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ANGLIA POLYTECHNIC UNIVERSITY

AN EXPLORATION OF THE RELATIONSHIP BETWEEN MUSIC THERAPY AND THE FORENSIC ENVIRONMENT

CATHERINE ROBERTS

A dissertation in partial fulfilment of the requirements of Anglia Polytechnic University for the degree of Master of Arts (Music Therapy)

Submitted May 2001

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ANGLIA POLYTECHNIC UNIVERSITY

ABSTRACT

SCHOOL OF PERFORMING ARTS

MASTER OF ARTS

AN EXPLORATION OF THE RELATIONSHIP BETWEEN MUSIC THERAPY AND THE FORENSIC ENVIRONMENT

By CATHERINE ROBERTS

May 2001

This thesis is an exploration of the relationship between Music Therapy and the forensic environment. It attempts to do this by collating existing material on the use of Music Therapy in this field and together with other relevant material from the Arts Therapies to draw some conclusions about the principal dynamics which a Therapist will face in this setting. It also considers how the contribution of psychoanalytic theory to understanding mental illness and violent behaviour can assist in understanding the role and dynamics that exist for the Music Therapist in a forensic environment. Through the use of case examples drawn from the writer's own personal experience of working as a Music Therapist in a secure unit, the issues surrounding Music Therapy within this setting and the theories presented are illustrated.

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"The worst of men does not injure another because, abstractedly, he would do himself a mischief. But in order to get rid of some pressure of evil upon himself. Take the envious man, the revengeful, the murderer for the sake of gain - or, what seems worst of all, the

murderer for the sake of murder - and, tracing the causes of his offence with a humane and thoughtful eye, we shall find that it is out of some imaginary disadvantage, some sense of

infelicity or inequality, or some morbid want of excitement, firghtening the poor inconsiderate wretch himself even more than he frightens others, that induces him under the notion or the impulse of procuring relief to his own desires, to thrust his evil upon the

head of another."

Leigh Hunt, "A Treatise Upon Devils" 1820?

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Contents

Introduction (page 1) Chapter 1: Introduction to Music Therapy with Forensic Services (page 4) Chapter 2: Arts Therapies in Forensic Psychiatry (page17) Chapter 3: An Understanding of Forensic Services (page 33) Chapter 4: The Contribution of Psychoanalytic Theories of Violence and Schizophrenia (page 39) Chapter 5: Case Studies and the Clinical Context (page 52) Conclusion (page 66) Bibliography (page 68) Appendix A (page 73) Appendix B (page 74) Appendix C (page 75) Appendix D (page 76) Appendix E (page 77)

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Introduction

I was encouraged to write this thesis on completion of my postgraduate diploma in Music Therapy at Anglia Polytechnic University in 1998. Having qualified as a Music Therapist I started work at a local low secure unit based within the Mental Health Services of East Cheshire NHS Trust. The unit where I worked operated from a medical-based philosophy and there was no tradition of either psychodynamic or creative ways of working. This presented a challenge to me from day one as there were no protocols in place for exactly how and what Music Therapy should contribute to the multi-disciplinary team approach to the patients' treatment. For a newly qualified therapist this presented a further challenge as I lacked experience of the operational day to day systems in place within the NHS. I was immediately challenged to test my beliefs in my new profession and there was much pioneering work to be done in introducing Music Therapy to both the unit and the Trust. In addition to these challenges I was also faced with what was perhaps a yet greater challenge. I had never been inside a prison or a secure unit and to my knowledge had never spent any length of time with a current or ex-offender. I had never been through an airlock, attached my keys and personal alarm firmly to my belt and ventured into what for me was very much the unknown. Naturally I was initially apprehensive and anxious on reading in case notes about the very real potential for violence which my patients possessed, but also surprised by how ordinary they appeared externally, and by how easy it would be to pass someone in the street unaware of their violent potential. One significant learning experience for me in all of this was that it is our own potential which we react against in the knowledge of our patient's crimes. I feel that this is one of the most significant challenges which anyone working in any role with forensic patients must face: how do I relate to this person as a human being without denying or splitting off the legacy of their violent offences; indeed is it possible to fully engage with someone's violent past? Whilst this is an important point for anyone working with forensic patients, I feel that it is particularly pertinent to psychodynamic arts and psychotherapists who in their consideration of the transference and countertransference as a therapeutic tool must try to find a way in which they can empathise with their patients. I am not suggesting that this is always possible as we are dealing with very emotive issues that touch on difficult and traumatic feelings and memories; however understanding what someone's offence means to you is one of the most important ways in which to help both individual patients and ward teams as a whole understand dynamically what is happening for them. Without the support of a strong team that is willing to look at the dynamics that operate within forensic units, the role of a therapist can too easily become a matter of survival rather than a matter of creativity. Since beginning work on the unit my practice as a Music Therapist has grown in terms of confidence, understanding, excitement and also frustration at my surroundings. It is this personal journey that has inspired me to look hard at what systems were operating within the dynamics of the unit; how were patients and staff existing side by side and relating to one another? How did I fit into this picture? Clinically, what could I offer? And what role did I play in the matrix of the unit as a whole? This thesis will consider and expand on these ideas whilst also providing an understanding of what we mean by forensic services and who we mean by forensic patients. Through illustrations of case studies it is hoped that some of the principles discussed will be exemplified in the context

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of different experiences of therapy. The similarities and differences between the arts therapies within the forensic environment will be considered in terms of distinct issues faced by each discipline. I will then attempt to draw together this understanding with psychodynamic theories, considering both violence and mental illness I intend to use this as a way of further informing our understanding of the institutional dynamics encountered with the forensic environment with specific emphasis on the meaning this has for the Music Therapist. As part of this introduction I feel that it may be helpful to consider what it is we mean by some of the key terms used in the title of this thesis and examine the relationship between;

MUSIC THERAPY FORENSIC ENVIRONMENT Music: Music can be described as an expressive collection of sounds and silence with an expressive purpose. Therapy: Therapy orginates from the Greek "therapia" which means to attend, to help or to treat. Forensic: Forensic can be as described as 'belonging to courts of law'.1 In this context a forensic patient is anyone who has a history of committing criminal offences. Environment: Environment can encompass both 'surroundings', and 'external conditions influencing development or growth of people' The consideration of how these four concepts can be linked and how this may both improve the quality of life for our patients is the focus of this thesis. The influences on our patients occur both directly through therapy and through the environment in which they live. As therapists we have a responsibility to understand this relationship between music, therapy, foresnic histories and the environment in which our patients live. Through the exploration and understanding of our own responses to everyday and extraordinary events within the forensic units where we work as Music Therapists, we can begin to glimpse some of the chaos and disturbance which our patients feel. Only then is it possible to begin a process of reparation.

1 Chambers English Dictionary, Chambers, Harrap, 1993.

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Chapter 1

Introduction to Music Therapy within forensic services.

Music Therapy in the UK has a long history of work within psychiatry beginning in the large institutions which provided care both for people with learning disabilities and for people with mental health problems. In 'Maranto' (1993) It was established that approximately 50% of UK Music Therapists worked in these two areas within the National Health Service. However, only 15% work solely with the field of mental health and very few of these within forensic mental health. As the large institutions were gradually disbanded as part of government policies in the early 80's, many of the residents were moved to a variety of settings within the community and to smaller hospitals. Responding to these moves, music therapists were also able to follow, increase in number, and begin to expand their services so as often to hold a more community base. The employment of Music Therapists in the NHS has steadily increased over the years and Adult Psychiatry is now a prominent area within which Music Therapists are employed. However, the inclusion of Music Therapy within the forensic services is a more recent development, along with the development of Music Therapy Services within prisons. Currently the APMT has 390 members, approximately 95 of whom work in adult psychiatry with 20 of those working in forensic psychiatry. As would perhaps be expected of such a recent service expansion into forensic psychiatry there is little literature published on the subject to date. I will summarise in chronological order the four contributions which have been published so far in the UK. They illustrate the main functions of Music Therapy in this field. Flower (1993)2 published a chapter entitled 'Control and Creativity'. This was based on her experiences within a Secure Adolescent Forensic Unit. She addresses the difficulties of "how much freedom and control to give clients" and the adolescents' search for identity. In doing this she also describes how, by giving the clients a situation over which they could be in control, many of them have been able to experience play. She is clear about the importance of this being highlighted in many of her clients, as their childhood had often been characterised by trauma which left little scope for play and hence normal healthy development. She summarises her aim as being that "the individual would discover an ability to play and, through play, move towards a deeper sense of self". The second piece of literature (Loth 1994) was an article entitled 'Music Therapy and Forensic Psychiatry - choice, denial and the law.' It is based on her work within an adult medium secure unit and looks at a case example of a short term closed group run within the unit. She also considers the environment of the unit in relation to the patients within the group and the role that Music Therapy can play within a setting such as this. She concludes that the freedom and choice within a Music Therapy group could provide patients with the support needed to "explore their negative behaviours and to begin to become aware of and accept their feelings."(p18) At the 3rd European Music Therapy Conference, Santos (1993) presented a paper entitled 'Women Patients in Forensic Psychiatry - The Forgotten Ones'. She also focuses on the impact of the environment on her patients in two separate units. One was a large high security hospital where male and females are segregated and the other was a regional secure unit where the wards are mixed. She considers first the public's image of and attitudes to mentally disordered women offenders and then describes how she felt the need for the women in the mixed wards to

2 Flower C in "Music Therapy in Health and Education" ed Heal M and Wigram T, Jessica Kingsley Publishers, London, 1993.

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have the opportunity to attend a female only Music Therapy group. "Sloboda A" has published the most recent article on Music Therapy within forensic psychiatry, entitled 'Music Therapy and Psychotic Violence' (1997). She describes her experiences of working within a regional secure unit and uses a case history of a violent man suffering from schizophrenia to demonstrate how Music Therapy could enable him to build a fragile sense of trust and use the musical medium as a way of 'experiencing and thinking' about their relationship, whilst keeping the therapist at a safe distance. Whilst a small number of other articles have been written on the subject of Music Therapy in forensic psychiatry outside the UK, I intend to focus mainly on work undertaken within the UK. The vast differences, both in some of the Music Therapy trainings outside the UK and within the forensic and psychiatric services of other countries, would create too wide an area of study for this research. Drawing on both published and unpublished resources and personal interviews I will relate the findings to my own experiences of working as a Music Therapist on a forensic ward. The unpublished material is by Rachel Ecclestone and is taken from a chapter submitted as a contribution towards the music therapy section of an as yet unpublished book on the arts therapies in forensic psychiatry edited by A.Sloboda and P.Cronin. The main common issues identified in the literature which are perhaps specific to Music Therapy work within a forensic setting are those of choice, power and control. The patients with whom we work have no choice regarding the secure setting in which they are detained and in some cases may have little choice as to whether they attend therapy. Being detained in an institution they have very little control over their lives and for some this control will continueon release from a hospital setting, from which where they may then be returned to prison. A large percentage of forensic patients have suffered some form of abuse; a large percentage have also committed violent crimes which led to their detention. All these issues recur time and again within Music Therapy sessions in a forensic environment and it is these particular issues which appear to create common ground unique to work in a forensic setting. All four sources mentioned appear to have given some acknowledgement to the importance of the secure setting both in the impact on the patients' well-being and in the progress and form which Music Therapy can take. These four sources give us a good cross section of work to consider covering adolescent and adult secure units and special hospitals. Whilst acknowledging the work done by Music Therapists within Adolescent Forensic Psychiatry, in order to keep the focus of this study within the field of recent research, only Adult Forensic Work will be explored. There are many similarities between the issues which clients bring to music therapy, within forensic settings, which are more common to these environments than to others. The most widely expressed issue both in my own experience and as demonstrated by Loth (1994) is that of being in or out of control: the need for control for the safety of the public; the need for control for the safety of the patient. Being contained within a secure environment can create polarised reactions in patients. The two extremes of these reactions range from fighting constantly against restraint within the health care system and the polar reaction of overwhelming relief and a sense of containment. This is also an important instance of the fine distinction within many of these services between control and containment.

