Constructing a grounded theory of young people's recovery of musical identity in mental illness

The Arts in Psychotherapy 41 (2014) 594–603

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The Arts in Psychotherapy

Constructing a grounded theory of young people’s recovery of musical identity in mental illness Cherry Hense a,∗ , Katrina Skewes McFerran, PhD a , Patrick McGorry, PhD b a b

The University of Melbourne, 151 Barry St, Parkville, Victoria 3010, Australia Orygen Youth Health Research Centre, 35 Poplar Rd, Parkville, Victoria 3010, Australia

a r t i c l e

i n f o

Article history: Available online 4 November 2014 Keywords: Youth Music Identity Mental illness Recovery Music Therapy

a b s t r a c t Musical identity is a highly relevant, yet little researched area within mental illness. In this study, the researchers explore how 11 young people’s musical identities changed during their experiences of, and recovery from mental illness. The researchers use a constructivist grounded theory approach to collect and analyse in-depth interviews with young people attending a music therapy programme at a youth mental health service. Findings are presented as a constructivist grounded theory of young people’s recovery of musical identity. This interpretation illustrates how aspects of these young people’s pathology presents as ‘musical symptoms’ during acute illness and the ways in which young people engage in processes of ‘bridging’ and ‘playing out’ musical identity in the community. The role of music therapy in supporting young people’s recovery from mental illness is presented, and the need to consider community-based music services is discussed. © 2014 Elsevier Ltd. All rights reserved.

Literature review The relationship between young people and their music The relationship between young people and their music is complex. Australian based research in particular (Cheong-Clinch, 2013; McFerran, Garrido, & Saarikallio, 2013; McFerran & Saarikallio, 2014), has begun explicating the ways in which this complexity increases for young people during experiences of mental illness. While there is support for conceptualising music as a health resource for young people experiencing adversity (Beckmann, 2013; Solli, 2014) some researchers also caution against assuming positive outcomes will result when young people with mental illness engage independently with music. In their study of 40 young Australians, McFerran and Saarikallio (2014) identified the ways young people with mental illness describe patterns of music use that contrast in important ways with their healthy peers. These young people describe allowing themselves to be “under the influence of music. . .and continuing music use despite sometimes negative or ineffective consequences” (p. 6). McFerran and Saarikallio theorise about the dangers of young people assigning

∗ Corresponding author. Tel.: +61 411 707 354. E-mail addresses: [email protected] (C. Hense), [email protected] (K.S. McFerran), [email protected] (P. McGorry). http://dx.doi.org/10.1016/j.aip.2014.10.010 0197-4556/© 2014 Elsevier Ltd. All rights reserved.

‘human qualities’ to music that places power in the music itself rather than focusing on their own appropriation of music. Studies by Miranda (2012) and Miranda and Claes (2009) further demonstrate how young people’s capacity for using music as an effective coping strategy can be impacted during experiences of depression. A number of authors have begun to caution against oversimplification of young people’s music use (McFerran et al., 2013) and undertake research into music use specifically by those with mental illness. Two recent studies (Beckmann, 2013; Cheong-Clinch, 2013) investigated everyday uses of music specifically among young people experiencing mental illness. Findings from these qualitative projects describe the complexity of young people’s commitment to music as a powerful yet limited coping strategy. The authors use in-depth interview data to detail the interplay between music listening practices and illness behaviours (Cheong-Clinch), and the role of music in constructions of illness identity (Beckmann). Cheong-Clinch also discusses the role of music therapists in addressing some of the limitations of this ‘health resource’ and fostering healthy music use for young people’s recovery through reflective engagement strategies.

Music therapy in recovery-oriented practice Within youth mental health more specifically, a large scale meta-analysis (Gold, Voracek, & Wigram, 2004) has demonstrated

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the ‘effectiveness’ of music therapy as an intervention with young people experiencing mental illness. Recent studies addressing the relevance of music therapy to ‘recovery practice’ with people of all ages contribute useful insights about the processes involved in achieving these outcomes (McCaffrey, Edwards, & Fannon, 2011; Solli & Rolvsjord, 2014). These studies demonstrate the congruence between music therapy and recovery philosophy and detail the ways in which music is maintained as a resource for recovery, despite the presence of illness. In contrast to the studies that investigated young people’s everyday uses of music (Beckmann, 2013; Cheong-Clinch, 2013; McFerran & Saarikallio, 2014; Miranda, 2012), these studies examine musical experiences within a therapeutic facility and therefore focus upon experiences of music that are carefully supported by a music therapist.

Method

Musical identity in mental illness

Data collection

Even Ruud (2010) suggests that identity may provide a bridging concept between music therapy and understandings of music use in everyday life (p. 38). Understandings of ‘musical identity’ appear two fold: where music itself is seen to provide material for construction of non-music aspects of identity such as personal qualities, style, values, lifestyle (DeNora, 2000); as well as the ways in which music provides social roles such as those of a musician or fan (Hargreaves, Miell, & Macdonald, 2002). Both interpretations offer useful insights for music therapists who may wish to explore the ways in which people appropriate music for personal insight as well as how people perform musical identities in social contexts. Studies investigating musical identity in music therapy provide insights about the benefits of exploring musical identities in therapeutic work (Amir, 1999; Ruud, 1997). Moreira, Franc¸a, Moreira, and Lana-Peixoto (2009) describe the value of musical identity as a vehicle for processing illness experiences; and Rolvsjord (2010) and Solli (2014) point to the potential of musical identity to evoke positive health changes through the inherent connection between music and individual resources. A meta-synthesis of mental health user’s experiences in music therapy also discusses the ways in which music offers ‘an arena’ for the stimulation and development of positive identity and hope (Solli, Rolvsjord, & Borg, 2013). Solli et al. (2013) argue these affordances of musical engagement for processing identity directly relate to mental health recovery given the focus on identity and personal meaning making as essential recovery processes (Anthony, 1993; Commonwealth of Australia, 2010). The overlap of young people’s experiences of mental illness and their music with the relevance of musical identity to recovery, justifies exploring musical identity within music therapy in youth mental health. However, such clinical approaches also demand further investigation to increase understanding for informed and appropriate mental health practices. This study aimed to investigate the musical identities of young people recovering from mental illness, with the view to understanding how their musical identity changes with experiences of, and recovery from mental illness.

