Music Therapy Today

Vol. VIII (3) (Dec) 2007

Benefits and limitations of

music therapy with
psychiatric patients in the
penitentiary system

Romanowski, Bob

October 30, 2007 NÖ (Lower Austria) Landesakademie, Krems/Austria - Best

Practice Day: Music therapy – psychiatric clinic in the penitentiary system

This is the revised version of a paper I presented to the Landesakademie

Niederösterreich on invitation by Dr. Gerhard Tucek, head of
I.M.A.R.A.A. (International Music & Art Research Association Austria).

The meeting had the following objectives:

• to give an overview of the current state of music therapy applications

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Romanowski, B. (2007) Benefits and limitations of music therapy with psychiatric patients in the penitentiary
system. Music Therapy Today Vol.VIII (3) December. available at http://musictherapyworld.net

• to establish or strengthen an awareness for the benefits of music ther-

apy interventions for the professional groups involved
• to discuss options to establish music therapy in Lower Austria

Based on these objectives I shall discuss the conditions, options and

problems involved in music therapy in the penitentiary system.

Music therapy in prison - context and conditions

I see the context of my work as the place where society has to cope with
the consequences of what went wrong in other areas. Prison is not the
best possible answer to the problem of criminal deviation and dissocial-
ity… but it is the answer our society has provided until today, and the
reality is indeed depressing.

For almost exactly 10 years I have been working as a music therapist in

the psychiatric department of the hospital at the Berlin-Charlottenburg
prison. The hospital provides services to several prison facilities within
Berlin comprising about 5000 prisoners in total.

This is the context where I gathered experience on which I shall report as

follows.

Let me first describe general conditions. The department moved location

several times in recent years, the last time to a new building. It is now
located in one building together with a department of internal medicine (I
am not authorized to present photos). This move occurred in early sum-
mer 2007 and we are still settling in and trying to adapt our structures
accordingly. Unfortunately the clinic was not built as planned originally,
due to insufficient funds, but plans were scaled down repeatedly (we all
know that Berlin is bankrupt – we have to work and live under conditions
of permanently restricted expenditures). But it is also a consequence of

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Romanowski, B. (2007) Benefits and limitations of music therapy with psychiatric patients in the penitentiary
system. Music Therapy Today Vol.VIII (3) December. available at http://musictherapyworld.net

the social context that the public is unwilling to invest more than abso-
lutely necessary into the penitentiary system – the widespread opinion is
that prison time is intended as a punishment. Prisoners are conceded only
the absolute minimum of what is seen as necessary.

I mention this to underline that life in prison is not easy, not for prisoners
who are ill, nor for nursing staff and other employees.

Our department has 3 wards for a total of 40 to 45 patients (only male

patients are accepted and treated), plus 1 ward for post treatment care (as
a transition facility). Members of the team are physicians, therapists, psy-
chologists, a social worker, a head physician and the hospital director.

Therapy services offered by the hospital comprise: psychiatric treatment

by physicians, occupational therapy (manual and creative activities in a
therapeutic setting), sports therapy, physical therapy, art therapy, music
therapy, psychological counselling (by psychologists in electives who
offer conversation, psychosis groups, social training, relaxation etc.)

Therapy within an institution is characterized and influenced by the rules

governing that institution. This involves a rigid time frame with a service
plan, with strict handing over procedures, locked doors at fixed times, 1
hour recreation outdoors, doctoral visits. All other activities have to be
arranged accordingly. These are inherent constraints of the penitentiary
system and affect all employees as well. In addition there is the general
rule of locked doors and other security requirements, equipment of minor
quality, limited resources.

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Romanowski, B. (2007) Benefits and limitations of music therapy with psychiatric patients in the penitentiary
system. Music Therapy Today Vol.VIII (3) December. available at http://musictherapyworld.net

Context and mission

The mission of the medical team, i.e. the treatment objective, is to stabi-
lize patients and make them “well” so that they can be returned to, and
endure the hardships of, the normal penitentiary system. Curing in this
case means to help patients to survive their sentence with as little (bodily
and mental) damage as possible.

