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From Music Therapy – Intimate Notes – case studies compiled by Mercedes Pavlicevic

Based on an interview with Clare Hobbs who works in acute and forensic psychiatry in London.

I went straight from music therapy training at the Guildhall into my first job - I wanted to work in psychiatry. My first job was in Brixton, London - I took the tube there, came out of the station and the whole feeling was volatile. Life on the streets seemed only just contained.... I had never been exposed to that, I hadn't lived in London, I'd only heard of Brixton spoken of in hushed tones... its riots... but something in me wanted to conquer my being terrified of that kind of thing. . . and on the acute wards, people seemed really disturbed. I was terrified.

Forensic psychiatry means that you work primarily with mentally disordered offenders. Everybody has a criminal history, or has become unmanageable in general psychiatric services. Some have committed crimes and while in prison have become mentally ill. At that point they are transferred to a psychiatric unit, one which is secure and meets prison requirements. There are also people who commit a crime during a psychotic episode: they may have been suffering from a paranoid delusion at the time, and you have to ask, did they kill somebody because they were paranoid? Because they feared that this person was going to kill them? A lot of our patients fall into this category, and forensic work demands an awareness of how the legal system impacts on patient care.

Then there are the psychopaths, and they are regarded as the most incurable of all forensic patients. Psychopaths basically have no sense of responsibility to themselves or other people. They tend to act out impulses directly, with no apparent thought between the impulse and the action. They appear to have no sense of right and wrong, and have no remorse for their often violent or aggressive actions. They tend to go to higher security services than ours. I worked on the acute and on the locked wards.

The Unit runs an assessment Programme for new people, for four to six weeks, and music therapy is part of this. People come to music therapy groups, and are asked to commit themselves to coming for those first four weeks as this gives me a chance to get to know them, and for them to get to know what music therapy is about. Most people find the sessions fun. I always take them to the room, show them around and explain the idea of music therapy to them.

The music therapy room is quite large, about five by five metres, and I have all sorts of instruments set out. I have a big xylophone, a metallophone, an Indian double headed drum, an orchestral gong, cymbals, conga drums, bongos, temple blocks, gato drum, small timpani drum, a bigger timpani type drum, a clavinova - which means I can see people. Whereas with a piano you tend to have your back to some people, and with those who are unpredictable that is not satisfactory.

Then there is a whole collection of small instruments, a thumb piano, cabassa (rattle with beads outside), shakers, woodblocks, pan pipes, recorder, tambourines, and so on.

When I started working here, I thought I could be very non-directive, just allow to happen what would happen in the group sessions. I quickly realized that many of the patients are so lost, they don't know how to communicate in any way, they don't know how to use music to communicate, let alone how to use music as a metaphor.

They are often hard to motivate in the first place, so I started to think about how to get them engaged in the sessions. Some have been locked away for such a long time that they have lost self-motivation and autonomy. I had to make a real effort to get them involved and interested by quite structured means - structuring sessions in such a way that I could then engage them in more long-term and insightful work…………………

Often, forensic patients draw out a caring part of me. They are like desperately lost children, so very often. The first thing we think of when a new patient comes in is, is it safe? We read the history - we usually know the index offence - so we know what someone has done. And we all do have this curiosity about the macabre... we have to find out what someone has done, how could they do that... perhaps it is the fear of knowing that we have those kind of impulses in us; these intensely destructive, aggressive impulses, but we wouldn't dream of being anything other than well behaved. For me to lose my temper is rare!

There is a curiosity to meet the person who has done this, and when I do meet them, I often think 'he's pathetic, he looks weak, he looks sad...' and yet there is still this kind of fear: he could do that to me.

I have a music therapy group at the moment - they are all rapists.

Two of those are intensely charming people and don't arouse any real fear in me - I know everything they have done, I know their history - and I now know that the fact that they don't arouse any real fear in me is their most frightening aspect. They are charming so they could easily draw me in - that is how they manage to rape people, because nobody has been suspicious, no one has felt frightened in their company.

Whereas the third member of that group never says anything openly, he makes all sorts innuendoes, he never makes eye contact with me at all.

And he brings out this kind of chill in me - because there is nothing you can talk about: you cannot talk about what he has done, he denies it altogether and has done several times.... I don't know whether he is aware of the effect he has on me. I feel chilled with him.

Some of the patients here are intensely self-destructive: people who cut themselves constantly, people who do things you'd never imagine anyone doing - and I sit in a room with a whole lot of sticks, and I sometimes think I have a lot of weapons in this room. But whatever is destructive can also be used creatively, and retaining faith in that is important. Here, I make music with some of the most destructive people I will probably ever meet. And they express such a love for music, an enthusiasm for music - particularly the Afro-Caribbean guys, they are often fantastic drummers! I feel optimistic for them when I hear how much they love playing. But I also wonder that when they don't engage in music therapy, perhaps they don't actually want to contaminate something that they love so much. . . with the part of them that they hate so much. People feel contaminated by their deeds, and they don't want to contaminate something that they love.

When working with patients we always wear alarms, and there is usually another member of staff in the music therapy group. If they are going to be away then I always make sure that there is someone in the room next door, in the office, when I am working. One of the things that I feel safe with, and that is also unrealistic, is that in this environment everything is quite controlled and secure. I have an alarm.

I've never used it but have accidentally set it off- and there is a team of people who respond, and they are there within twenty seconds. They are so fast! And this is not real life. If this were out on the street, I wouldn't be wearing the alarm - I wouldn't even approach someone like these patients, let alone talk to them....