A Consumer- Directed and Partnered Community Mental Health Music Therapy Program

Program Development and Evaluation

By Sue Baines

[Editors note: The article presented here is republished from Canadian Journal of Music Therapy Vol. VII, no. 1 2000 with the kind permission from the publisher and the author.]

Abstract

In the developed world, as mental health care continues to move out of institutions and into the community, an emphasis on prevention and health promotion, accountability, and consumer involvement have been identified as fundamental. Currently, most community mental health programs remain grounded in the medical/psychiatric model, however examples based on the psychosocial rehabilitation model and work inspired by a health and wellness/holistic model as well as blended approaches which utilize elements of more than one model are increasing. In the interest of developing the most efficacious, respectful, accountable, and ethical model, a consumer partnered and directed mental health music therapy pilot program was launched at the community clubhouse site of the largest community mental health service provider in the lower mainland of British Columbia in September, 1997. This article will describe the process of the development of the program, demonstrate how it functions, present the results of a consumer evaluation of the program, and discuss plans for the future.

Résumé

De plus en plus la santé mentale laisse les institutions et vient s'installer dans la communauté. Or il est important de mettre l'emphase sur la prévention et la promotion de la santé, ainsi que la responsabilité et la participation du consommateur. En ce moment, la plupart des programmes communautaires sur la santé mentale se basent sur le modèle de la psychiatrie médicale quoique l'on retrouve aussi des exemples basés sur le modèle de réhabilitation psychosocial, sur des travaux qui s'inspirent du modèle holistique de santé, et des approches fusionnées qui utilisent des éléments de differénts modèles. Afin de pouvoir développer le modèle idéal, en septembre 1997 un partenariat de consommateurs et projet pilote dirigé en musicotherapie pour la santé mental est fondé a la maison communautaire sur le site d'un service de soutien pour une large communauté de santé mentale en Colombie Britannique. Cet article illustre le procédé de développement du programme, défini le rôle du programme, présente le résultat de l'évaluation du programme par le consommateur, et discute des objectifs futurs.

Introduction

In Canada, based on work initiated in the 1960's and 1970's (for example, the Foulkes Report (Foulkes, 1974)) the recommended trend has been to shift the practice of health. Numerous provincial Royal Commissions and commissions of inquiry into the health system have reached consensus on the need to redirect the health system in three ways: towards greater emphasis on disease prevention and health promotion, towards community-based alternatives, and towards greater accountability (Angus, 1989 & Brunton, 1992 in Hoffman and Dupont, 1992).

An equally important concept for improved health service, particularly mental health service, is a consumer initiated and supported health model. (Graham, 1988, as cited in Morell-Bellai & Boydell, 1994; Minister of National Health and Welfare, 1988, as cited in Morell-Bellai & Boydell, 1994). A great deal of work in inaugurating the consumer/survivor mental health movement in Canada has been initiated by consumer activists such as Fat Capponi (Church & Capponi, 1991). Her clear and concise reasoning regarding the ethics of consumer initiation of treatment development and implementation delineates the massive ethical, physical, psychological, and spiritual flaws concerning our historical and current system of mental health service delivery. Particularly, she highlights the on-going coercion and abuse manifested in many approaches, treatment models and practices.

A consumer-initiated and informed model would primarily incorporate consumer values, skills, initiatives and priorities into the team approach already in existence in much of our health care system in Canada today. Secondly, the awareness of families and community care-givers would be explored and synthesized. In this way, the expertise of people living with various health conditions followed by the expertise of those most directly care-giving would be integrated into the overall process of health delivery in the community, including treatment and prevention programs. Discussion on this process can be found in Kopolow (1981), Pape (1988, as cited in Morell-Bellai & Boydell, 1994), Ridgeway, (1988, as cited in Morell-Bellai & Boydell, 1994), and Wilson, Mahler, & Tanzman, (1990 as cited in Morell-Bellai & Boydell, 1994).

