Music Therapy Today WFMT online journal Volume 15, No. 1 by World Federation of Music Therapy

Music Therapy Today

WFMT online journal Volume 15, No. 1

SPECIAL EDITION: MUSIC THERAPY & TRAUMA Music Therapy Today publishes articles that are related to music therapy education, practice, and research. Categories may include, but are not limited to Editorials, Presidential Notes, Position Statements, Curriculum Reports, Clinical Case Studies, Research Reports, Service Projects, World Congresses Proceedings, Interviews, Book Reviews, and Online Resources. 2019 WFMT. All rights reserved. ISSN: 1610-191X

MUSICTHERAPYToday, Volume 15 No. 1, 2019

Suggested Citation of this Publication

author a. a., author B, B., & author C. C. (2019). Title of article. Music Therapy Today 15(1), pp-pp. Retrieved from http://musictherapytoday.wfmt.info

MUSICTHERAPYToday, Volume 15, No. 1, 2019

Disclaimer

The opinions and information contained in this publication are those of the authors of the respective articles and not necessarily those of editors, proofreaders, or the World Federation of Music Therapy (WFMT). Consequently, we assume no liability or risk that may be incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this publication. For this issue authors have prepared their own manuscripts attending to content, grammar, language ďŹ&#x201A;uency, and formatting. any errors may be discussed with the authors.

MUSICTHERAPYToday, Volume 15 No. 1, 2019

Music Therapy Perspectives 2019 Edition Co-Editors

Annie Heiderscheit, Ph.D., MT-BC, LMFT Gene Ann Behrens, Ph.D., MT-BC

Business Manager

Melissa Mercadal-Brotons, Ph.D., MT-BC, SMTAE

Editorial Board

Juanita Eslava, Ph.D. Nancy Jackson, Ph.D., MT-BC Doug Keith, Ph.D., MT-BC Jin Lee, Ph.D. Satoko Mori-Inoue, Ph.D. Kathleen Murphy, Ph.D., MT-BC Karyn Stuart, MMT

Translations

Melissa Mercadal-Brotons, Ph.D., MT-BC, SMTAE

Graphic Design

Editorial MÃ©dica Jims, S. L.

Published by

World Federation of Music Therapy (WFMT) www.wfmt.info Music Therapy Today ISSN 1610-191X

MUSICTHERAPYToday, Volume 15, No. 1, 2019

CONTENTS MESSAGE FROM WFMT PRESIDENT ..... 7 melissa mercadal-brotons

CO-EDITORS MESSAGES ..... 9

annie HeiderscHeit & Gene ann beHrens

SPECIAL EDITION: MUSIC THERAPY & TRAUMA

1. ChalleNges, BeNeFiTs, aNd TReNds FRoM a NeuRoBiologiCal appRoaCh To MusiC TheRapy ..... 13 Gene ann beHrens, PH.d., mt-bc

2. deVelopMeNT oF The sMaaRT pRoToCol FoR adulT Male pRisoNeRs WiTh pTsd ..... 21 Clare macfarlane (netHerlands)

3. MusiC TheRapy, NeuRology & soMaToseNsoRy- iNFoRMed TRauMa TReaTMeNT ..... 33 Kristen stewart, ma, mt-bc, lcat, seP(Us)

4. RhyThM-To-BeaT TRauMa: a TRauMa-iNFoRMed appRoaCh FoR MusiC TheRapy WiTh a JapaNese iNTeRNMeNT CaMp suRViVoR ..... 47 laUrien HaKvoort, PH.d., srmtH, nmt-f (netHerlands)

5. hoW NeuRosCieNCe ReseaRCh suppoRTs MusiC TheRapy WiTh ChildReN Who haVe expeRieNCed sexual aBuse ..... 59 dr. sc. mUs. Gitta streHlow, diPl.mUsic-tHeraPist (Germany)

6. CoNsideRaTioNs FoR MusiC TheRapy iN loNg-TeRM RespoNse To Mass TRagedy aNd TRauMa ..... 78 Jennifer soKira, mmt, lcat, mt-bc (Us)

7. The sTaRTle ReFlex: iMpliCaTioNs iN TRauMa aNd MusiC TheRapy ..... 91 elizabetH steGemoller (Us)

MUSICTHERAPYToday, Volume 15 No. 1, 2019

BOOK REvIEWS

1. The Body keeps sCoRe By Bessel VaN deR kolk ..... 99 review by annie HeiderscHeit, PH.d., mt-bc, lmft

2. poCkeT guide To polyVagal TheoRy By sTepheN poRges ..... 103 review by annie HeiderscHeit, PH.d., mt-bc, lmft

REvIEW ARTICLE

MusiC iNTeRVeNTioNs FoR iNTegRaTiNg loss Based BuddhisT psyChology pRaCTiCe ..... 108 PUcHoinG cHimPiboo, ma, dr. PornPan KaenamPornPan & dena reGister, PH.d., mt-bc

ORIGINAL RESEARCH

does a CusToMized MusiCal soNg pRoMoTe a MoRe posiTiVe expeRieNCe Vs. RhyThMiC audiToRy sTiMulaTioN WheN used To eNhaNCe WalkiNg FoR people WiTh paRkiNsoNâ&#x20AC;&#x2122;s disease? ..... 119 Kristen barta, Pt, PH.d., dPt, ncs, carolyn da silva, Pt, dsc, ncs, sHiH-cHai tsenG, Pt, PH.d., toni roddey, Pt, PHd., ocs, faaomPt

COMMISSION REPORT

MoViNg The pRoFessioN FoRWaRd: goVeRNMeNTal ReCogNiTioN, iNCReased aCCess, aNd CoMpeTiTiVe pay ..... 134 daniel taGUe, PH.d., mt-bc & Petra Kern, PH.d., mt-bc

BOOK REvIEW

adolesCeNTs WiTh auTisM speCTRuM disoRdeR: a CliNiCal haNdBook ediTed By NiCholas gelBaR ..... 159 review by lindsay marKwortH, mmt, mt-bc

ADDENDUM

saTo, k. & soNoyaMa, s. (2018). iMpleMeNTiNg a soNg as a ReWaRd FoR TRaNsiTioN FRoM FRee-play TiMe To a gRoup aCTiViTy. mUsic tHeraPy, 14(1), 37-51 ..... 169

MUSictHeRaPYToDAy, Volume 15, No. 1, 2019

Presidential note SPecial edition: MUSic tHeRaPY & tRaUMa The 2019 edition is dedicated to Music Therapy & Trauma and I am very pleased we have had the collaboration of Dr. Gene Ann Behrens, past chair of the Global Crises Intervention Commission, as co-editor of this issue.