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The common factor which affects every forensic patient is that of being detained usually against their will. Along side this comes issues of loss of liberties, loss of personal space, loss of some property (i.e. lighters), restricted movements, diminished contact with family and friends, rigid timetables and intrusion into personal life. Whilst each patient must continue to be observed as an individual, these issues surrounding detention are ones which on some level all patients within a locked environment will face. So what effect does this have on music therapy and the music therapist? Firstly in a clinical sense it is likely that the issue of power and control will often be very prominent when working with a forensic patient, as this is the most immediate issue which the forensic patient will face when entering secure care. This is also relevant, of course, to general psychiatry where a patient is detained on a section. However, within forensic settings there is a sense of heightened security and a reality of stronger restraints. Many patients within forensic services have committed violent acts which brought them to the service, but patients can enter the service with any charges against them, not necessarily ones relating to violent damage against persons or property. In my own research and experience it is true of the majority of patients within forensic psychiatry that they have committed violent acts. It is also in the nature of these patients and the contained environment where they are living, that some degree of violence will continue within the secure setting. It is possible then that detention within a secure setting could be extremely difficult to cope with internally for those who, in committing violent acts, have demonstrated an extreme need for power and control. However, on entering secure care patients are forced to accept the loss of many liberties and are, by the nature of detention, placed in an extreme state of loss of power and of control. Should a patient polarise towards extreme control, for example if a patient becomes frustrated and creates an argument resulting in assault of another patient or member of staff, this actually then becomes an extreme loss of control then following an assault the patient is physically restrained by nursing staff. These issues of polarisation of control are often brought into, and can become enhanced within, the therapy session. I have encountered them as often evident both within the musical transference and counter-transference created within a clinical improvisation and also within 'acting out' within the therapeutic relationship. Within music therapy the therapist must consider carefully these often volatile issues. The therapist provides the patient with a therapeutic space to work in by establishing certain boundaries of a consistent time and place to hold the session, ensuring the session is free from distraction and remaining non-judgmental towards the patient by choosing not to reveal much personal detail. Although these boundaries seem essential to the growth of a productive and supportive therapeutic relationship, they are nonetheless boundaries. For a patient who is in such a polarising position, then the establishment by the therapist of therapeutic boundaries, within the boundaries already imposed by the secure setting, is also an important issue which the therapist must be aware of. Patients may vilently resist and attempt to break these therapeutic boundaries and without supervision the therapist may find it difficult to manage this. The extreme need for power and the proven capabilities of the patients violence can all be acted out within the session. The therapist must therefore take great care and use supervision to protect themselves and find ways of understanding any attacks on the sessions. It is also the nature of the secure setting that these attacks may also come from outside the session i.e. other patients (those involved in music therapy and also those not) or staff. Bion (1961)3 wrote in detail about the difficulties of working within institutions and this will be discussed in further detail in chapter 4. 3 Bion W R ""Experience in Groups and Other Papers", New York, Basic Books, 1961.

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In 'Control and Creativity' Flower (1993) describes how it is often difficult to know how much control to give a patient in a secure setting, the therapist has to face her own anxiety of what may happen if the client assumes complete or too much control. She also addresses the importance of choice, and explores how patients experience an often extreme need for, and lack of, control. She describes how it is important for patients who have no choice over being within a secure setting to offer them a) the choice of whether to attend therapy and b) choices within therapy, such as which instruments to play, when to play, should the session be taped, what to do within the music. Building a musical relationship with someone in this situation could provide a means to be in control within an interpersonal dialogue that has a creative end to it. It could also provide an opportunity to allow someone else to be in control in a non-intended threatening manner. Through drawing together these experiences as the relationship develops and is sustained, therapist and client may be able to work towards sustaining a dialogue where the patient feels able to express himself within the music without the need to collapse or feel pressured under the control of the therapist or excessively control the music, blocking out the potential for dialogue. Mary Priestley in her book 'Analytical Music Therapy'4 describes a way of working whereby the therapist and client are able to reflect back on feelings and thoughts derived from the clinical improvisations and use psychoanalytic techniques as a tool for further understanding and exploring these thoughts. In the scenario described of the violent patient within a secure setting, the opportunity to use the feelings in, and the observations of a clinical improvisation, to look at the roots of the need for power and control or indeed any emotion or idea expressed in the music, would provide the patient and therapist with a way of working through and understanding the root of the patients' difficulties. Of course within a psychiatric setting this is not always possible, and may not always be appropriate, as for many very disturbed psychotic patients verbally relating and reflecting may not be manageable. When working as a music therapist in this way it is the music alone which will become the language of the therapy session and any working through will have to be done in the music itself. Although this may not involve the patient and therapist discovering and understanding the root of the patients' difficulties, it will, however, still allow them the experience of gradually being able to hold an equal dialogue without an excessive need for control. Flower (1993)(p45) describes the task of Music Therapy within a secure setting as 'to transform this often stifling institutional control into a more permissive therapeutic containment.' For many forensic patients the spontaneity of creative improvisation may initially be too great a demand on the inner self; the damaged patient with a distorted sense of self may find this sudden pathway to inner expression and emotions too much to cope with in a fragile inner state. Patients often use their defences against feeling too exposed by focusing on concrete objects such as the physical attributes of the instruments (Sloboda 1997) or relying on previously learnt songs or tunes (Flower 1993). Loth (1994) describes how the playing of learnt tunes can be seen as a safe musical starting point from which to explore the potentially unsafe world of the music therapy session. However, as a sense of trust develops within the therapeutic relationship it is the physical action of playing the instruments which can help to link the inner and outer world of the patient. The issue of choice is also an important one for the therapist to consider. Clearly, as discussed in the previous paragraph in relation to issues of power and control, forensic patients have no choice about their detention. This lack of choice can create feelings of resentment in the patient towards the team of staff involved in their care. Many patients who have progressed from the acute stages 4 Priestly M "Analytical Music Therapy"

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of their illness, realise that to attend group work, activities and especially therapy sessions will encourage the team to conclude that they are working towards becoming well. This is often directed particularly at the doctors whom patients know hold the main responsibility, but can also become an issue in therapy and be directed at the therapist. The 'carrot' that the patients feel is on offer can be many different things, from working towards discharge, being given unescorted leaves or simply being able to take charge of one's own lighter. All these rewards are things for which patients must demonstrate varying degrees of responsibility. A difficulty which many therapists face in this situation is the pressure which may come from the multi-disciplinary team to allow therapy sessions to become part of the reward system in a patients' care programme. Whilst it may encourage patients to attend sessions and see music therapy as an important part of their programme, I feel that the principle of linking sessions in to a reward or parole system is likely to essentially undermine the therapeutic nature of the work. In order for the patient to be helped in some way and for change to occur in the patient during the therapy process there must be a certain amount of personal investment. It is my view that whilst there is a role within psychiatric services for the therapist to actively encourage patients to attend sessions, it must be clear to the patient that it is their choice as to whether or not they attend. The time boundaries within sessions such as lateness or non-attendance can offer the therapist an important means of understanding and interpreting what may be happening within the therapy relationship. This factor must be taken into account when observing the relationship between patient and therapist, as therapists are often asking clients to accept some form of responsibility. Through the nature of therapy, therapist's are also asking patients to constantly make choices and these two factors combined could easily produce strong feelings of resentment towards the therapist. However, the patient needs to be encouraged to express these feelings and it is an important function of therapy that it should give the patient a feeling of being in a space which is able to contain these feelings of resentment towards the team. Estela V Weldon (1998), consultant psychotherapist at the Portman Clinic, describes a key feature in the background of many forensic patients as emotional deprivation, and often also material deprivation. Loth (1994) refers to this when describing a music therapy group run within a medium secure unit. She describes how during the first session the members of the group gathered instruments around them much as deprived children may do if suddenly given a bag of toys, feeling very unsafe and not believing that these wouldn't be taken away from them. Weldon also indentifies key features of the forensic patient as being poor interpersonal skills, lack of self esteem and inability to form healthy relationships. These characteristics may also describe many of the patients we work with who are not treated within forensic services but as this study does not intend to be comparative with other areas of work and conditions of patients, describing the forensic patient is intended to clarify how Music Therapy may help someone with problems such as these. It is also the case that many patients within secure environments do become institutionalised and will try to sabotage attempts at rehabilitation in order to stay within the secure environment. For some the very strong boundaries which are the physical walls and locked doors of the ward, could represent a security which some very damaged patients could have been searching for. This search for security could be expressed as strongly as in their index offence which enabled them to enter secure care. The issues highlighted here as being prominent in work with forensic patients such as those of

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power and control, those of containment and those of freedom and choice are demonstrated in the following case example of Michael, a patient whom I worked with for six months in a fifteen bedded medium secure unit within a district general hospital. Michael is a 48 year old man who is diagnosed as having schizophrenia and has been convicted on a number of occasions of sexual offences. He attended music therapy for a relatively short period of 6 months after which he chose not to attend any further sessions. Michael was one of 4 children and during his early years he is reported as being not very bright but well behaved. He was bullied at school and was socially excluded from his peer group. This bullying continued as he grew older and he was verbally and physically abused by local youths. His father became anxious about his poor academic abilities and began to set him extra work to do at home which Michael came to resent. At this point, aged 14 when he left school he was lonely and had few friends; he was also prone to violent outbursts at home. He worked in unskilled jobs for 15 years from the age of 14 and over the next few years continued to remain isolated. He developed an interest in young girls, and his first conviction, when aged 19, was for indecent exposure. Over the next few years he had various hospital admissions after displaying signs of schizophrenia. He had a number of further convictions for sex offences over the next 20 years. He was convicted of his index offence 4 years ago. He was accused of bringing 2 young girls back to his flat and exposing himself to them trying to get them to touch his genitals. At the time of his admission to the secure ward he was actively psychotic and showed little insight into the effect that his offence could have on his victims. At this point he seemed unable to establish normal adult relationships and remained isolated within the ward. Michael presents as a somewhat moody but generally timid and well dressed man who whilst still finding it difficult to interact with peers on the ward is keen to carry out any jobs or helpful tasks which the nursing staff can give him. When he was referred to me by the nursing staff, the reason for referral was that he had difficulty relating to peers and difficulty forming and maintaining appropriate relationships. When Michael initially attended music therapy he appeared nervous and very anxious as to what he should be doing. He had an interest in music and we were able to use this as a basis for both discussion and improvisation. From the very first session Michael began to use the instruments and appeared to very quickly feel comfortable using the musical medium. He left very little space for discussion between improvisations and I would find myself desperately trying to create breathing spaces between these often very intense bits of music. This pattern of how the sessions ran continued for the majority of the therapy and, unlike many of the other patients whom I see within the ward, most of our work was done within the music. I felt that for Michael words were just too frightening and that music was genuinely a medium through which he could both express himself and hold a dialogue with me. As the relationship developed he was able to express in his music, something of his isolation and the difficulties which he had in forming relationships. Michael's music was extremely expressive and he would often fluctuate between very sad, moving passages and extremely angry passages. I experienced these latter as being very frightening both for me and for him. However, as Michael immersed himself in his expressive music-making, this stirred up many difficult emotions which I feel he had been unable to address previously, and expressing them in a relationship with me proved to be very difficult for him. He had never been able to express himself appropriately to another person and as such our

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relationship seemed to become increasingly difficult for him to tolerate as his music appeared to become more emotional and expressive by the week. This was a very uneasy period as he was becoming more unpredictable and volatile. His music increasingly seemed to contradict the way he related to me when he spoke to me, which was at some points hostile and abusive. One the one hand in the sessions he would engage in incredibly powerful music, whereas if he passed me in the corridors, as would often happen on the ward, then he would either become angry and abusive or polarise towards being overly helpful. On one occasion having told me the previous day outside the session that he was "not getting anything out of it", "it's a waste of space", the next day he passed me in the corridor when I dropped some papers, at which he rushed over to help me, trying to insist that he pick them up. At the time I was unsure why but was aware that I found this experience very disturbing and it was only on reflection with a colleague that I was able to make some links and further understand my countertransference. I felt that whilst in the session I was seen as the person in the position of power and as such was projected into the role of abuser, outside the sessions however, within the ward which was essentially his domain (the therapy room was mine) the roles were reversed and he could fulfil the role of the abused becoming the abuser, he was in the position of power and I was his victim. This was expressed as either verbal aggression (a throwback to his teenage years abused by the local youths) or by being overly helpful (which was perhaps how he had related to his victims by grooming them and enticing them back to his flat in his index offence). This was also expressed in our musical relationship where we constantly seemed to negotiate between us a feeling of control of the music. Michael would often create dramatic pauses within the music, where there was a sense that our music became suspended in mid-air. He would then seem to take great staisfaction in breaking these pauses by suddenly interjecting with loud discordant chords, followed by a gradual move into long passages of descending scales. The sense of control which he gained from this was clearly very powerful and this represents a central part of Michael's personality. Passages of descending scales were a central feature of Michael's music and much of my responses in the music was to either provide a backgroud of chords on to which the scalic passages could be projected, but more often to echo and develop both ascending and descending scales. Within these passages it was possible to detect a melody that was disguised within the scales; this was often very moving and melancholy in character. I felt, however, that Michael had needed to disguise it within the scales, as to have openly played purely a melody would have felt too exposing and this was something about which he clearly held a lot of anxiety. There was a sense of power behind this music which was usually played by Michael on an electric keyboard and by myself on the piano. At times we were able to move towards clear dialogues within the scales; however, at other times when Michael began to find things difficult to cope with, there was a more cathartic but very creative shared improvisation. Ultimately no matter how un-obtrusive and supportive I tried to be, it proved too difficult for Michael to continue engaging in this way and he ended the therapy. I felt that his need for control and the instability caused by his attempts to engage in a therapeutic relationship despite his clear ability to engage in the music, made it important for him to know he had that choice of finishin the work and was left with some control. So we agreed to end the therapy. Although this was a significant rejection for me as a novice therapist, I felt it was important to continue to provide Michael with a positive experience of a relationship by accepting his decision but not rejecting him, as had been the pattern throughout his past. He always appeared a little surprised at first when I would ask how he was or say good morning in the weeks that followed. He fully expected that I would not be able to contain his feelings which he had poured into his music and as such expected to be rejected. Whilst being a difficult experience for him and essentially one that ended prematurely, I felt that he had been able to

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access parts of himself that had remained cut off or dead for many years and he had also been able to experience an emotionally intimate but appropriate adult relationship. The experience of working as a music therapist with schizophrenic patients has been well documented5 as often demonstrating the natureof the illness in the inability to stay with challenging emotions or engage in and then stay with relationships which may challenge the detached, paranoid aspects of the patients internal worlds. I suggest that not only did Michael demonstrate this atypical schizophrenic affect but his nature as a sex offender also demsonstrated an atypical effect of what could be considered the illness of paedophilia. The combination of the two provide a complete detachment from both reality, empathy and one's own emotions. Within our work Michael was able both to express and get in touch with some of his emotions, but the personal hazards which he perhaps unconsciously felt were a risk of engaging in this work ensured that he would cut off just as he was beginning to feel a real sense of his emotions again. In this way Music Therapy was able to clearly demonstrate some of the inherent aspects of Schizophrenia and through this lead to a greater understanding of Michael and how he may be helped to manage his illness. In the next chapter issues relating not only to Music Therapy will be discussed but to the wider arts therapies, specifically art and drama therapy. Some of the issues which both Michael and the therapist faced during his period of Music Therapy will also be illustrated in terms of the other arts therapies.

