McDerment G. Singing towards freedom: An exploration of music therapy practices in Norwegian prison contexts. HPHR. 2022;56.10.54111/0001/DDD3
This narrative review explores the impacts of music therapy in Norwegian prisons as a powerful model for international mental health efforts for incarcerated populations. Exploring international prisoner mental health trends, Norway’s successful prison model, and challenges to Nordic prison contexts, significant background information explores the complex context around prisoner mental health and why Norway provides the best existent context for studying and implementing music therapy as a novel intervention. Looking at both qualitative and quantitative studies, this paper explores the effects of music therapy in Norwegian prisons. Though music therapy is difficult to study by its long-term nature, recent research speaks to music therapy as a viable treatment option that is effectively implementable in prison contexts and provide much needed help to incarcerated individuals. Many qualitative studies speak to this, focusing on how case studies and experiences with small cohorts create a personal experience for those receiving music therapy. In all of the qualitative studies explored, music therapy helped incarcerated Norwegian patients reach mental health goals in ways that other interventions had not been successful. Quantitative studies feature more ambiguous results, but all suggest successes for music therapy and suggest future experiments that have adequate ability to cover patients over longer timespans in more consistent incarceration contexts. Further exploration of all studies present inspire hope that music therapy can be successfully implemented further in Norwegian and international contexts.
Throughout existing literature, there remains consistency in reports of the declining state of mental health of incarcerated individuals around the world. Several years since entering the 21st century saw spikes in the number of publications on prisoner mental health, including those bolstered by governmental and United Nations efforts. The UN’s Trenčín statement on prisons and mental health remains resounding as the result of a large spike in the number of prison mental health publications in the preceding seven years. The document then codifies new standards for understanding and enacting prisoner mental healthcare that focus on the need for individualized and complete treatment.1 Across the world, this vision has received recent recognition, based on the collective respect for these goals, but there is much work to be done to ensure that incarcerated individuals do not endure mental illness and instability.
Across the world, different penal systems have historically yielded different results based on the intricacies of their programs. The United States, for example, has often ignored or oversimplified the mental health realities of its incarcerated population. A 1993 study from the National Coalition for the Mentally Ill in the Criminal Justice System details the processes that the US used to identify and treat prisoner mental health at several stages within the admission process, often finding lack of consistent definitions of mental illnesses.2 Four years later, researchers found that prison facilities were finding success taking creative, individualized treatment in directions helpful to inmates.3 Yet, prisons still faced lack of resources and restricting administrations operating in punitive correctional frameworks.4 More recently, the US process of decarceration will see the release of many incarcerated individuals with mental health ailments with specialized services for reintegration after release.5 It remains conceivable that these services, though, may not be able to provide adequate treatment for the large decarcerated population, adding strain on the non-incarcerated population. Though professionals in the United States are making great strides towards adequate mental healthcare in prisons, many logistical challenges exist.
Many recent studies highlight the tumultuous state of mental health in prisons in the United Kingdom, where negative trends prevail across the board. A study published in 2003 noted that the environment of the prison contributed to mental health issues amongst inmates. The physical and social background that a prisoner was to endure could speak to their mental health outcome to the degree where substance use patterns and other negative coping mechanisms could be correlated to isolation, negative relationships with prison staff members, and lack of staff.6 With few publications on prisoner mental health in the coming years, a particularly strong showing (4 publications) arose in 2018, all agreeing in the lack of emphasis on and equity of prison mental healthcare in the UK.7-10 As in the United States, resilience by frontline mental health workers have drastically improved prisoner mental wellbeing in the UK, but are not capable of solving widespread prisoner mental health issues without vast systemic change.
Australia has witnessed a similar trend, as deinstitutionalization of patients had reduced national psychiatric beds by 22,000 between the mid-1980s and 2006 as the population doubled. Starkly higher mental illness rates among prisoners in Australia suggests that the services are now not only less accessible to incarcerated individuals, but that a criminalization of mental illness is likely occurring when mental illness causes conflict with the law.11 This is especially prevalent in pre-conviction remand centers, which only worsen environmental factors to mental health explored in the UK. Australian researchers expand on the environmental element of mental health in prisons by highlighting the benefits of biophilic prison design, focusing on how the design of prisons can either serve as psychological benefactors or detractors of mental health, based around the biological needs of inmates.12
As many ideas for how mental healthcare can be improved, different national attitudes towards prisoner mental health dictate different guidelines and practices that work differently across contexts. This article features Norway’s system specifically, due to its progressive stance on prisoner welfare and its notable success meeting the mental health needs of its incarcerated population to a fuller extent than other nations.