The WFMT journal, Music Therapy Today is a peer-reviewed publication which is made possible through the editorial directorship of Dr. Annie Heiderscheit and the dedicated editorial review board comprised of reviewers from various regions of the globe. The purpose of the journal is to disseminate current knowledge and information about music therapy education, clinical practice, and research worldwide. I am delighted that in this edition, we have papers that represent music therapy practice and topics of interest from different parts of the globe.

Music therapy practice is diverse around the world, and this diversity is reflected in the populations treated by music therapists, problem areas addressed, and publications. The consequences of trauma and its symptoms have become more common to be addressed by music therapists. There is a long and rich tradition of using music to cultivate resilience and facilitate healing in the wake of violence and oppression. And nowadays, there is theoretical and empirical evidence to suggest that individuals with trauma expo-

sure and Posttraumatic Stress Disorder (PTSD), may derive benefits from music therapy. The articles included in this issue of Music Therapy Today are rich contributions to this area of Music Therapy.

In addition to the seven articles on trauma, the 2019 edition also includes three book reviews, a review article, two original research articles and a commission report. The WFMT strives to produce a publication that is accessible to everyone who endeavors to continue to learn and develop their practice as music therapists and health care practitioners. The papers for this issue indicate a real desire and commitment by authors to contribute to the knowledge base of music therapy and to grow our profession internationally.

I trust you will enjoy this edition and hope that it inspires you to consider submitting an article for publication in future editions. As President of the WFMT it is an honor to serve as the Business Manager for this important publication. Regards,

Melissa Mercadal-Brotons, PhD, MT-BC, SMTAE president@wfmt.info

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about the author

Melissa Mercadal-Brotons, Phd, Mt-Bc, SMtae Melissa Mercadal-Brotons is the Academic Director and Director of the Music Therapy Master Program at the Escola Superior de MuĚ sica de Catalunya (ESMUC). She is the President of the World Federation of Music Therapy (WFMT) and the Spanish Delegate of the European Music Therapy Confederation (EMTC).

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Co-editors messages It is with great anticipation and excitement that I write this message for the 2019 issue of Music Therapy Today. This issue has been under construction for a while, from incubation stage to determining contributing authors, to now being available to you the reader. Our understanding of trauma and its impact has grown in leaps and bounds in the past several years. As a result, the work that music therapists are doing all around the world is important to bring into our literature. Gene Ann Behrens has been one of those very professionals championing this topic and striving to advance the understanding of the neurobiology of trauma and how this impacts the work we do as music therapists. Many thanks go to Gene Ann for her passion, vision, and dedication to collaborating with Music Therapy Today to bring this issue to light.

Many thanks to the authors contributing to this topic, sharing their clinical work and research to inform our global profession on this topic. We are fortunate to have an international cadre of authors contributing their work on the topic of music therapy and trauma. You will see in this issue that this special edition issue on music therapy and trauma includes seven articles from a variety of aspects related to trauma, as well as two

book reviews on important topics impacting informed trauma practice and research. You will find this issue informative and intriguing. While the focus of this issue is a special edition issue on music therapy and trauma, we do have additional articles in the issue as well. You will find a review article, original research article, a commission report, and book review. This is a robust issue and indicative of the growth in our profession.

The work of all the authors in this issue is what helps to support and foster the development of the profession. It is exciting to be able to share and exchange information from so many countries around the world. Enjoy reading all that is included in this issue. Be inspired! I hope that as you explore and discover the work being done by music therapists around the work that you decide to share some aspect of your work and consider submitting a manuscript, report, book review, etc. for publication in Music Therapy Today.

Annie Heiderscheit, Ph.D., MT-BC, LMFT

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This 2019, special edition of Music Therapy Today focuses on how several music therapists use neuroscience in their trauma-informed work. The collection of articles and book reviews marks the culmination of years of advocating for and educating about what has become a passion for myself. The publication also represents what I see will be the future of music therapy in trauma workâ&#x20AC;&#x201D;one that involves the use of neuroscience research to assess and direct trauma-informed treatment. Following an introduction to the topic area from myself, six courageous music therapists share their knowledge and treatment approaches based on their perspective and use of neuroscience research. Readers also can consult two book reviews as they consider further investigations on the topic.

I am grateful to the World Federation of Music Therapy (WFMT) for providing this critical platform that promotes and advocates for music therapists across the world to adopt a neuroscience perspective to their trauma work. I encourage music therapists to read the articles, ask questions, struggle with the concepts, look up additional descriptions and articles, and discuss the relevance of a neurobiology of trauma approach to treatment. Neuroscience is paving an exciting future for how we understand and employ music to help clients regain self-regulation and homeostasis and become socially engaged with significant others and themselves as important resources.

Gene Ann Behrens, Ph.D., MT-BC

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About the Author

Annie Heiderscheit, Ph.D., MT-BC, LMFT is the director of music therapy at Augsburg University in Minneapolis, Minnesota, where she oversees the undergraduate and graduate music therapy programs. She is currently the Publications Chair of the WFMT and the Communication Chair for the International Association of Music and Medicine. She is a senior music therapist at the University of Minnesota Masonic Childrenâ&#x20AC;&#x2122;s Hospital, maintaining an active clinical and private practice, as well as an active research practice.

About the Author

Gene Ann Behrens, Ph.D., MT-BC, is a professor and the director of music therapy at Elizabethtown College, Pennsylvania, USA. Besides her professional interests in research design/statistics, Gene Annâ&#x20AC;&#x2122;s national and international presentations and clinical work focuses on the neurobiology of trauma.

Special Edition: Music therapy & Trauma

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Challenges, Beneﬁts, and Trends from a Neurobiological Approach to Music Therapy Gene Ann Behrens, PhD, MT-BC

Elizabethtown College, Elizabethtown, Pennsylvania. United States

I am grateful and honored to be the guest editor for this special issue of the World Federation of Music Therapy Journal, Music Therapy Today, on current applications of the neurobiology of trauma research within music therapy. I also am fortunate to introduce readers to a courageous group of music therapists who are laying the foundation for trauma-informed work. This special edition is timely and important within the body of music therapy literature for two reasons. First, the incidence of trauma experiences is increasing across the world. Unfortunately, natural and human-caused disasters continue to occur. (Benjet et al., 2016; Hansen, Østergaard, Sønderskov, & Dinesen, 2016; Harper & von Hein, 2018; McLoud, 2017; Rhee et al., 2014). Ongoing conﬂicts exist in many countries; weather shifts are increasing the incidence of natural disasters; transportation accidents often are in the news; and shootings, abuse, and neglect touch the lives of more people each year. Second, the comorbidity of trauma, post-traumatic stress disorder (PTSD), also has increased within mental health, medicine, and special education (Brady, Killeen, Brewerton, & Lucerini, 2000; Fuld, 2018; Grubaugh, Zinzow, Paul, Egede, & Frueh, 2011; Turk, Robbins, & Woodhead, 2005). Trauma is now comorbid with most mental health disorders, a component of many medical diagnoses, and a part of the experiences of many

children and adults dealing with developmental and intellectual disabilities.