Setting This research took place in the outpatient clinical music therapy programme at a youth mental health service in Australia. The music therapy programme includes a weekly, 2-h music therapy group, as well as individual sessions. Participation in the music therapy programme is voluntary and youth are recruited via case managers and psychiatrists of the service, or self referred. Activities are determined collaboratively by the group and can include instrumental improvisation, jamming on songs, shared music listening and lyric analysis, and song creation. The first author of this paper is also the clinical music therapist at this programme. While the interview data comprises young people’s reflections upon experiences facilitated through these sessions, the purpose of this study was not to evaluate the music therapy programme.

In order to generate theoretical understandings of the topic, the authors chose a constructivist grounded theory approach, modelled primarily on the work of Charmaz (2006, 2011). Grounded theory is a theory building method of analysis based on core features of theoretical sampling, constant comparison of data to theoretical categories, and development of theory through theoretical saturation of categories rather than substantive verifiable findings (Bryant & Charmaz, 2007, p. 11). Theory ‘building’, rather than ‘testing’ refers to the way inductive processes are employed to move from the specifics in data to the more generic in abstracting to larger scale concepts. ‘Grounding’ of the theory refers to the way that theories can be traced back to the raw data (Charmaz, 2014).

Participating young people The study was open to young people aged 15–25 who were accessing the music therapy programme at the youth mental health service. The service supports a range of diagnoses including Personality Disorders, Psychosis, and Mood disorders. Many of the young people accessing this service present with symptoms from a number of diagnostic groupings and comorbid substance use, although their ‘primary’ diagnosis is meant to be representative of the most prominent symptoms (Singh & Kirby, 2007). Young people with any diagnosis are able to access the music therapy programme and a variety of diagnoses were included in this study (see Table 1).

Table 1 Information about participating young people in the study. Participating young person by pseudonyms

Number of interviews

Primary diagnosis at time of study

Participant 1 Anna Participant 2 Kate

4 3

Participant 3 Dan Participant 4 Sandy

3 3

Participant 5 Jordan Participant 6 Emmanuelle Participant 7 Emma Participant 8 Sam Participant 9 Minna Participant 10 Tim Participant 11 Shayna

1 3

Bipolar I disorder Borderline personality disorder/major depression Major depression Borderline personality disorder/major depression/gender identity dysphoria Psychosis Major depression

1 4 1 4 4

Major depression Psychosis Psychosis Bipolar I disorder Psychosis

Design This study forms the first cycle of a participatory project investigating how and why promoting musical identities may facilitate young people’s recovery from mental illness. The purpose of the cycle reported here was to develop a theory explaining what conditions influence young people’s musical identities to change during experiences of mental illness and recovery.

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Recruitment and theoretical sampling Recruitment to the study was via a third party, who was either the young person’s case manager or their psychosocial keyworker at the mental health service. Capacity to provide consent was established based upon the young person’s mental state and was obtained from the young person’s case manager or psychiatrist on the day of their interviews. Theoretical sampling (Glaser & Strauss, 1967) was used to seek out new participants or data that would test or ‘fill out’ emerging categories. Theoretical sampling involved returning to specific young people for subsequent interviews at particular times throughout the analysis process. This process allowed the researchers to pursue emerging theoretical ideas and ‘check’ analysis with young people as the theory developed. Interviews with a young person concluded once their data generated no new categories.

Collaborative interviews To align with the collaborative clinical approach of the service, the qualitative interviews were open, collaborative and informed by Feminist Interviewing theory (Hesse-Biber, 2012). Interview questions varied in each interview and evolved from open and exploratory questions at the start of the project, to targeted questions later in theoretical sampling. The concept of looking for change in musical identity was central, and therefore present in all interviews. Final interviews involved collaboratively mapping the young person’s change in musical identity across their recovery.

Analysis Codes and categories Initial coding strategies were inductive and involved careful dissection of raw data into small components that were labelled with ‘in-vevo’ codes to distill young people’s own words. ‘Focused codes’ were then created by going beyond what young people said in their data, to consider what it was they did with their words and actions (Charmaz, 2006). In the next level of coding, the researchers shifted from inductive analysis to employ abductive reasoning that involved looking across focused codes for patterns of similarities and difference, creating abstract categories. The researchers then used several different forms of axial coding to look across the data at large and identify how the properties and dimensions of each category related to one another (Charmaz, 2006, p. 60). Visual diagrams were used to conceptualise processes in the data through identifying conditions and consequences. Matrix diagramming was then used to sort through the ways in which conditions and consequences were instigated and responded to (Charmaz, 2014). Axial coding and memoing (see below) were used to develop theoretical concepts and a core category that conceptualised how categories related to one another. Data that could not be explained by the core category and concepts was explored as ‘negative cases’ and used to build variation into the theory (see accompanying appendix for a more detailed explanation of the analysis process).

