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Sing Your Heart Out: community singing as part of mental health recovery
  1. Tom Shakespeare,
  2. Alice Whieldon
  1. Norwich Medical School, University of East Anglia, Norwich, UK
  1. Correspondence to Professor Tom Shakespeare, c/o Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK; Tom.Shakespeare{at}uea.ac.uk

Abstract

This paper reports on a qualitative evaluation of a Norfolk-based network of community singing workshops aimed at people with mental health conditions and the general public. The aims of the study were (a) to evaluate the effectiveness of the Sing Your Heart Out (SYHO) project and (b) to identify the key features which made the project distinctive. The study draws on 20 interviews with participants, two focus groups with organisers and workshop leaders, and participative observation over a 6-month period. Interviewees all reported improvement in or maintenance of their mental health and well-being as a direct result of engagement in the singing workshops. For most it was a key component, and for some the only and sufficient component in their recovery and ongoing psychological stability. SYHO was regarded as different from choirs and from most other social groups and also different from therapy groups, music or otherwise. The combination of singing with an inclusive social aspect was regarded as essential in effecting recovery. The lack of pressure to discuss their condition and the absence of explicit therapy was also mentioned by most participants as an important and welcome element in why SYHO worked for them. The combination of singing and social engagement produced an ongoing feeling of belonging and well-being. Attendance provided them with structure, support and contact that improved functioning and mood. We conclude that the SYHO model offers a low-commitment, low-cost tool for mental health recovery within the community.

  • arts In health/arts and health
  • mental health care
  • community arts
  • music
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Introduction

Recovery approaches in mental health are not about regaining symptom-free normality, but moving beyond the role of patient and living a satisfying and hopeful life with mental illness.1 A conceptual framework comprising connectedness, hope, identity, meaning in life and empowerment is commonly identified as the core processes of the recovery approach.2 Participation in self-help groups, community organisations and arts activities can play an important role in this journey to recovery and well-being for people with mental health conditions.

Many studies have now shown the benefits of choral singing for social and mental well-being.3–7 Evidence suggests that group singing can help as coping strategy for people who are experiencing stressful life events.8 Liebowitz et al report that participatory choral music was beneficial in a residential setting for at-risk veterans, particularly because it promoted engagement and connection.9 A recent systematic review found evidence that participation in ongoing community singing programmes can improve quality of life and social and emotional well-being in adults living with chronic conditions.10 An Australian study found that participation in a community choir promoted well-being, improved social connectedness and benefited health and functioning for a group of adults with mental health and physical conditions.11 Sapouna and Pamer report from Cork on the benefits of the arts in mental health recovery in both inpatient and community mental health settings.12 These benefits of participatory community arts for people with chronic health problems should be distinguished from the well-evidenced clinical practice of music therapy.13–16

The Sing Your Heart Out (SYHO) project in Norfolk, UK, is a community-based network of four singing workshops, aimed both at people who have experienced mental health conditions, but also the general public. As one of the organisers put it, the project ‘recognises the inherently therapeutic effects of singing and singing with others’. The initiative began at the local psychiatric hospital, Hellesdon Hospital, in 2005, but afterwards moved into the community. The four different groups raise funding to employ professional musicians as leaders and offer weekly 90 min workshops free of charge to anyone who wants to participate. Once a year, the Big Sing event brings together participants from the whole network for a daylong celebration: up to 200 individuals participate in the Big Sing. As a user-led activity promoting connectedness, control, hope and empowerment, SYHO clearly adopts a recovery focus.

The authors were commissioned to conduct an evaluation of the project in 2015–2016, with the aims of (a) evaluating the effectiveness of the SYHO model in promoting well-being for all, and recovery for participants who have experience of secondary mental health services, and (b) characterising the distinctive SYHO approach, in order to understand what features of the SYHO project might contribute to positive outcomes for participants, to aid others who wish to replicate the approach.

Methods

This was a mixed-methods study, drawing on a desk review, semistructured qualitative interviews with leaders and participants, participant observation of the workshops, plus a psychological measure (WHO Quality of Life assessment) for preassessment and postassessment of the impact of attending the singing group for one term. This paper reports on the qualitative findings only.

The evaluation was conducted between July and December 2015. One focus group was conducted with the four founders and key organisers of SYHO. A second was held with the two senior voice coaches who work with the singing workshops. Twenty in-depth interviews were conducted with participants from all four SYHO groups. Participants were self-selecting, volunteering to be interviewed or responding to invitations from organisers. The sample comprised 14 women and 6 men (roughly proportional to gender make-up of the SYHO community). Seventeen participants identified themselves as current or former service users, a further two disclosed that they had significant ongoing health problems. Six participants identified as carers or former carers; five identified their caring role as a significant cause of mental health difficulties. Both researchers conducted participant observation; interviews/focus groups were conducted by AW.