5 Odell - Miller "Group Improvisaion Therapy: The Experience of One Man With Schizophrenia" in Bruscia Case Studies. 19??

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Chapter 2

Arts therapies in Forensic Psychiatry Whilst focusing this thesis on the relationship between music therapy and the forensic clinical environment, it is also necessary to consider the contributions of the other arts therapies, essentially, art and drama therapy. Many of the key principles highlighted in the previous chapter as being central to music therapy in forensic settings are also likely to be relevant to art and drama therapy. However, there may also be issues specific to each separate discipline which need separate consideration. The aim here is not to explore individual therapists', clients' or institutions' agendas within their forensic settings, but to explore the principal factors governing arts therapies work in this area, and illustrate this with case examples. Whilst clearly, there are links between the arts therapies, each has its own clear and very separate identity. By retaining autonomy within a profession, but looking at the relationship similarities and differences between the professions, a positive balance can be achieved. I feel that each of the arts therapies can offer the others considerable mutual support as well as professional and clinical insight into working, not just in a forensic context but with a whole range of client groups including forensic. However, this is best achieved by each discipline retaining its separate identity and focusing on issues primarily related to its own creative medium. An interesting way of looking at this connection is by considering the theoretical symbolism of psychoanalytic group work, where the client negotiates a compromise with the group of retaining their identity but being able to share and contribute to the group experience and learning. The concept can be paralleled with the relationships between the three arts therapies. It is hoped that this piece of research all three groups of therapists will be able to further consider and gain some insight into their own relationships with their forensic patients and organisations. In this discussion I shall focus on those professions which currently have state registration, music, art and drama therapy, but I also wish to acknowledge the work of other creative arts therapists done within the forensic field i.e. Dance Movement Therapists. Art therapy is the longest established of the arts therapies in the UK. The British Association of Art Therapists was founded in 1964 and currently has around 1000 members. As is the case with music therapy, the definition given of art therapy will have different emphases depending on with the way in which an individual art therapist chooses to work. Art therapy can be described as 'a form of psychotherapy in which the client is encouraged to use creative media to facilitate self-expression and ways of relating to others in addition to or instead of talking'. Teasdale (1997) describes a tradition of individual art therapy work within the prison system. He also describes the majority of any group work undertaken to be fixed term open groups due to the difficulties encountered by staff and patients, because of 'the complex boundaries of containment and disclosure'. He describes how the majority of his patients have had little previous contact with using art for self-expression and that this can be a significant advantage, as it encourages spontaneity in contrast to the often 'controlled and calculated' ways in which patients have planned their crimes or organised their internal worlds. This idea of increased spontaneity through non-familiarity with the medium can also be applied to other creative media. For example, in music therapy I have found that patients who have some past experience of playing music, usually as performance, are usually hampered by this and find it more difficult to engage in expressive improvisation which is not concerned with technical abilities of playing the

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instruments. However I have also found that patients with previous experience of an other art form other than music often have a greater ability to use their creative aspects in improvisation than the majority of forensic patients whose past creative experiences are often very limited. Whilst it is accepted that unfamiliarity could also cause increased anxiety, I suggest that it is precisely the unfamiliar expressive nature of the medium that enables it to be used as an expression of the unconscious. When thinking about this in terms of the forensic patient, for whom one of the reasons they have come into therapy may be to explore their crime, it is in this context that using a creative medium as a form of self-expression may be of particular value. Whilst images, sounds or actions carry with them the added dangers of prompting strong emotional reactions, it is the non-verbal aspect of these media which could become the beginnings or catalyst from which to form a therapeutic relationship and further explore these issues. Teasdale (1997)(page 214) also notes that "A point common to violent criminal behaviour is the dissociation of the perpetrator from the totality of what he or she has left in emotional pieces following the crime." He then reflects on this by describing how the "potentially cathartic act of simply being able to create images" can be used within a group setting to help patients begin to address some of these issues. The task of reparation appears to be central to much of the work described by arts therapists in their respective forensic settings. It is inevitable that the crime will often remain central to therapeutic work, as it is this which has brought the patient into the setting and hence into therapy. Helping patients to accept and understand the destructiveness of their crime and the effect which this has had on both the victims and the perpetrators allows a new way of relating to develop. It becomes possible to begin to form relationships that are not based on unconscious destructive impulses, often stemming from negative feelings of self-worth informed by early childhood experiences. Using a creative medium whether it be art, music or drama can be seen or felt as taking risks, the risks of self-expression. This is in stark contrast to the institutions in which we work - prisons, special hospitals, psychiatric units - where the rules and regulations focus around minimising risks. One of the first pieces of work undertaken within the team when a new patient enters any of these different establishments is a risk assessment. Whilst a therapist would need to be mindful of this assessment and may even be able to contribute she must also be aware of the greater emotional risks the patient is taking in coming to see her and also the risks she herself is taking in accepting the patient for therapy. Klugman (1999) talks of the great sense of loss that many of his patients experience. He describes his task as an art therapist within a special hospital in relation to this loss as to "hold, contain and help transform creatively into a form that is manageable and empowering, allowing for a more mature way of being"(page 33). It is now widely understood that merely locking up someone who has committed an offence is no deterrent against committing further offences; therefore by offering a prisoner an experience of dealing with their sense of loss, their time in prison can become more than a frustrating period of waiting only to continue the cycle of committing further crimes. Laing (1984) describes how many offenders in committing their crime have displayed both 'inventive and ingenious' characteristics. She considers the creative aspects of these traits and suggests that, combined with a desire for change, they would increase suitability for art therapy. The idea that a persons creativity has been mis-directed through negative relationships or experiences into criminal activity provides a base from which a persons creativity can be

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chanelled though art or other creative therapies where a positive relationship can be formed. This can also lead to creating a stronger sense of self and a more established role within society. Laing also discusses the implications in choosing the right space for therapy to take place in. Whichever part of a prison or forensic unit becomes designated as the therapy space will carry with it advantages and disadvantages, both of which must be considered carefully as they will have a substantial impact on the progress of therapy, i.e. choosing a space on the education wing, hospital wing or even chaplaincy area will bring associations with those areas of prison life. The individual arts therapist must make a choice as to how she would like the therapy to be portrayed to the staff and patients, and then attempt to shape it thus. This produces a different dilemma for the therapist working in a prison, where the majority of inmates are not mentally ill, compared to a hospital or psychiatric setting, where patients have some knowledge that they have been deemed mentally ill. Whether or not they accept this diagnosis creates a need for further consideration by the therapist as to how they choose to engage clients in therapy. Both patients and staff may have many pre-conceived ideas and fantasies about arts therapy sessions and their role and potential for change in relation to the patient. To some extent the therapist will with careful consideration be able to inform these ideas, but some will remain as part of the dynamics of the institution and must be explored in such a light. Murphy (1994) describes the environment of the high security prison where she works as an art therapist in the context of Winnicott's model of the parent child relationship. The parent provides the child with both the nourishment and shelter which they need to survive. They create a secure base from which the child can explore and grow creatively; he describes this as 'the holding environment'. All the forensic institutions within which we work provide the patients or inmates with both food and shelter. So in a physical sense they are getting some form of nourishment; however, these environments tend to be harsh and there is often little room for emotional nourishment. The forensic environment is in one sense extremely strong and could provide a very solid containing environment which these patients are often in great need of. However, most forensic institutions become more restricting and suffocating, allowing little if any space for the creative freedom needed for exploration and development of self to take place. I suggest that this is often due to anxieties within the system as a whole and of staff within the institutions as to the potential outcomes of allowing patients more creative and personal freedom with the confinement of the walls. The violent crimes committed can easily create fantasies in staff about the potential for re-enacting them, and being very restrictive provides the staff with a means of coping on a day - to - day basis with their fears and fantasies around this. Winnicott describes the 'good enough mother' as one who can provide a 'facilitating' or 'holding environment' but is not and cannot be perfect. In order for the child to develop a strong sense of true self in relation to the world around, it needs a balanced experience of reality in the mother who sometimes gets things wrong or cannot always be there on demand for the infant. Here a therapist who is symbolically a parent figure can use any 'mistakes' or misjudgements they make as an important part of the therapy process in recreating a positive and 'good enough' relationship with the patient. This is particularly evident in the therapist who tries to satisfy the demands of the patient who in a childlike re-enactment is craving the attention of the therapist. By offering these patients more time with the therapist, this can begin a cycle of acting out behaviour on the part of the therapist in response to the patient's transference which, in the thinking of the object relations school of thought in psychoanalysis, often symbolically represents an insatiable need to gain control of the breast. All therapists make 'mistakes' or mis-judgements with patients and I have found that it is

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often these mis-judgements which produce some of the most fruitful work in therapy, as they tend to produce a strong reaction in both patient and therapist which can be explored in the context of the therapeutic relationship. Can a 'good enough' therapist do some useful work within an overall restrictive environment? And to what extent does this work change because of the environment? Murphy (1994) describes the danger of becoming a mother figure who by providing a sensory, creative environment tries to feed the insatiable appetites of the patients who have few or none of these experiences outside the therapy space. Clearly this is an impossible task and as such could result in 'burn out' on the part of the therapist. Every arts therapist's role within these difficult environments is to recognise the limitations and impossibilities of trying to do too much. They must find a way of working that allows them to build creative relationships with the patients and provide them with the conditions set in order for the patients to be able to explore and grow. On that basis the patients would gain some nourishment from this 'good enough' experience, the therapist would remain able to continue to provide without becoming a symbolic version of the children's nursery rhyme character 'Old Mother Hubbard'. This stark vision of a mother with nothing to feed her child could be symbolic of both the patients' experience in early life which has lead to their current situation, and of the therapist who has tried to give everything to feed all her patients and is left' burnt out' with nothing more to give. All of our patients carry with them deep and painful feelings from their lives before they entered the forensic system. It becomes of paramount importance that the therapist treads carefully when beginning to think about and explore these feelings. The institutions themselves provide little support to help patients contain feelings and issues between therapy sessions, while visits from friends and family are often limited or infrequent. This creates a potential within the patient for acting out what cannot be contained, and although this is potentially the same issue in any therapy setting and not unique to forensics, what is unique is the likelihood of violent or destructive acting out through lack of support and of untimely intervention on the part of the therapist. It is equally as important not to ignore these feelings and collude with the patient's defences which could give a sense of 'these things don't matter' and reinforces for the patient an image of false self. By communicating with a patient through non-verbal creative media such as art, drama or music, it is possible to by-pass some of the verbal or cognitive rationalisations that many people develop as a means of denying, explaining or transferring blame about their index offence. Working purely verbally with a patient who presented with these often common views of their offence would be extremely difficult unless some degree of responsibility was accepted. The creative media allow a space to 'play' and re-discover creative impulses that have been suppressed by the regimented, clinical institutions and thus create the beginnings of a shared experience which in turn becomes the foundations of a therapeutic relationship. Cronin (1994) describes the importance for the therapist working on her own allowing herself to 'accept the prison setting for what it is'. I feel that this applies to any creative therapist working in a secure environment as the same difficulties of incarceration, punishment, harshness of environment are evident in many different secure settings. This acceptance of the environment by the therapist is vital in order to be able to help patients accept the reality of their situation. If the

