Bridget Doak, Ph.D, MT-BC, has 25 years clinical experience in music therapy and has been an adjunct instructor of music therapy at Augsburg College for 14 years. This AMTA.Pro Symposium focuses on her experience providing music therapy for adolescents in crisis who are clients in an inpatient mental health program located in a large general hospital.

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Music Therapy with Adolescents in Crisis

in a General Hospital’s  Short-Term Inpatient Mental Health Unit

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Bridget Doak, PhD, MT-BC

AMTA.Pro Symposium

I work for Fairview Behavioral Services, in a mental health program located in a very large general hospital that is owned by Fairview Health Systems, one of the leading health care providers in Minnesota. Fairview Behavioral Services provides mental health and chemical dependency programs for a wide variety of clients from age five and up in both inpatient and outpatient settings. This podcast is an informal discussion about my experiences working as a music therapist for teens in crisis, ages 13 to 18 years, admitted to the inpatient mental health program. In addition to highlighting some case examples, the discussion provides an overview of the clinical process involved in working with adolescents in this setting – admission criteria, assessment, treatment planning, and music therapy interventions.

Philosophy and theoretical orientation of music therapy

The unit in which I work is located in Fairview’s University of Minnesota Medical Center, near downtown Minneapolis. Three separate hospitals consolidated in the Fairview system, and are currently going through name changes. Currently, we are also considered part of the Amplatz Children’s Hospital -which is being built in our former parking lot.  Fairview’s mission is to provide world-class medical care within the framework of patient and family centered care – a common philosophy in health care at this point in time. Patient and family-centered care comes from a humanistic approach that believes in x  supporting and collaborating with the unique needs of each individual to optimize health outcomes.

My role as a music therapist is to remove obstacles and to provide the right kind of supportive environment for the adolescent to heal. This includes motivating the adolescent to participate in his/her own treatment, being transparent about the treatment plan, goals, and expected outcomes, soliciting suggestions from the adolescent and collaborating with him/her on treatment interventions, and monitoring my own responses and reactions.

Our program is designed to be a short-term (3-7 days) assessment and stabilization unit, although we do have adolescents who are sometimes with us for months due to medical complications and discharge issues. Adolescent patients come to the hospital in many different ways. Some are brought by parents, others by police group homes, and still others from a therapist’s office or doctor’s clinic. They go through the emergency department and come to our unit if they meet admission criteria.

Admission Criteria

Adolescents (ages 13-18) are admitted to inpatient psychiatric units because they meet one of two primary admission criteria: (1) the teen is suicidal with serious suicidal attempt or threat to self, or (2) the teen is aggressive or out of control and considered at risk to hurt themselves or others. Many adolescent patients also have substance abuse and other treatment issues. If substance abuse issues are co-occurring with mental health issues, the adolescent will be placed on the inpatient mental health unit for stabilization of mental health concerns and then transferred to an inpatient substance abuse program/dual diagnosis program as needed.

Assessment Process

All adolescents in the unit where I work automatically receive music therapy as a regular part of the treatment program. I meet individually with each adolescent prior to music therapy group to determine their musical background, music preferences, interest in treatment, developmental level and social skills, ability to identify and express feelings and to manage stress. A few adolescents may not be appropriate for group and will then be seen for individual sessions. Otherwise the adolescents will participate in daily music therapy groups to work on their treatment goals.

Treatment goals and therapeutic process

Inpatient music therapy with adolescents requires a focus on the admitting criteria, with an emphasis on safety. Treatment goals are individualized for each patient and may include one or more of the following goals, among others: to identify and express feelings, to develop relaxation/stress management skills, to improve coping skills, and to develop insight.

The therapeutic process for adolescents admitted to the inpatient psychiatric unit involves these key steps:

(1) assessing the problem with salient features and potential causes for the illness;

(2) reducing the symptoms related to admission,

(3) helping the patient practice healthier coping skills, and

(4) helping the patient prepare for discharge.