Norway’s prison system has long been seen as a leader in global criminal justice, known for its high success rates and impressive commitment to human rights. Though Norway’s reputation proceeds it in humane and successful prisons, there are several distinctions necessary to understand nuances of the trends. In a look at Norway’s prison system from the Correctional Service of Norway Staff Academy, evidence highlights distinct advantages in smaller prisons in Norway and urges the nation to move towards a more decentralized approach.13 Highlighting the interpersonal elements of Norwegian prisons that leads to higher quality of life for prisoners is witnessed between inmates themselves. This is reflected in the social structure of the prisons that foster a communal landscape in which prisoners even share drugs.14 The communities present in Norwegian correctional facilities are at the forefront of Norway’s prison success, spurring the system’s benefits.
This may also directly result from early childhood exposure to humanistic outlooks towards those with unfavorable relationships to the law. In an award-winning study published in the Nordic Journal of Criminology, a criminologist from the University of Oslo explores two 1950s canonical children’s books that looks at offenders from a humanistic perspective in ways that focus on “desistance-conducive cultures” focusing on second chances and re-integration into society. These books proved seminal to early education in Norway, and the humanism spread far beyond the books themselves. Thorbjørn Egner, the author of the books explored, also had a hand in elementary school curriculums, songs, broadcasting, translating, and teaching.15 The study highlights the role that childhood development has on the institutions that dictate national policy. As a culture, Norway has moved towards a non-punitive mindset with criminal justice that may directly inform the successes of the country’s prison systems.
Norway’s prison mental health system finds some success in mental healthcare in comparison with its European counterparts. Norway’s prison system is actively implementing new methods to fight mental illness, including trauma-informed care.16 Higher staff levels are also associated with increased numbers of patients seeking treatment. Yet, there exist no actionable standards for mental healthcare that create uniform treatment approaches.17 There also remains an observed discord between the practices of correctional and mental health services in Norway, given that there is little evidence for collaboration between the two, though there are notable similarities in practice that suggest that such a collaboration may be occurring on some level, though not to the degree of competence where it becomes effective on any scale.18
Even through the country’s incredible prison success rate, several challenges exist to Norway’s mental health treatment schedules, several of which revolve around at-risk populations. Continued inequalities within mental health treatment produce significant challenges to equitable mental health care in a prison setting. A significant number of inmates, for example, suffer from intellectual disabilities, reaching 10.8% in a 2008 study in a landscape where services for patients with intellectual disabilities are largely nonexistent.19
The purpose of this article is to highlight the current role of music therapy in prison settings, explore its efficacy in clinical prison settings, and suggest updates to implementation, both in Norway and in other countries based on Norway’s present trajectory. Music therapy remains a cost-effective method by which prison populations in Norway and beyond may significantly benefit.
This narrative literature review explores academically published, peer reviewed articles that explore the intersection of prisoner mental health in Norway and a music therapy. There are nine publications that directly explore this intersection, with many speaking to the potential for insightful further study and successful clinical implementation of effective music therapy practices in prisons across Norway and the world. Articles were found using online search tools, as well as within extensive readings of a wide range of papers with referencing citations. Papers were chosen based on their relevance to the prison mental healthcare landscape in Norway and their relevance to discussions seeking to improve said landscape.
Present literature supports music therapy as an effective aid to mental health in prisons Music Therapy in Norwegian Prison Contexts. Many of these are qualitative, due to the interpersonal nature of music therapy and the varying range of ways in which patients respond to music therapy. Recently, researchers have begun to explore music therapy’s impact on prisons quantitatively, featuring a number of successful short-term studies that point towards future studies looking to realize long-term goals across cohorts.