Memoing Theoretical memos were developed for each theoretical concept and explored all categories contained within them. Memo writing was analytic and focused on defining the category, its parameters, and offering conjectures about what might be happening. Conjectures then assisted the researchers to identify gaps in the analysis that required further data collection or analysis of existing data (Charmaz, 2014).

Storylines Once theoretical concepts and the core category were established, the researchers returned to the remaining five young people in the study to discuss the theory and create individual maps of each young person’s musical identity journey (see Fig. 1). Young people were asked to contribute feedback about the interpretation of their experience and contribute further information that would expand the theoretical notions. Fig. 1 shows Emmanuelle’s story line, generated from the hand drawn copy. Words outside the arrow indicate words collaboratively written on the day. Words underlined or in the arrow are written by the researcher based upon prior analysis. Theoretical model and narrative At the final stage of analysis, the matrix and memos were integrated to develop a theoretical model that explained the three stages of recovery of young people’s musical identity (see Fig. 2). The model illustrates young people’s presentation of musical identity during acute illness, followed by processes that occur through music therapy during their early recovery, and highlights young people’s goals for ongoing community music engagement for wellbeing. The memos from each central category were brought together to create a theoretical narrative of the findings as a theory of young people’s recovery of musical identity in mental illness, grounded in the data collected and interpreted by the researchers. Findings The process of recovering musical identity The 11 young people who participated in this study all described changes in their musical identity that corresponded with changes in their mental health. These changes spanned the continuum of acute illness, early recovery, through to engagement with the outpatient mental health service, and plans for recovery in the broader community. Three phases of change in musical identity emerged and could be aligned with three stages of their recovery. Experiences of these changes formed a process of recovery of musical identity in which musical experiences of pathology in acute illness were bridged through processes in music therapy into social wellbeing in later recovery. ‘Musical symptoms’ of an isolated musical identity in acute illness All 11 young people described experiences of an isolated musical identity during stages of acute mental illness. Expressions of the isolated musical identity manifested as ‘musical symptoms’; where young people could detail one or more musical symptom that aligned with aspects of primary or secondary diagnosis, but were not necessarily indicative of their complete diagnosis. The concept of ‘musical symptoms’ interprets the data to suggest that young people’s subjective changes in experiences of music during acute illness were expressions of their pathology. Three categories of musical symptoms appeared to align with three different areas of pathology: ‘privatised musical symptoms’ experienced by those with mood symptoms; ‘fragmented musical symptoms’ experienced by those with borderline personality disorder traits of interpersonal difficulties and identity instability; and ‘disconnected musical symptoms’ experienced by those with psychotic symptoms. Properties and dimensions of the isolated musical identity symptoms The ways in which these three types of musical symptoms are grounded in the data provided by the 11 young people are detailed in the following section. In each case ‘italics’ are use to convey in vivo and focused analytic codes from the data. Direct quotes from raw data also demonstrate how the theory is grounded in young

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Fig. 1. Example story line of changing musical identity.

people’s descriptions. Selected quotes do not provide a comprehensive list of young people who contributed to each code, but aim to illustrate how categories are analytical interpretations of young people’s descriptions. ‘Privatised musical symptoms’ with experiences of mood disorder. Five young people described experiences that have been interpreted as privatised musical symptoms associated with depressed mood in acute illness. These privatised musical symptoms were characterised by substituting the social qualities of life with music; by turning to music as a surrogate friend and musically nurturing the self in private rather than seeking social support. Five of these young people described withdrawing music from the social world to private places such as the bedroom. In these young people’s experiences, musical identity was privileged over other social identities and kept safe in fear of judgement. Music was silenced from the public sphere through the use of headphones, withholding preferences in social discussions, and playing instruments in secret. Instruments provided four young people with means to personal achievement

without the need for social interaction, as a form of private productivity. With privatised musical symptoms the isolated musical identity appears to have existed in young people’s acute awareness of their social context yet was protectively kept separate and treasured as a private personal resource that in turn, perpetuated isolation. See Table 2 for direct quotes of young people’s descriptions that have been interpreted as privatised musical symptoms. ‘Fragmented musical symptoms’ with borderline personality traits of interpersonal difficulties and identity instability. Two young people presented with experiences interpreted as fragmented musical symptoms with borderline personality traits of interpersonal difficulties and identity instability. Fragmented musical symptoms distinctly lacked flexibility and social integration. These two young people detailed abandoning a once highly valued facet of their music when it was perceived as socially rejected by peers. This abandoning mimicked the young person’s severing of social ties connected to the experience of ‘rejection’. The abandoned musical identity was described as favourable but suppressed – the memory held onto

Fig. 2. Diagram of the stages and dimensions of recovery of musical identity.

