The Selection of Music for Therapeutic Use with Adolescents and Young Adults in a Psychiatric Facility

The Selection of Music for Therapeutic Use with Adolescents and Young Adults in a Psychiatric Facility LOIS KAY METZGER, RMT-BC* Lawrence, Kansas ABSTRACT: The selection and use of Popular music in the clinical setting is the topic which is explored in this paper. There are references to current religious and popular articles about the effects of rock music on behavior, and a challenge to music therapists to begin to formulate some guidelines for the use of popular and rock music in the clinical setting. The article details an example of a policy that war developed in a clinical setting. It gives the rationale and the procedure for writing the policy and tells how the policy was implemented and some of the responses to that implementation. The paper emphasizes the importance of evaluating musical tastes and choices, and of using good judgment in determining appropriate music for therapeutic use. There are a variety of articles, workshops, books, and tapes presented by Christian organizations and popular magazines that talk about the influence of popular music on adolescents. Lamp (1985), Davis (1985), and King (1983) look at the values that are perpetuated by rock music, popular lyrics and videos. Peters (1985) and Johnson (1983) consider the effect of album covers and backmasking on the consumers of rock music. The influence of subliminal messages on the unconscious mind and subsequent anti-social behaviors are discussed by Packard (1981), Mountford (1979), Athens (1978), and Kehl (1975) in such magazines as Christianity Today, Reader's Digest, and Family Health. Time (1979) and People (1982) magazines also have had articles discussing the possible anti-social behaviors resulting from subliminal messages in rock music. In addition to these articles, the National Parent-Teacher Association and a group called the Parents Music Resource Center have asked the recording industry to begin using a rating system on record and tape labels and to monitor the playing of recordings and videos. Much of this concern is with the lyrics. But the musical content conjoined with these lyrics isn t entirely arbitrary. Clearly, music and poetry (lyrics) must be compatible to sell a popular song. With all this concern, opinion, controversy, and even dogmatic doctrines being expounded by the public, it seems that music therapists ought to begin to investigate the influence of popular music (lyrics included) in the music therapy setting; specifically, investigating how it relates to our standards of practice and our intentions to be involved therapeutically * Mr. Metzger wason the staffof the RainbowMental Health Facility,Kansas City, Kansaswhen she wrote this article. Mr. Metzger invites dialog about this article. Readers may write her, and other authors represented in this issue, in care of the Editor. 1986, by the National Association for Music Therapy, Inc. in the healing process of our clients. The issue has prompted this writer to detail a process and policy developed that does use judgment and discrimination in guiding patients to select music. It is hoped the following information will create interest in, and dialog about, the use or misuse of popular music in our culture and in our clinics. It is hoped this information will create interest in, and a dialog about, the use or misuse of popular music in our culture and our clinics. A Music Therapy Committee has been established, at a state mental health facility, which consisted of two registered music therapists, two activity therapy aides, and at least one intern. It meets once monthly to formulate policies, to discuss business, and to share treatment techniques. The committee became aware that a policy was needed to establish guidelines for the selection of music to be used in activity therapy. Consequently, it formulated a policy and decided to present an inservice explaining and clarifying the policy to the hospital staff. When the policy was implemented, it was monitored by staff members from the various disciplines and found to be effective for patients and staff. Observations of Behavior and Formulation of the Policy Four basic observations led to the formation of the policy for the selection of music: 1. Adolescents and young adults often used their leisure time listening to songs that related to their diagnosis. 2. Non-music therapists used music in activity groups without an awareness of the effects of that music. 3. Adolescents with problems of violence, sexual abuse, and drug abuse verbalized an excitement and fascination with songs about sex, violence, drugs, and satanism. 4. Therapists observed incidents of sexual acting-out, as well as physical aggression, in conjunction with listening to popular music. Exploring each of these four observations in more detail will provide a better understanding of the concerns of the music therapy committee. Regarding the first observation, the committee members noticed that about 10 patients a day asked to listen to either particular records or general categories of songs during moderately structured leisure time. When listening to music as a leisure activity the patients are 20