Hospitalization in the clinic lasts about 50 days on average. Patients are

detainees pending trial and those sentenced to imprisonment whose men-
tal problems were revealed in detention. Detention causes a number of
trigger factors for psychological disorders in persons with a predisposi-
tion or vulnerability. I refer to stress caused by deprivation in arrest. Loss
of freedom has far-reaching consequences. It means loss of social con-
text, loss of social status, loss of material assets like a place to live and a
car, loss of partners and friends, threat of extradition. These risk factors
endanger mental health because they result in fundamental, existential
insecurity.

The patients

I shall describe some of the problems patients bring into the hospital and
into therapy. Such problems must be addressed in successful resocializa-
tion. I understand therapy as an integral part of resocialization.

Many patients come from the fringes of society, from the bottom. They
have little resources to improve their social status.

This has to do with to their unfortunate background: no schooling, no

professional training as the basis for a regular income and secure living.
Very often they lack the mental prerequisites (not necessarily intelli-

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Romanowski, B. (2007) Benefits and limitations of music therapy with psychiatric patients in the penitentiary
system. Music Therapy Today Vol.VIII (3) December. available at http://musictherapyworld.net

gence) to cope with school or professional training. Consequently the

majority of our imprisoned clients are younger males without proper
training. They lack basic abilities and social skills, adequate demeanor
and behaviours that are required to become integrated and socially
accepted.

In addition there are language problems – the inability to express oneself.

Reasons are a migration background and other educational deficits.
Highly relevant for mental health is the ability to talk about emotions and
personal experience; these patients often suffer from a kind of speech-
lessness regarding their inner life.

Antisocial behaviour constitutes an aggravating problem – improper,

offensive, insulting behaviour to others (nursing staff and other prison-
ers) without reasonable cause. This is one of the hardships for employees
to endure and cope with.

30 to 40% of prisoners have a migration background. Migration brings

other problems in addition to language: lacking integration into the social
environment and loss of roots in the culture of origin, with resulting iden-
tity problems specifically in the second and third generation.

Addiction and drug problems are frequent among prisoners, with sub-
stance abuse, addictions in general as well as politoxicomania (use of
multiple substances).

Why are prisoners referred to our clinic? Some people become physically
ill in the normal penitentiary system, others draw attention with behav-
iours like withdrawal, self-neglect, suicide attempts or self-injury (graz-
ing, cutting, swallowing objects, or other forms of autoaggression), or
wildly aggressive behaviour towards others, kicking up a row or destroy-
ing cell equipment etc. Such patients can no longer be kept in the normal

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Romanowski, B. (2007) Benefits and limitations of music therapy with psychiatric patients in the penitentiary
system. Music Therapy Today Vol.VIII (3) December. available at http://musictherapyworld.net

system (employees are responsible for their welfare) because they endan-
ger themselves or others or give the impression of being ill for other rea-
sons (for example manic or compulsory behaviour).

If this occurs they are referred to the hospital, examined by physicians

and referred further, depending on the diagnosis. In case of mental prob-
lems they come to one of the psychiatric wards.

Which mental disorders are diagnosed by our physicians? There are

patients with antisocial behaviour and those who are suicidal. In addition
there are many schizophrenic psychoses, schizoid and delusional disor-
ders and addiction syndromes. Affective disorders (depressions) and per-
sonality disorders (e.g. borderline) are also very frequent, and we see
occasional posttraumatic disorders as well. Many patients are diagnosed
with multiple disorders.

Weekly team meetings are attended by physicians, nursing staff and ther-
apists; this is when patients are referred to individual therapies. As a rule
the physician has discussed this with patients before, e.g. on his visits. I
then contact the patients in question and arrange details of their participa-
tion in therapy.

Some patients refuse to cooperate – they do not wish to do anything that

might be strange, stressful or disturbing. In a preliminary conversation I
inform the candidates – no musical skills or knowledge are required for
music therapy – and try to facilitate access on a low level.

CONTEXT OF Why does the treatment team expect interventions to have beneficial
TREATMENT
effects on patients? A simple explanation: normal/healthy forms of
behaviour are exercised in therapy.