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Table 2 Quotes illustrating young people’s descriptions that were theorised to be privatised musical symptoms. Turning to music as a friend Emma’s description that has been interpreted as turning to music as a friend Qn. So what do you think music was doing for you in those moments? An. I think it was reassuring me that maybe whatever’s going on right at that moment was going on, but music will always be there for me whenever the hardest things happen. . .reassuring me that no matter how sad things were, music or an instrument will always be there for me Qn. So you would use music after you’d self harmed is that right? An. Yeah. . .it just reassured me that everything was going to be okay. It was like my guitar was just like a little person pushing me along the railway tracks and I’d listen to it and keep going Tim’s description that has been interpreted as the artist as a supportive friend Qn. Can I ask, this sort of private music here (pointing to area on collaborative map), what would you say was the reason you weren’t sharing music so much? An. Um, lack of friends Qn. Okay. Some people during this sort of time also describe intense personal relationships with music, in a way, like they feel that other people can’t be part of that, or they privilege that relationship over ones with people. Do you think you fit that description or is your experience different? An. No (affirming researchers question). I definitely feel like with music you have that connection. . .I think music is a way for the artist. . .to communicate a certain issue and you can then relate to that issue. . . Qn. Do you feel like you’re connected to other people during that time? An. Not so much other people, more the artist Sam’s description that has been interpreted as feeling more connected to music than other people: An. (When really low) I tend to go into my shell. . .I don’t really want to connect or engage Qn. Do you feel more or less connected to music at that time? An. More connected yeah. . .cause in a song you have a reflection of what you’re feeling, reflected back at you, of you listen to the right song. . .but sometimes it’s really hard to communicate to another person that you’re struggling - feeling vulnerable Musically nurturing myself: Sam’s description of diffusing her emotion through music: An. I guess it’s (music is) a sort of outlet for me because whenever I’m feeling lonely or whatever, down, or a negative emotion, I can just pick up my guitar and strum. . .it doesn’t take the whole emotion away or the ache away, but it does sort of diffuse the emotions of it Qn. Does it help you cope with the emotion of it? An. I guess it helps me cope by lessening the emotion. . .it helps me forget too. Like it takes me away from all the crappy stuff, the shit stuff Emma’s description of escaping into a musical world: An. When I was abused, I used music to get away from that and I could escape into another world. . . .like music takes me to another world where no one else can take me. . .I’d play music and it would seem like everything else would go away in the course of the time of The time of that song Instruments as private productivity: Emmanuelle’s description that has been interpreted as music providing private productivity: An. It’s good to learn something because then you feel like you’ve actually achieved something during the day. . .it does make you feel good about yourself, especially when you don’t have any hobbies. . . Withdrawing music from the social world: Dan describes keeping music private in fear of judgement: An. Besides my dad, I always kept (music) to myself. . .I guess it’s something that I didn’t really share because I didn’t really have a reason to, um, it was a bit more like exposing. . .just like, with my musical taste, people will judge people. I could have been judged on my musical taste Tim reflecting back upon his experience that has been interpreted as keeping music private in fear of judgement: An. I remember I couldn’t do that (play with other people). I always had to play by myself cause I was afraid of criticism Emmanuelle’s description that has been interpreted to be about withdrawing her music to a private space: An. I got unwell and stuff. . .like with my mental health. Yeah I used to play basketball and stuff, and I had piano lessons. I just kind of stopped doing all that stuff. . .well technically I stopped doing lessons but I still had a piano at home but I only ever played it if people we re out. I never played it when people were home. . .my mum ended up selling the piano because she thought I didn’t use it. And I did, just when she wasn’t home. So I used it all the time just not when she was home

as a painful reminder of past experiences. These two young people described constructing a ‘refuge’ identity that, from the outside, replaced the abandoned musical identity and enacted the young person’s social reinvention and instability. The ‘refuge identity’ afforded ongoing experiences of ‘safe’ musical engagement that were less open to criticism from others but lacking integration. For one young person, this refuge identity provided a way of maintaining a social musical identity that did not require interaction with others, while for the other, facilitated new less-intimate social connections. With fragmented musical symptoms, the isolated musical identity appeared volatile and defensive. The intense value these young people placed in their music was privileged over social relationships and contributed to perceived social barriers in achieving social connectedness. See Table 3 for direct quotes of young people’s descriptions that have been interpreted as fragmented musical symptoms. ‘Disconnected musical symptoms’ with experiences of psychosis. Five young people have been interpreted to present with forms of disconnected musical symptoms during experiences of psychosis. Disconnected musical symptoms were characterised by musical

egocentricity with positive psychotic symptoms and musical blunting with negative psychotic symptoms. Musical egocentricity was experienced as a heightened sensitivity and intensely personal experience of being music. These young people described experiences of profound acceptance and understanding in music in ways that went beyond what was possible in human interaction. Others found special meaning in music, or held special connections to artists in forms of musical delusions. Musical egocentricity offered an expansive musical experience of an intensely pleasurable and highly individualised nature. With these experiences, young people described no longer feeling a need for social interaction when music provided an all-encompassing sense of gratification. One exception to this pleasure, was a young woman’s experience of musical delusions that although initially created a heightened sense of being ‘special’, lead to intense paranoia and subsequent disconnection from the social world in fear for her life. Musical egocentricity contributed to isolation of the musical identity when young people perceived they no longer needed the social world. One young woman expressed musical blunting with experiences of negative psychotic symptoms, telling of repetitive but