While many use the term “trauma-informed”, I believe to have a perspective and treatment approach that truly is supported by knowledge about trauma, music therapists need to have a basic understanding of research about the neurobiology of trauma. In fact, given the continued advancement of technology, neuroscience now provides insight into the diagnoses and treatment strategies for most mental health diagnoses and supports the comorbid link to trauma symptoms. As Dahlitz (2017) states, the future of mental health resides with those who are open to call themselves “neuropsychotherapists”.

While the ever-expanding body of neuroscience research may suggest shifts in perspectives and treatment approaches, the outcomes or results of these studies are “aphilosophical” and therefore, can be incorporated into most all therapeutic philosophies and methodologies. This research challenges all health care workers, including music therapists, to consider interpreting PTSD symptoms as the result of trauma negatively impacting the brain and body by essentially hijacking a person’s nervous system; however, this research does not suggest therapists change their philosophical view. Music therapists wor-

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king from a wide range of approaches, for example, humanistic, psychodynamic, behavioral, cognitive-behavioral, music-centered, somatic, dialectical behavioral therapy, Greenspan Floortime®, Acceptance and Commitment Therapy, Creative Music Therapy, or Neurologic Music Therapy, will ﬁnd the research outcomes amendable.

Besides enhancing one’s philosophical perspective, implications from the neuroscience research also suggest adding goals that focus on positive neural change to the psychosocial or music-based goals that guide music therapists; this addition often leads to a more purposeful use of therapists’ techniques and strategies (Dana, 2018; van der Kolk, 2006, 2014, 2018). Most importantly, as a result of early outcomes from these studies, traumainformed researchers and therapists strongly recommended strategies to avoid re-traumatization (Levine, 2008, Perry, 2009; Porges, 2017, 2018; van der Kolk, 2006, 2014). Clients will be re-traumatized if triggers set their nervous system into a path of uncontrollable hyperarousal, ﬁght/ﬁght, and eventual dissociation if they have not yet found ways to feel safe and learn to manage or calm their responses.

In addition, researchers are now using this continually advancing brain scan technology to investigate the impact of music on the brain which in turn is providing credibility to the phenomena of music (Chanda & Levitin, 2013; Legge, 2015; Levitin, 2013; Moore, 2013; Overy & Molnar-Szakacs, 2009; Stegemöller, 2014, 2017). These research results validate the positive impact of music on the brain, identify the potential for speciﬁc applications of music and music components, and support what music therapists intuitively have observed when working with clients.

Unfortunately, the layers of complexity and

technical terms are often daunting to music therapists reading the neurobiology of trauma literature. Articles on the neurobiology of trauma didn’t begin to appear in the literature until around the 1990s–2000s, about 20 years after several technological advances in brain scan research. This ﬁrst wave of literature began deﬁning details about the negative impact of trauma on the brain and body and precautions when treating trauma. For example, outcomes from this initial group of studies revealed how hyper-aroused sensory information moves from the thalamus, acting as a relay center, simultaneously to the prefrontal cortex and the amygdala; and that the left hemisphere tends to shut down which inhibits Boca’s area identified as the “center of expressive language” (van der Kolk, 2006; van der Kolk, McFarlane, Weisaeth, 1996).

A second wave of research began to appear in the literature around 2014-2016. With continued advances in brain scan technology, researchers conducted studies that further clarified the roles of specific brain areas related to trauma responses. For example, they discovered that the thalamus, in addition to functioning as a relay center, also initially categorizes incoming sensory information (van der Kolk, 2014). When trauma impacts the brain, this sensory information remains fragmented and may cause someone to have difficulty organizing details regarding a trauma experience. Investigators also are redefining the role of Broca’s area. Based on research outcomes, Flinker et al. (2014) proposes that Broca’s area organizes the sensory information people use as they plan to speak, but then the area tends to disengage when people begin to speak.

Inﬂuenced by a directive from the National Institutes of Health (NIH), researchers also began investigating how trauma impacts speciﬁc neural pathways or circuits. This focus led

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to (a) renewed interest among investigators studying the influence of PTSD on the mirror neuron system (Nietlisbach & Maercker, 2009; van der Kolk, 2014) and decision-making network (Dahlitz, 2017; van der Kolk, 2914) and (b) the discovery of new networks also found to have a significant effect on PTSD such as the default mode network (Davey, Pujol, & Harrison, 2016; van der Kolk, 2014) and context processing system (Liberzon & Abelson, 2016; Pennington, Anderson, & Fanselow, 2017).

In addition, this second wave includes researchers interested in how music influences the brain (e.g., Alluri et al., 2012; Alluri et al., 2017; Chanda & Levitin, 2013; Kay et al., 2012; Legge, 2015; Levitin, 2013; Menon & Levitin, 2005; Moore, 2013; Stegemöller, 2014, 2017; Taruﬃ, Pehrs, Skouras, & Koelsch, 2017). Legge (2015) reviewed a large group of studies and compiled a list of brain areas facilitated and deactivated by familiar, pleasurable music. Other researchers studied the impact of various music components on specific areas in the brain (Alluri et al., 2012) or demonstrated changes in neuroplasticity as a result of music experiences (Alluri et al., 2017). Similarly, investigators also are studying the influence of music within the specific neural networks, such as the default mode (Kay et al., 2012; Taruffi, Pehrs, Skouras, & Koelsch, 2017), the reward system (Menon & Levitin, 2005; Stegemöller, 2014, 2017), and the mirror neuron system (Overy, 2012). Outcomes from these studies suggest important applications to trauma-informed treatment. Besides the complexity of the neuroscience literature, readers also are faced with sorting through the interpretations and models of experts describing their perspectives on trauma treatment (e.g., Fisher, 2017; Herman, 1997; Levine, 2008; Perry, 2009; Porges, 2017,

2018; van der Kolk, 2014). While some commonalities exist across the approaches to treatment, the diﬀerences can leave music therapists wondering how the various focuses connect. In addition, each expert uses terms that are speciﬁc to that model. Porges coined the term “neuroception” (2017, 2018); Levine (2018) discusses the principle of “pendulation”; Ogden (2018) presents the Modulation Model; and van der Kolk (2014) writes metaphorically about “the cook”, “the smoke detector”, “the watchtower”, and “the timekeeper” (pp. 60-70). And these experts represent only a few of the therapists or researchers proposing a neurobiological approach to trauma.