In the literature, there exists a plethora of sources citing the value of music therapy as an efficacious therapeutic intervention for people living with mental illness and psychiatric conditions. Some of the ground breaking as well as the most comprehensive writing on this subject can be found in Unkefer (1990), Hodges (1980), Tyson (1981), Alvin (1966), Wolfe (1988), Priestley (1975), Hadsell (1974), Hanser (1987), Gaston (1968). Although the music therapy approaches and models cited vary considerably, the effectiveness of music therapy as a viable mental health intervention appears to be quite universal. Widely respected throughout the United States, England, and much of Europe, the use of music therapy with persons experiencing mental illness continues to have a low profile in Canada. This is evidenced by the continued lack of availability of music therapy programs throughout the country. From a consumer point of view, this situation is untenable.

To recap, music therapy is an efficacious, non-toxic, non-invasive, cost effective, individual and group therapy modality for persons with mental health issues. There is an on-going transition of health services into the community in Canada focusing on "disease prevention and health promotion" as well as greater accountability as priorities. There is an ethical reality of ensuring excellent service through consumer co-creation. Clearly, there is a need for consumer partnered community mental health music therapy program development, process, and evaluation. The following is a description of a model for developing a program founded on the newly recommended principles and the subsequent evaluation of that program.

Background

In September, 1997, an eight-week music group was piloted through a non-profit society in Vancouver, BC. The service provider is currently serving over 1500 mental health consumers in a variety of settings. The service provider's mission statement reads". .. is a co-operative community which fosters an environment that promotes restoring health, personal growth, and a return into society for consumers of Mental Health Services through advocacy and direct service." (1999Annual Report, p.2.) A variety of community mental health services are offered at a number of sites including the Clubhouse, a Drop-In, and the Eastside Rehabilitation Project. Employment and Training Services are provided as well as housing including Community Homes, Transitional Housing, Apartments, Supported Independent Living Program, and Satellite Housing Program. The service provider's approach is grounded in a holistic and humanistic philosophy and model of treatment (Service Provider's Policy Manual).

The eight week music group was piloted as part of the social program at The Clubhouse. This community mental health space is based on the International Clubhouse Model developed from The Fountain House Model for psychosocial rehabilitation (Beard, Propst & Malamud, 1982). Within the context of the Clubhouse site which distinctly maintains a "no therapy" (referring to verbal psychotherapy) policy, the concept for the pilot was to develop a cost effective group music therapy program that prioritized the requests of the consumers as the process for development, thereby readily incorporating consumer concerns and hopefully meeting consumer needs.

The therapist utilized a feminist framework for group process (Cammaert & Larsen, 1988) which blended well with the philosophy and approach of the service provider. In this role, she functioned primarily as a facilitator, engendering the role of paid professional support to a selfhelp group (Yalom, 1995) rather than recreating a more traditional psychotherapy group model which would have been inappropriate to the setting. The work in community psychology developed by Rappaport (2000) and his colleagues directly informed the process as well, particularly regarding the concepts of mutual help, helping transactions, (Roberts et al., 1999) and assisting others in the job of turning tales of terror into tales of joy (Rappaport & Julian, 2000).

Program Format and Model of Practice

Over time, the initial clubhouse music program format has remained fairly consistent and, based on consumer advice, has been utilized at the initiation of music therapy services at other Service Provider sites. The following is a description of the format.

All attendance in the program is voluntary meaning there is open on-going attendance; open in and out policy during the sessions; we work in an open space; there is no required intake; and participants are self-referred. At each hour session, participants choose and sing familiar personally significant songs from our community book (developed and maintained by the consumers) while we accompany ourselves playing small drums and ethnic hand percussion instruments. To date, our songbook has over 200 community requested repertoire songs in it which address a wide spectrum of emotional themes and needs. The songs are popular music from this century. The singing, listening to, and accompanying of personally significant songs in a group as the primary therapeutic intervention appears to meet a wide variety of needs for these consumers. Evidence documenting the process of this phenomenon for individuals can be found in Hammel-Gormley, 1995. As well as creating and producing music, as part of the process, sometimes people spontaneously dance. Occasionally, there is a short instrumental improvisation and when it occurs, it usually takes place upon initiation of the group. Other times, poetry and/or personal compositions and/or solos are performed. At the direction of the group, the music therapist plays the guitar for the majority of each session although everyone else is welcome to play guitar. Staff are welcome to participate in the group and frequently do although they rarely stay. Generally, by unstated agreement, verbal interaction has been limited to short statements, brief dialogues, and bits of support. Songs are readily requested and if group members begin to chat too long between song requests, often a "regular" will say, "more music, less talking." Individual goals are managed personally for the most part, although, occasionally, they are briefly discussed with the facilitator or with other group members both in and out of the group. Peers offer support and referrals and if needed, the music therapist intervenes, reporting concerns to staff.