C. Hense et al. / The Arts in Psychotherapy 41 (2014) 594–603 Table 3 Quotes illustrating young people’s descriptions that have been interpreted as fragmented musical symptoms. Abandoning musical identity: Kate’s describes an experience interpreted as a process of silencing her singing as a form of abandoning: An. I did a show at a jazz bar. . .it was for school. . .it was nerve wracking but fun at the same time you know, and everybody was like “wow your voice is so good I can’t believe it”. And then I came back to school the next day and I got told that I sounded horrible and that I shouldn’t be singing, and that’s really put me off singing. . . An. Not only that with singing, but I did a show and I got a massive solo at the end of one of the songs. . .it was amazing, on stage with the microphone you feel like “oh my god a feel like Madonna”. Unfortunately the next year I cam back and I auditioned again and I didn’t get anything as good as last year. . .and that made me really upset. Now my music is something I do when I’m by myself so no one else can hear me Sandy’s description interpreted as suppressing her country musical identity: I was writing music, and always wanted to be a performer, but I?? just never thought that, you know, no one really enjoys country (her written music was country), you know what I mean Sandy’s description interpreted to be about abandoning shared music due to interpersonal difficulties: Qn. So relationships became difficult? An. Yeah a lot difficult. To be honest after that I quite the band, quit guitar, quit songwriting, and took up DJing Qn. Why DJing at that point? An. I think it was more the aspect of doing it on my own, like not with other people Constructing a refuge musical identity: Sandy’s description of constructing a refuge musical identity to please others: When I got into DJing I basically decided that I would make music for other people that enjoyed it instead of making country music. . .more to please others. So people could say “gee that’s a good track”

meaningless engagement with music. Her past sense of personal music preference diminished, any musical sensation became dulled and there was an inability to experience musical pleasure. Musical blunting was disconnected from the self, and simultaneously formed a way to disconnect from others by isolating in music to ‘block out’ others and thoughts of the social world. See Table 4 for direct quotes of young people’s descriptions that have been interpreted as disconnected musical symptoms. Processes of bridging musical identity in early recovery Young people’s reports of experiences within and through music therapy are interpreted as processes of bridging their isolated musical identity to the social world. Three different processes of bridging are identified, each dependant upon the nature of the musical symptom experienced in acute illness. Given the complexity of young people’s mental illnesses, young people do not neatly fit into one category of musical symptom and subsequent trajectory of bridging. Some young people experience multiple musical symptoms across different categories. However, each category of musical symptom is proceeded by a particular process of bridging. Young people expressing multiple musical symptoms from different categories therefore recover along multiple trajectories as their symptoms resolve. Building musical belonging. Young people who expressed privatised musical symptoms reported reasons for attending music therapy that have been be interpreted as building musical belonging. Building musical belonging involved using the music therapy group as a means of establishing a social musical purpose through routine, structure and musical roles. Having a musical purpose offered an experience of belonging within a wider social structure formed upon occupations and social roles. Two young people described

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Table 4 Quotes illustrating young people’s descriptions that have been interpreted as disconnected musical symptoms. Musical egocentrism: Tim’s statement that has been interpreted as grandiosing in music: “Who needs other people, I am music, music is me” Jordan’s description interpreted to be about profound musical experiences: An. Yeah well for a while it (music) was a lot more intense, it meant a lot more to me. Yeah I was going through my episode or whatever. But then, when I went on meds it went a bit more two dimensional, a little less alive I suppose. . ..before, like very line would have a story Qn. Was it more enjoyable? An. Yeah for sure Tim explains his experience of heightened sensitivity to music: Qn. You said that around the time you were unwell, you were meditating a lot to cope, and that’s lead to you experiencing increased sensitivity to music? An. Yeah yeah. It sounds beautiful. I mean back then (pre illness) it would just sound like noise, but now it’s just, you know, the composure of everything will just be so in sync, you know “whoa”. . . Qn. Are you still more sensitive? An. No I’m even more sensitive now. . .oh and every time someone talks to me they got it as well. . .they get the increased sensitivity Profound connections to artists: Anna alludes to her perceived special connection to artists: An. All these people (artists) that have made me shape who I am. . .in the way they sing and how they deliver what they’re singing. Sort of how they approach music. . .it’s a message as well, to me, that I want to put into my own words Minna talks about experience interpreted as her special connection to artists: An. There was a time where I’d listen to music and it made me think, can the person (artist) think of me, like is he thinking of me right now while I’m thinking of him? Tim tells of feeling accepted by guitar: An. Yeah no one understood me at all in fact. I mean, I had no one to turn to. . .yeah the guitar was the only thing that understood me. . .it felt as though I could play anything and the guitar would like, just accept me. . .like it wouldn’t argue. And I just felt like ‘oh man this thing understands me’ Musical blunting: Shayna describes music use interpreted as repetitive but ‘meaningless’ Am. That was when I was the worst (most unwell). (Listening) on repeat for hours everyday, up to nine hours, just to any song. Even music I didn’t like Shayna describes a process of isolating in music An. I relied on music a lot (during acute illness) like I had periods where I would stay home and listen for 10 hours and wouldn’t even leave my room. . .I needed something to pass the time and I’d sway back and forth to music Because the psychosis I had, I thought certain things were going to happen to like the world, to I wouldn’t leave my room. . .in preparation for what was going to happen

how they valued musical skills as social assets for building up their social musical identity. Young people also described a gradual process of offering their music within the social space of the music therapy group. This process appeared both challenging and self-determined, characterised by incrementally exposing elements of their musical identity to others through song choice or increasing the volume of their music making to be ‘heard’. For these young people, the music therapy group offered a context for their musical identity that was one step out of the private environment yet not fully visible to the wider community. See Table 5 for direct quotes of young people’s descriptions that have been interpreted as building musical belonging. Integrating past and present music. Two young people who described fragmented musical symptoms during acute illness engaged in a process interpreted as integrating past and present music through individual and group music therapy. The refuge iden-