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therapist herself has not accepted the situation, then there is a great danger of splitting within staff of the institution. The patient may also receive some confusing mixed messages which could be perceived as parents quarrelling i.e. the therapist and the rest of the staff, which the therapist must accept she is part of, become the symbolic parents for the patient. Clearly an environment which is created by 'quarrelling parents' is not conducive to therapy as it does not provide the safe, containing, nurturing space which therapy aims to be. Edwards (1994) discusses the differences in her role as art teacher and art therapist within the prison system. The issues she raises appear to be unique to art therapy. There is a long history of art education within prisons and for many years art teachers have been employed. She describes her initial anxieties as a newly qualified therapist about what inmates may perceive as confusion if she were to combine the two roles. However, she was able to create her own identity and way of working from the basis of her training. She describes how she responded to patients' requests for her to teach them by passing on her skills and knowledge in order to give patients greater confidence in their abilities as artists and hence in themselves. Also passing on skills to patients enables them to develop greater scope and technique for using the creation of an image as a way of relating and expressing emotions. As music therapists we are often asked "Can you teach me to play the guitar?" "I'd love to be able to play the piano". Whether or not we decide to offer our patients teaching as part of therapy is an issue for each individual therapist, institution and patient; there is no right or wrong answer. However, it is an inevitable question which all music therapists must be ready to address. As described in the previous chapter many forensic patients exist in a world of very concrete thought, and many have demonstrated this in acting out behaviour in the form of their index offence. It is for so many of these patients that remaining fixed in a very concrete way of thinking becomes both a way of life and of survival within the penal or secure hospital system. Should a music therapist decide that it would be beneficial to include some element of teaching within the therapy she could easily be criticised as colluding with the patients 'stuck' and defensive way of forming relationships. However, I have often found that on rare occasions when I have decided to use pre-composed music and helped a patient to learn how to play it, the experience has produced an intense feeling of connection often not normally attained in a very guarded and wary therapeutic relationship. Although in once sense it may by colluding with defensive, strategies I feel that it can also be a useful grounding point giving both patient and therapist a safe way in which to begin to truly share in something together. The positive transference that I have felt in these instances suggests that it has given patients a sense of hope and a glimpse of a vision of their potential capabilities, not necessarily musical ones. In my own work I remain wary of becoming too involved in the technicalities of teaching and becoming diverted through the patients' unconscious reactions away from the therapy path. Also, as a relatively newly qualified therapist I am constantly involved in re-defining my thoughts, ideas and ways of working and consider that it is safer and more beneficial for my patients for me to retain a more traditional stance whilst I explore, to find my version of what I feel is my model of music therapy. Clearly there will always be limits in terms of how much knowledge and skills it is possible to pass on to patients; it will not be possible to teach any of the instruments to little more than basic standard. This is perhaps where art therapy differs from music therapy, in that the benefits of learning a new brush technique to use in art therapy are much more immediate and may take only a few sessions to achieve, whereas extensive practice would be required to gain most musical skills. It seems that the role of the music therapist is to create a balance and

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anticipate when it would perhaps be useful to respond to a client's request for teaching. This is not to say that a therapist would disregard any therapeutic aims and concentrate on teaching ones. By creating a safe place within which to explore engaging in playing of pre-composed music, which might involve some suggestion or teaching to the client, this could create a strong beginning from which the therapeutic relationship may develop and the need for this nature of dynamic can be further explored. However, there is also the risk that through the dynamic of the therapist responding to a client's wishes and anxiety by taking on a more structured role, this could create a precedent for the therapy to remain stuck in its early developmental phase, due to the inhibiting structures imposed. Odell Miller in Bruscia (1991) describes her experience of this in group therapy with psychiatric patients: "My theory is that if I had become the teacher or taken control, this could have kept the group in its paralysed beginning stage rather than allowing the group to begin its own process."(page 421) I suggest that the application of these techniques in individual therapy may have different consequences from applications in groups. Within a group patients have the opportunity to re-create family dynamics and explore their responses to different social situations; the use of pre-composed music could divert the group from its task in a way that it would not be possible to recover. Within the group the therapist could symbolically represent a controlling parent or one who was unable to listen or attend to their child's needs. However, within individual therapy work I have come to view the use of pre-composed music as a valuable tool to keep within the therapy room and rather than display permanently where there is the danger of it becoming the focal point in the room. The aim has been simply to gain confidence and a sense of often much - needed grounding in these difficult interactions with patients from the knowledge that it is there to be used along with many other therapeutic techniques. As arts therapists working in a secure environment we must all develop our own defence mechanisms and ways of coping with the intense sense of fear that exists within our work place. This can be a fear of past violence, a fear of potential violence, a fear of reactions to that violence, a fear of the unknown both in patients and staff. It is essential as a therapist to find a way to confront your own fears about working in a forensic environment and acknowledge feeling threatened. By working in the here and now as art, music or drama therapists, having acknowledged our fears we present ourselves within sessions as both open and vulnerable. Karban (1994) describes "Remaining vulnerable and open in the presence of potential violence and fear is a powerful therapeutic tool." (P143) I aim to treat patients as if they have not committed a crime, treat them as equally as someone who does not have a forensic past; however, this is always necessarily informed by the fact both therapist and patient are aware that both know of the patient's index offence. As arts therapists we must always respect patients' defence mechanisms and recognise that in all cases they have been put in place for a good reason. When working with forensic patients this becomes paramount, as not to respect a defensive strategy or to move too fast in therapy could present a real acting out or repeat of offence. This must be acknowledged as part of the fear of working as creative therapists with forensic patients. The work of drama therapists in forensic settings is perhaps better documented than that of music therapy and the notion of prison theatre has sparked nation-wide interest within custodial settings. Dramatherapy can be described as using theatre and drama in the therapeutic context to enable people to access and explore their inner world in a way in which they can relate to others. Improvisation, games, role play or protective techniques (such as those using masks and puppets) may all be used to provide contained therapy. Through exploration within the therapy, the roles

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that individuals take on in life can be played out and reflected upon. Cox (1992) describes the importance of metaphor within psychotherapy and dramatherapy at Broadmoor hospital. He introduces us to metaphor within forensic settings by the use of the example "I made a killing", which in a non-offender situation could relate to a business transaction but in a forensic setting clearly could have very different meaning. He discusses the importance of the choice of words and interpretation of metaphor being crucial to patient, therapist and supervisor. He explores the use of the common phrase "if looks could kill"; in an actively psychotic patient this could be felt to be literally true as they may have looked threateningly at someone in the past who since died. In a patient suffering from disturbed thought patterns, this idea can become embedded in their way of thinking and dramatically alter their perceptions of the power which they hold over others. In this case particularly the power of looking at someone in a situation where patients believe that, should they want to, then it would be possible to kill someone by a 'look'. When thinking about the use of metaphor in therapy it is vital to try to understand the possible significance of a metaphor and the relationship between the metaphor and the thought patterns of the patient. In this particular example it becomes crucial that the relationship between the metaphor and its various possible meanings are thought about carefully before any interpretation is made or any thoughts formulated about the progress of therapy. There are often fears within forensic institutions about the use of any form of therapy which is action based, as all the arts therapies are. The fear here is that the patient/offender who has demonstrated in the action of his violent crime a lack of self-control, would be unable to restrain himself from committing further violent acts when confronted with an active medium that encourages self-expression. I feel that this is particularly the case with dramatherapy where patients have the possibility to re-enact difficult situations in their lives, some of which may be their index offence. The idea of a patient re-enacting his offence arouses massive anxiety within an institution, I feel that one of the main reasons for this could be what the staff perceive as the lack of boundaries. The therapist will have his own therapeutic and personal boundaries to rely on to contain anxiety within the session; he will have put great thought into establishing these, and as such they provide the foundations of the therapeutic relationship. The only boundaries which many institutions have are the repressive, physical ones such as locked doors and walls etc. Staff know from experience that these hold no guarantee of eradicating violence. Asking a patient within a psychodrama session to explore role reversal and act out his offence clearly does pose a risk and the anxiety of the staff is well founded. However, the therapist must judge for herself whether or not to use this very powerful technique, and, if used in the right instance, it can prove to be a true momentary catalyst for change and release of previously long suppressed emotions. Roine (1992) in 'Shakespeare comes to Broadmoor' describes two examples of this type of work where she clearly has judged the right moment to embark upon what in psychoanalytic terms could be compared to a 'direct interpretation' (Barnes 1999) In the following example she describes her work within a secure hospital with a young man convicted of a brutal manslaughter. "I used the strongest weapon in psychodrama, namely, role reversal. I asked him to lie down on the floor, to close his eyes and go into the body of the man he had killed. This strange therapy session did not last very long. Moreno's potent way of using surplus reality worked, catching repressed feelings of guilt, anger, grief and longing for security and love. An intriguing aspect of his history was revealed during the course of the therapy. Namely, that as a boy of five, he had

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been abused by his father on exactly the same spot as the killing had taken place many years later."(p203) "Another patient, a woman of 38, refered for psychodrama, had been in the habit of stabbing people in the street. These actions always happened at random and, one night, she killed a man. In this case role reversal also proved most effective. One day we managed to enact the scene where the man was stabbed to death. By this time she had started to show emotions, having previously worked on her relationship with her father. She had been an incest victim, and had lived part of her life as a prostitute. We felt that she presented a very difficult case for rehabilitation. But there was something unique about her personality and we did not want to give up. The day she role reversed with the dead man, she cried. She told us that she had read the newspapers at the time of the trial and knew that her victim had recently been married and that his wife was expecting a baby. She could not remember the last time she had cried."(p203) Through the applied use of dramatherapy patients are able to work through both views of the self and how they form relationships and also work as has been demonstrated above on re-experiencing specific difficult events in a persons life. It also allows the psychotic or severely disturbed offender to experience dramatic reality through which they can enter into another role and explore the boundaries between the drama and everyday reality, this in turn could help them to gain a greater sense of their own relationship to everyday life. All the existing literature on art, drama and music therapy within forensic settings, cites the importance of caution in embarking on work with dangerous and violent patients. Above all, to work as an arts therapist in a forensic setting it is essential to try to maintain an understanding of the work within the institution and as far as possible to nurture a safe and supportive environment. Many of us do work in isolation and there are many problematic features in the relationship between therapist and forensic environment. These will be explored further in the next chapter. However, the work of all creative and expressive therapists can certainly bring about change in a patient and as part of the whole picture of a patient's treatment programme, can become a stimulating, invigorating and, creative way in which patients can be helped to re-establish a connection with their own and a wider reality. Cox describes his view that offering patients an experience of dramatherapy concurrently with analytic psychotherapy can offer patients the most useful experience that is conducive to change. Many patients need to learn that 'explosive action' in response to emotional impulses is not the only way of dealing with feelings. For these patients there is often a confusion and/or split between their inner and outer emotional worlds. Having an action- based therapy from which to explore this and also a more interpretative, analytic therapy to explore the reactions can lead to a more positive re-enactment in future therapy and day-to-day settings. It is my view that the principle of and reasons behind using an action- based therapy can be applied to all arts therapies. It is a matter of individual patient profiles as to which particular arts therapy would be the most appropriate. Cox (1992) in 'Shakespeare Comes to Broadmoor' provides us with a clear vision of how he conceives the similarities between the arts therapies and is able to relate this specifically to forensic settings. He quotes a passage from Bruscia (1990) :"Music Therapy may serve as primary or adjunctive treatment modality, depending on the client's responsiveness to music, and

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other kinds of services also available." Bruscia (1989) describes this in great detail in terms of four clear levels of clinical practice; "Auxiliary level: all functional uses of music for non - therapeutic but related purposes." "Augmentative level: any practice in which music or music therapy is used to enhance the efforts of other treatment modalities, and to make supportive contributions to the client's overall treatment programme." "Intensive level: any practice in which music therapy takes a central and independent role in addressing priority goals in the client's treatment plan, and as a result, induces significant changes in the client's current situation." "Primary level: any practice in which music therapy takes an indispensable or singular role in meeting the main therapeutic needs of the client, and as a result, induces pervasive changes in the clients life." Cox then interprets Bruscia's statement on four levels of clinical practice by saying that the above statements could be equally applied to art therapy, drama therapy or dance movement therapy. He suggests that, by considering the contribution that any arts therapist makes to the life of a forensic patient as being on these four levels, we are able to gain further insight into what it is that we as arts therapists are able to provide within a secure setting. At a most basic level arts therapists are able to provide a reality - based experience of the possible warmth of human relationships. Whilst this may appear a simple statement, it is often difficult to describe to colleagues the way in which the therapist may use their clinical judgement to provide this nurturing and warmth without exposing the chaotic and disturbed inner worlds of many forensic patients and there by causing an external reaction. In my own case studies, described in chapter 5 I will use Bruscia's four levels of practice as a way of exploring the different interventions I have been able to make. However, in order to further consider the forensic environment the next chapter will outline what services and settings encompass the term 'forensic'.