Therefore, as I begin to read on the neurobiology of trauma, I often get lost in a web of articles. When I present on this topic, I include a slide that shows a picture of a woman staring at a complex wall covered with multiple layers of interlocking cogwheels—many laugh as they empathize with me trying to navigate the density of neuroscience articles. I initially read what I can, as I connect what I understand with my past knowledge base. Sometimes I begin with reviews of studies as I constantly look up definitions and the function of different areas in the brain; and then I eventually move into reading more complex outcome studies. Now, I am certainly not an expert in neuroscience and often consult colleagues at the college where I teach. But I do describe myself as a music therapist who has an avid interest in learning about the neurobiology of trauma and music and the brain; believes, as others, that the future of mental health lies in the growing body of neuroscience research; and is committed to sharing this information with others in the field of music therapy. When approached to be the guest editor for

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this special edition on trauma, those three beliefs guided the focus and the selection of articles for the journal. I wanted to highlight the courageous work of music therapists who are using the neuroscience of trauma to support their work with a variety of populations dealing with trauma. These are music therapists who are paving pathways, forging into the complex world of neuroscience, daring to adapt what they do based on neural science, and open to sharing their successes and challenges with the world of music therapists. Each of the music therapists uniquely incorporates concepts from the neurobiology of trauma research into her own philosophical approach to trauma. Therefore, this body of work represents a range of philosophical beliefs, treatment approaches, and populations that are tied together by the commitment to work based on the neurobiology of trauma.

Clare Macfarlane, MA, SRMTh, NMT-F, works as a music therapist with male adult prisoners in the Department of Art Therapies at the Penitentiary Institution Vught in Vught, the Netherlands. I ﬁrst met Clare at a symposium in the Netherlands where she presented on her protocol and research. Her approach is especially important for music therapists working with populations who for various reasons are unable to pursue integration of their trauma, for example, due to short term treatment or an inability to escape conﬂicts causing the trauma. Her psychoeducational, rhythmic method is grounded in several neurobiological concepts.

Kristen Stewart, MA, MT-BC, LCAT, SEP, is a music therapist at the Veterans Administration at the Hudson Valley Healthcare System in Montrose, New york, United States. In her article, she shares more speciﬁc details about her trauma-informed music therapy work with soldiers based on the Polyvagal

Theory (Porges, 2017, 2018) and Somatic Experiencing® (Levine, 2018; Payne, Levine, & Crane-Godreau, 2015). Her discussion provides readers with key neuroscience concepts which she presents along with a sixphase protocol approach to trauma treatment.

Dr. Laurien Hakvoort, SRMTh, NMT-F, also is from the Netherlands and a lecturer and codeveloper of the bachelor and master music therapy program at the ArtEZ University of the Arts, in Enschede; she also has a private practice. Laurien oﬀers readers a case study of an older adult with a multi-traumatic background. Based on concepts from the neuroscience literature, she provides an intimate view of the successes and challenges of approaching trauma-informed music therapy. Her candid descriptions and connections back to research and theory provide insight into the step-by-step decisions music therapists need to make when working with individuals diagnosed with trauma.

Dr. Gitta Strehlow, Dipl. Music Therapist, works at the Clinic for Psychiatry and Psychotherapy within the Bethesda Hospital Hamburg-Bergedor in Hamburg, Germany; she also is a part-time lecturer at Hamburg University of Music and Theatre and Swiss Forum Further Education Music Therapy. Using neurobiological concepts of trauma, she discusses her work with children dealing with sexual abuse. Besides neuroscience, she combines psychotherapy and Fonagy’s concept of mentalization (Fonagy, & Luyten, 2009) to support her approach to music therapy.

Jennifer Sokira, MMT, LCAT, MT-BC, is founding director of Connecticut Music Therapy Services, LLC and clinical director at the Resiliency Center of Newtown, Newtown, Connecticut, United States. She bravely writes about

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her experiences in responding to a mass tragedy, the shootings at Sandy Hook School, and the importance for all music therapists to develop a preparedness plan. She discusses the six phases of responding to a disaster and brings the content of each stage back to how she and others speciﬁcally responded to the disaster within the community. Supported by neural science and experiences with other professionals in her community, she discusses her responses as a music therapist from a variety of approaches such as psychodynamic theory, complicated grief, and the work of Levine (2018) and Perry (2009).

Finally, Dr. Elizabeth Stegemöller, MT-BC, associate professor in the Department of Kinesiology and director of the graduate program in neuroscience at Iowa State University in Ames, Iowa, USA, provides readers with an introduction to one of the newer topics within the neurobiology of trauma—how reﬂexes, speciﬁcally the startle response, provide possible insight for treatment frameworks. Elizabeth’s expertise as a music therapist and neuroscientist plays a critical role in helping the profession of music therapy to synthesize, interpret, and apply neural science research within the areas of trauma, music, and the brain.

As guest editor of this edition, I hope these articles will (a) encourage readers to begin or continue their own pathway of incorporating the neurobiology of trauma research into their work as music therapists and (b) prompt an increase in formal and informal discourse related to the application of neural science within the profession of music therapy. Music therapists have access to an increasing body of research that is now documenting and challenging how therapists employ music in the healing process. I believe it is an ethical responsibility of all contemporary music thera-

pists to seek out methods to understand this complex network of communication, that is, the nervous system within the brain and body, to eﬀectively meet the needs of clients responding to the ever-growing traumas of life. These six authors provide one avenue— an introduction to and interpretation of the neurobiology of trauma and its application to music therapy. references

Alluri, V., Toiviainen, P., Jaaskelainen, I. P., Glerean, E., Sams, M., & Brattico, E. (2012). Large-scale brain networks emerge from dynamic processing of musical timbre, key and rhythm. NeuroImage, 59(4), 3677-3689. Alluri, V., Toiviainen, P., Burunat, I., Kliuchko, M., Vuust, P., & Brattico, E. (2017). Connectivity patterns during music listening: Evidence for action-based processing in musicians. Human Brain Mapping, 38(6), 2955-2970. Benjet, C., Gromet, E., Karam, E. G., Kessler, R. C., McLaughlin, K. A., Ruscio, A. M., … Koenen, K. C. (2016). The epidemiology of traumatic event exposure worldwide: results from the World Mental Health Survey Consortium. Psychological Medicine, 46(2), 327-343. Brady, K. T., Killeen, T. K., Brewerton, T., & Lucerini, S. (2000). Comorbidity of psychiatric disorders and posttraumatic stress disorder. The Journal of Clinical Psychiatry, 61(Suppl7), 22-32. Chanda, M. L., & Levitin, D. J. (2013). The neurochemistry of music. Trends in Cognitive Sciences, 17(4), 179-193. Dahlitz, M. (2017). The psychotherapist’s essential guide to the brain. Brisbane, Australia: Dahlitz Media. Dana, D. (2018). The Polyvagal Theory in therapy: Engaging the rhythm of regulation. New york, Ny: W. W. Norton.