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Romanowski, B. (2007) Benefits and limitations of music therapy with psychiatric patients in the penitentiary
system. Music Therapy Today Vol.VIII (3) December. available at http://musictherapyworld.net

In occupational therapy, for example, patients form objects of daily life

out of materials and with tools (ashtrays, basecaps, decorative objects).
Where possible they do so in groups, in contact with others with whom
they have to get on somehow.

Sports therapy, and to some degree physical therapy, is about movements

that are normal for human beings, for which our bodies are made, which
are intended for all of us and keep us healthy.

Art therapy addresses the need for aesthetic performance and processing
of mental processes in the form of created pictures. The objective is to
externalize inner processes in a non-verbal form, as a picture or sculp-
ture, so that it may be discussed and made aware or handled in some way.

The expectation and experience is that these interventions help patients to

re-organize mental processes and overcome a crisis.

MUSIC THERAPY WORK I shall describe music therapy in more detail. This intervention was intro-
duced at the psychiatric department ten years ago. I offer music therapy
sessions on the basis of a 6-hour contract per week and am expected to
cover as many patients as possible within this time; accordingly I offer
group therapy: two groups with 4 to 6 patients each, for a therapy session
of 45 to 65 minutes. In addition there are team discussions, preparatory
work etc.

I see music therapy as a psychotherapeutic intervention. This therapy

form uses music as a medium and has a variety of objectives. Music and
musical experience are essential parts of human culture. Music is among
the oldest cultural forms we know. It serves purposes of mental hygiene
and social integration. Music is a key technique to ensure contact and
synchronization between individuals in groups. Music is embedded in

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Romanowski, B. (2007) Benefits and limitations of music therapy with psychiatric patients in the penitentiary
system. Music Therapy Today Vol.VIII (3) December. available at http://musictherapyworld.net

social relations and fulfils its function in these contexts – for example in
church, at the opera, in military service, in dancing, at open air festivals
or rave parties, at the Love Parade; ultimate objectives are harmony,
accord, catharsis (emotional release).

Talking about music I refer to more than the general, everyday concept of
music. Sometimes I ask my patients: what is music? Then I hear general
descriptions like: what comes out of the radio, the CD player. Instru-
ments, rhythm, notes, hip-hop, techno …

I think music is more. From the perspective of a therapist I say: music is

a prelinguistic form of communication – think of a typical lullaby. This is
a situation where you direct your attention to someone, you tune in. The
mother uses the lullaby in order to influence the infant’s emotional state
so that the child calms down and falls asleep. She sings and hums this
soft melody for the child and shows in a prelinguistic form what she
expects from the child: to calm down. If this communication works then
the child falls asleep. Music can also be much fun, can touch you deeply
and trigger a variety of emotions.

Dancing and celebrating are closely and directly connected to music.

Music always is movement as well – without movement there is no
music – movement that follows formal rules or plays with them. This
applies to external as well as internal movement. We follow the progress
and dynamics of what happens in music. And of course music is play –
we play music.

Fun and emotions emerge from the experience of contact with others, of
being moved together with them and being absorbed by a mutual contin-
uum, being surrounded by music, moving and communicating with oth-
ers. When we listen to a musical recording we feel touched in a

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Romanowski, B. (2007) Benefits and limitations of music therapy with psychiatric patients in the penitentiary
system. Music Therapy Today Vol.VIII (3) December. available at http://musictherapyworld.net

secondary way as well, although this is not the same intensity you feel
when you attend a musical event. Music in the process of generation has
the quality to address the now, the situation and atmosphere of the
moment. A feedback is created between all involved actively and pas-
sively.

This is the offer I have for my patients. I suggest: come to me, take up
contact, come into this prelinguistic space, let us do so together. And later
on I ask questions: what is it we just experienced? The premise is that it is
important for us to express in words what we experience, to find terms to
describe, locate, evaluate and change or adapt our behaviour. This in par-
ticular is a therapeutic approach.