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Chapter 3

An understanding of Forensic Services In order to consider the relationships that evolve in the work of a music therapist, both clinical relationships and relationships with the institution itself, it is important to have some understanding of the forensic system and provision available for offenders. By acquainting oneself with the different services available and an understanding the different channels by which one could gain access to these services it becomes possible to 'set the scene' for further exploration of work as a music therapist in this often challenging and difficult area. There are two principal systems which house offenders. The prison system and psychiatric hospital units each run independently from the other and despite the fact that there is often some overlap in the type of patients in each service, the two need separate consideration. In 1997 HM prison service in association with the arts therapies advisory group to the Standing Committee on Arts in Prisons published a document of 'Guidelines for Arts Therapists Working in Prisons'. This document was designed to help therapists negotiate working conditions suitable for therapeutic work to take place and also to help Prison services understand the role and potential value of the arts therpaies within Prisons. At the time of publication there were 132 penal establishments in England and Wales and the inmate population was 62,000 (4.3% of whom were women). This figure has continued to rise. Very few prisons empoly arts therapists, I am currently only aware of 5 within the country and only one of these has offered Music Therapy. Almost all inmates enter prison through police arrest and subsequent court conviction and sentencing; for many the first time in prison is just the beginning of a long series of repeated offences and repeated prison sentences. Adult male prisoners are categorised according to their level of security risk and are detained in a prison suitable for this level of risk. Whilst prison authorities can try to take into consideration the location of friends and family when assigning a prisoner to a prison there is often limited choice due to lack of suitable resources or lack of space within local prisons. There are currently four categories of security risk: A, B, C and D. Category A prisoners have been deemed to pose the highest risk either because of the seriousness of their offence or their potential for escape. Category A prisoners are housed in separate prisons known as dispersal prisons, of which there are 6 in England and Wales. Categories B, C and D are the lower levels of risk and are all housed in local prisons. Many arts therapists in prisons are employed to work with some of the most vulnerable inmates. They are usually classified as rule 43 inmates and are housed on separate wings within local or training prisons. Many rule 43 inmates have requested the status of vulnerable prisoner and this has been granted by the governor; this is often due to the likelihood of abuse by other inmates, sometimes because of the nature of the index offence or on account of debts owed. Rule 43 can also be imposed by a governor if he/she feel that an inmate's current behaviour is unacceptable to such an extent that they cannot remain in their current position within the prison. Local prisons contain often transient populations as they receive prisoners straight from court both those on remand, who are awaiting sentencing and those for whom a suitable prison has not yet been found. They also house inmates who have been given relatively short sentences. Training prisons house both category B and category C prisoners, but can be essentially separate institutions i.e. a category B prison functioning idependently from an adjacent category C prison. Open prisons house the lowest risk inmates; there are no locked gates and inmates often become involved in community

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work during their time at the prison. Young offender institutions house both male and female inmates under age 21 and cover all levels of required security and potential risk. Remand centres are designed specifically to house those who have not been allowed bail during a trial or who are awaiting sentencing. Women's prisons usually house all categories of prisoners. However, as their are many fewer places available, it is more difficult to take account of the geographical location of friends and family. Most women's prisons now also house mother and baby units. Clearly there are some prisons within England and Wales who provide a variety of therapies for the inmates including arts therapies. Some also provide addiction treatment centres or specific personality disorder programmes. Only Grendon Underwood prison is specifically designed as a therapy unit and is run along the lines of a therapeutic community. Arts therapists in prisons often have to face some of the same difficulties as therapists in other forensic institutions, such as lack of appropriate working space or equipment, lack of understanding of therapy by staff, possible negative counter-influences from staff, and inappropriate referrals. However, the specific difficulties of working within an environment whose foundation philosophy is one of punishment, in total contrast to the aims of every arts therapist, presents an even greater challenge to those who choose to work in this situation. It is paramount that an arts therapist working within the penal system also works with the penal system. To work 'alone' within such an oppressive regime would create ample opportunities for sabotage, acting out and splitting. The alternative to prison for those who have committed an offence is the specialist psychiatric services offered by nation-wide NHS trusts to cater for those offenders who have either learning disabilities, some form of mental illness or both. It is the NHS setting which is the focus for this work.The emphasis within these institutions tends to be on treatment and rehabilitation rather than the punishment philosophies of the penal system. There are of number of secure units in existence for offenders with learning disabilities. Most of these are either small units which form part of the mental health services of regional NHS trusts or form separate wings in the old Victorian-style learning disability hospitals. There are also several such hospitals which are currently run privately. By far the most common offences committed by adults with learning disabilities are sex offences and many units are specifically designed to run sex offender treatment programmes. It is in the context of these programmes that many music therapists in this very specific area work. The procedure by which offenders gain access to these services is very similar to the procedure for those with some form of mental illness and as such they will be considered together. Firstly it may be helpful to clarify some terms commonly used within mental health services and defined in the Mental Health Act of 1983. The term mental disorder is defined as having four specific categories: mental illness, mental impairment, severe mental impairment and psychopathic disorder. The term mental impairment is used to describe patients with some form of learning disability. There are three levels of secure services available within forensic mental health services.(See Appendix A) the highest level being Special hospitals which admit the most disturbed patients or

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those who present the greatest risk to society. There are three Special hospitals operating in the UK: Ashworth, Rampton and Broadmoor. Each functions as an NHS trust in its own right. The next level of service is the Regional Secure Units of which there are three in the Northwest Area, providing a medium level of security. Patients detained within these units still present a need for secure care but not the extreme degree of high security provided by the special hospitals. The level at which I have gained my experience as a music therapist is in the High Dependency Units which provide a level of security below regional secure units. There are currently seven of these units in the Northwest Area and they are designed to provide care for patients with severe mental illness and long term challenging behaviour. Not all High Dependency Units will take forensic patients; however, within East Cheshire NHS Trust it was felt there was a need within the forensic services to provide care for patients at a medium secure level who were still under restraint by the Home Office in relation to their index offence. (Appendix B). The role of the unit includes diversion from court of mentally disordered offenders from the Criminal Justice System and also providing psychiatric court assessments. (Appendix C) Patients will usually gain access to these services by a diversion from court. The forensic team will provide an assessment of the offender and recommend whether they should be remanded to hospital for assessment or treatment if they are thought to suffer from some form of mental illness or mental disorder. The core forensic team consists of a consultant psychiatrist, an approved social worker and a forensic community psychiatric nurse. Patients who were convicted and given a prison sentence may also be referred if they become mentally ill during their time in prison. Patients will often be transferred from higher level security units in the area, with which there will be close liaison, as the patients need for security diminishes as they progress through the system. Only the three special hospitals are determined as 'long stay' units. The two other categories of lower level secure units are focused around rehabilitation. This rehabilitation can have a different outcome in each individual patient's case. Whilst some patients may progress through the system with a gradually decreasing need for security, the long term goal may be a return to community, living either in a mental health hostel or in some cases local council accommodation. For other patients with enduring mental health problems some form of secure care may always be necessary and a permanent unit will have to be sought. One of the most difficult categories of patient rehabilitation is for those patients who have been transferred from prison and, when deemed to be well enough, should return there to carry out any remaining time of their sentence. This presents the arts therapist with many different problems, as patients often feel that they have nothing to gain from becoming well again. If they are seen by the multi-disciplinary team to be actively improving and engaging in therapeutic activities, then they are more likely to be returned to prison sooner. Whilst a patient could have a desire to improve and become well, the reality of their return to prison could become a catalyst for undermining any therapeutic work. Appendix C: Mental Health and Diversion From Custody, published by MIND(1992) illustrates the different services which an offender may encounter, and the way in which they may progress through the system. The current government policy is clearly defined In the introduction to the accompanying booklet to the Home Office Circular 12/95 "Mentally Disordered offenders: Inter Agency Working",

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which supplements HOC 66/90. "It is the government's policy that those suffering form mental disorder who require specialist medical treatment or social support should receive it from the health and social services. Those who are suspected of committing criminal offences should be prosecuted where this is necessary in the public interest. In deciding whether a person should be charged, it is essential that account be taken of the circumstances and gravity of the offence and what is know of the person's previous contacts with the criminal justice system and the psychiatric and social services. Where proceedings are instituted, access to treatment should not be delayed or prevented and the needs of mentally disordered people should be met, for example, by the use of bail with condition of residence at a hostel or hospital, by remanding to hospital, by transfer from prison to hospital or by the making of a hospital of guardianship order. However, mentally disordered people should not be drawn into the criminal justice system unnecessarily, for example in the hope of securing treatment. Detention in prison is likely to be damaging to the mental health of a mentally disordered person, and the prison service is not equipped to provide treatment equivalent to that available in hospital." Within this context of the forensic environment theoretical concepts developed in the field of psychoanalysis and psychotherapy will be discussed in the next chapter with specific reference to violence and schozophrenia.

Chapter 4 The contribution of psychoanalytic theories of violence and schizophrenia

In an attempt to draw together the main issues discussed in previous chapters it is important to understand some of the theories of both violence and severe mental illness and consider the impact they may have on our work. The most common diagnosis encountered within the forensic setting is that of Schizophrenia. In the diagnostic manual DSMIV (date?) Schizophrenia is defined as exhibiting two or more of the following symptoms for a significant period of time during one month: • Delusions • Hallucinations • Disorganised Speech • Grossly Disorganised or Catatonic Behaviour • Negative Symptoms (i.e. Apathy, Social Withdrawal) However some psychotherapists have also developed dynamic criteria for the diagnosis of schizophrenia. Benedetti (1987) describes these as:

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• "Disturbed ego activity" ("the ego's basic incapacity to relate to the world and make it its own" or "to integrate itself")

• "Vulnerability or loss of ego boundary" ("where self and world can no longer be distinguished")

• "Multiple splitting"("ego fragmentation") The schizophrenic patient projects his chaotic feelings on to both staff and other patients as a way of ridding himself of these disturbing feelings i.e. splitting them off. This clearly will have a large impact on the dynamics of a locked unit where a high proportion of patients are diagnosed with schizophrenia. Perhaps it is for this reason that a standard feature of any long stay ward, whether forensic or otherwise, is either a high staff turnover or precisely the opposite, institutionalisation of both staff and patients. In NHS psychiatry today it is widely accepted that across the country there are bed shortages which sometimes may lead to premature discharge. However in my experience of the forensic setting, such are the risks associated with premature discharge that consultants have a tendency to remain, if anything, overly cautious. For a consultant who carries ultimate responsibility for a forensic patient, the anxiety surrounding discharge of the patient must be enormous. Lotz (1996) describes the interaction of three different psychological areas in the schizophrenic patient on a psychiatric ward: "the interactional and psychodynamic history of the patient, his current psychological functioning, and his interaction with the ward staff". One widely held group analytic view is that we all re-create our family relationships in our different work, social, recreational and, of course, therapy groups. In the case of the schizophrenic patient who is an in-patient, it is reasonable to assume that his or her family relationships will be re-created or played out within the immediate environment of the ward. Schizophrenic patients often come from disorganised and chaotic backgrounds or very strict, rigid families thus adding to the difficulties of managing an environment where the majority of the patients are perhaps re-enacting these types of dysfunctional relationship. In addition to the typical characteristics of the schizophrenic patient, a forensic psychiatric patient will also bring to the ward his added experience of family relationships. It is very common for forensic patients to have suffered from deprivation or abuse as children, so these factors add an even more complicated dynamic to the environment of the locked ward. How does Music Therapy fit into this environment? Each member of staff will be part of each patient's unconscious re-enactment of his family relationships, and being aware of this the Music Therapist can gain insight both into individual patients and into the dynamics of the staff team. As Music Therapists we are particularly susceptible to dynamics re-enacted from childhood, as the physical experience of improvising and encountering musical instruments often reminds our patients of their childhoods. I have worked with many patients on psychiatric wards whose first impressions of the Music Therapy setting are a reminiscence of experiences in music lessons or of participating in music groups as a child. This direct link to childhood at the beginning of therapy can be a useful tool for enabling patients to think further about their experiences; but when, as has been acknowledged, much of their experience relates to abuse and deprivation, it is of paramount importance to be aware of the impact that thinking back to these events could have. This is not only crucial for the patients themselves, but for the team as a whole in the form of projections from the patient. Lotz (ibid.) (page112) also describes the principal ways in which a schizophrenic interacts with his environment, highlighting the concept of projective identification as often being the schizophrenic's elected means of communication. In summarising he states

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"one might say that the ability of the schizophrenic to disturb meaningful, planned

activities on the ward, and his propensity to make the ward a projection screen for his paranoid fantasy, can be very straining. The primary gain will be to unburden himself of his inner chaos, his splitting, and his ambivalence; the secondary will be to disturb others who are making demands on him, and furthermore to satisfy his narcissistic and oral demands for attention and contact."