The Selection of Music for Therapeutic Use 21 provided a space and necessary equipment, and are minimally supervised. In order to qualify to use leisure time in the activity area they need to be on a non-escorted status and have shown enough self-control to not act out in a way to harm themselves or others. Staff members noticed that people chose songs related to their diagnoses. Depressed people chose songs that made them feel sad by verbal report and facial affect; a suicidal person repeatedly chose the theme from M*A*S*H which states that suicide is painless ; a few patients who had alcohol and drug abuse problems liked to listen songs that reminded them of parties and getting high; for example, Tequilla Sunrise by the Eagles. The Music Therapy Committee became concerned about this tendency. The second observation which led to the development of the policy became apparent to the committee because nonmusic therapists had asked members of the committee what music would be appropriate for some activities. A music therapist had also observed that during crisis situations in crafts, exercise, or recreational groups, other staff members would not use the option of turning off or changing the music to alter the environment and thereby possibly influencing the behavior. When asked if they realized that the music could affect a patient s increasing agitation or isolation, these therapists replied that they had not realized it could be an important environmental stimulus. The committee collected some pertinent data in connection with the third observation. An investigation of medical record charts revealed that out of 29 patients, ages 8 to 17, 23 had presenting problems involving violence, sexual abuse, or drug abuse. Problems stated in the medical records including violences were carried a shotgun to school with intent to shoot, pre-occupation with violence, hitting peers and teachers, fire setting, and physical abuse by father. Sexual abuse problems included sexually abused by stepfather, raped by two boys, repeated sexual abuse since age 10, and incest. Problems showing substance abuse were alcohol and drug use, alcoholic father, history of alcoholism in family, and unable to express feelings. All of these examples can be seen as cases of maladjustment or family dysfunction. In order to pursue the ramifications of these maladjustments and dysfunctions in relation to choices of musical stimuli, the committee decided to engage 20 adolescents in discussions during music therapy groups and lessons over a period of three weeks to determine the nature and degree of the fascination with popular music and its accompanying videos. These teenagers expressed that if given the opportunity they would listen to, and watch, the popular music productions all day and evening. They said they liked the loud, fast, neat (distorted) sounds of heavy metal rock, and also liked the costumes, make-up, and stage stunts of many of the popular performers. Some groups mentioned were AC/DC, Kiss, Blue Oyster Cult, Queen, Judas Priest, and Motely Crue. These groups all share popularity at one time or another and have songs that refer to violence, satanism, and overt sexuality through their lyrics and/or videos. Some examples are Queen s Another One Bites the Dust, Highway to Hell by AC/DC, Cod of Thunder by Kiss, and Blue Oyster Cult s Don t Fear the Reaper. However, it is not only the rock music that is a vehicle for these subjects. Some patients who prefer country or soul music are exposed to songs such as lets Get Drunk and Screw by Jimmy Buffet or Sexual Healing by Marvin Gaye. Because of the direct connection between these young people s problems and their choice of musical and visual stimuli, the committee felt that staff members needed to use discrimination in guiding the adolescents choices. Staff members noticed that people chose songs related to their diagnoses. To best illustrate the fourth observation, three examples which are representative of incidents that occurred approximately weekly among the patient population of 50 adolescents and young adults will be given. The first example is the case of a group of 4 adolescent boys, ages 11 to 13, who were choosing songs in a structured music listening group. They chose to listen to Lets Get Physical, a 1982 hit by pop star Olivia Newton-John. On the surface, it seemed like a neutral, upbeat song about exercise. All the boys became more active physically and one hid behind the piano and began to masturbate. At this time the therapist stopped the record and calmed the boys down by verbal instruction. The boys agreed to talk about the incident at the next session. During the talk, the boys mentioned that they became sexually excited when listening to the song. They agreed that it was the repetitive words, lets get physical, and the driving beat of the music that had influenced their mood, energy level, and behavior. The group decided to eliminate this song as one of their listening choices. Another example of sexual preoccupation in relation to a popular song occurred in an adult music therapy group. This group was utilizing lyric interpretation as a focus for discussion. One patient remarked in a stage whisper that he d like to discuss a certain song. There were side-long glances and giggles to indicate some previous common experience among the group members. The leader was able to encourage them to share what the collusion was all about. They revealed that there had been joking and simulation of masturbation in the patient day hall when listening to the song Beat It, Michael Jackson s smash hit of 1984. Some of the group members stated that they were too embarrassed to talk about it, but others disclosed that it carried definite sexual suggestions of masturbation. Even though the lyrics do not specifically refer to the act, the title and the rhythm of the music led these patients to think of the sexual act. The third example relates to physical aggression, in conjunction with listening to music, and concerns an adolescent female patient who had a history of hallucinating. She expressed an interest in listening to music and was allowed to