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Table 5 Quotes illustrating young people’s descriptions that have been interpreted as processes of building musical belonging. Music as purpose: Dan describes using the music group for establishing routine: An. It’s interesting, and it’s something I like (coming to the group). Yeah, it’s sort of forcing myself to do something, even if I don’t feel like it. . .the routine thing. It’ll be like you know, one of the first ways that routine is good, like being able to do something that I like. I guess I generally feel more positive Musical skills as social assets: Emmanuelle offers a description that has been interpreted as building musical skills as social assets: An. If you’re talking to somebody about their hobbies and stuff. . .when you’re having a conversation about what kind of stuff you like to do, if you’re going “I don’t really like to do anything, I just sit at home and do nothing” . . .it’s sort of. . .it’s like “when I’m at home and I’m not doing anything I like to learn stuff on the keyboard” Sam reflects upon a process interpreted to be about negotiating the social musical role in the group: Qn. In my perspective you still maintained that identity as someone who plays guitar (discussing that she chose to sing rather than play guitar in the group sessions) because we talked about your guitarist didn’t we? And you’d give the others tips. . . Am. Yeah yeah Qn. What was that like for you? An. Kind of cool actually. Because even though I wasn’t playing guitar, I still felt like I belonged Qn. How did being known as a guitarist create a sense of belonging? An. Because nearly everyone in the group played guitar Gradually offering music: Emmanuelle offers a description interpreted as a process of gradually offering her music: An. For the first few months I played with the volume (on her keyboard) turned right down . . .Just like, challenging thinking, like turning the volume up a little or playing something that’s different for someone, like show someone. Like to sort of see, maybe their reactions aren’t going to be as bad as you think

tity that was developed during acute illness was maintained and initially drawn upon as the primary engagement tool in social settings. However, both these young people began expressing desires to reconnect with their past abandoned musical identity, carefully, in private contexts while the refuge identity maintained the social ‘face’ of the musical identity. Over time, these young people seemed to work through a process of integrating the fragmented parts of their musical identity into a multifaceted whole. See Table 6 for direct quotes of young people’s descriptions that have been interpreted as integrating past and present music. Connecting musical identity to social reality. Young people who expressed psychotic musical symptoms reported coming to music therapy to engage in processes that have been interpreted as Table 6 Quotes illustrating young people’s descriptions that have been interpreted as processes of integrating past and present music. Reconnecting with past abandoned musical identity: Sandy talks about wanting to reconnect with her past music: An. Basically, I want to reconnect with guitar again, reconnect with songwriting An. (reflecting in a later interview) Paying guitar again. . ..it felt good, I loved it. It was like an old love coming back Maintaining the refuge identity: Kate tells of her goals that are interpreted to be about her desire to integrate bass and singing within the group: An. I guess when I’m around other people I won’t sing properly, or as loud or as much because I’m too worried about them judging me. . . I think I’d like to be a little more confident in my singing. I don’t want to be “oh Kate can sing, you can be the person (in the group) that sings”. And I really want to play more bass

Table 7 Quotes illustrating young people’s descriptions that have been interpreted as processes of connecting musical identity to a social reality. Maintaining enhanced musical experiences: Tim describes a process that can be described as finding reality based ways to maintain his enhanced musical experience: Qn. Why did you choose to come to the music group? An. I wanted to hear how everyone plays Qn. Were you interested in the music of other people or? An. In their music, I don’t know about other people, but in their music and what they could come up with, even as nubes. So I could see their frustrations. Okay I’m gonna be honest here – it was because I was winning a lot, and if they lost, then I felt like I was still winning Qn. We’re you starting to experience some of this ‘failure’ (previously described early recovery as failure as he perceived medication took away the ability to experience ‘winning’) at this point? An. Yes, yes Transitioning musical delusions to a shared reality: Anna describes processes interpreted to be about transitioning her private love for Paul Kelly to a shared musical interest in the group: Qn. Do you think your engagement with music has changed at all since you started coming to the group? An. It’s made me appreciate it a little better, a little more. Like how other people can play like ‘deeper water’ (favourite Paul Kelly song). . . And they tell me they appreciate that music, and what it stands for

connecting their musical identity to a social reality. As psychosis subsided, these young people sought out reality-based ways of maintaining their enhanced musical experiences. These young people identified the music therapy group as a potential opportunity to continue engaging with new experiences of music that were developed during acute illness. For some, this process involved finding others who also played an instrument or shared musical preferences that featured in their musical delusions. This process has been interpreted as transitioning musical delusions to a shared reality. Here, the group offered a means of normalising intensely personal musical connections to artists and instruments through opportunities to connect with others with shared interests. This process or bridging from a disconnected musical identity to a to a shared reality-base was gradual and nuanced. For one young man the group initially provided a way to maintain experiences of ‘winning’ that began in musical egocentricity but decreased with medication. Over time, the experience transitioned from being achieved individually through comparison to others, to being shared with others in co-learning experiences on guitar. Three young people, having experienced profound acceptance in music, came to the group seeking acceptance in a broader social sphere. One young woman who experienced musical blunting offered another facet of connecting; illustrating nuances of sensitising her musical identity by developing a sense of preference, style and pleasure in music. She noted how learning bass and sharing music in the groups assisted her to develop skills that enabled these sensitised experiences, connecting with herself, and affording shared experience. See Table 7 for direct quotes of young people’s descriptions that have been interpreted as connecting musical identity to social reality.

Processes of ‘playing out’: musical identity in later recovery These 11 young people described coming to music therapy to pursue musical goals. Rather than targets to be reached in the therapeutic setting, young people expressed musical goals described here as ‘playing out’ musical identity in everyday community settings. The ongoing nature of these goals can be represented as a form of musical participation in society through normalised forms of musical engagement. Young people discussed three categories of playing out that depended upon the nature of the musical symptoms and subsequent trajectory of bridging processes in music therapy.