Patients are discharged when they are no longer actively suicidal, out of control, or aggressive and the behavior is stabilized. Each adolescent must also have a plan for treatment/care for after discharge.

Music therapy interventions

The primary goal of music therapy is to develop a therapeutic relationship. Music is an outstanding way to do that. The music therapy techniques I use come from a variety of sources are based on the initial and ongoing assessment of each patient’s interests and needs. Others factors considered when selecting music therapy interventions include acceptance or resistance to relationship with the therapist as well as interactions with or isolation from peers. Some specific music therapy interventions I use in my work in teen inpatient psych include:

• drum improvisation/circles
• improvisation on acoustic guitar, electric guitar, piano, etc.
• relaxation/stress management sessions
• drawing to music
• song discussion- selection of music for themes
• song writing
• music listening with adolescents identifying issues and selecting music
• movement/dance with close monitoring and supervision

Effects of Trauma

Many of the adolescents we see have suffered from some sort of trauma. This includes adolescents who meet the criteria for post-traumatic stress disorder as well as those who don’t meet that diagnostic criteria because they have suffered multiple traumas rather than one single event. Trauma rewires the brain. It is important in my work to remember that the adolescents I see may be in a high state of stress (flight/fight/freeze) and need help to calm. In addition, if they have a lot of trauma, their baseline level for stress is high and they will react much more quickly to stressful events. Furthermore, typical adolescent brains are still developing and their ability to problem solve and to think logically lags behind their emotional reactions and impulses. This is even more challenging for adolescents who suffer from mental illness. They often misperceive facial expression and may assume, for example, an adult is angry if their brow is furrowed just because they are thinking about something.

Trust and the therapeutic relationship

Adolescents often do not trust adults. However, music is often very important to adolescents. This makes music therapy ideal for connecting with teenagers and establishing a therapeutic relationship. I have been able to make a connection with adolescents just by offering them a wide selection of music that includes some of the music they like. The music opens a door. They are often surprised that I have some of their favorite music and they begin to feel more relaxed and comfortable. They do complain that the music is edited because we do not provide music that has explicit or violent lyrics. However, they usually accept the explanation that we also don’t show R rated movies on the unit and we are using the same standard. This is due to our belief that when people are in crisis, too much stimulation, especially violence, is not helpful. They can listen to whatever they choose outside the hospital, but we are trying to provide a healing environment for everyone.

Music therapy session structure

Many adolescents say they are not interested in music therapy because they think it will be like their music class at school. I reassure them that it is different. Adolescents are often uncomfortable singing or making music in front of their peers. It takes time for them to be comfortable making music together. Adolescent girls are typically more open to singing (eg. Karaoke) and dancing than boys. We start wherever their comfort level is. Often that means everyone is listening to music and relaxing. Many times I will have groups where everyone is on headphones. Some may be listening to music, some may be playing keyboard, and some may be playing electric guitar (all on headphones).

Case example of a skilled musician expressing emotions

Some teenagers are excellent musicians but they may not be comfortable playing in front of their peers. I had one teenage boy who was a very skilled musician but who was depressed and refused to play at all. He just sat and watched the others. Eventually he did choose music for listening. He asked to play piano after peers left group. I let him play while I cleaned up the room and got ready for the next group (so as to not make him any more nervous). He played classical pieces from memory and was amazingly talented. The next day he brought piano music and was very concerned about playing every note perfectly. This time he played in group, although peers were on headphones. He also played with emotion, which was the first time I had heard him be emotionally expressive. At the end of group he also played guitar, and he sang a wide variety of songs from the Beatles to Cold Play. He was currently denying suicidal thoughts to feelings, which had brought him to the hospital. However, he couldn’t say what had changed or why he no longer felt suicidal. I encouraged him to improvise to express his feelings. He said he had never improvised and didn’t know how. I encouraged him to play his memorized pieces with different feelings and emotional expression. He thought that was interesting and was willing to try it. The treatment team decided he didn’t meet criteria for admission and he was discharged to a step-down unit which was less restrictive and where the physician could still assess his suicidality. We continued to encourage his emotional expression through his music.