The emerging format is in keeping with feminist theoretical process and uses an empowerment approach (Ballou & Gabalac, 1985; Dutton-Douglas & Walker, 1988), highly compatible with a consumer initiated ethic. All group goals, norms, and experiences have been developed by and are managed by the group co-operatively. The requested song-based open group approach directly addresses the issue of accessibility, readily simultaneously addressing the needs of many active, passive, and peripheral participants, including both staff and consumers. During the time that the music group is in session, participants, staff, and non-participants report a positive shift in the atmosphere at the site which can carry-over for quite an extended period of time. Upon the completion of the initial pilot program, at the request of consumers, the program was extended and then increased, eventually launching out into other of the Service Provider sites: initially, into five community homes.

In the community homes, over time, there has been an increased interest in improvisation as well as in music and relaxation, broadening the original Clubhouse music group format. Additionally, there has been some performance development in the course of the community homes groups. Of significance is that community home residents are starting to attend the Club house music programs, linking the community more directly.

At the request of clubhouse members, an additional music based program known as the "Talent Show" has been developed and takes place intermittently in the course of the yearly schedule. This program offers consumer musicians who are more performance oriented the opportunity to develop their skills in front of a supportive audience backed up by well-trained musicians: the music therapist, musicians from the audience, and the music therapy intern. Some performers invite the audience to participate, leading the process. The audience is respectful, offering supportive and involved feedback. Sometimes, as in the previously mentioned music therapy programs, some of the audience spontaneously dance. Seniors from the broader mental health community are periodically bussed in for the event and non-Clubhouse members, Service Provider Apartment Tenants and other housing program dwellers are welcome to attend providing an excellent opportunity for community development. In keeping with this community development sentiment, the Clubhouse Community Kitchen volunteers to provide excellent refreshments. The program addresses basic human needs from providing food to addressing social isolation to offering comfort and validation. Over time, the consumer community as well as the stlaff are able to see and hear consumers enhancing and improving their skills. This seems to offer an increased sense of inspiration and community connection as well as an overall sense of increased esteem.

Intervention Strategies

All therapeutic interventions take place in the paraverbal realm and function through a reflexive process. A central tenet of paraverbal therapy is the acknowledgment that verbal communication can be disorganizing due to distortions of comprehension and meaning that may occur when participants do not have the affective tolerance to deal with what is being communicated verbally (Heimlich, 1972). According to paraverbal theory, manipulation of such communicative elements as dynamics, tempo, pitch, tone, and rhythm white simultaneously engaging the client in a positive environment can dramatically address therapeutic concerns (MacKay & Heimlich, 1972). In the approach described in this paper, for example, white singing personally significant familiar songs, manic behaviour by one group member can readily be addressed by a dramatic decrease in dynamics and/or a sudden decrease in tempo by the facilitator. In the context of the group singing, the" over-the-top" participant suddenly hears their own voice standing out in stark contrast to the rest of the group sound and responds appropriately, decreasing tempo and volume autonomously. The group works together to support a myriad of needs such as energetic discharge, sensory gratification, comfort and sustenance, a supportive place for grief work, opportunity for creativity, validation, familiarity and togetherness, and personal and group expression. Through this group supported positive process of expression, maladaptive behaviours decrease and amelioration of symptoms can follow (Heimlich in Bruscia, 1987). Paraverbal intervention in the group music context, although sometimes obvious to those not directly in need of that particular intervention, is a non-confrontational, respectful way to shift individual and group behaviour without directly socially singling out specific persons and behaviours. In the community mental health context, paraverbal intervention offers participants personal autonomy, respect, and acceptance in an environment enhanced for therapeutic change.