C. Hense et al. / The Arts in Psychotherapy 41 (2014) 594–603 Table 8 Quotes illustrating young people’s descriptions that have been interpreted as processes of presenting musical identity. Playing in highly public yet anonymous spaces: Emmanuelle recounts an experience that has been interpreted as presenting her musical identity in public: An. There was a piano in the city in the holidays that was the coolest thing ever. I was like, last year I totally would have just walked passed but this year I was like, yeah I’m totally gonna play that! The need for ongoing musical support: Sam talks about her desire to busk and related need for ongoing musical support: An. I would like to busk in the city. . .that’s definitely one thing I’d like to be able to do. . .but I need to build up my skills, that’s what guitar lessons are for An. Finances are an issue An. I think it would be awesome to have a mental health music group in the community somewhere Qn. But why wouldn’t you come? (Had said she wouldn’t come despite thinking this a good idea) An. I don’t feel that confident in my guitar skills

Table 9 Quotes illustrating young people’s descriptions that have been interpreted as processes of tolerating musical identity. The desire to connect through music: Sandy describes a desire interpreted as connecting to others through song (after initially wanting to do this in person but struggling to find a way): An. I feel because it’s helping me be a better person (music), as long as I can help other people just like me that are feeling the same way I can say “hold your head up high it’s going to get better” Reframing musical identity: Kate talks about reframing her singing as enjoyment: Yeah, it’s cool how I’ve gone back (to singing), and like now that I think about it it’s cool how I’ve gone back after all the stuff that’s happened I’m going back and I want to sing again. . .and then, I might start auditioning for musical again, go back into singing jut as a hobby, like I wouldn’t do it as a job (describes wanting to be a professional singer in the past)

Presenting musical identity. Young people who worked to build musical belonging identified processes related to presenting their musical identity in highly public yet anonymous spaces. Presenting was sought through busking on instruments in the streets or starting online music blogs. One young woman played on the public pianos in the city. These processes appeared to be about presenting the musical identity to the public as a means of finding belonging within a broad cultural context. While some young people engaged with this goal by the end of their time in music therapy, others expressed a need for ongoing opportunities for building musical skill in preparation. This finding raised important issues about the need for ongoing resources beyond therapy that will be discussed below. See Table 8 for direct quotes of young people’s descriptions that have been interpreted as presenting musical identity. Tolerating musical identity. The two young people who worked to integrate their musical identity in music therapy set goals relating to tolerating musical identity in later recovery. They both described aspirations for connecting with others through music that were beyond what they appeared capable of achieving, but reached a point of compromise. This tolerance involved personal reframing of their musical identity, to integrate social feedback and selfperception in a more dynamic and resilient musical identity. Tolerance was reached for their own musical self-perceptions as well as being able to tolerate the experience of their musical identity within social spaces such as peer groups. Both young people expressed interests in ongoing musical engagements that drew upon multiple facets of their musical identity – seeking group music making and amateur skill development courses. See Table 9 for

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Table 10 Quotes illustrating young people’s descriptions that have been interpreted as processes of sharing musical identity. Sharing through music: Anna describes her desire for sharing music: An. It’s more about sharing. . . Sort of socialising as well as just getting my guitar needs. . .maybe the group at (this service) could continue being a group in hue he community? Tim also talks about wanting to share his experience with others interpreted as imparting musical wisdom: An. I want to share it with the world, what I’m experiencing. . . as well as skills I learned on my own, like finger picking and finger slapping and stuff Shayna talks about musical plans that can be interpreted as joining a social music scene: An. I realised it is a hobby and something I enjoy doing and I need to take time to do things that I enjoy and that I’m good at Qn. And do you have a clear idea of how you might do that? An. I could join one of those hip-hop groups that you’ve suggested and um, maybe even go to concerts and gigs and stuff like that could be a way to be involved as well

direct quotes of young people’s descriptions that have been interpreted as tolerating musical identity. Sharing musical identity. Young people who engaged in processes of connecting musical identity to a social reality through music therapy spoke about desires to share their musical identity in the community. For some, this was discussed as sharing musical experiences of learning and challenge with others in regular informal group jamming sessions. Other young people described a type of imparting of musical knowledge though mentoring others. One young lady expressed desires to join social music scenes based upon rediscovered musical preference and interest that had diminished during musical blunting. See Table 10 for direct quotes of young people’s descriptions that have been interpreted as sharing musical identity. Final thoughts The grounded theory resulting from the analysis of data in this study suggests that for young people who experience musical symptoms during illness, recovery of musical identity is a critical part of their overall recovery process. The 11 young people who chose to participate in this study presented with musical symptoms during the acute stage of their illness. Each of these young people also voluntarily chose to engage in music therapy and construct musical goals in collaboration with their music therapist. While not all young people will necessarily experience musical symptoms of pathology, the choice of these young people to engage in music therapy suggests a need to resolve (not extinguish) their musical symptoms in their process of recovery. Discussion The philosophy of recovery in mental illness is concerned with the individual’s shift away from a state of illness driven selfconstruction, to one where illness is understood and incorporated as one facet of the larger self concept (Davidson, Rowe, Tondora, O’Connell, & Lawless, 2008). This process involves change in the way the self is conceptualised and expressed. The results from this study suggest that musical identity is one way that young people may be able to address aspects of self concept to facilitate recovery. The relevance of resource-oriented theory The construct of ‘musical symptoms’ developed in this study could be interpreted as a deficit focused orientation where ‘symptoms’ require ‘treatment’ in order to be extinguished. Some music