If you read this article and are not present at my lecture, please try to
imagine the following situation. We can try something together and you
will get an idea of what self-experience is, what music therapy is, what
you experience in music therapy. It is an intervention with the opportu-
nity of self-experience. The idea is to experience the self in a specific sit-
uation with another individual or a group and to discuss this experience.
The context is protected and supportive, which is necessary for processes
of self-experience. Therapy follows the principle of guidance, is super-
vised by a qualified therapist, and in this function I ensure discipline and
intervene if something unexpected happens. Such situations are particu-
larly productive because they serve to exemplify something: how joint
interaction is successful or fails.

In the lecture version of this paper this is when I invite the audience to
sing together with me. The motif has an Indian touch and goes “na-na-na-
na, na-na-na-na, hey-hey-hey – good-bye (from a popular title by the pop
group Steam in the 1960s: “Kiss him good-bye”).

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Romanowski, B. (2007) Benefits and limitations of music therapy with psychiatric patients in the penitentiary
system. Music Therapy Today Vol.VIII (3) December. available at http://musictherapyworld.net

Then I tell my audience: You now had the opportunity of a short self-
experience when we tried to sing this melody together. In therapy this is
the moment for a feedback with the question: What did you experience?

Part of the audience probably enjoyed singing together. Perhaps you had
associations and memories. Others may have reacted offended and were
not in the mood, perhaps thought “oh, this is childish and not appropriate
in this context”.

Others did not wish to joint in at all – being ashamed of their own voice,
“what will others think of me?”. These are some possible responses. In
therapy this is the starting point for therapeutic work; the idea is to find
out what these different responses mean. How and what did the individ-
ual experience?

Let me address the function joint singing fulfils in human society. Sing-
ing is a pleasurable activity and promotes social and mental hygiene. It
improves interaction within a group. It produces feelings of togetherness
and being integrated in joint activity (sense of community). It means tun-
ing in to a joint rhythm or a melody followed by all involved. Just imag-
ine this situation!

In singing we breathe in and out together, we produce patterns of vibra-

tion in synchronization, we move mouth and speech organs in the same
pattern of movements. We swing together and thus improve harmony
within the group.

Joint singing is one possible method in music therapy. Depending on a

patient’s disorders, however, I have other therapeutic approaches avail-
able that might be more appropriate. I do not adhere to a strict plan, I
adapt to my patients and the specific situation and try to find out what
would be best in this moment.

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Romanowski, B. (2007) Benefits and limitations of music therapy with psychiatric patients in the penitentiary
system. Music Therapy Today Vol.VIII (3) December. available at http://musictherapyworld.net

If work with patients is very hard, if they are not in the mood and not pre-
pared to get involved, if they resist, then sometimes I find something new
and spontaneous to trigger the process – and if I succeed this is particu-
larly satisfying for all participants and the therapist, too.

MUSIC THERAPY Music therapy activities I employ at the psychiatric ward (there are other
ACTIVITIES
music therapy methods as well):

• Listening to music (sound experience with therapeutic instruments or

recorded music, and conversation)
• Joint singing and music-making (e.g. popular songs – I play the guitar)
• Improvisation (free or within a given framework) with easy-to-handle
instruments (percussion)
• Singing of songs to learn the language – I developed this method spe-
cifically for music therapy with prisoners
• Rhythmic work (e.g. with shaman drums and other percussion instru-
ments)
• Movement to music
• Guitar lessons in single therapy
• Spontaneous interventions as response to a client’s reaction (e.g. role
play with instruments, acting out an emotional situation or an experi-
ence)
• Conversation with clients as additional intervention outside group ses-
sions, e.g. in case of disciplinary problems

Group sessions have three phases. First a general welcome and introduc-
tion of newcomers. “The motto of this session is we do what is possi-
ble!”. The main part of the session is played out as spontaneously as
possible, depending on the situation. In the final phase participants have
the opportunity to evaluate what happened, and I announce what is
planned for the next session.

Which are the objectives of music therapy? The Dutch music therapy
researcher Henk Smeijsters explored “Therapy effects of music”
(Smeijsters 1997) and evaluated a number of studies on depression and
schizophrenia. From his findings I shall quote two very general “rules of

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Romanowski, B. (2007) Benefits and limitations of music therapy with psychiatric patients in the penitentiary
system. Music Therapy Today Vol.VIII (3) December. available at http://musictherapyworld.net

thumb” that may be considered as a “baseline” for the indication of music

therapy.

