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This paper describes music therapy within a community mental health setting for adults using a care programme approach in England. It describes the setting, and emphasises the importance of multidisciplinary teamwork in order to enable music therapy to be effective. It provides some statistics and descriptive clinical information which demonstrate the efficacy of music therapy for adults with long-term mental health problems and argues that music therapy should be a priority for this client group. To support these points of view, the article includes a case study showing a psychoanalytically informed approach in music therapy. This paper was given as a keynote address at the 1994 Australian Conference of Music Therapy.

In this paper, I would like to share some of my thoughts about work with depression and how aspects of loss are linked with depressive states. I will show how, through the use of music, patients stuck in the depths of a painful depression are able to begin to express feelings through an experience in music, and how this gives them access to feelings that can then be articulated in words. My theoretical basis for understanding depression comes from the field of psychoanalysis.

A number of approaches exist within the field of music therapy. Some models for evaluating the efficacy of therapy have been adopted in the UK in recent years. These have measured the occurrence of specific behaviours within therapy, or compared music therapy with other interventions. There is a need to find reasonable reliable methods of describing change and the therapeutic process occurring with music therapy. This paper describes change occurring in five people with learning disabilities, in terms of their levels of engagement in therapy and in the therapeutic relationship. A method is provided, to evaluate independent observers' perceptions of change in the patients over a 30-sessions period of therapy. A significant increase in levels of engagement over time was found. It was also found that the degree of change over time was not related to the mean level of engagement. We discuss some subtle factors involved in therapeutic engagement for the five patients in the study, and stress the importance of a therapy which emphasises the dynamics of interpersonal communication for people with limited opportunities to express thoughts and emotions.