An inductive approach was taken to data analysis. The interviews and focus groups were transcribed and analysed thematically, with both researchers looking independently for themes and categories derived from data, and then comparing findings. The project was written up by TS.

Findings

Benefits of singing

As SYHO does not require participants to be good at singing, or even to sing at all, this has enabled people to enjoy an experience that is otherwise difficult to find. It was noted by interviewees and also by other participants at the workshops that SYHO actually made a very nice sound much of the time.

Organisers and particularly coaches stressed the focus of SYHO as a place to sing; at its most basic they saw it as an ‘opportunity to sing together’. Mental health or illness was not the focus of the workshops. Participants all regarded singing as key to the efficacy of the model and reported a thorough enjoyment of singing. For many this represented a chance to feel good and express happiness with others. The focus on singing rather than therapy allowed participants to use it as a resource and interpret it however they wished. Some saw it as a fun, low-key opportunity to sing, others saw it as a crucial component to the maintenance of their well-being.

There was a SYHO Songbook, with songs chosen for their uplifting or emotional content and harmonies. The songs were mostly musically simple and quite short. Several participants described the repertoire as ‘world music’ as there were quite a number of short foreign-language songs. This variety of songs was welcomed by all participants. The songbooks were kept by the coaches and handed out at each session. The songbooks were regularly edited and updated. The way of teaching meant that reading was not essential. One blind participant found this particularly important, saying, ‘If it was just a book and told to turn to a page, then couldn’t do it. They build up a song line by line and they repeat it.’

All interviewees reported positive effects on their mental health from participation in singing together. For some it represented one component of a wider programme of support. For others it stood out as key to their recovery or the maintenance of health. Participant 1 called it a ‘life saver’ and ‘the key to my recovery … the single most important thing for me’. Participant 2 noted, ‘Without SYHO I wouldn’t be here, I wouldn’t have managed.’ Participant 4 said, ‘SYHO saved my sanity that year.’ The combination of singing and social engagement produced a feeling of belonging and well-being that often lasted for more than a day and, as a weekly engagement, gave ongoing structure, support and contact that kept them at a higher level of functionality and their moods better than they would be without. More specifically, participants explained that singing was, for instance, a form of communication that was safe, that it enabled them to express emotions in a supported environment and communicate in a socially unthreatening way. For many who had a history of social anxiety, this was highly valued and the majority of interviewees reported a significant improvement in social skills and confidence.

A common theme was the change in mood brought about by singing in the group. For example, one participant said, ‘It gives you a real feel good factor and really lifts you.’ Another said, ‘My husband says – you always come home smiling, and probably singing as well when you come back from SYHO …. I feel different … it’s done me some good.’ Another participant said, ‘I always come out on a high … sometimes I don’t want to go, but I make the effort and am always glad I did…. it definitely lifts the mood’. Another said, ‘It builds self-esteem and protects against relapses. It gives people a lift …. I did CBT etc. but didn’t get on with it. But this is actually doing something that’s having an effect.’ The organisers stress there is no serious intent to the singing in SYHO, it is for fun. This was repeated many times in different ways by most participants. They used words like ‘joy’ and ‘happy’, ‘funny’ and ‘silly’. Making mistakes and laughing together about them was part of the experience. For many participants, it was 90 min in the week when they are happy.

Physical benefits to singing were also mentioned by a few participants. One participant reduced her asthma medication after being in SYHO first and then joining other singing groups. Another had found singing helped with rehabilitation after a brain tumour in helping relearn speech. Another mentioned that he had learnt to breathe better at SYHO and that this had been very important to him. One interviewee noted that she had learnt to breathe out and that this had been significant in helping deal with long-term anxiety attacks.

The coaches particularly stressed that SYHO was not a choir. Specifically, the workshops did not rehearse towards performances so there was no expectation or pressure to perform to any particular standard on any given day. Singing was central to the workshops, but the quality of the sound produced by the group was considered only in terms of the best the group could achieve on that day, rather than according to standards of musical excellence. The quality varied from week to week. But as coach 2 said, ‘Their best is always good enough. We wouldn’t want them to feel that they have to be different from that.’