Clearly this strong degree of splitting and projection will cause stress for the staff at whom the projections are directed; in terms of feelings of chaos, paranoia and painful emotions. Lotz goes on to discuss how staff will often unconsciously feel "uncomfortable and powerless" and consciously feel a desire to control and also care for the patient. It must also be questioned why the staff choose to work in such a difficult and controlling environment, as, for many, part of their own agenda may also include splitting as a defence against intolerable thoughts or feelings. I suggest the combination of these two different agendas is likely to inflame chaotic thoughts and emotions but also strengthen desires within the schizophrenic to withdraw from contact in an effort to manage his fear of contact with others. The feelings of chaos are acted out by the staff as well as by patients. Teams can become directionless and disorganised; meetings are often disrupted by patients, and in this way the chaos becomes a shared experience within the ward as a whole, as the staff reflect the chaos back on to the patients. So how as a therapist working in this environment can we best manage our work? The concept of splitting can be most easily recognised and at some level all staff become part of this effect. The therapist, in working behind a closed door, in a specially designated room has in a sense engendered a split between themselves and the team. It is of great importance that the therapist communicates her ideas and thoughts about a patient with the team, and in turns listens to the ideas of others. The danger is that it becomes very easy for therapists to become 'passive' members of the team, in that they are seen to sit down and 'just talk' whilst nurses could be considered 'active' members who actually do practical work with the patients. The negative effect of this is that should a nurse want to sit down and talk with one of her patients in order to support and fulfil her caring role, she is danger of being branded as 'passive' by her colleagues and accused of not 'pulling her weight'. It is possible that Music Therapy could be seen as more active than the traditional role of the verbal based therapist, because in the act of playing the instruments, patients are both seen and heard to be practically 'doing' something. "Respect for the patient's subjective world is what characterises the therapeutic situation, and it is this which distinguishes it from other relationships in the hospital" Bell (1997)(p10). Bell also writes about the anxiety which arises within institutions which deal with severely disturbed patients, describing the inability of the staff to sustain 'not knowing' (i.e. not having all the answers relating to a patient's behaviour) and the fear of missing details which may later be seen as important. This can develop into a perceived need for many different meetings, in which different aspects of the patient's care are fed back to the team over and over again, which leaves little space for creative thinking. The patients would then receive the message from the institution that staff were unable to tolerate the patients anxiety. This drive for total knowledge and a type of 'black and white' thinking are in fact typical of many disturbed

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psychotic patients and in this way the patient has projected this aspect of themselves on to the institution. When a patient becomes a container for the projections of others it often leads to violence. The claustrophobic environment of the locked unit is only likely to increase the potential for this, and, as already indicated, the nature of the history and illness of the forensic population make projection and splitting a central part of both the individual and group dynamics. Through keeping alive the possibility for understanding the patient's behaviour, this provides the container for these projections and feelings that makes therapeutic work possible. In her book 'From Pain to Violence' psychotherapist Felicity DeZulueta (1993) discusses the priority which she gives to theories of attachment in understanding violent behaviour. Attachment theory describes the innate need in all of us to form attachments. This is usually considered in the first instance in life, in terms of the child forming an attachment to the main care giver (usually mother). We progress through our life developing many other attachments' but it is our early experiences of attachment during our formative years that inform how we will relate and form attachments to others throughout our lifetime. For the majority of us these early attachments will provide us with what we need as children and will form a healthy basis for our relationships. Whilst these attachments are by no means perfect they can be thought of in Winnicottian terms as 'good enough'. That is, we may have our basic needs such as food, care and shelter met, but there may not always be an emotional connection which matches the desires of the child. However if the basic qualities are missing and the child experiences its first attachment as deprivation or neglect, or if attachments are formed at an early stage that are then suddenly broken i.e. by a parent dying or not having contact for whatever reason with the child for a prolonged period, then this can be linked to violent behaviour. This is illustrated in the final chapter of this thesis in the case example of Leena, who suffered violent outbursts and had experienced early separation from her natural mother, followed by an inability to attune both on the part of Leena herself and her adoptive mother. Bowlby (1984) described three stages which an infant would go through in response to his attachment being threatened or withdrawn. Firstly the infant would protest when having not received a restorative response; the infant would then begin to despair, before finally becoming detached. Infants who have reached this stage of detachment in the relationship to their main care giver show no response when the care giver leaves and then show an avoidant when the care giver returns. Children of parents who, instead of comforting a frightened child either represent that which is frightening or reject the child by not offering comfort, are then likely to detach and 'cut off' from their emotions of fear or anger in order to be able to stay with the care giver. This can also be considered in terms of object relations theory as the creation of an internal split, as the child develops his relationship with the parent in terms of good and bad object. Children who have shown these avoidant responses also tend to exhibit low self esteem and unprovoked hostile reactions. This in turn affects their peer relationships which could have been an added source of support in developing relationships, particularly on reaching adolescence, but which instead remain negative. This can be summarised by stating that children who have experienced abuse, neglect or trauma, particularly in relation to their early attachments, often develop violent or abusive behaviour in adult life. In further attempting to understand violence DeZulueta (1993) puts particular emphasis on psychological trauma (Post Traumatic Stress Disorder) as a trigger for violence. This occurs in the form of unconscious re-enactment of the traumatic event through becoming the abuser or the abused/victim i.e. in the case of battered wives there is an unconscious expectation that this is how attachments/relationships work. Violent offenders are locked up in prisons as punishment

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and are often seen as evil, despite the fact that the research of psychotherapists such as DeZulueta (1993) and Gilligan (1997) have shown clear links between the violence and psychological damage. Through the practice of psychotherapy the patient is encouraged to recognise his pattern of repeating past traumatic events or experiences of relationships. Then, by working through the emotional issues surrounding these patterns through his own relationship with the therapist, it is hoped that a resolution of his internal conflicts may be possible. In Music Therapy the same aims of resolution of internal conflicts may also be true but the use of the musical medium to express the patients anger, fear, loss of their previous attachments also becomes central to the work. For many patients with mental illness to try and put these emotions into words may simply be too frightening, and, whilst also being fearful of putting one's feelings into music, it allows for a creative return to a playful and childlike way of forming positive attachments with the therapist. When considering the forensic institution, violence is a stark fact that it is difficult to evade and is never far from the surface. The units themselves are often violent places to be, both in terms of violent attacks from patients on persons or property and in terms of controlling responses from staff. (This was discussed in more detail in chapter 1). Most patients admitted to forensic units have committed some form of violent crime and, in looking at the history of these patients, most have been exposed to violence and suffered as victims of violence from an early age. Gilligan (1997)(page?) writes "Our responses to violence are as complex as the subject itself is. Many respond to violence with a mixture of horror, revulsion, outrage, fascination, arousal and valorisation. If we have had some personal experience of violence, we may find it too disturbing to speak of or think about. Or our personal experience may draw us deep into research, study, and action against violence. Whatever our response each of us has a working theory of violence - conscious or unconscious - that steers our attitudes, behaviours and judgements." Writing about some of the patients with whom he has worked in a maximum security American prison, Gilligan observed that the salient feature in all of his violent patients was one of 'feeling dead inside'. This feeling of deadness which the prisoners describe is perhaps in fact linked to Bowlby's description of detachment. Many offenders describe a lack of feeling or emotion when they committed their crime. Interestingly, Gilligan notes that, in his interviews with prisoners, the more violent the crime the greater degree of detachment or lack of feelings. By considering broken attachments and trauma as roots of violence, this gives us an understanding of how it is possible to experience the anger and the need for detachment. What Gilligan shows is how this is enacted in the crime itself. He describes murderers experiencing the unbearable feelings of seeing others alive when one feels 'dead inside' and a longing for relief in physical death, either their own or that of others, from the 'empty' life which the murderer is leading. This extreme experience of still being left "feeling nothing" even after having killed someone is perhaps what motivates many violent offenders to become self-injurious, "the only way to feel alive, since they cannot feel anything emotionally, is to feel physical pain" (page?). The death or murder of a person's sense of self to such extreme levels must be related to and considered in terms of the horrendous abuse that our violent patients have often suffered during childhood. Violence communicates a lack of love and if the self (or soul) is starved of love then it dies.

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When reading some of Gilligan's graphic accounts of the lives of his patients and indeed the traumatic and brutal histories of some of my own forensic patients, it is easy to begin to question what therapy could offer these people. Is it possible to bring about any sense of reparation, integration, or feeling to their lives? I suggest that in the work we do with violent offenders it is of vital importance to have the good working conditions and support, although in reality this is not often the case. Clinical supervision is vital if we are to be able to hold and contain the feelings which our patients bring to therapy. It is often only through supervision that we are able to clarify our minds from these projections sufficiently to be able to begin to process some of the material. However, patients are also extremely sensitive, albeit for the most part unconsciously, to the relationships which we as therapists have with the rest of the institution, and this dynamic through the matrix6 will unavoidably affect the therapeutic relationship. I believe that Music Therapy has something unique to offer where access to psychological intervention is often limited and the quantity of long term therapy available and the support structures (within the institution) necessary to begin to undo some of the damage are lacking. For a severely damaged patient for whom it may be 'too much' to begin to look in detail at his past experiences, Music Therapy can offer many things that may give the patient a sense of being alive again. This was detailed in chapter 1 and can be seen through the case examples in chapter 4. Through a return to a more playful/ creative time (which was often missing or limited during childhood) it is possible for patient and therapist to develop trusting relationships which allow space for self expression, creativity and listening. When engaging in Music Therapy work and indeed any therapeutic work with a patient, it is important to consider the patient's limitations at this point in time, i.e. what degree of internal disturbance will they be able to tolerate? What are the risks of offering different degrees of therapy such as interpretative or supportive? However, an equally important consideration is that of what the institution is able to tolerate. Of course, the two questions are also inextricably linked. The support of the entire unit or individual institution is crucial in working interpretatively with fragile patients, particularly those in the forensic setting who in the nature of their violent crime have already proved their capability of acting out their internal conflicts or cut-off emotions. This is not to say that it is not possible to work therapeutically unless one has a wholly supportive team and ideal working environment; it does however highlight the relationship between the therapist, patient and institution. There could be times during therapy when patients may need additional support from the institution and the therapist must be aware whether this is available or not. It is also likely, however, that the patient has a very good sense of the likely response of an institution in terms of aggression or of a need for additional support particularly for those patients who have been resident some time at the particular unit. This is often the case in forensic settings. Forensic institutions themselves appear to exist in an anxious state trying to balance control and containment. The dynamics within a group of staff on a forensic unit and within the group of patients whose care they are responsible for, are all linked in the group matrix of the institution which also includes managers who may not be often present on the unit, but have ultimate financial or

6 A 'Matrix' is a group analytic term used to describe the network of communications between all members and conductors of groups. The nature of the Matrix is one which allows members to feel 'held' but also one which members have to negotiate coming to terms with through realising that they're inextricably a part of the matrix. See appendix D for illustration.

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clinical responsibility. For example, a manager who has difficulty managing budgets and becomes increasingly anxious about this is likely to have an impact on both staff and patients, albeit an unconscious group dynamic process. Also vice versa, a particularly anxious group of patients on the ward may create waves of anxiety throughout administration departments with whom they have little direct contact. Patients may respond to this dynamic between control and containment in many different ways. For example, a patient who is prone to self-harm may in fact be expressing a desire to retain a sense of control of the self, possibly in response to the dynamic of the controlling/ containing institution. Likewise a patient who is prone to fire-setting may well be trying to express a desire to gain a sense of control over the institution rather than simply the self. Clearly both of these acts are acts of rage, no matter how calculated they may appear. Either arson or self-harm will have a powerful effect on the institution. As the body has been cut so that the related emotional scars are now clearly visible and can be seen, the wider body of the institution may also feel attacked and cut. Arson may feel to an institution like a threat to the whole organisation as it is a threat to the structure of part of a building. This may inspire a bigger response than that of self-injury and managers or clinicians may start to look at changing policies or tightening security as a response to the threat. For a patient who has reached the detached stage in his attachments as discussed earlier in this chapter, I suggest that the act of arson, whilst violent, is typical of someone with detached or avoidant personality traits, as the fire itself is left to do the damage for the patient; there is no prolonged personally active involvement. In a sense the patient has used displacement as the defensive mechanism which enabled him to act out. Both arson and self-harm are examples of acting out behaviour which can be described as an expression of an unconscious wish or fantasy in order to relieve psychic tension. One of the most difficult dynamics that forensic institutions face is that of institutionalisation, as this can be especially damaging for patients and staff alike. Institutionalisation can be understood as only relating to people's role i.e. Doctor, Music Therapist, Nurse, Patient, and losing sight of the person that fulfils that role. This in turn creates an atmosphere of depersonalisation which encourages in already damaged patients a fear of extremes of attachment and abandonment. This also creates in staff a fear of intrusion. Again this gives us an illustration of the interconnectedness of the group matrix that is the forensic institution. I suggest that the relationship which the Music Therapist has with the institution within which she works is one of the most important factors governing the outcome of therapy for her patients. Clearly there are ideals which would strengthen this relationship, such as good clinical and managerial support, a basic understanding of dynamic processes by other members of the staff team, adequate physical space within which to work, and a healthy respect between team members for each other's profession. As already stated, these are ideals and are rarely all available to Arts Therapists working currently within the NHS. Working in what are often grossly under-funded services, each profession must be able to compromise their own ideals in order to continue the service. However, Arts Therapists must remain vigilant in terms of ensuring that the basic conditions which they require in order to practice as competent therapists are available. There is much good work to be done within units that do not sustain all of these ideals, but without good support both patient and therapist are in danger of limiting the potential for change to occur. Patients need support and often encouragement from staff who are willing to listen and are sensitive to their needs. Nursing staff need support to manage the difficulties of caring for extremely damaged patients day and night. Medical staff need support to manage the responsibility they carry for the patient's general well-being. And Arts Therapists/

