The Realities of Inpatient, Psychiatric Music Therapy

I’ve had the opportunity to work within the same acute inpatient psychiatric facility for two years. It’s not a long time in the grand scheme of a career, but it’s enough to collect some insight on how things work in our world. When I started this particular job, I had a certain assessment of who I was as a person and as a music therapist. I was confident in this assessment and in my experiences that had led me to this point. This confidence propelled my implementation of a music therapy program and resulted in some great feedback from patients and staff alike. But recently, as I’ve settled into what I’ve created, I’ve been asking myself, did my personal understanding of music therapy hinder my approach to working in an inpatient, crisis stabilization program? 

When I started working at my current facility, I was very comfortable with the clientele, my knowledge of psychiatric disorders, and the realities of a locked unit and society’s view of that. Excuse the jargon as I go on, but I took my Crisis Prevention training to prepare myself for healthy de-escalation techniques and to learn “safe holds”; I brushed up on common psychotropic medications and their side effects; I learned about trauma-informed care; I double-checked that my equipment would be considered “psych-safe”; and I made sure to be vigilant of “elopement risks” when entering and exiting a unit. I was well-prepared. My education had trained me for this.

So I began to formulate a vision of what my role on this treatment team would look like. I created session plans around themes of self-esteem, emotional expression, positive coping skills, mood regulation, identifying support systems, and more. I implemented these sessions and received positive feedback from patients and staff. I followed our structured schedules to ensure patients received the most out of their hospitalization. Patients thanked me for my time, offered positive comments, and told peers to make sure to attend my groups. I saw myself doing what I had been taught and it was successful.

Until it wasn’t.

It’s not that my music therapy groups stopped being helpful, it’s that one day I simply walked into the hospital and suddenly asked myself, “what am I really doing here?” The bubble that held my beliefs of what my role was — popped.

My internal struggle became clearer to me when a colleague presented a case to our clinical team. This colleague was frustrated with the lack of help we were able to offer to this particular patient due to our limitations as a crisis stabilization unit. This patient was a complicated case and would require intensive therapy for most of their life due to their particular dual diagnoses. I realized that my own internal struggle was feeling the same helplessness and frustration with the system; not with who I am as a music therapist, but who I have to be within the system. I began to see that despite our ability to recognize how a patient may benefit from a multitude of therapies and treatment plans, we have to accept the realities of what we do and the systems in which we work before true progress can be made.

This realization was something education and training could not have prepared me for. I had to discover the realities on my own.

The reality is: that when someone is undergoing a mental health crisis and presents as a danger to themselves or others, they are admitted against their will into a stabilization facility.

The reality is: the facility is not meant to provide intensive, individual therapy.

The reality is: patients are only meant to be hospitalized for a couple of days.

The reality is: the psychiatrist does not spend time getting to know the patients because their focus is on providing medication stabilization.

The reality is: our mental health system is dependent on outpatient therapies to provide the brunt of the therapeutic work.

The reality is: those of us who work on a crisis stabilization unit have limitations as to what we can do to help.

The reality is not: that we do not want to help our patients or that we don’t know how.

The reality is: sometimes we simply can’t.

And it’s not an easy reality.

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As a music therapist, I had to change the way I viewed myself as member of the treatment team through this new lens. I had to change the way in which I assessed a “successful” day.  I had to change my expectations for my colleagues and how we support the patients who return. And return. And return. I had to realize that I am now a part of the system and music therapy is no longer floating along as a shiny, new attraction to my patients at my facility.

Suddenly, it seemed crucial to change my session themes from the abstract towards the more proactive. I stopped asking, “What goals do you have” but instead asked “What can we do now that will make you more successful when you leave”? I saw myself as a resource more than anything else and began to question how my role works within the overall mental health crisis process. I began to see that who I was as a person in and outside of my music therapy work was more important than any theoretical framework or thoughtfully planned session would ever be.

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Inpatient, stabilization, psychiatric facilities are not for the faint of heart.

I came into my facility with a vision of who I was as a person and as a music therapist, but I’ve since had to give myself a humble ego-check. My patients are not shy in letting me know when something isn’t working, but it’s more difficult to address when the problems are systemic, rather than personal to you. With these challenges, I’ve had to re-assess myself and who I am as a part of the system in order to determine how music therapy can prevail in order to continue to bring hope, humanity, and understanding to a system that is imperfect.

And that’s my current reality.