22 do so as a reward for completing other tasks. On one occasion she became very involved in the popular record she had chosen to listen to; she began to sing the lyrics, her eyes glazed, and tears flowed. She refused any communication offered by staff or peers and became verbally hostile and physically abusive. On several other occasions this young woman became agitated while listening to popular music. When the therapist turned the music off, she did not escalate but calmed down enough to either return to task or return to her cottage. In order to prevent harm to others or herself, it became important that staff consider music as a possible anxiety-provoking stimulus. The Policy Using these observations as a basis for decision, the committee came to the conclusion that particular songs in certain situations were inappropriate for use in the therapeutic setting. It was also noticed that some songs that were inappropriate for leisure time could work as a tool to deal with issues or problems in a therapy session. Consequently, the following policy was devised: Since the problems for which patients are admitted often include suicide, depression, aggression, sexual abuse (victim and perpetrator), and drug and alcohol abuse, and since it has been demonstrated that some patients have a tendency to choose songs that intensify or perpetuate these problems, this committee has decided that there is a need to set guidelines for the music used during leisure time and for therapy sessions. All records and music that are a part of, or about to become a part of, our collection will be reviewed and sorted according to: 1. Usable for leisure time. Leisure time music will not include any lyrics that refer to violence, explicit sexuality, drug or alcohol abuse, satanic worship, suicide, or, in short, anything that in the trained therapist s judgement will intensify or perpetuate the patient s problems. The leisure time music will be stored on shelves accessible for leisure time use. 2. Usable for therapy sessions.any of the music not usable for leisure time can be used in therapy sessions if guided by a trained therapist, and if judged to be helpful to the patient in working through his or her feelings and problems. This music shall be marked for therapeutic use only and it is suggested that it be catalogued according to its message, mood, and possible therapeutic use. 3. Not usable for any clinically beneficial purpose. Music that tends to intensify or perpetuate the problems of patients, and is too shallow for use in discussions, will be disposed of properly. This policy is intended to provide patients with appropriate alternatives for selecting music during self-directed leisure time activity. This policy is further intended to guide staff in the use of music for developing positive attitudes, healthy emotions, and appropriate behaviors in the clinical setting and the community. ln its initial stages the policy was reviewed by the activity therapy department supervisor, the superintendent of the facility, and music therapists not working at the facility. It was revised to its present form and then included in the Policies Music Therapy Perspectives (1986), Vol. 3 and Procedures Handbook of the activity therapy department. This policy will continue to be reviewed and revised annually along with other music therapy policies. Because of the direct connection between these young people s problems and their choice of musical and visual stimuli, it was felt that staff members needed to use discrimination in guiding the adolescents choices. Staff Inservices After the policy was approved, the chairman of the committee presented an inservice to the activity therapy department staff, and then to the staff of the entire hospital. An experiential approach was used in these inservices. The music therapist conducting the inservices felt that the use of instrumental music with specific rhythmical components would allow a clearer response to the musical elements, and not evoke a prejudicial response by adult staff who were familiar with the popular music preferred by the patients. Questions were asked to stimulate discussion, to develop insight into individual preferences, and to emphasize the uniqueness of musical tastes. Participants were asked to write down brief, automatic responses to the following questions: 1. What feeling describes your response to the musical selections? The following were played with a few minutes allowed after each for responses: (a) Batacuda by Mikis Theodorakis from soundtrack of Z (strong drum ostinato with upbeat pulsations), (b) Skating in Central Park by Bill Evans (improvizational, smooth jazz piano), (c) Evocation of the Ancestors from Stravinsky s Rite of Spring (syncopated, polyrhythmic and non-traditional sound), and (d) Air on G String from Bach s Suite No. 3 in D Major (straight rhythm at 60 beats per minute). 2. What is your favorite popular tune today? 3. What was your favorite tune when you were 16 years old? 4. When you hear music in shopping centers, grocery stores, dentist s offices, or on hold on the telephone, what is your response? Answers to question one demonstrated that we each have unique and specific responses to music (Hanser, 1986). There were a great variety of responses to each musical selection. For example, answers to Stravinsky s Evocation of the Ancestors included bright, exciting, boring, and disturbing. Questions number two and three brought out that a person s musical choices may be governed by age or attitudes. Most individuals chose a different song for question two than for question three. The last question elicited very definite, but different, responses from each person. These varied responses showed that music does affect our mood or attitude even when we are not consciously aware of it (Rosenfeld,