SYHO groups have sung in public on occasion but only with the understanding that the open principles would be maintained up to and on the day of performance and participants were free to engage or not. For example, a public performance in Norwich Cathedral Cloisters was flagged by several as a significant high point of the year or even of their lives. Many interviewees reported thoroughly enjoying these events but also appreciated the low commitment of the SYHO model.

Once participants had taken the step of joining in with SYHO, they were then led by the singing coach. This balance between taking the initiative and being carried by the structure was empowering. Organiser 2 said, ‘You all draw breath together. It’s unlike a conversation where one person goes, and then the other. Producing the same sound together with others and making music, just with the voice, there is a kind of magic in it.’ Coach 1 said, ‘You often see a look of amazement on people’s faces, like we did that. It’s easy to do, but we did this big thing together.’ Several interviewees noted that working together towards a single, achievable goal was a ‘win’ and, as such, empowering. One participant noted that ‘the singing somehow unites you’. For many, this feeling of being together was stronger through singing than it would be in a group that was just social.

Holding a tune in this semipublic way can be a boost to self-confidence. One of the coaches gave an example of an occasion when there was only one man present at a workshop. He was quite shy and was given the option of joining in with a set of ladies, but chose to hold the bass part on his own, with support from the coach. At the end of the session, coach 1 reported that he said, ‘Thank you for that. It was the first time I’ve felt like I really mattered.’

It was reported by several organisers and coaches that singing in the group had helped participants ‘remember’ parts of themselves that are well-functioning. Through engaging, some people had rediscovered lost aspects of themselves. One participant ‘remembered’ that she used to play the violin and started playing again. Her family told the coaches that she had been considerably more like her old and happier self as a result. A coach said: ‘I have witnessed an almost immediate growth in stature when a former singer recovers that part of him/herself which is able to do something well (possibly better than their carer) and own some pride and sense of identity.’

Inclusivity

Organisers saw SYHO as a space that welcomes current and ex-mental health service users as its main target audience, but openness to everyone was the goal. Issues like the accessibility of the venue and the welcoming ethos ensured this outcome was achieved. The aim was to provide a safe environment in which there was understanding of the varieties of mental ill-health and the needs that may arise with such conditions. There was a wide community of occasional attenders, of whom around 120 people each week attended the four different workshops. Two-thirds of participants had had contact with mental health services. With no fee, no pressure to rehearse towards a performance, no questions asked about background and no audition, the workshops were low commitment.

Openness was a key theme in participant interviews, with over half of the respondents noting SYHO’s inclusiveness. One participant said, Lots of things say they are inclusive but aren’t really. SYHO really is. There are no cliques, no animosity, no competition.’ Another said, ‘It all goes back to a feeling of being part of something; to that feeling of inclusion. Some choirs can feel like the opposite. I’ve been in choirs that make people feel they’re not up to scratch – that wasn’t the intention but it was the effect.’ More diverse behaviour was accepted in SYHO workshops than in more mainstream singing groups. For instance, a person who made undifferentiated sounds throughout may be accepted by other participants if it were recognised as a ‘happy’ noise or one that was not intended to be disruptive. It was for this reason that SYHO was described as a workshop, rather than a choir.

For many participants, the low commitment model was very appealing. One said, ‘This was probably somewhere I didn’t have to come every week and no one would ask questions’ as an important advantage. This participant had a fairly high commitment to SYHO and had been attending for some years on and off as part of their programme for managing mental health problems. The safety of SYHO was key for many people. One participant said, ‘I felt OK from the start. I didn’t have to justify taking a break. I didn’t have to say … I could just nip out.’ Another participant, who had joined SYHO during a breakdown when signed off from work but had since returned to work, said, ‘Without SYHO there wouldn’t have been a recovery … I would never have got back to work … it really was that significant … without them I couldn’t have done it … I didn’t realise how bad I was …. If the advert had been worded differently, about mental health problems, I wouldn’t have gone.’ For some, the absence of pressure to give personal information was a significant factor in first coming to the group.

For people who do not have lived experience of mental distress, SYHO acted as public education. Most people ordinarily would not engage with others who behave a bit unusually. But singing together ‘softens the edges round people’ (organiser). Some people found it too strange and had not stayed for that reason. But for others it changed their perception of who is too strange to engage with. They might have been singing with someone happily, and then spoke to them in the break and found out they had been referred by their doctor. According to organiser 3, ‘It opens the door to being with people you might never have been together with before.’ For this reason, some student doctors and nurses had attended SYHO as a small part of their training. At SYHO, no one was identified as a service user, and no one labelled anyone else. This meant that friendships had been formed between professionals and service users that would have been almost unthinkable in other circumstances. For example, the chair of the Mental Health Trust reported sitting next to a service user who helped her. Neither knew who the other was. This kind of contact changed relationships and reduced stigma.