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Davey, C. G., Pujol, J., & Harrison, B. J. (2016). Mapping the self in the brain’s default mode network. NeuroImage, 132, 390397. Fisher, J. (2017), Trauma-informed stabilisation treatment: A new approach to treating unsafe behaviour, Australian Clinical Psychologist, 3(1), 55-62. Flinker, A., Korzeniewska, A., Shestyuk, A. y., Franaszczuk, P. J., Dronkers, N. F., Knight, R. T., & Crone, N. E. (2015). Redefining the role of Broca’s area in speech. Proceedings of the National Academy of Sciences, 112 (9), 2871-2875. Fonagy, P., & Luyten, P. (2009). A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder. Development and Psychopathology, 21, 1355-1381. Fuld, S. (2018). Autism spectrum disorder: The impact of stressful and traumatic life events and implications for clinical practice, Clinical Social Work Journal, 46, 210– 219. Grubaugh, A. l., Zinzow, H. M., Paul, L., Egede, L.E., & Frueh, B. C. (2011). Trauma exposure and posttraumatic stress disorder in adults with severe mental illness: A critical review. Clinical Psychology Review, 31(6), 883–899. Hansen, B. T., Østergaard, S., Sønderskov, K. M., & Dinesen, P. T. (2016). Increased Incidence Rate of Trauma- and Stressor-Related Disorders in Denmark After the September 11, 2001, Terrorist Attacks in the United States, American Journal of Epidemiology, 184(7), 494–500. Harper, J., & von Hein, M. (2018, June 6). Global conflict continues to rise, index shows, Deutsche Welle (DW). Retrieved from https://www.dw.com/en/global-conflictc o n ti n u e s - t o - r i s e - i n d ex- s h o w s /a 44090159 Herman, J. (1997). Trauma and recovery: The aftermath of violence—from domestic abuse to political terror. New york, Ny: Basic Books.

Kay, B. P., Xiangxiang, M., DiFrancesco, M., Holland, S. K., & Szaflarski, J. P. (2012). Moderating effects of music on resting state networks. Brain Research, 1447, 53-64. Legge, A. W. (2015). On the neural mechanisms of music therapy in mental health care: Literature review and clinical implications. Music Therapy Perspectives, 33, 128-141. Levitin, D. J. (2013). Neural correlates of musical behaviors: A brief overview. Music Therapy Perspectives, 31(1), 15-24. Levine, P. (2008). Healing trauma: A pioneering program for restoring the wisdom of your body. Boulder, CO: Sounds True. Levine, P. A. (2018). Polyvagal Theory and trauma. In S. W. Porges & D. Dana (Eds.), Clinical applications of the Polyvagal Theory: The emergence of polyvagal-informed therapies (pp. 3-26). New york, Ny: W. W. Norton. Liberzon, I., & Abelson, J. L. (2016). Context processing and the neurobiology of posttraumatic stress disorder. Neuron, 92, 1430. McLoud, D. (2017, November 27). Deaths from transportation accidents rise 5% in 2016. Equipment World. Retrieved from https://www.equipmentworld.com/deaths-from-transportation-accidents-rise5-in-2016/ Menon, V., & Levitin, D. J. (2005). The rewards of music listening: Response and physiological connectivity of the mesolimbic system. NeuroImage, 28, 175-184. Moore, K. S. (2013). A systematic review on the neural effects of music on emotion regulation: Implications for music therapy practice, Journal of Music Therapy, 50(3), 198-242. Nietlisbach, G., & Maercker, A. (2009). Social cognition and interpersonal impairments in trauma survivors with PTSD. Journal of Aggression, Maltreatment and Trauma, 18, 382-402. Ogden, P. (2018). Polyvagal Theory and sensorimotor psychotherapy. In S. W. Porges

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& D. Dana (Eds.), Clinical applications of the Polyvagal Theory: The emergence of polyvagal-informed therapies (pp. 34-49). New york, Ny: W. W. Norton. Overy, K. (2012). Making music in a group: Synchronization and shared experience. Annals of the New York Academy of Sciences, 1252, 65-68. Overy, K., & Molnar-Szakacs, I. (2009). Being together in time: Musical experience and the mirror neuron system. Music Perception: An Interdisciplinary Journal, 26(5), 489-504. Payne, P., Levine, P., & Crane-Godreau (2015). Somatic experiencing: Using interoception and proprioception as core elements of trauma therapy. Frontiers in Psychology, 6, 1-18. Pennington, Z. T., Anderson, A. S., & Fanselow, M. S. (2017). The ventromedial prefrontal cortex in a model of traumatic stress: Fear inhibition or contextual processing? Learning and Memory, 24(9), 400-406. Perry, B. D. (2009). Examining child maltreatment through a neurodevelopmental lens: Clinical application of the Neurosequential Model of Therapeutics. Journal of Loss and Trauma 14, 240-255. Porges, S. W. (2017). The pocket guide to the Polyvagal Theory: The transformative power of feeling safe New York, Ny: W.W. Norton. Porges, S. W. (2018). Polyvagal Theory: A primer. In S. W. Porges & D. Dana (Eds.), Clinical applications of the Polyvagal Theory: The emergence of Polyvagal-informed therapies (pp. 50-69). New york, Ny: W. W. Norton.

Rhee, P., Joseph, B., Pandit, V., Aziz, H., Vercruysse, G. Kulvatunyou, N., & Friese, R. S. (2014). Increasing trauma deaths in the United States. Annals of Surgery, 1, 1321. Stegemöller, E. L. (2014). Exploring a neuroplasticity model of music therapy. Journal of Music Therapy, 51(3), 211-227. Stegemöller, E. L. (2017). Exploring the mechanisms of music therapy. Scientist, 31(3). Taruffi, L., Pehrs, C., Skouras, S., & Koelsch, S. (2017). Effects of sad and happy music on mind-wandering and the default mode network. Scientific Reports, 7(14396), 110. Turk, J., Robbins, I., & Woodhead, M. (2005). Post-traumatic stress disorder in young people with intellectual disability, Journal of Intellectual Disability Research, 49(11), 872-875. van der Kolk, B. A. (2006). Clinical implications of neuroscience research in PTSD. Annals of the New York Academy of Sciences, 1071, 277-293. van der Kolk, B. A. (2014). The body keeps the score. New york, Ny: Viking. van der Kolk, B. A. (2018). Safety and reciprocity: Polyvagal Theory as a framework for understanding and treating developmental trauma. In S. W. Porges & D. Dana (Eds.), Clinical applications of the Polyvagal Theory: The emergence of polyvagalinformed therapies (pp. 27-33). New york, Ny: W. W. Norton. van der Kolk, B. A., McFarlane, A. C., & Weisaeth, L. (Eds). (1996). Traumatic stress. New york: Guilford Press.