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therapists have critiqued the deficit focus of symptom treatment in mental health care and advocated for approaches that focus on the resources afforded through music (Baines, 2013; Procter, 2004; Rolvsjord, 2010; Stige & Aaro, 2012). Norwegian music therapy scholars (Solli et al., 2013) have been the most prolific in articulating the relevance of resource-oriented music therapy practice in recovery-oriented mental health care. Here, placing ‘musical symptoms’ in the context of recovery philosophy offers a different perspective of musical symptoms that aligns with resource-oriented approaches – where symptoms are individual experiences of internal states that can assist in meaning making. From this perspective, music affords an experience of illness, in the form of musical symptoms, that provides material for working into health. Music can be experienced as symptoms that do not require extinguishing, but can be carried into everyday health contexts for participation, offering a powerful medium for promoting ongoing meaning out of an illness experience. This process captures ‘recovery’ at its philosophical core.

Implications for service providers Playing out musical identity is described by all young people in the study and is interpreted as central to their recovery of musical identity. Processes of transitioning musical identity from private to social arenas has been described recently by music therapist Solli (2014) who illustrates the value of fostering musical identities in building upon resources and expanding social networks in recovery. However, Solli’s discussion also alludes to the limitations of institution-based music therapy services in supporting people’s integration of musical identity into community-based networks when the role of the ‘therapist’ does not stem beyond the institutional setting. Sending vulnerable people into potentially inappropriate or ill-equipped community-based musical settings may not facilitate positive musical integration. Similarly, setting people up for musical experiences that may not exist outside of therapy also has ethical implications (Bolger, 2013). The importance of playing out in these findings suggests that music therapists working in recovery-oriented models should consider community linkages as core business rather than potential additional support. A decade ago, British music therapist Simon Procter (2004) raised discussion about the appropriateness of the ‘consensus model’ of music therapy (Ansdell, 2002) in meeting mental health recovery goals. Procter challenged both the hierarchical and institutional basis of this consensus model and asserted the potential of Community Music Therapy orientations (articulated more recently by Stige & Aaro, 2012) for ‘freeing’ music therapists to think beyond the constraints of traditional therapeutic settings and personal boundaries. In relation to mental health, Community Music Therapy pioneer and scholar Stige (2003, 2006) highlights the relational notions associated with recovery, defining health as both ‘participation’ and a state of being that requires mutual care in ‘human co-existence’. From a services perspective, recovery is not just about ‘treatment’ models undertaken within clinical settings, but supporting individuals towards fulfilling life pathways. Baines (2003) also postulates that a recovery-informed attitude towards the role of services in mental health necessitates that therapists look beyond what is offered within clinical settings to address how the opportunities within communities can support individuals to participate actively beyond their ‘illness’ role. Investing in the notion of recovery as a process of working to reorient the self concept away from illness towards health, requires careful consideration of how much emphasis is placed upon services within mental health settings. There is a need for music therapists to draw upon Community Music Therapy principles to think beyond their setting in order to

ensure appropriate community services are in place and accessible to young people. Social capital in recovery beyond the mental health setting Young people’s musical goals not only represent forms of playing out their musical identity beyond the mental health service, but demonstrate the need for opportunities for musical participation in society. Putnam (2001) asserts how active musical participation not only promotes the wellbeing of individuals through their engagement in communities, but increases potential for collective action towards positive social change through the raising of social expectation. Here, Procter (2004) draws the link between social capital theory and music therapy stating how music therapists “have enormous potential for changing the status quo” (p. 227). Ensuring young people have adequate opportunities for musical participation is not only integral to recovery of their musical identity, but can be viewed as central to supporting their capacity for accessing resources through developing social capital (Procter, 2011). In this study, the question arises then, of what communitybased resources are available to young people for playing out their musical identity? Conclusion The young people involved in this study came to music therapy to address the ways that they were engaging with music in their everyday lives. Their stories teach us about the ways their musical identities changed with experiences of acute mental illness and how they were able to engage in processes of bridging through music therapy. Their musical aspirations illustrate their visions for community-based musical participation for ongoing wellbeing. Music therapists have an important role to play in young people’s recovery of musical identity. Supporting recovery processes involves collaboratively identifying musical symptoms that require the therapist’s detailed understanding of both pathology and the resource-potentials of music. Processes of recovery also involve the music therapist’s capacity to facilitate a range of musical experiences appropriate to the individual’s trajectory from musical symptom through to preparation for playing out musical identity in the community. While existing literature demonstrates the importance of music in healthy young people’s lives, this study raises awareness of critical ways in which musical identities can change with experiences of mental illness, and the relevance of addressing this change in promoting young people’s recovery. This study raises the issue of young people’s access to community-based music resources that are appropriate to their needs. The process of linking young people in with communitybased music services is not always possible, when the services available appear inappropriate to the young person’s goals or needs. Providing musical opportunities suited to those already thriving in the community but not those who struggle with everyday engagement, raises ethical questions about the ways in which music resources, like many other privileges, can be limited for those with mental illness. Music therapists working with young people recovering from mental illness are well placed to address issues around the specific musical needs of young people recovering from mental illness, and in doing so, address these issues of social inequity. Acknowledgements The authors wish to acknowledge the young people who participated in this research, staff members of the facility at which the project was run, members of the National Music Therapy Research Unit, and the Australian Postgraduate Award funding scheme.

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