Social capital

All interviewees said the social aspect was a vital component of the SYHO model and a reason why it worked for them. Many cited SYHO as an important turning point in their lives. For instance, one man who had been attending for a few months said that ‘there have definitely been changes since going’ and went on to say that because of gaining confidence going to SYHO he had started going to other social and creative groups. Another noted, ‘I’m left happier so more confident. I know more people and have new friends and contacts.’ And another in a similar vein, ‘It’s given me a lot of confidence. I was scared and anxious and I was only used to unfriendly people. I got welcomed, the people were very nice. The coach gave me eye-contact and wanted to know my name and was considerate to me. She went out of her way, which is what she does for everybody. I really enjoyed it.’

People found there was a camaraderie in singing together, and particularly in singing different parts in smaller groups. There was a physical closeness that people exaggerated in leaning towards each other, listening to the parts and helping others by singing the parts they remembered when others did not. One person remarked, ‘You lean in bodily with your own group. This is bonding and I find this very valuable.’ So although each person was responsible for the sound they made and for joining in, this helping and being willing to receive help increased the sense of being in something together. It also, and perhaps crucially, represented a model of good communication which seemed, in many cases, to rehabilitate the ability to develop relationships which people could then transfer to their lives more broadly.

Organisers in particular, but also a few interviewees, noted that people had formed friendly relationships and sometimes friendships with people they would otherwise never have had social contact with. This had, for some professionals, greatly enhanced their sympathy for service users. For some service users, it had helped support self-esteem as they had found themselves able to engage socially with people, both mental health professionals but also people they thought of as ‘ordinary’ or ‘normal’, on an equal social footing. One participant noted, ‘You talked to everybody, it didn’t matter who they were …. We were all in this together.’ The inclusivity of SYHO enabled several interviewees to feel acceptable whereas they had experienced exclusion and/or alienation in other social groups, ‘When I joined I felt like an outsider because of what was going on inside. With SYHO I felt much more at ease with myself.’ For some it had been the beginning of greater engagement with others, both in SYHO and more widely.

The tea break halfway through the workshop was an important part of the structure. It allowed people to engage socially with low intensity on ordinary matters. There was initially some resistance from the organisers to a refreshment break, due largely to logistics, but the original coach insisted and it was swiftly recognised as an essential aspect of the workshop. She said, ‘When we finally did it and sat down, I said to the organiser, “listen to that”, and there was this amazing sound, “that’s people talking to each other for the first time.”’ Before this, there had just been a 10 min loo break and no one had spoken to each other. Now, coach 1 said, ‘They understood that it wasn’t about the tea, but you need the tea as a prop. It was just ordinary talk about what tea you want? Do you want a biscuit? … but people also start talking about their mental health, things like, “when were you sectioned?”’

The tea break was an element of ordinary pleasure, mentioned regularly by organisers and participants as vital to the model. It allowed them to engage socially, have a break from singing, quench thirst or take a break from the group. A few interviewees reported that they had found the tea break challenging due to social anxiety. But the high acceptance of unsociability within SYHO and the lack of pressure to speak meant that all those interviewed had come to value the break and some to view it as a place to gain social confidence. Some additionally saw it as a chance to have nice tea and chocolate biscuits that they would not otherwise have. A few also noted that being served made them feel valued. It also gave people concrete roles within the group. Everyone could wash up or put the kettle on or pass around the biscuits, and people could grow in these roles.

Coach 1 talked about the role of the annual gathering of the whole network:

One way in which the Big Sing helps further is in offering an extended sense of this immediate family – including all the distant and lesser known ‘relatives’, who, despite not knowing the individual, nonetheless hold this same ‘family’ ethos of acceptance and therefore expand this feeling of safety and a place where you can be the whole of who you are. Of course in time, it’s wonderful if people do recover a sense of their healthy selves and become more recognisable to their family, but in the interim phase, it is essential to feel this sense of another family who are not waiting for you to feel better before they can relate to you.

While a sense of community may often be important in any singing group, in SYHO, the community was especially important because for many participants contact with others was one of the biggest benefits they experienced.