The Selection of Music for Therapeutic Use 23 1985). Some people said they ignored the piped-in music, others liked it, still others said it aggravated them. There was open discussion about each question and everyone at the inservices added incidents of their own that showed how music had influenced their behavior. One participant remarked how the music industry and producers used sexually suggestive packaging because they knew it would sell. This participant felt that the principle of What will make the most money? dominated the market. He felt there was very little consideration given to the attitude of What would be of value to the consumer? Most of the staff agreed that it was up to the caregivers in the facility to help the patients decide what was best for their leisure time use and not rely on the commercial market to provide good, healthy music or rock video productions. After several minutes of discussion, the written policy was handed out and the presenter invited questions about the policy. There were no questions as to the need for the policy, but some staff voiced concern as to how to monitor patients and how to carry out the policy. Staff members agreed to evaluate the use of the policy by informally meeting and by talking with members of the committee as necessary. Several participants expressed interest and respect for the issue being addressed and for a policy being written. Effect of the Policy After the policy was in effect for six months, staff, patients, and music therapy sessions reflected the implementation of the policy. Staff who gave feedback regarding the policy included recreational and occupational therapists who expressed that they observed patient behavior in relation to music and that they became more aware of its effects to excite, isolate, or calm patients in crafts or exercise groups. In addition, nursing staff reported monitoring a patient who was listening repeatedly to a song on her cassette recorder during her spare time. The song on the tape was one that increased the patient s withdrawal from others and fed her depression. A staff member had observed the patient becoming tearful, isolating herself, and having a sad affect. As a result of the inservice, and an increased awareness of the effect the music could have on the patient s mood, the staff person made a contract stipulating that the patient would interact with other patients in the cottage an amount of time equal to the time she listened to her casette tape. This contract helped minimize the patient s feeding into her own depression and withdrawal. Patients showed interest in the policy. When they chose to listen to songs in their leisure time, and the policy was explained to them, they asked questions about how to develop good judgment. They also expressed curiosity as to what songs might be considered for each category of the policy. The adolescents accepted the authority of an objective policy with less protest than they did the rules of an adult staff member. In some cases the adolescents admitted scary or disgusted feelings towards some of the popular music, but felt that it was too risky to express these feelings in front of their peers. The policy helped open the door for honest discussion. The following illustration shows how the policy was implemented in one specific music therapy group. The group consisted of 6 adolescent boys and one music therapist. It was a highly structured group, and one that had developed to a stage of openness that allowed sharing feelings with one another. Although records by Kiss were not allowed for leisure time use, a member of the group asked to listen to Rock City, Detroit by Kiss as a topic for discussion. The music therapist agreed to do so. After listening, the consensus of the group was that it was a depressing song. The therapist played Bridge Over Troubled Water by Simon and Garfunkel and asked what bridge each person wanted to build to get out of their depression or problem. Each person drew a bridge and illustrated the way across or out of the depressed mood. El Condor Pasa, also by Simon and Garfunkel, was used to further motivate thoughts of alternative moods by having patients fill in sentences beginning with the lyrics I d rather be..." The boys listened to The Greatest love of All by George Benson as a transition for the next session dealing with self-esteem. At the end of the session, all the boys expressed that they felt in a brighter mood and better able to cope with the rest of the day. Summary No definitive conclusions have been drawn concerning this policy. It can be seen, however, that the observations which led to the formation of the policy, the process of formulating it, the presentation of inservices to staff, and the actual implementation of the policy led to significant realizations from staff and patients alike. The members of the committee support the idea that as music therapists we must evaluate not only our own musical tastes and choices, but also the value of musical selections for the clients we serve. If this is done with careful thought and good judgment, we serve as role models and facilitate a better understanding of the applications of music as therapy. This committee s actions and results merit close attention by those therapists needing to determine appropriate music for therapeutic use. REFERENCES Athens, A. (1978, December). Beware here come the mind manipulators. Family Health, p. 38ff. Davis, B. (1985, November). Rock music: Parental guidance suggested. The Christian Century, pp. 1032-1033. Emerging from her grief. (1982, September 13). People, p. 80. Hanser, S. (1986). Music therapy and stress reduction research. Journal of Music Therapy, 22(4), 193-207. Johnson, M. (Speaker). (1983). Rock music revealed. (Cassette Recording available from Mike Johnson Ministries.) Wichita, KS. Kehl, D. H. (1975, January 31). Sneaky stimuli and how to resist them. Christianity Today, p. 9ff. King, M. (1983, July). Rock unveiled. Conquest pp. 9-11.

24 Music Therapy Perspectives (1986), Vol. 3 Lamp, R. (1985, November). Rock--what it s got and what it s not. Potential, pp. 8-9. Mountford, R. D. (1979, May 4). Does the music make them do it? Christianity Today, p. 21ff. Packard, V. (1981, February). The new (and still hidden) persuaders. Reader s Digest, p. 12Off. Peters, D., & Peters, S. (1985). Rock s hidden persuader: The truth about backmasking. Minneapolis: Bethany House. Rosenfeld, A. H (1985, December). Music, the beautiful disturber. Psychology Today, pp. 48-56. Secret voices. (1979, September 10). Time, p. 71.