Case example of dealing with dual diagnoses

We often have teenagers who are admitted with both mental health issues and substance abuse issues. They do go back and forth between our programs, depending on what is the primary treatment concern. We had a teenage boy admitted to us from our substance abuse program because he was hallucinating, and aggressive and appeared to be psychotic. By the way, some people cannot use illicit drugs. This teen used marijuana once and had a substance induced psychosis, from which he did not recover. After we stabilized his psychosis, we sent him back to CD treatment. Music therapy involved encouraging him to come to group, helping him stay focused in the present and be able to select music (with words) that would ground him and stabilize him. By the end of his stay he was able to operate the CD player independently, choose his own music, and engage in conversations with peers and staff.

Case example of connecting with non-verbal, aggressive teen

We also see adolescents who have developmental delays. This is further complicated when there is a concern about English as a second language. We had a teenager who was from an African country. He was very large physically, making us think he was actually much older than the age reported in his records. This teen was aggressive and frequently hit people, including staff. No language skills were observed and he appeared to be developmentally delayed. I brought in a drum, placing it in front of patient in order to connect and communicate with him. He began beating on the drum and singing vowel sounds. The interpreter explained that the sounds were not in the patient’s language. I began playing my drum and waiting for a call and response drum pattern back from patient. He was able to understand this concept and repeat back. I also learned that he had been in an American school in the US so I started singing young children’s songs that required a response either on the drum or with body gestures., such as “If you’re happy and you know it”. The teen responded and attempted to sing along with the rhythm, although the speech/language was not clear. This drum interaction was the first time he made a positive connection with anyone since arriving at the unit. The more appropriate interaction continued in subsequent music therapy sessions. Staff members were encouraged to sing to him. He enjoyed playing so much he turned a plastic garbage can upside down when the drum was not available. We were better able to observe his level of functioning through the music, train his brain to focus and manage his impulses, and eventually prepare him for discharge to a school that could address his developmental delays.

Case example of connecting with reluctant guitarist

Sometimes mental illness inhibits teens from playing their music. We had a teenage boy who was admitted for suicide attempt. He had a flat affect with minimal interaction or verbalization with anyone. He answered music survey questions and reported he played electric guitar but had no current interest in music. He isolated and was refusing groups. He was invited to come to music therapy with the motivation to play electric guitar. The guitar was set-up in the music therapy room. He watched peers first. He was told he could play guitar any time he wanted and the headphones were hooked up to an amp so he could play by himself. After some time, he started playing guitar. Eventually he played guitar aloud and let others hear. He received positive feedback from peers and began expressing his feelings of anger/frustration musically and then verbally to music therapist. He began writing his own music (lyrics and music) but did not want to share this with anyone. He was able to continue music therapy in outpatient program.

Case example of adolescent refusing to talk or participate

Sometimes the diagnosis is confusing because the presenting symptoms can be similar for different isues. We admitted a teenage Asian girl who presented with selective mutism and questionable psychosis. She was not doing ADL’s  (personal care,) was aggressive toward her parent, and refused to talk. She remained isolated in her room and ignored her interpreter. The teen did come to group but did not answer any questions. I put several CD’s in front of her to see if she would select music. She did not. I put on a popular CD from a movie for her and set her up on headphones. She listened. Other MT did the same in the next group. Eventually she began choosing her own music. She began talking a bit to interpreter and we learned through family meeting that she had been in US for less than 2 years and had moved several times. She did begin talking and could speak some English. ADL’s improved. She took more initiative in selecting music for listening. Improvements suggested trauma response rather than psychosis, with need for immersion school and support to connect and manage anger.