Rules of thumb:

1. Singing reduces anxiety (paranoid tendencies, distrust towards hospi-

tal staff)
2. Improvisation activates (withdrawal tendencies, negative effects of
hospitalization)

In addition music therapy pursues a variety of other objectives. I think of

music therapy as a holistic approach and do not presume to give a com-
prehensive list of aims but only a selection.

OBJECTIVES. • Generally improved condition through beneficial effects of joint

music-making
• Stimulation of breathing and vital functions through singing and
movement
• Improved mood
• Distraction from problem-oriented thinking and worries
• Emotional release through discharge of affect (e.g. loud drumming
gets rid of rage)
• Experience of compassion and comfort in the group
• Raised self-esteem through experience of success
• Improved motivation for participation
• Resources are discovered
• Expansion of mental horizon through new experience
• Promotion of creativity – ability to find solutions
• Improved self-perception and self-confidence, e.g. through orientation
to experience of one’s own voice and effects of personal activities on
others
• Improved perception of environment through directed listening (per-
ception of instruments in concert)
• Improved perception of others, attention directed to other group mem-
bers
• Experience and awareness of group dynamics
• Awareness of behaviour patterns
• Changes in behaviour (wrong attitude, antisocial behaviour)

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Romanowski, B. (2007) Benefits and limitations of music therapy with psychiatric patients in the penitentiary
system. Music Therapy Today Vol.VIII (3) December. available at http://musictherapyworld.net

Music therapy is no rigidly defined approach to be applied to every situa-

tion in the same manner. It is a creative approach where therapists must
always address their clients’ needs in imaginative ways in order to attend,
support and accompany them in the healing process, to heal them in the
sense that a patient learns to take the initiative in a positive way. An addi-
tional task of a music therapist is to recognize the individual needs of
patients in specific institutions, to adapt and shape the setting accordingly
in order to work with the patient in this context.

Important effective mechanisms in music therapy are: communication,

relationship, self-experience, and also reflection, which means that what
happens in music therapy must be described and presented in verbal
form. Verbalization of emotions, developments and conflicts then
becomes the basis for good relations because it helps to become aware of
personal behaviour patterns which become evident in musical interaction
as well. This requires to overcome anxiety and resistance again and again
(rejection, refusal, self-abasement, depreciation of therapist). A positive,
friendly and attentive atmosphere provides a healing and supporting con-
text for this endeavour.

It is not easy to achieve these objectives, because prison as an institution

basically is not a supportive, but rather a threatening place that can be
harmful. We see this for example in the attitude of guard and nursing per-
sonnel who show so-called transference phenomena, when patients’ anti-
social behaviour infects guards and carers. Moreover, life in prison
brings its own specific hardships, which we witness all the time, for
example extradition of asylum seekers to totalitarian regimes. Therapists
have to cope with such problems, too.

Supervision by experienced psychotherapeutic mentors is helpful to ther-

apists and other staff. Supervision may be a context to find empathy and

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Romanowski, B. (2007) Benefits and limitations of music therapy with psychiatric patients in the penitentiary
system. Music Therapy Today Vol.VIII (3) December. available at http://musictherapyworld.net

understanding, to discuss problems, address frustrations and hear valu-

able suggestions. Supervision is an essential part of successful therapy
work but has not been integrated in our institution so far. Nursing staff
did not make use of such offers but rather opposed them. One reason may
be that supervision was not established as necessary from the beginning.

Outlook

In future our society will have to find new ways how to guide individuals
who have fallen into deliquency or are under the stigma of psychiatry to a
socially integrated and accepted existence. Music therapy and other cre-
ative therapies may help because they promote an understanding of pro-
ductive togetherness and a deliberate employment of personal resources
in situations of conflict.

This article can be cited as:

Romanowski, B. (2007) Benefits and limitations of music therapy with
psychiatric patients in the penitentiary system. Music Therapy Today
Vol.VIII (3) December. available at http://musictherapyworld.net

Outlook 475