Of the studies involved in music therapy, some of the greatest studies feature narrative accounts of music therapy’s personal psychological impacts. Being such an intimate, interpersonal practice, much of the research done on it historically has been qualitative. The closeness of these studies is exacerbated even more inside prison systems with relatively little implementation of music therapy practices, leading to smaller sample sizes. Such is true for a study at the University of Bergen, where researchers focus in on a music group, called Me and THE BAND’its, in which its three members were at one point incarcerated. The study finds that participating in musical outlets helps them overcome the negative mentalities associated with incarceration and see a hopeful future beyond their time in prison.20 In a similar study from the University of Bergen, a number of prisoners reflect on their music therapy experiences as that of a “freedom practice”, allowing them to transcend the physical walls of the correctional facility and feel more human.21 In both of these studies, the ability to participate in musicking, or the process of making music, affords prisoners a view beyond the darkness of their current situation and gives them hope that transcends that achieved in any of their other interventions. For the musicians, the music makes freedom a marker of identity for the ex-inmates, as they choose not to exact violence on the correctional system but find a new voice in community with each other.22 This act of subversion allows band members to find themselves outside of the revenge landscape. As this cultural shift occurs, one can look at a similar phenomenon to the societal mindset shift in favor of humanistic approaches to criminal reform in children’s literature mentioned above.15 As researchers at Norway’s Bjørgvin Prison suggest, the ability to create music is a central part of the human identity as an essential piece of the development23 and maintenance24 of an identity based around humanistic desistance. When treated as a human right, music’s ability to transform the lives of incarcerated individuals surfaces as what many argue to be a requisite for human existence. The art of practicing freedom through music therapy will create future benefit for incarcerated individuals and aids the purposes of the state by enabling successful prisoner re-introduction to society. Music therapy gives incarcerated individuals a humanness that, when fostered, aid rehabilitation efforts within and after prison in ways that increase chances of successful reintegration after prison.25
Still, much progress has yet to be made in Norwegian prison systems. Currently, music therapy is still seen as enrichment as opposed to a potential treatment cornerstone. When seen as a reward, music therapy’s efficacy becomes exclusive to mostly domestic male prisoners and incredibly limited to those that receive it.26 Under the current system music therapy remains limited, a problem that may be alleviated with national recognition and standardization of practice between prisons. Scandinavian research also supports the efficacy of music therapy in historically marginalized populations. A joint study from the University of Bergen and the University of Melbourne explore the experiences of female prisoners’ experiences with music therapy as incredibly successful when done within specific settings that foster the humanistic trust of participants.27 In another paper, the same researchers look at the benefits of performance in a therapeutic setting, yielding much the same results.28 In both cases, the music served as an engine for great change, if the environment was purposefully organized to support the core pieces of the humanity that the music was designed to reach.
In Norwegian prisons, three cohort-based studies in particular shed light on music therapy’s efficacy in on prisoner mental health. One, undertaken by Danish research in the United Kingdom uses both qualitative and quantitative methods to quantify the individual experiences of incarcerated individuals that experience music therapy. The study confirmed the efficacy of music therapy for helping prisoners, especially female prisoners, through mental challenges in ways that non-musical control group interventions could not.29 By bridging qualitative and quantitative, the researchers could pair the intense individuality that music-based interventions require with the statistical understanding to know that music therapy works on a large scale, beyond just individual interventions. Additionally, two fully quantitative studies, led by Christian Gold out of the University of Bergen, explore the effects of music therapy on larger- scale prison groups. The first, a pilot study, explored music therapy’s impact on depression and anxiety, suggesting that, for example, two weeks of music therapy can lower anxiety scores.
Though the study was inconclusive post hoc, the positive data points suggested that a longer study was possible and could yield positive results.30 For the team at the University of Bergen, this pilot kicked off a six-year follow up-based study that extended the ideas of the first and looked at not only mental health metrics, but also recidivism (re-offence rate). This study was also inconclusive, due to short sentence times. The study did, however, provide hopeful insights to randomized control trials with long-term studies individualized based on prisoner sentence and number of session.31 As far as this exploration leads, this is the only long-term analysis of mental health studies across prison populations. These reports are the first steps in a long line of projects that should speak well to the efficacy of music therapy within prison populations quantitatively.
As seen in the presented studies within a Norwegian context, music therapy shows great promise in aiding positive mental health outcomes and successful social re-integration after incarceration. For music therapy to serve as an effective engine for mental health improvement in prison populations, there must be greater long-term research in the field. Many of the highlighted studies feature the Norwegian prison system’s setup to be especially conducive to such further research. As the Norwegian system looks to continually improve its treatment of incarcerated patients, it remains vital that Norway keep progressing in its implementation of music therapy in prisons. It is also imperative that the follow-up, longitudinal studies described in the context of music therapy in prisons must be completed so that researchers and clinicians alike will be able to best understand and implement music therapy across relevant settings.
Future studies in Norway should also include more of a rural outlook. Given Norway’s vast rural landscape, wholistic research should seek to address more remote populations and their specific therapy needs.
