and NMEH has been a real pleasure. I would like to thank Bob Plews, Claire Smith and Sarah Grant at St Andrew’s Healthcare for their help in getting the project up and running, as well as Simon Steptoe, Musical Inclusion Programme Manager at NMEH, for his guidance and support. I hope to be back there soon building upon this valuable work.
To learn more about the organisations involved in this project, please follow the links below.