Support and self-help

An important feature of SYHO was to provide support for people who were experiencing distress. Alongside the singing coaches, there were usually others present who were on the lookout for anyone who was distressed or disruptive or otherwise experiencing symptoms of mental ill-health. These were participants of any background, experienced in being with people presenting with mental health problems. Those supporting other participants were knowledgeable and able to contact services and carers where necessary. Participants willing to take on greater responsibility within the group were increasingly encouraged by SYHO to take Mental Health First Aid training (run by MIND), so they had greater awareness of what may have been going on for other participants and knew the basics of how to offer assistance. Support in SYHO was experienced as being welcoming and participants felt emotional behaviour was acceptable. Most of those interviewed experienced this support as coming from the coach and other participants. Those also on the committee were aware of a somewhat more formal arrangement, but in fact, much of the support was gained from the group as a whole.

The aim of SYHO was that the organisational aspects of the workshops would be user-led where possible. Several of the interviewees had been on the organising committee for their group, and others made a point of helping with particular tasks such as making tea, bringing biscuits and putting chairs out. Four participants credited helping, along with the singing, as crucial in regaining their mental health. SYHO offered roles to any participant who wanted to take on any degree of responsibility. For some, this might be as simple as washing up, while others had taken on more substantial positions of responsibility on committees and a few service users had gone on to be key organisers and developed skills in management, public speaking and fundraising. Getting involved in organising provided the benefit of self-efficacy and positive feelings about helping others. One person said, ‘Gradually, as I got more and more drawn in and asked to do things, you feel you need to give more commitment and by giving more commitment you find you’re more satisfied.’

Conclusion

The findings from this study reinforce the benefits of participating in singing in a community context for people who have experienced mental health conditions. Singing was cited as joyful in and of itself and the low-pressure nature of the SYHO model was regarded by all participants as engendering fun and happiness. The social and self-help aspects of the SYHO model were also cited as important opportunities for developing social skills in a safe environment, as well as rediscovering work-related skills. SYHO clearly fitted within an overall mental health recovery ethos because it was about life beyond illness.

The distinctiveness of the current study derives from it being conducted with a group of people who predominantly had been patients in secondary mental healthcare settings; but it was not music therapy; and it was a self-organised community project, rather than operated within clinical settings. While the themes of this study echo some of the findings of Secker et al’s research on participatory arts in mental health, for example, reduced social isolation; relaxation; enhanced self-esteem and confidence; and rebuilding identities,17 however, the current study provides richer detail on exactly how these benefits accrue in the context of singing. The study echoes the findings of Dingle et al’s study.12 However, whereas the Australian study followed the first year of a new choir, the SYHO singing groups have been operating for >10 years, with many long-term participants.

The SYHO project appeared highly effective among those who continue to attend. There was a high level of commitment among attendees even though they may take long breaks. But SYHO was not for everyone. One limitation of this qualitative study is that we were unable to follow individuals who did not find SYHO worked for them. More research is needed with those who do not find the SYHO model appealing, or who dropped out after coming once or twice. It would be helpful to conduct a randomised controlled trial of the SYHO model versus conventional community mental health approaches.

As with any voluntary organisation, sustainability of SYHO was a big issue. For organisers who themselves had mental health conditions, participation and responsibility can add stress. Maintaining the mixture of people with lived experience, and others who are carers, members of the general public or professionals, seemed valuable to maintain continuity and avoid individual crises having adverse effects on the project as a whole. Funding to pay the workshop leaders and meet the costs of venue and refreshments remained an important issue. In the longer term, a paid facilitator for the whole network would help promote efficiency and sustainability.

Despite these caveats, the SYHO experience offered a very good model for community singing as part of mental health recovery. Beyond the immediate benefits of choral singing, SYHO built social capital. With minimal funding, this grass-roots network had survived and grown over more a decade, and remained vigorous and highly valued by participants. This study reinforces previous findings about the benefits of arts for well-being.10–12 18 The results also demonstrate the subsidiary values of empowerment and social participation deriving from participation in community singing workshops.

Acknowledgments

The authors thank Penny Holden, Maggie Wheeler and all the SYHO organisers, workshop leaders and participants for their support. Thanks also to Hannah Zeilig and Guy Peryer for their advice on writing up the project, and to the journal referees for extremely helpful comments.

References

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Footnotes

  • Contributors The study was conceived and led by TS. TS and AW conducted participant observation, and interviews/focus groups were conducted by AW. Both authors collaborated on analysis. The project was written up and revised by TS.

  • Funding The evaluation on which this paper is based was funded by the SYHO network.

  • Competing interests None declared.

  • Ethics approval UEA Faculty of Medicine and Health Sciences Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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