Program Goals

Goals for the pilot music program focused on universal needs such as decreased isolation, increased community development, increased empowerment and communication skills, enhanced creativity and quality of life, and fulfilling consumer driven initiatives. These were addressed each session through the process of actively making music together at the discretion and request of the participants. As stated previously, verbal process was not utilized at all at the direct request of the consumers. As part of the on-going developmental process, consumers concurred with the need for an evaluation process. Because the music program had its greatest longevity at the Clubhouse and Community Homes, these sites were mutually chosen for the evaluation.

Research Method

Program Evaluation Purpose:

The purpose of the music program evaluation questionnaire was multi-faceted including the gathering of written information and opinions regarding the music program from the consumers to feed back into the on-going development of the program, soliciting how the music program was addressing their needs, to provide accountability and quality assurance for the consumers, and to directly inform the staff and administration in a written report regarding the state of the music therapy program to enhance their understanding of the process.

Participants:

The music therapist has partnered with a consumer advisor throughout the term of the program. This person was self-selected and volunteers her service. At her discretion, the music therapy consumer advisor has attended and participated in most music sessions offered by the facilitator through the Service Provider. As part of the program development process, after each session, and sometimes in between sessions, time was spent together for self-reflection, to debrief the process, and planning any changes that needed to be implemented. An on-going element of that process was the initiation, design and administration of the program evaluation.

Participants in the evaluation included Clubhouse and community home music group members. All have a diagnosis that includes "severe and persistent mental illness". In keeping with the consumer-initiated model, all participants in the evaluation were self-selected.

Materials

The questionnaire was designed collaboratively. Questions were suggested by consumers as well as by Senior Coast Staff, the music therapist, and the music therapy consumer advisor. A single-page design was used to address the oppressive nature of the on-going requirement of mental health consumers to fill out extended written questionnaires as part of their treatment process. According to some of the more empowered consumers in the program, this has created an existing low tolerance of the target population to fill out forms. A single-page form was chosen as the most ethical and respectful way of gathering the needed information. Based on recommendations by the group, we decided to use both a check-mark and open question format to offer people words if they needed them and space to write their own words if that felt more authentic. In addition, the varied format offered us a broader spectrum of data: both quantitative and qualitative. Once drafted, the form was further refined and edited by Senior Administration as well as Senior Staff before it was put into use.

Procedure:

All music program evaluations were administrated jointly by the music therapist and the music therapy consumer advisor. The music therapist presented the evaluation process verbally while both she and the consumer advisor handed out the form and pens. Consumers were assured that they were free to refuse to fill out the form and some chose not to; others hesitated and then initiated, others still, were interested and eager to fill out the questionnaire. While consumers filled out the form, the music therapy staff assisted, supported, and generally encouraged them. The community home music therapy programs were evaluated using the questionnaire format in late March and early April, 2000, and the Clubhouse music therapy program was evaluated using a questionnaire format on two consecutive Fridays at the end of March, 2000.

Results

The process of administering the music program evaluations indicated both interesting similarities and notable differences. As some of the most empowered members of the Service Provider' s community, the Clubhouse group members were quite eager to participate in the process whereas the more isolated community home residents who require more support overall were more reticent. Each home houses a specific mental health population. Some houses have specific goals like "transition to the community" or long term housing for elderly women.

In the following combined questionnaire data, all comments are grouped by site with the community homes comments listed first. All comments are noted verbatim.

Clubhouse and Community Home Data Combined: Total Summary of Questionnaire to Evaluate the Music Groups: total number of respondents - 43

1. How many times have you attended Music Group?

1-5 (11)

5-10 (18)

10-15 (7)

more than 15 (12)

2. What do you get out of the group? What is the best thing about this group?

(33) relaxation	(11) focus	(24) sense of belonging
(5) structure	(18) creativity	(30) socializing
(23) leisure	(17) skill development
(28) fun	(32) like to sing
(6) other, please describe: "spiritual", "educational: ex. The inspiration for Vincent and other songs and the musical instruments provided appreciation for music and residents musical talents" "like dance and movement" "health" "Sue is the best thing about music group" "chance to be free and wild on percussion" "music lessons" "learning a new song".