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About the Author

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Development of the SMAART Protocol for Adult Male Prisoners with PTSD Clare Macfarlane, MA, SRMTh, NMT-F

Department of Art Therapies, Penitentiary Institution Vught, Vught, The Netherlands. Correspondence: Department of Art Therapies, PI Vught, PO Box 10055, 5260 DH Vught, The Netherlands, claremacfarlane@dji.minjus.nl

Abstract

Researchers recently have found that the PTSD hyperarousal subscale is specifically correlated with a heightened recidivism risk among prisoners with PTSD (Barret, Teeson, & Mills, 2014; Sadeh & McNiel, 2015). Hyperarousal also affects a person’s ability to focus and sustain attention (van der Kolk, 2014). In fact, several researchers identify that a prisoner’s ability to maintain sustained and selective attention is a stronger predictor for treatment completion than the prisoner’s treatment motivations (Cornet, van der Laan, Nijman, Tollenaar, & De Kogel, 2015). Based on these findings, the Short-term Music Therapy Attention and Arousal Regulation Treatment (SMAART) protocol was developed to address sustained attention and offer arousal regulation strategies for prisoners who were: (a) within a penitentiary psychiatric setting in the Netherlands, (b) diagnosed with PTSD, but (c) unwilling or not eligible for to undergo EMDR for various reasons. Due to the constraints of the penitentiary psychiatric setting, SMAART was designed as a time-limited, manualized treatment protocol. As a means to enhance treatment responsivity, it was offered as a first step intervention to prisoners who otherwise avoided treatment. This article discusses (a) the SMAART protocol developed for research purposes and (b) how the neurobiology of trauma and music research forms the foundations for the protocol. Clinical case material is used to demonstrate elements of the treatment protocol.

Keywords: PTSD, short-term music therapy, adult male prisoners, treatment protocol, neurobiology of trauma. Resumen

Los investigadores recientemente han descubierto que la subescala de hiperactividad PTSD está específicamente correlacionada con un aumento del riesgo de recidivas en reclusos con PTSD (Barret, Teeson, & Mills, 2014; Sadeh & McNiel, 2015). La hiperactividad afecta también a la habilidad de las personas para focalizar y sostener su atención (van der Kolk, 2014). De hecho, varios investigadores identifican que la habilidad de los reclusos para mantener una atención selectiva sostenida es un predictor de finalización del tratamiento más efictivo que las propias motivaciones de los reclusos (Cornet, van der Laan, Nijman, Tollenaar, & De Kogel, 2015). Basándose en estos descubrimientos el protocolo Short-term Music Therapy Attention and Arousal Regulation Treat-

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ment (SMAART) se desarrolló dirigido al mantenimiento de la atención y a ofrecer estrategias para regular la actividad a reclusos que estuvieran: (a) en una cárcel para reclusos con problemas psiquiátricos en Holanda, (b) diagnosticados con PTSD, pero (c) que no desearan o no fueran seleccionables para experimentar el EMDR por diversas razones. Debido a las limitaciones de la cárcel para pacientes con problemas psiquiátricos, el protocolo SMAART se diseñó como un protocolo de tratamiento manual de tiempo limitado. Como un medio para mejorar la respuesta al tratamiento, se ofreció en primer lugar a reclusos que evitaban el tratamiento. Este artículo expone (a) el protocolo SMAART desarrollado con propósito de investigación y (b) como la investigación neurobiológica del trauma y la música constituye el fundamento del protocolo. Se describe un caso clínico para mostrar elementos del protocolo de tratamiento.

Palabras clave: PTSD, musicoterapia de corta duración, reclusos masculinos adultos, protocolo de tratamiento, neurobiología del trauma. Prisoners with PTSD – Need for a Protocol

The penitentiary psychiatric center (PPC) is a unique setting within the Dutch prison system. It houses prisoners with severe mental health issues of whom 50% are awaiting trial, while others are serving time or transferring to secure, mandatory treatment settings outside of the prison. The average length of stay in the PPC is 3 to 5 months, a relatively short time period to provide treatment for this complex population.

only recently have researchers begun to turn their attention to understanding the needs and treatment for adult male prisoners. With this new focus, researchers are discovering the varied diagnoses of this population, especially within the area of post-traumatic stress disorder (PTSD). While diﬃcult to diagnose, therapists are becoming increasingly aware of the prevalence of PTSD and how this diagnosis aﬀects their prison stay and re-entry into society (Pettus-Davis, Renn, & Motley, 2016).

At the same time, there also has been an increase in research on the neurobiology of trauma. As therapists expand their under-

standing of the neurobiology of trauma, they also consider possible connections between PTSD symptoms and offense-related recidivism risk (Ardino, 2012; Ardino, Milani, & Blasio, 2013; Barret, Teeson & Mills, 2014; Sadeh & McNiel, 2015; Sommer, Hinsberger, Elbert, Holthauzen, Kaminer, Seedat et al., 2017; Wahlstrom, Scott, Tuliao, DiLillo, & McChargue, 2015). Sadeh and McNiel (2015) and Barret, Teeson, and Mills (2014) found a significant positive relationship between the PTSD hyperarousal subscale and recidivism risk; that is, prisoners with high hyperarousal subscale scores were 1.4 more times at risk of perpetuating violent crimes. A dual diagnosis of PTSD and other mental health disorders resulted in being 1.5 more times likely to reoffend.

In their systematic review and meta-analysis, Baranyi, Cassidy, Fazel, Priebe, and Mundt (2018) reviewed PTSD prevalence among a total sample of 21.099 prisoners from 20 countries at point prevalence, one-year prevalence, and lifetime prevalence. They found a point prevalence of 6.2% for male prisoners with the prisoners’ lifetime prevalence reaching as high as 32%; one-year prevalence was 10%. These scores suggested that the occurrence

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of PTSD was more frequent among male prisoners than previously assumed and was higher among prisoners than in the general population. Their results further highlighted the need for PTSD interventions within the prison setting.