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Psychotherapists/ Psychologists need their own support structures which enable them to manage the challenges of working with, and often being left with, some of the difficult, painful and often highly disturbing emotional material which our patients in forensic settings bring to their sessions. The diagnostic criteria for schizophrenia mentioned earlier conveyed a sense of having lost the ability to distinguish between fantasy and reality or between self and others. Gilligan suggests that the key to understanding violence is understanding what is being acted out through the violence. I would also add that we should attempt to understand how this acting out of fantasy or rage has become distorted through dysfunctional ego development. He sees the key to violence as being in the experience of shame, "...shame and humiliation, which when they become overwhelming because a person has no basis for self-respect, can be intolerable, and so devastating as to bring about the collapse of self-esteem and thus the death of self." Gilligan (1997)(page?) This shows us perhaps how the ego may have developed so as finally to reach the point made earlier by many violent offenders that they felt "dead inside". Whilst shame is the underlying cause of violent crime, the purpose in the crime is to gain a sense of what is precisely the opposite of shame: pride. For offenders who feel they have been humiliated and shamed in life and therefore have little self-esteem, it is easy to understand the satisfaction gained through being in a very powerful position of control that is a result of violence. Gilligan quotes one of his patients as saying "You wouldn't believe how much respect you get when you have a gun pointed at some dude's face" Gilligan (1997)(page?) It was Freud, the founder of psychoanalysis, who first traced the origins of shame to a child's perception that he is not loved and it is at that point where we must begin if we are to start to try to develop understanding of violent crimes committed throughout society today. Hobson (1985) (p135) writes "In shame, judge and offender are the same 'me', in self-disgust I am split from a part of myself which is alienated as an object - maybe as a thing". Both Gilligan's and Freud's theories of ego development lead us back to the same place in a child's early development. The love, care, hate or rage that he receives from his adult care givers will form and shape his experience of the world and appreciating that could give us as a modern society much greater understanding of the violent population who have committed crimes and are now incarcerated or the potential violence within all of us. This in turn can only assist us in providing the most appropriate type of therapeutic treatment to our patients. In the follwing final chapter the theroetical concepts described throughout the thesis will be illustrated by case examples from my own work. All patients mentioned within this chapter including the case example in chapter one have given their permission for details of their work to be used anonymously and as such names and initials have been changed.

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Chapter 5

Case Studies and the Clinical Context In order to explore further some of the principles of practice outlined in previous chapters, I shall draw on some of my own experiences as a Music Therapist working in forensic psychiatry, by reference to case examples. By this means I hope to exemplify the theories discussed in this research through association with individual patients. I shall also refer to the writings of a variety of arts therapists working in the forensic field as well as research from psychoanalysis and the theories that psychoanalysts have developed about violence, offenders and trauma. All of the cases were located on one secure ward where I work part time and I will begin by providing a short description of the unit in order to clarify the context. The unit is a fifteen-bed medium secure unit which was moved to the site of a general hospital five years ago following the closure of the local area psychiatric hospital. It provides care for ten men and three women between the ages of 18 and 25. The main function of the unit is to provide assessments and where necessary treatment for those patients sent straight from court; it also takes patients who are being transferred down from other hospitals of a higher level of security because they no longer need such strict confinement. Music Therapy forms an integral part of these assessments both in terms of providing a recommendation of whether longer term music therapy treatment might be appropriate and also in providing the team with an additional facet of the patients general mental health. Other functions of the unit include transfers from prison of patients who require more intensive psychiatric intervention than the prison can provide, and also occasional transfers from acute psychiatric wards where patients are likely to abscond. Because of this varied role of the unit, it's patients suffer from a wide variety of symptoms such as acute psychosis or schizophrenia, long term clinical depression or mood disorder. For longer stay patients who are not sent back to court long term music therapy treatment of up to 2 years can be offered where appropriate. For more disturbed patients music therapy sessions are provided on less regular basis and vary in regularity depending on the patient's state of health. The work I do on the ward takes a very different form with each individual patient. Patients on the ward have a wide range of mental illness and varying degrees of illness. As part of my role in the unit I have the freedom to allocate different regularity and duration of therapy as appropriate for each individual patient. For Leena, a patient whom I will discuss in the second case study in this chapter I was able to arrange regular weekly sessions over a long period of time. However for other patients who suffer from chronic psychosis and extreme delusions, the therapist must be able to be flexible and adapt her work to the individual. For example, one particular patient, whom I will call "D", I do not offer regular sessions; she is unable to concentrate for more than a few minutes and most of her conversations revolve around delusions and hallucinations. However I do not consider her to be unsuitable for Music Therapy; it is my role to meet her where she is and adapt the treatment that In order to make it accesible for "D". If I have a space during the day I will approach her and invite her to come to the Music Therapy room; she will also sometimes approach me and ask to go to the Music Therapy room. Whilst each session lasts no more than 10 minutes, during that time we are able to improvise together, sometimes in a completely chaotic style and at other times with more coherence. We also sometimes use songs which "D" spontaneously sings or snippets of piano music which she remembers. Working in this way provides little opportunity for 'working through' or for thinking about 'process' but from this

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experience "D" is able to get a sense of being listened to through the music where we are both using the same language. This is an important difference from her everyday experience of relating to people where she has cut herself off from any meaningful conversation or relationship with anyone. Although on one level "D" is able to develop some relationships on the ward, she is unable to talk in way that would make sense to the listener for very long and is certainly unable to discuss or express her feelings verbally. It then becomes much easier for her to express her feelings physically and often violently. Whilst there is little written within Music Therapy literature about working in this way, there are short term models of Music Therapy such as Bruscia's Auxiliary level of clinical practice as descibed in chapter 2. This type of model is most commonly used in psychiatry on the acute admission wards where patients are often highly disturbed but may come into hospital for only a brief stay before they return to the community. The second case is that of Leena. Leena was a 37 year old woman who was admitted to the unit for treatment with a possible diagnosis of schizophrenia. She was of mixed race origin and had been given up for adoption at birth by her natural mother. Leena saw her colour as being the main reason why her natural mother may have given her up. She was adopted by a couple whom she referred to as mum and dad and with whom she was in regular contact. She had a brother who was also adopted; and when Leena was 18 he was killed in a car crash that was suspected suicide. Leena did well at school, gaining three A levels, after which she went to college to study Art. During her time at college her health began to deteriorate; she suffered from extreme mood swings and her behaviour became unpredictable and hostile. After dropping out of college Leena's mother encouraged her to pursue a modelling career, Leena amassed a large portfolio which she then destroyed, referring to it as being "no good". Leena began to neglect herself and ran up large debts . Her relationship with her parents deteriorated and she left home to go to London with a man with whom she was having a relationship. During this time Leena began to abuse alcohol and also became pregnant. She had an abortion after which she returned home to her parents. Leena is noted as having described herself at this point as feeling "vulnerable to exploitation and lonely". She began phoning her GP day and night asking for medication and took 2 overdoses; following this she had several admissions to the local psychiatric hospital. Whilst at the hospital she was also given a diagnosis of suspected MS. She became aggressive and would throw furniture and urinate around the ward. This escalated until she assaulted a member of staff, after which she was sent to court and from there transferred to the unit where I work. During the first few months of her stay she was extremely unsettled and suffered from acute auditory, visual and sensory hallucinations whereby she felt her skin was changing colour or that her arm or limbs were missing. She was constantly troubled by hearing groups of voices, at which she would often become angry as they "would not leave me alone". She often responded to this in violent outbursts by throwing furniture, cups or radios. After a period of 6 months on medication she became more stable and I was able to offer her an assessment. She found it difficult to mix with other patients, whom she felt intimidated by. Many patients often exploited her for money or cigarettes. She was aware of this and blamed herself as she has described herself as a "bad person". She found it difficult to accept that her health had improved a little and constantly complained of "feeling terrible". She presented as being dependent on staff and when not in her room constantly sought out reassurance. Leena's mother seemed to be a strong figure but was often cold and distant towards Leena. Leena

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felt that her mother made little effort to understand her illness and the relationship was often dominated by arguments. Leena's father remained very much in the background and whilst she had no direct conflict with him she felt she could not rely on him. On admission to the unit both parents had told Leena that they did not want her to return home after discharge. When Leena initially came to Music Therapy for an assessment she found it incredibly difficult to focus on anything and it was difficult for her even to stay in the therapy room. She would leave the room anything up to six times within a one hour session and this became a predominant feature of our work together. From the therapist's view in the counter-transference at this point it was very difficult to create a sense of containment and holding within the session as individual sessions could easily become fragmented with Leena's need to frequently leave. However, I was reassured by the fact that although she often left she also always came back and I felt this showed a commitment in Leena to work with me. After the assessment I was uncertain as to whether I felt Leena was well enough to be able to attend regular weekly sessions and I offered her a regular slot when she felt able to begin. To my surprise she stated that she did feel well enough and would like to start straight away. One of the clearest aspects of Leena's presentation was her very low self esteem accompanied by considerable feelings of guilt. She would often comment that "I'm not worth helping" or "I don't deserve this". Leena would often push the boundaries of the therapy and test me by saying that she didn't want to play anything today and would then leave; after a few minutes she would then come back, sit down, and begin to play. During these early sessions she left little space for me to respond to her either musically or verbally and in the counter-transference I often felt like a passenger on a journey over which I had no control. This may have meant that at this stage it was just too frightening for her to allow me to share her emotional space and hence by keeping absolute control of the session Leena could protect her fragile inner world. Leena was still actively psychotic during this first phase of our work and it seemed that the most important things which I could offer her at this stage was simply to be there to try to contain her fears, anxieties and emotions. I would experience powerful and overwhelming feelings of confusion and chaos whilst working with Leena and I interpreted this as a projection of the intolerable feelings which she was experiencing either as the root of or the expression of her psychosis. It was during these sessions that the importance of supervision became most active as I and my supervisor would attempt to unravel the complex and painful feelings which were around in the session. My supervisor was both a Music Therapist and a trained Analytic Psychotherapist. I felt that having both these skills available within supervision enabled me to understand the role that the music played within the session and also develop greater insight into understanding Leena's patterns of behaviour and experience of the world. Using the counter-transference as the main tool within this process helped further my understanding of Leena, and this knowledge in turn enabled me to provide the stronger sense of holding, warmth and containment which she so desperately craved but felt she was not entitled to. Gradually over time my constant presence at a regular time each week, despite the fact that she was still leaving the session a couple of times during the hour and despite the chaotic emotions she was showing me, seemed to reassure her that I was not going to leave or reject her as she had unconsciously expected. This was the necessary difficult groundwork before we could develop a sense of trust within the therapeutic relationship. During the first few months of the therapy we would usually begin each session with an

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improvisation where I would play the piano and Leena would play the large wooden xylophone or sometimes the large drums. These improvisations were often fast and furious and musically were a challenge to me as she would set up complicated rhythms which I regularly found hard to follow, feeling that we were always one step apart from each other. Whilst we were able to create a feeling of connection in the music during these improvisations, it would usually disintegrate as we gradually became out of sync with each other due to the complexity of the underlying rhythms. There was a sense that brief moments of connection were all that were possible at that stage; anything further would have felt too intrusive to Leena and it seemed important that I remained aware of not pushing the music forward but of continuing to meet Leena where she was in the music and in her development. After our improvisations we would usually talk for a while; often this would focus around how "terrible" she was feeling or how much "the voices" had been troubling her, but it was also a time where sometimes she was able to think just a little about the music we had played. She would comment on technical aspects of how it sounded but also on me and her fantasies about my judgements of our music. The sessions were still dominated by Leena coming and going; however she was gradually able to bring more of her feelings or more of her whole self to the sessions. This came through not only in the music but also in the warmth of our growing relationship. In terms of her illness, she had become more settled, her medication had been stabilised and this seemed an important factor in helping the music become more fluid. I feel strongly from my own experiences as a Music Therapist that medication has an important role to play when working with this often very disturbed client group. It is only when someone's psychotic symptoms can be managed (usually though medication) that some of the roots of the difficulties can be addressed. Gradually Leena began to explore more instruments and eventually settled on playing the electric keyboard. In making this move to the keyboard there was a sense that we became more equals within the relationship. There were feelings of a shift in our relationship together as we moved into a new, more reflective phase of work. We left behind complex rhythms and the music took on a new style which incorporated both more space and more diversity. After six months she was now able to stay for thirty minutes and occasionally for a full hour. Leena was clearly a creative person having previous experience of being an artist. I felt that this creativity helped the work in music therapy but I also felt that had Art Therapy been available it would not have been the best medium within which to work, as Leena's previous experience would have left her with pre-conceptions and fixed ideas about any images she might have created. Odell-Miller7 has discussed the importance of ensuring that clients receive therapy from the most appropriate medium for them. By using a completely new medium but nevertheless a creative one, Leena was able to work in a flexible way, creating her images of music as the work progressed and allowing greater scope for personal growth and change to occur. The most striking feature of this next phase of work was the way in which Leena began to reflect on the new music in a different way. There was a sense that something had been 'freed up'. She started to used spontaneous, creative visualisations and imagery as a way of telling me about her music and hence her inner world. Continuing to use the electric keyboard as her main instrument,

7 Odell Miller H "Investigating the value of Music Therapy in Psychiatry: Developing research tools arising from clinical perspectives" in Wigram T and De Backer J "Clinical Applications of Music Therapy in Psychiatry" 1999 Jessica Kingsley Publishers.