3. What would you improve about this group? How would you change this group for the better?

(*) scheduling

(7) content: what else would you like to do in music group?

(4) other: please describe: - "it's okay" - "No change." - "more Tuesdays please! Good, positive, energy, relaxed", "more times per month (once a week)", "come more often, more Broadway songs", "have more music group" - "more talent shows", "how 'bout just drumming", "I usually am tired when I come (after work), the singing is uplifting for me", "some other instruments than we already have", "Keep Sue", "more please", "Have it more often", "Singing in rounds and also in parts, more harmony (I' m not sure if this would make it better)", "ear-training", "knowing what key I'm playing in - eartraining", "Longer or more than once a week", "Having been in choir in high school years ago, one five minute warm-up before singing is suggested", "teach people the basics about music. And let them know their voice (vocal) range. Bass-soprano."

4. How do you use music in your life?

(30) relaxation	(21) inspiration	(14) social connections
(28) leisure	(16) dancing	(21) creativity
(16) company	(28) release tension	(15) distraction
(21) pass the time
(*) other, please describe: - "spiritual" - "travel to a better place", "it just feels good, good mental health. To show off sometimes (hey, I know I'm good)", "housework", "to make the muses feel welcome", "Hear from God", "to gain confidence"

5. What changes and/or additions would you like to see in the music group in the coming season? The coming year? * all comments have been listed and then grouped according to site

• - "More of it." "more"
• - "more frequently", "I like it the way it is.", "JUST KEEP MAKING MUSIC!!", "No changes".
• - "Just Get Better", "change the content" "N/A".
• - "add some more songs", "I would like to see in the music group in the Summer, 2000 years."
• "more selection of songs, current songs and world music",
• "more learning of guitar, more Peter Gabriel songs and Sinead and Tracy Chapman (FAST CAR)", "more funding so we can have more music therapy it is very important to a lot of people."
• - "daylight group (for people who are afraid to come out at night)", "the chance to learn how to play a musical instrument (i.e.: piano, drums, etc.)", "more instruments", "Thank you!. It is great.", "Have more talent shows and more entertainment more often.", "This music therapy is a sure thing and a great confidence builder. I love it! Thanks to Sue Baines! Great job Sue!", "more singing and more music days and more people.", "Maybe show others basic vocal techniques, do some warm-up exercises, stuff like that. Have some more jamming times interspersed in the singing perhaps. Maybe we could move the piano into the library sometimes. Anyway, it's a really terrific group. It's very positive for Coast members.", "Basic Theory lessons", "More of me in cooperation with other musicians in talent night", "More singing, less talk", "The changes and/or additions I would like to see in the music group: produce a video of socialization on special occasion for fond memory produce a CD or 'Christmas Choir for 2000!! '"

Description of Summarized Data

Question #1: Attendance data

Each program evaluated in our research had been in existence for different amounts of times. The data was collected to inform the management of each house of the degree of voluntary participation in the evaluation and to frame the rest of the data with that understanding. On-going attendance figures were presented in the actual evaluation reports presented to the house managers. Overall, attendance at each program is high although actual participation in the evaluation did not always reflect that fact.

Question #2: Value of the group for participants

At the community homes, the most frequent response for attending the group was relaxation followed very closely by like to sing. Socializing and a sense of belonging were important reasons for attending as well. At the Clubhouse, the primary reason for attending was fun followed in rank order by socializing, relaxation, like to sing, sense of belonging, and skill development. At all sites, the music group clearly addresses the pervasive problem of isolation as well as offers a social environment in which relaxation, although not a direct goal of the group, is a result.

Question #3: Suggested changes to improve the group as it now exists

The primary change requested by the participants was for more service. Overall, comments indicated that participants enjoy the group the way it is. Some would like increased music knowledge as part of the process and others are interested in working with more advanced singing experiences such as singing harmony.