Norway’s research in and implementation of music therapy principles speak clearly to music therapy’s efficacy into its own context while serving as a testing ground for new practices that have the potential to bring these positive outcomes to other countries around the world. It would be a great fallacy to see Norway’s successes in music therapy as necessitated by a vacuum that the progressive system creates. Instead, Norway’s position as a global leader in prisoner rights places it in a top position for implementation of new methodologies across the world. In a study of prisoners in China, depression and anxiety were shown to be significantly decreased in comparison with a standardized treatment group.32 This widescale mental health improvement is consistent with studies found in prison populations in the United States,33 Australia,34 the Netherlands,35,36 and Israel.37 All of these studies describe notable successes implementing music therapy in prisons as having unique benefits to patients not found in any other treatment options available to incarcerated patients. The ability to implement music therapy in these forums is also aided by its cost effectiveness. In mental health settings, music therapy is found to be more cost effective than pharmacological interventions to depression, anxiety, and other manifestations of neurological stress.38-41 When compared to standard care landscapes, music therapy is a way to provide successful, helpful care in the most cost-effective way possible, working towards favorable outcomes that utilize resources the most efficiently.
During the COVID-19 pandemic, researchers were able to explore the future of telehealth as a means of delivery for music therapy. A case study of a 33-year-old woman with COVID-19 (asymptomatic) found that a single session of music therapy lowered negative mental health fallout rates significantly as she dealt with the fear, anxiety, delusion of death, etc. associated with COVID. This case study has its drawbacks, though, as it makes sweeping claims of telehealth as a full-scale revolution in music therapy that will overtake the field in time. In fact, as the article claims that “lengthy” and “regular” psychotherapy meetings are “no longer relevant in the case of COVID-19.”42 As helpful as this would be to the psychotherapeutic community, a magic one-session treatment is hardly conceivable. However, the study’s take on the ability of music therapy to help inaccessible populations in moments of intense emotional distress speaks well to the perceived power of music therapy in larger psychotherapeutic contexts. A United States-based study found similar success over a three different forums in a series of case studies that all promote telehealth as a successful means for music therapy to improve the lives of individuals that are not readily accessible by in-person mental health personnel.43 Telehealth may be another avenue that bridges the patient care gap for incarcerated individuals, especially in remote facilities or that lack funding for resident staffers. As music therapy receives more attention as a means of mental health improvement in incarcerated environments, telehealth may see a significant increase due to its proven efficacy and tangible benefits.
As novel interventions into mental health outlets for incarcerated individuals remain in great demand, music therapy shows great promise, as explored and enacted in the Norwegian context. Within Norway specifically, music therapy holds great power to be able to better prisoner outcomes, both in terms of their wellbeing and their ability to re-integrate into society in the post-correctional period. Of the national systems explored, research into Norway’s current work using music therapy suggests that measures can be taken internationally to aid the advancement of prisoner mental health through the use of music therapy that mirror the current and future steps being taken within Norway itself.
From a policy perspective, this relies on investment from governments into both research into music therapy and implementation of music therapy practice. Due to the limited geographic extents of research that are to be done, it is imperative that more universities have access to funding for music therapy research, so that more research can exist in different contexts, aiding the practice of music therapy in the unique cultural and socioeconomic contexts present across the world. Additionally, governments should standardize guidelines based on localized research that promote informed consent and cultural sensitivity. The research moves the practice closer to the music therapy that can accurately and effectively in prisons around the world.
The author(s) have no relevant financial disclosures or conflicts of interest.
The author would like to thank Professor Christian Gold, of The Grieg Academy – Department of Music, at the University of Bergen, who advised him on this project. He would also like to recognize Professor Viggo Krüger, Professor Lars Tuastad, and Professor Claire Ghetti of the same department at the University of Bergen, and Professor Sybil Cooksey, his primary advisor at New York University. In addition, he would like to thank Professor Irene Morrison-Moncure and Rae Georges Navarro, both of whom advised his participation in research at New York University. The author was funded by a grant from New York University’s Gallatin School of Individualized Study via the Dean’s Award for Summer Research.
Gabriel McDerment is currently an undergraduate student at New York University’s Gallatin School of Individualized Study, where he is designing a concentration in Binaural Psychophysics and Sonic Ethnography. He is a Martin Luther King, Jr. Scholar and an Albert Gallatin Scholar with research focusing on sonic interventions to mental illness from neuroscience, anthropology, and public health contexts.