In the Netherlands, adult male prisoners number 32,440 or make up about 92% of the total number of prisoners (35,250). Research suggests that 32% or as many as 10.380 of the adult male prisoners have PTSD with an elevated risk for offense related recidivism. The Short-term Music Therapy Attention and Arousal Regulation Treatment (SMAART) protocol was created to address the needs of this neglected population, adult male prisoners with PTSD. To develop the protocol, I integrate the three components of Evidence Based Practice (EBP): best strategies supported by research, clinical expertise, and patients’ values (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). As SMAART was developed in response to patients’ needs, I will first discuss those concepts. once I understood the constraints, needs, and strengths of the population and context, I then consulted the literature for the best research evidence; this search focused on the neurobiology of trauma and music. My expertise as a music therapist with this population contributed to my interpretation and application of the literature. Finally, I will discuss the culmination of all the components involved in the SMAART protocol1. Development of Protocol Patients’ Identified Needs

Case A. A. is a 35- year-old prisoner with a reputation for displaying sudden aggressive

behavior seemingly unprovoked. He already has a long history of being in and out of prison; his charges are all for aggressive violence and excessive use of force. He does not sleep for more than an hour every night and only when he’s so exhausted after a few days of no sleep. On the ward, he behaves in a dominant and aggressive manner to both staﬀ and fellow prisoners that frequently leads to physical confrontations. When referred to music therapy, he was recovering from a serious almost successful suicide attempt; but he continuess to refuse any type of verbal/ psychological therapy. However, he does want to learn how to sleep more during the night and be able to keep his attention focused during telephone conversations with his children. His children complain that he doesn’t listen. Case B B. is a Dutch truck driver who was beaten and gang-raped while incarcerated in a Southern European prison. His lawyer managed to have him transferred to the Dutch judicial system. B. experiences nightmares which leave him tired and exhausted. His arousal level also is heightened daily whenever he encounters a group of men. He is referred for music therapy because he is desperate to relieve his high level of tension, heightened awareness, and intrusive memories and nightmares. However, he is ashamed of the rape and doesn’t want to talk about it. As represented in the two case examples, these men mainly are focused on ﬁnding relief from their hyperarousal states. Most of them have had little to no experience with psychological treatment or talking about their

1. All case vignettes have been made anonymous and are used with permission of the participants. Because the facility where SMAART was developed is an all-male setting this article will use him/his.

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feelings. The male prisoners in a feasibility study (Macfarlane, Masthoﬀ, & Hakvoort, in review) also expressed a desire to focus their attention so that they could read a book, watch a movie, and stay in-the-present when talking with family and friends.

Most often these men also identify that they wish to learn how to be “less jumpy”. The hypervigilance keeps them awake at night and always expecting to “face danger”. This heightened awareness and reactivity is perceived by peers in their criminal worlds as a strength, a threat, and a force with which to be reckoned. The men are so hyperaroused and alert that “nothing gets past them”, or they respond with sudden violence to neutralize what they perceived as a threat. While letting go of these ‘qualities’ would make them feel exposed and vulnerable, their strong desire to regain control over their attention and hyperarousal motivates them to enter the music therapy treatment.

Development of Protocol ‘Best’ Research evidence2 Neurobiology of trauma

Developments in brain imaging techniques have had a profound impact on the way trauma experiences and PTSD are now perceived (Behrens, 2017; van der Kolk, 2014). Brain imaging studies not only reveal how the brain is negatively impacted by traumatic experiences, but also show the physiological re-traumatization of the brain when re-encountering unresolved traumatic experiences (van der Kolk, 2014). The physiological responses to trauma are stored in a person’s non-verbal memory and can be easily triggered by seemingly unrelated events as well as

sensory or physiological tags related to the original traumatic event (e.g., sounds, touch, visual cues, a speciﬁc heart rate) (Tinnin & Gantt, 2014; van der Kolk, 2014). When the trauma-related physiological responses are activated, brain imaging studies reveal that the nervous system responds as if the traumatic experience was happening in the present (Rauch et al, 1996; Hull, 2002; Bremner, 2007; Francati, Vermetten, & Bremner, 2007; Hopper, Frewen, van der Kolk, & Lanius, 2007; Kolassa & Elbert, 2007) and eﬀectively limiting the brain to function as if it is in reptilian survival mode (Tinnin & Gantt, 2014; van der Kolk, 2014).

As a result of this research, trauma treatment shifted from focusing on the emotional and psychological impact to also emphasizing the effects of trauma on brain function. This perspective involves understanding the neurobiology of trauma and the symptoms connected to negative brain change. More importantly, trauma treatment now also involves the goal of preventing and regulating re-traumatization specifically within the brain (Behrens, 2017; Tinnin & Gantt, 2014; van der Kolk, 2014). PTSD and attention

Recent research also has focused on several areas related to PTSD and attention. Executive dysfunction, reduced inhibitory control, attentional bias to threat stimuli, limited memory, and diﬃculty focusing attention all have been associated with PTSD (Aupperle, Melrose, Stein, & Paulus, 2012; DeGutis, Esterman, McCulloch, Rosenblatt, Milberg, & McGlinchey, 2015; Quereshi, Long, Bradshaw, Pyne, Magruder, Kimbrell, et al., 2011; Shucard, McCabe, & Szymanski, 2008). Sarapas, Weinberg, Langenecker, and

2. This section is not intended as a comprehensive literature review and therefore is limited to the selected topics.

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Shankman (2017) found inhibited executive control was related to reactivity.

Recent studies also have focused on the beneﬁts of improving attentional control. Lazarov et al. (2018) found that attentional control training leads to a greater reduction in PTSD and depressive symptoms. Bardeen, Tull, Daniel, Evenden, and Stevens (2016) concluded that training one’s attention could serve as a moderator against threat-related attentional dys-control for those with PTSD. Badura-Brack et al. (2015) found attention control training addressed ﬂuctuations in attention allocation; they believed training was most effective when the goals focused clients on balancing their attentional fluctuations rather than attending to or away from threat stimuli. In a study among Dutch prisoners, Cornet, van der Laan, Nijman, Tollenaar, and De Kogel (2015) concluded that a high score on the D2-CP task (a neuropsychological task for sustained attention) was a better predictor of treatment completion than a measure of the participant’s motivation.