Question #4: Value of music in the participants' lives

At the community homes, the response to the question regarding the personal use of music was quite mixed, each population seemingly utilizing music in unique ways. For the older men, passing the time was the most frequent response. For the younger men, inspiration was primary. The older women use music for relaxation and leisure whereas the younger women rated relaxation, leisure, inspiration, dancing, release tension, social connections, and creativity equally. At the home which houses both men and women in the 20 to 40 year old range, the primary responses for the personal use of music were company and passing the time. The Clubhouse participants indicated that they use music personally (in rank order) to release tension, for leisure, relaxation, and to pass the time. The comment, "it just feels good, good mental health" seemed very telling. The natural inclination of community mental health consumers to use music in these positive ways indicates its potential value as a therapeutic instrument.

Question #5: Specific changes to improve the group in the future

In requesting information regarding changes, the researchers were attempting to elicit more consumer input into the process. Like the responses to question #3, comments indicated that consumers would like increases in the current service being offered. There was little new input regarding program changes other than those mentioned in question #3.

Ranked Comparison of Results for Question 2 and 4

Question 2	Question 4
relaxation	relaxation
like to sing	leisure
socializing	release tension
fun	inspiration
sense of belonging	pass the time
leisure	creativity
creativity	dancing
skill development	company
support	distraction
focus	social connections
structure

In studying the contrasting nature of this data, we can notice that the music group fills social needs not readily met by accessing music on an individual basis. The music group provides an environment where commonalities are celebrated, where it is safe to engage with others, and easy to become active in a community. A member stated that in music group, they receive a "whole" picture of individual members. Music group members experience a strong sense of connection to each other further evidenced by such things as the out-growth of an art group and a drama group from the music group. As well, reports of increased socializing with each other outside of the group including meeting for coffee and acknowledging and supporting each other on the street are common. This written and reported information indicates that participation in the music group addresses the ubiquitous problem of social isolation for persons living with mental illness in the community.

As well, the elements of liking to sing and skill development as reasons to attend the music group scored high. Although not an original focus of the group, the universal experience of liking to sing and then enjoying the development of that skill would seem to cross populations here. In the context of developing personal and social skills, music group members also develop music skills which are readily tangible and can easily be noticed by fellow group members. Often, during the course of the group, the facilitator and group members comment on the quality of the music we produce. There is a sense of pride in our on-going development as musicians as well as in personal and social development.

In the overall results, we can see that, for the most part, music group members are very positive about the group. Their participation can address needs on many levels and readily speaks to are as of personal development and social development.

Summary and Discussion of Results

As stated previously, according to our results, the number one reason why these consumers choose to attend music group is for relaxation. The number two reason is that they like to sing. Both relaxation and singing are health enhancing on all levels including physical, emotional, cognitive, social, and spiritual. Same consumers of the service appear to be actively conscious of these attributes, indicated by their written comments. Socializing, fun, and a sense of belonging all scored very high as well. For many community mental health consumers, these elements are difficult if not impossible to experience. Many of the individuals attending music group have commented that usually, they cannot be in group, don't like groups, and avoid group work of any kind. However, they readily participate in the music group of their own volition. According to one verbal comment, the music group provides a place they can be and participate at their own discretion even when they may be having trouble elsewhere. The music group clearly offers participants an awareness of increased intrapersonal balance as well as interpersonal comfort. According to one community home resident, "It is a break from feeling what is wrong with me, physically, emotionally, mentally. It is a rest for my soul." In a Clubhouse Music Group Member's words, "Sometimes the music alters my gait - puts a bounce in my step. Sometimes after group I feel better about humanity. Sometimes I gain insight into one or some of my fellow group members. Sometimes the music triggers tears and the tears are a release. Sometimes I walk with more grace afterwards. Sometimes it helps me to focus, sometimes to relax."

Clearly music, both in group, and in the community generally, is a positive resource for persons living with mental illness. However, in contrasting these results, we can see how the social aspect and the skill development aspects of making music together fill a very important need for the consumers of the service. For example, it has been noted that singing alone is much more difficult than singing in group and that the group supports the development of singing. Over time, through the strengthening of the singing process as well as the enhancement of additional music skills such as rhythmic drumming and active listening, participants receive a resource which they can utilize to enhance their mental health at their own discretion.