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Leena began to describe the music we would play in terms of scenes, clearly using her very visual mind stemming from her inclinations as an artist. After one improvisation she described the music as being a quiet, empty garden. This was the foundation, the background canvas on to which the rest of our work would be expressed. Each improvisation which we engaged in from this point on added or changed something about the original scene of a quiet, empty garden. In a sense Leena began to use the metaphor of a garden to work through her difficulties with relationships. She described a young girl in the garden who was caring for her father in a cottage, I felt that this girl was perhaps a child part of Leena which she was able to identify with, being able to sustain a caring relationship within which she held an important role of caring for her father. This also perhaps represented a natural desire to be a carer rather than be cared for by hospital institutions as she had been for some time. At this point she also began to describe "the sun breaking through the clouds" in the garden, perhaps suggesting a change in her mental state and in her ability to think with more clarity but also perhaps a change in the quality of our relationship as we developed a warm friendship with the context of therapy. Leena developed a musical 'theme tune' for the garden which re-curred most weeks; even in weeks where Leena did not feel able or inclined to play this theme, she would always refer to the garden and we were able to reflect metaphorically on what was happening within it. I was aware that because of Leena's previous psychotic hallucinations and delusions, there was a possibility of her experiencing the garden as part of her reality or that in some way it was linked to a hallucinatory experience. However, I did not experience it as such and there was no suggestion within the counter-transference or within Leena's general presentation that this was linked with her illness. In this we can see that Leena had developed the ability to work symbolically which is an important part of any interpretive psychotherapeutic work. When we were coming up to a three week break, through reference to the garden Leena was clearly able to use this metaphor as a way of expressing her anxieties about the break. She described how the young girl in the garden had become lost. I interpreted this as her anxiety that she would become lost if I did not return after the break which was her unconscious expectation. Also there was a reality element to the feelings of loss, as for a short time she would not have our weekly time together. This fear of loss was confirmed on my return from the break as she seemed genuinely surprised to see me, having fully expected me to abandon her as her birth mother had done. During the break I had arranged for her to be able to use the Music Therapy room as a quiet place to go whilst I was away. It seemed important that she had something concrete to hold on to in order for the work to continue to progress, as she had still only recently emerged from her psychotic episode. For patients whose inner world is so unstable that something has broken down within them and is then expressed in the form of the onset of psychosis, I feel it is important sometimes to use concrete objects or material as a means of reinforcing a message which you are trying to communicate to the patient as a therapist. In this case that message was some sense of continuity that just because I was physically not there did not mean that everything we had experienced together was lost. After the break Leena reported that she had used it but said that "it hadn't been the same", I felt that this had helped her to realise what was important to her about therapy and this in turn was able to move us on into the final phase of the work. She continued again to use creative visualisations and we returned to the garden using the same musical theme which she had initiated. It seemed important that we spent some weeks setting the scene and re-aquainting ourselves with the garden until it seemed a safe and secure enough place

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for us to visit each week, as we did from this point on and in a sense the garden became the embodiment and focus of therapy. The garden which had initially been a quiet and empty place gradually began to fill with life and Leena would describe new sections of music as a stream, squirrels, butterflies, birds and flowers. I felt that this projection of animals into the garden was a parallel with the concept of projection8 used in psychotherapy, where the therapist is used as a blank screen on to which the patient is able to project difficult feelings or parts of themselves that are hard to acknowledge. Over the weeks Leena gradually added more elements, such as badgers, rabbits and deer. She would often direct me to sustain the music of the garden or the stream so that she could then add the animals or projections. There was a sense that garden, which had initially been full of bare trees had come to life; there seemed to be a creation of more space both in her descriptions of the garden and in the music which inspired the imagery. I also felt that on some level Leena herself was the garden, as she too seemed to come to life as she became wholly involved in this process and hence in the therapeutic relationship. As we continued to work in this way I felt concerned that perhaps the garden was too idyllic, and that there was the potential for Leena to use the garden as a medium for escapism rather than working through. I tried to suggest that there might be something missing. At first she claimed that, no, there was nothing, but after some thought she suggested that perhaps there should be some wind. In this way the darker side of Leena's feelings came in the form of the elements. This seemed much more realistic of Leena's life up to this point, which had been full of difficult and painful experiences. She was able to create the music for the wind using the ocean drum which provided more volatile, unpredictable music. I felt that Leena was able to use the garden as a safe space within which she could explore her own creativity in the context of a therapeutic relationship with me. After 12 months on the ward Leena had made enough progress to make the possibility of discharge feasible and we were able to use her final month's stay to work towards an ending. We continued to use the metaphor of the "garden" but in this later context the garden seemed able to help contain all her fears and anxieties about moving on. Whilst we discussed these fears verbally the containing aspect of the music was central to the process. A principal feature throughout all the different interpretations that Leena made of a garden was that she was unable to finish them and we were unable to bring them to a natural end. All the improvisations were cut off by Leena. The inability to create or sustain endings within the music left me wondering how she would manage the ending not only of the therapy but also when the time came to leave the ward. Leena was also now able to begin to make links herself between what was happening in the music and how she felt or responded in other situations. When we talked about being unable to finish improvisations Leena spontaneously commented that she was also unable to finish many other things in her life such as knitting or her painting. Together we were then able to consider that her different relationships often seem to have cut off or ended prematurely. Although we weren't able to thoroughly work through issues about ending and leaving things in the middle, no matter how difficult this ending was for her, Leena was able to stay with her anxiety and continue therapy until she left the ward. The time restrictions and Leena's recently fragile state made it inappropriate to look further into these issues at this point without risk of undoing what until this point had been good progress. In our final session she wanted to try to create an ending for the music of the garden. However we were unable to bring it to a musical close. Leena, in this final moment, showed just how much progress she had made by connecting this difficulty in ending 8 Brown D & Pedder J, "Introduction to Psychotherapy", Routledge, London, 1991.

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the garden with the fact that she was reluctant and sad to end therapy. It could also be considered that I was part of the garden and if the garden had ended then I would also end. At the time it simply felt very important that it was all right to leave the garden unfinished; we did not have to close it. During the final session we listened back to the tape which we had been adding to each week and made a copy so that we could each have one. This seemed an important symbol of our relationship which she would be able to take with her. For Leena, who only a year before had been so psychotic, the concrete object of the tape allowed things to feel more solid and safe during a time of transition which put her under great emotional stress. Within our final session Leena also talked about the new house to which she was being discharged. She explained she had looked around and been introduced to the staff and residents, but also said "There is a lady therapist there, so there's someone I can talk to, someone to replace you with". This could be interpreted as a need to carry on, as denial of the loss of our relationship would have had painful resonance with Leena's life experience of loss ie. that of her birth parents and also of her brother. However, I also felt that in this way she was able to acknowledge that our time together had been a valuable experience for her, and that I was worth replacing, which for Leena, who had such very low self esteem, was a big step in her return to health. Having gained confidence drawn from a positive experience of a relationship helped her to deal with a stressful situation rather than collapsing inwards or defending herself against the world in her psychosis. I would equate this level of working with Bruscia's 'intensive level' of clinical practice where Music Therapy took on a central role as part of Leena's treatment programme in facilitating change and recovery form psychosis. In adapting to each individual patient I also sometimes work through regular sessions but on a short term basis. A young man whom I shall call "A.B" had shown little interest in music therapy, but as he, too, prepared to be discharged he approached me saying that he would like to write a song. After explaining a little about Music Therapy I agreed to see him weekly for six sessions during which time we would think further about his song. He was reluctant to engage in improvisation and the work focused on his song. He would often arrive clutching pieces of paper with ideas for lyrics scribbled on them. He also had ideas for melodies which he would sing and I would play back on the piano. In this way the work was very much a two-way process which we engaged in together. I made musical and verbal suggestions to enable the song to take shape, but it was always A.B's ideas and feelings which the short term therapy process around this song was able to facilitate. Our sessions took the form of A.B and I discussing the words for the text of the song based on ideas he would bring with him. My input into this was to guide the rhythm of the words in order for it to make musical sense as a final product towards which we were aiming. The basic text and intention behind it, however, remaind A.B's. He would begin to sing lines from the song and I would then play the melodies back to him on the piano. When we had created a melody that he was content with, I then began to suggest chords which could accompany the song. There arose from this a clear indication both of the limitations of short term therapy and of A.B's inability to emotionally connect with or express some of his more painful feelings. I felt the text of the song to be a deeply painful reflection on A.B's experience of the world and of his destructive image of himself. This can clearly be seen in the text used for the chorus of the song "Only time will tell, livin' it ain't so swell. Don't know where I'm coming from. Maybe it's a place in hell". I suggested chord structures which I felt reflected the essentially sad, lonely and painful emotions which A.B had expressed in the song; however, A.B rejected these sounds saying that

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he absoloutely did not want it to sound sad. This seemed to me to represent a clear internal split within A.B between his emotional experience and his cognitive processes - he could not combine thinking and feeling. For A.B to allow himself to experience the pain in the words that he had written about his life may have been too frightening. What would he do once he had acknowledged these issues? This was a very short term therapy in which it was simply not appropriate to begin to look at the reasons for the split between the feeling behind the words and the feeling behind the music. So I modified the chord structure to one that remained simple but modulated between the key chords of Aminor and Cmajor and Jazz style 7ths to give the Music a less bare sound and lighten the mood of the song in a way which A.B was happy with. As I played the chords he would try to describe the sound that he wanted and I would attempt to play this back to him on the piano; eventually we arrived at a point that I felt worked musically and A.B felt gave the song the emotional qualities he desired. Clearly this style of short term therapy set a very different dynamic between therapist and patient to that of the previous case example. The interpretation of a transference relationship was not possible in such a short term piece of work and for this reason, in order to utilise the limited time available, I feel it was appropriate for the therapist to take on a more pro-active role within the session, allowing herself to be seen as the musical 'expert' and working with that. The use of the structured form of a song seemed to be not only a motivating factor in attending therapy but also a safe way in which in which A.B was able to think further about his own emotions.

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Conclusion

In drawing together the principles of Music Therapy and Arts Therapies practice, with the complex dynamics associated with forensic patients and the environments in which they are detained, I hope I have been able to convey some of the key features that influence and embody the relationship between the two. The very nature of Music Therapy work denotes that we as therapists are there to empathise and respond to our clients in order to facilitate change that would bring about an improved quality of life and relationships, in the forensic setting this brings two principal challenges; Firstly how to begin to understand and empathise with the violent crimes which some of our forensic patients have committed, secondly how to negotiate a way of working within the forensic environment. In fact one of the conclusions I would like to draw from this research is that first of these two principles, namely empathy and understanding of violence, is not possible without the support needed from the environment, namely the second principle. The two are inextricably linked and challenging patients come hand-in-hand with challenging environments. However, in order to work effectively as a psychodynamically informed therapist, the relationship which you as the therapist have with the environment and teams within which you work is one of the biggest single influences on the outcome of work with individual or groups of patients. Through considering some of the issues faced by the other arts therapies in forensic settings and drawing on psychoanalytic theory relevant to this area of work, I hope I have been able to demonstrate the way in which arts therapists function within this environment. I also hope that I have been able to give some indication of what I feel are pre-conditions necessary in order for the therapist to be able to function and indeed survive in what are often fundamentally non-therapeutic environments.

To conclude I would like to reflect on my own experience of working in a forensic unit. The unit was an unpredictable and often volatile place. It was predominantly unsupported therapeutically/emotionally and was deeply institutionalised. Whilst changes were taking place, this was a painfully slow process for a unit that had built up defensive support structures based on control and containment as a way of managing the huge anxiety that often surrounds forensic patients. These defensive mechanisms were a means of survival for both staff and patients, but ultimately without the emotional support necessary to try and further understand these defences the unit became 'stuck' in the way both staff and patients related to each other. This was also influenced and perhaps re-inforced by wider institutional structures. Through engaging in this research alongside regular psychotherapy supervision I was able to begin to understand not only the way the unit was functioning but more importantly how I was functioning within the matrix of the unit. This allowed me to recognise my own emotional coping mechanisms that were operating in the face of the violent histories of my patients and the difficult dynamics of the ward environment. This research has informed all aspects of my practice, not only that which takes place with forensic patients. However, it has also enabled me to recognise the basic conditions which I require for myself as a Music Therpist from the places within which I work, in order to function and work creatively in a way that is going to be most beneficial to my patients.

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Guidelines for Arts Therapists Working in Prisons, HM Prison Service, 1997. Service Specification for North West Adult Forensic Mental Health Services, NWRHA, 1998. Unpublished documents available from East Cheshire NHS Trust: 1) Multi-Agency Working in East Cheshire to Access Health and Social Rescources for Mentally Disordered Offenders. 2) Service Specification For NorthWest Adult Forensic Mental Health Services. 3) Annual Report For The East Cheshire NHS Trust/ East Cheshire Social Services: Criminal Justice Liason Scheme.