Case example of longer term music therapy

Although our program is designed to be a short-term assessment and stabilization unit, we do occasionally have individuals for longer periods of time. One such case involved an adolescent from Somalia who was admitted after a serious suicide attempt that resulted in complicated medical injuries. She was first stabilized on a medical unit and then admitted to mental health. She had denied the suicide attempt and had told family it was an accident. On the unit she continued to try to hurt herself and needed constant monitoring. She had no language for feelings and did not talk about personal issues. We learned through the interpreter that her English was actually better than Somali. Further testing revealed an IQ below 80. This was a very complicated case that involved months of hospitalization because of medical and cultural issues. She began to play guitar in music soon after admission. Her family bought her a guitar and she continued to practice, play and sing (in English) the music of Taylor Swift. Music therapy became a very important therapy for her and she never missed group, except for medical appointments. Playing guitar gave her a skill, helped her feel competent, gave her positive and appropriate attention, and gave her an outlet for self-expression. She sang and played the same songs on guitar repeatedly. Her affect brightened when she played, indicating her satisfaction with playing and her feeling of success. This young lady took her guitar along when she was eventually discharged to another facility.

Providing a safe place

Safety is an important part of my work as a music therapist. The adolescents who come to us for help do not feel safe. I use music to make a connection with them, to help them to relax and feel comfortable, and to feel safe and calm. It is well-known that developing a therapeutic relationship in which the client feels heard and cared for is critically important. There is a saying that goes, “Clients don’t care what you know until they know you care”. The teenagers need to know that I care about them and am there to help them. Music helps. I use music to establish this connection. Just listening to music helps them to feel safe and calm. Adolescents do listen to music throughout the day. Not being able to listen to music in the hospital would make them feel even more isolated and alone. Music is a normalizing factor in the environment.

Providing choices

I also make sure to give the adolescent opportunities to make choices. First, they are in a developmental state of rebelling against authority. Second, they are in a hospital where they do not have access to many of their personal belongings. And, finally, every teen patient is in crisis and is often very angry. Under the circumstances, it is very important to give them a sense of autonomy and choices. That’s why I rarely come into group with a predetermined theme. I let the group evolve, based on where the group is at the time. Sometimes we all just make choices and do independent musical tasks in the same room (like parallel play). Sometimes we have a small group playing instruments together and others listening to music. Sometimes we have the entire group all making music, improvising, or writing songs together. The main point is that I don’t usually come in with a set agenda (although with the children structure is much more important). With the teenagers, my focus is to use music to connect with them in a positive way, and to help them to make choices with their music that helps them to get better.

Making a difference as a music therapist

When people ask me what I do in my daily work, I sometimes answer that I get to just sing, dance and play all day long. And, in essence, that is what I do. I do try make music therapy fun. When the teens teach me to dance hip-hop, they laugh and have great fun at watching me try to dance. They shake their heads and then say, “do it again.” Sometimes having fun, laughing, and making music is the best way to help teens in crisis to feel better. Once they are feeling better and are stabilized, they are discharged. Some might continue with music therapy but most will not. However, each teen is in a better place than when they were admitted and music helped them out of a crisis. Every time that happens, it feels good to able to say that I am a music therapist.

Again, my name is Bridget Doak. You can reach me through email at bdoak1@fairview.org. I have been a music therapist for over 24 years in various settings. I have worked for Fairview Behavioral Services, in Minneapolis for over 19 years. My undergraduate degree in music therapy was from the University of Dayton and I received my Ph.D, in Music Therapy from Temple University. Please feel free to comment on any aspect of this AMTA Pro Symposium. We welcome your feedback. Thank you.

Bridget Doak, Ph.D, MT-BC

Music Therapist & Clinical Development Specialist

Fairview Behavioral Services

University of Minnesota Amplatz Children’s Hospital, Fairview

Bdoak1@fairview.org

612-273-2686

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