Implications

The consumer-initiated music therapy context is unique to the consumers in many ways. Unlike most therapy and/or rehab groups they have attended in the past, group membership is completely voluntary, with an open in and out policy. Group membership is based on a personal connection to music rather than on a problem that needs solving or a diagnostic categorization. Group members comment that in the music group, they feel free to be themselves, that group membership is not dependent on their illness or diagnosis but rather on the old and new skills they are developing: understanding, accepting, caring and encouraging each other in unique, non-medical/diagnostic ways (Elaine Kanigan, personal communication, July 11, 2000). Group members readily offer each other broad tolerance and acceptance, thereby creating a space where consumers can participate with their own awareness of themselves and of others in a supportive, non-verbal group context. Their participation presents the opportunity for the development of new identity elements tempered by historical experiences. Of interest is that the music group has quite a high attendance rate of consumers who have a low participation in other programs.

The therapeutic process and support described in this approach occurs in the context of singing and accompanying personally meaningful songs together and concurs with a health and wellness model. This contrasts with more traditional music therapy approaches which require insight-oriented verbal process grounded in a psychodynamic model, a model which developed out of the medical model. In our program, as participants autonomously initiate the group to sing personally significant songs, they are readily able to direct the group to match and support their particular emotional status and needs of the moment. This can occur simultaneously in both in the conscious and unconscious realm. Over the course of the session, a variety of emotional needs are addressed in a supportive and both direct and indirect manner as we sing together. In addition to the support experienced in the group singing and music making context, lyrics of the community repertoire readily address issues not always easily accessed and addressed in the verbal realm. Through the singing of these words, participants experience such things as insight inspired by the poetry of the lyrics, a sense of connection to a greater whole, and emotional release. Another benefit of the described process is that participants in all the music programs are able to see and hear themselves as well as their colleagues enhancing and improving their personal, social, and musical skills. Again, this occurs without the requirement of stating it verbally in the context of the group. Rather, through supportive non-verbal and paraverbal musical processes, interpersonal as well as intrapersonal development occurs. The music group offers active, passive and peripheral participants a sense of inspiration and community connection as well as increased esteem in themselves and their fellow mental health consumers.

Important additional benefits of the program not measured in our research project are the increased development of inter-site music programs, linking the service provider community in a supportive, non-threatening environment. As well, verbal reports indicate increased participation of consumers involved in the music program in the broader social public music community including attending jam sessions, songwriting, going to concerts in the community, socializing and talking about music and music-based experiences, and learning new instruments from community based instructors.

By creating a context in the mental health spaces in which consumers autonomously access the benefits of participating in music experiences, consumers have been encouraged to access increased music resources in the public community, enhancing their broader social connections and decreasing isolation.

Conclusion

Based on our experience to date, a consumer-initiated and partnered efficacious model for music therapy program development and evaluation is an attainable ideal; clearly possible and ethically appropriate. The goal of this paper was to articulate an approach for such a program. On-going and future development will include addressing continuing verbal requests for lessons, music and relaxation, individual music therapy, and music appreciation plus more of the current programs that we are running. Research into the themes represented in the songs chosen and the seasonal aspect represented in the requesting of those themes is being considered. Verbal reports indicate that the music group offers a place of sanctuary, particularly in times of increased distress. Due to the high mortality and suicide rate present in the mental health consumer community, inquiry as to how the music group provides opportunity for grief-work and support is another area of research to address. Based on numerous personal requests as well as based on comments on the evaluation, proposals for increased service have been submitted by consumers as well as by the music therapist. To date, there has been no new allocation of budget. This problem, (Hyde-Price, 1986, as cited in Stallard, Hudson, & Davis, 1992) is another unfortunate example of the on-going struggle of consumers to have their views, ideas, and requests for rehabilitation and treatment backed-up by action.

References

Alvin, Juliette (1966). Music Therapy. London: Stainer & Bell.

Ballou, Mary & Gabalac, Nancy (1985). A Feminist Position on Mental Health. Illinois: Charles C.Thomas Publisher.

Beard, John; Propst, Rudyard; & Malamud, Thomas (1982). The Fountain House Model of Psychiatric Rehabilitation. Psychosocial Rehabilitation Journal, V(1), 47-53.

Bruscia, Kenneth (1987). Improvisational Models of Music Therapy. Illinois: Charles C. Thomas Publisher.

Church, Kathryn & Capponi, Pat (1991). Re/Membering Ourselves: A Resource Book on Psychiatric Survivor Leadership Facilitation. Toronto: Ontario Ministry of Health, Community Mental Health Branch.

Dutton-Douglas, M.A. & Walker, L.E.A. (Eds.)(1988). Feminist Psychotherapies: Integration of Therapeutic and Feminist Systems. Norwood, New Jersey: Ablex Publishing Company.

Foulkes, R. (1974). Health Security for British Columbians: A special Report. (4 volumes). Minister of Health: Victoria, BC

Gaston, E.T. (Ed.). (1968). Music in Therapy. New York: Macmillan Company.

Hadsell, Nancy (1974). A Sociological Theory and Approach to Music Therapy With Adult Psychiatric Patients. Journal of Music Therapy, XI, 113-124.

Hammel-Gormley, Amy (1995). Singing The Songs: A Qualitative Study of Music Therapy With Individuals Having Psychiatric Illnesses As Well As Histories of Childhood Sexual Abuse. Unpublished dissertation.

Hanser, Suzanne (1987). Music Therapist's Handbook. St. Louis, Missouri: Watten H. Green, Inc.

Heimlich, Evelyn (1972). Paraverbal Techniques In the Therapy of Childhood Communication Disorders. International Journal of Child Psychotherapy, 1(1), 65-83.

Hodges, Donald A. Lawrence (Ed. )(1980). Handbook of Music Psychology. Kansas: National Association for Music Therapy, Inc.

Hoffman, Ken & Dupont, Jean-Mare (1992). Community Health Centres and Community Development. Ottawa: Health Services and Promotion Branch, Health and Welfare Canada.

Kopolow, LK (1981). Client Participation In Mental Health Service Delivery. Community Mental Health Journal, 17, 46-53.

Morrell-Bellai, T. & Boydell, K. (1994). The Experience of Mental Health Consumers as Researchers. Canadian Journal of Community Mental Health, 13(1), 97-110.

MacKay, M., & Heimlich, Evelyn (1972). Psychotherapy With Paraverbal Therapy in a Case Of Gilles de la Tourette Syndrome. American Journal of Psychotherapy, 26(4), 571-577.

Priestley, Mary (1975). Music Therapy in Action. New York: St. Martin's Press.

Rappaport, Julian. (2000). Community Narratives: Tales of Terror and Joy. American Journal of Community Psychology, 28(1), 1-24.

Roberts, Linda; Salem, Deborah; Rappaport, Julian; Toro, Paul; Luke, Douglas; Seidman, Edward (1999). Giving and receiving help: Interpersonal transactions inmutual-help meetings and psychosocial adjustment of members. American Journal of Community Psychology, 27(6), 841-868.

Stallard P., Hudson J. & Davis B. (1992). Consumer Evaluation in Practice. Journal Of Community & Applied Social Psychology 2 (4): 291-295.

Tyson, Florence (1981). Psychiatric Music Therapy: Origins and Development. New York:

Unkefer, Robert F. (Ed.).(1990). Music Therapy in the Treatment of Adults With Mental Disorders: Theoretical Bases and Clinical Interventions. Toronto: Collier Macmillan Canada. Fred Weidner & Sons Printers, Inc.

Wolfe, David E. (1988). Group Music Therapy in Short-Term Psychiatric Cafe. In Furman, Charles E. (Eds.). Effectiveness of Music Therapy Procedures: Documentation of Research and Clinical Practice. Minnesota: University of Minnesota.

Yalom, Irwin D. (1995). The Theory and Practice of Group Psychotherapy. New York: Basic Books.