Neurobiology of music

Schneck and Berger (2006) focus on the clinical implications of using ‘music physiology’, specifically various levels of entrainment, to influence human physiology. Several researchers identify rhythmic entrainment as one of the strongest, most automatic, unconscious responses to music (Crasta, Thaut, Anderson, Davies,, & Gavin, 2018; Nozaradan, Peretz, & Mouraux, 2012; Schneck & Berger, 2006; Thaut & Hoemberg, 2014). Because music enters at the most basic level of the brain and does not require semantic interpretation or higher cognitive awareness to affect the brain and body, rhythmic entrainment remains an involuntary response that can also be applied in a therapeutic manner.

Development of Protocol - Clinical expertise

The need for a treatment protocol emerged from my clinical practice with adult male prisoners in the PPC. Prisoners who were otherwise not inclined to engage in any type of verbal therapy, either because they refused to speak to a psychologist and/or psychiatrist, or because they did not speak Dutch, were willing to “do something with music”, as they often stated. These prisoners frequently presented with many compounded problems mostly leading back to traumatic events. I began to realize that they were displaying symptoms of complex PTSD: avoidance (often by abusing drugs and alcohol), nightmares and ﬂashbacks, being constantly alert (always looking for the safest spot in the room from where they could keep an eye on everything), prone to outbursts of anger, extreme emotional dysregulation resulting in self harm or harming others, and so forth. The prisoners responded strongly to music but could not tolerate any type of emotional content in the music. I found that providing a steady beat with a repetitive rhythmic pattern would help “calm the nerves”, as they would say, and allowed for a musical connection that the prisoners seemed to appreciate. one prisoner commented, “feeling human again, instead of a caged animal ready to pounce.” Although they found these sessions helpful, the music experiences in the music therapy sessions, of course, didn’t help them when they were in their prison cells. So I began developing exercises the prisoners could do in the moment to manage rising tensions when they were behind locked doors. Development of Protocol – Putting eBP Components Together

Based on client need, research, and the music therapist’s experience, the SMAART protocol

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and manual for implementation were developed as a first step to creating a time-limited intervention. However, several constraints related to the PPC setting influenced the development of the protocol, such as a relatively short treatment period, uncertainty about the length of stay (advancement of their judicial path takes precedence), raised arousal levels due to incarceration, and very divergent backgrounds (Macfarlane, Masthoff, & Hakvoort, in review). I also needed to be mindful of their environment. Prisoners are restricted in what they can have in their cells, the sound insulation between cells is limited, and they have minimal funds for purchasing a radio/CD player. Therefore, I focused on abdominal breathing and rhythmic entrainment using body percussion as experiences that would provide them with tools that could be applied anywhere at any time.

Because I only have about seven sessions with the prisoners, I also needed to develop a short-term intervention. In addition, the protocol needed to focus on self-management strategies that the prisoners could learn to apply when needed. Giving them a role in their treatment also would enhance the men’s sense of mastery and self-empowerment and enable them to take more responsibility for their behavior instead of succumbing to emotional dysregulation. As plans for the protocol evolved, I quickly identiﬁed the need for a manual that would provide a standardized approach to the implementation of SMAART. Besides documenting the protocol, the manual also provided an ability to replicate implementation among the men who would become subjects for a study as well as ensure all prisoners received the same type of treatment. Rolsvjord, Gold, and Stige (2005) discussed diﬀerences between a manual based on therapeutic princi-

ples versus one based on prescribed techniques. They believed that if the therapeutic principles were clear enough, then the development of a manual would allow more freedom in the application of techniques and an ability to match a patient’s responsivity.

Therefore SMAART is based on six therapeutic principles that guide the various steps of the protocol. These principles are:

1. oﬀer psycho-education to the patients. 2. Teach patients how to recognize and regulate brain’s stress response. 3. Remember treatment can only go as fast as the brain can handle. 4. Provide in-the-moment feedback about regulatory skills during sessions. 5. Include repetition, repetition, repetition. 6.Monitor progress with validated measures.

I quickly discovered that providing pyschoeducation about trauma the first principle responses to the prisoners was a critical component to the protocol; this component ensured that each patient understood how to manage stress responses in the brain. While all patients received psychoeducational information, how it was presented depended on the characteristics and responsivity of the patient (Bonta & Andrews, 2007) and the therapist’s clinical expertise with adult male prisoners. More specifically, I found it important to include concepts about common responses to trauma and a short explanation of stress responses in the brain in keeping with guidelines (APA, 2017). However, most prisoners cannot assimilate new information because, as they state, their “brains are in stress”. Therefore, this psychoeducation presentation often was modified. Instead, the I found using pictures of the brain as a successful way to illustrate the information.

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Case C. C. is a combat veteran who has been diagnosed from PTSD for the past 20 years. Previously he received multiple treatments for his PTSD but to no avail. While listening to an explanation of stress responses in the brain, he suddenly burst into tears and laughter at the same time. After regulating his breathing, he explained that the information helped him understand that his brain was still on ‘high alert’ and how responses in his brain lead to his caused him to be on the oﬀence. He was sad and frustrated that he had not known this explanation sooner. His laughter was for the relief he felt once he understood that he was ‘not a total lost cause’ but could learn to manage his stress response. The second therapeutic principle for implementing SMAART involves teaching patients how to regulate stress responses in their brain. To help calm their brain, the music therapist teaches patients (a) low and slow breathing techniques and (b) rhythmical entrainment. This principle, teaching patients how to control their stress. empowers them with tools for self-management.

The third principle involves a key concept from the neurobiology of trauma research— the speed at which treatment moves forward with a patient depends on the level of disruption in the brain. Therefore, it is important to monitor signs of stress throughout the protocol, such as changes in breathing pattern, muscle tension, voice, attentional focus, restlessness, and emotional responses at unexpected moments. The therapist many need to scale back and implement brain calming techniques before moving forward.

Given the importance of maintaining a calm brain, the fourth principle stresses the impor-

tance of providing feedback on signs of stress responses throughout treatment to the prisoners. To obtain a calm brain, it is imperative that this feedback occur in the moment for the prisoners to beneﬁt. Throughout the SMAART intervention, the music therapist provides live feedback on signs of stress responses and helps patients recognize these moments themselves. once patients have some command of the techniques, the music therapist can create small moments of musically induced stress by increasing the speed of the exercises, complicating the rhythmical subdivision, or providing a musically distracting stimulus. These music strategies involve the use of the Music Attention Control Training (MACT) step of selective attention (Thaut & Gardiner, 2014).

The MACT is designed to train and improve attentional control through the use of musical stimuli (Thaut & Gardiner, 2014). The first step in gaining attentional control is learning how to select and focus attention by ignoring competing distractions. Musically, one example would be asking patients to focus on a specific cue to stop and start playing musical instruments. Next step in gaining attentional control is learning to sustain your attention. To practice extending one’s focus, a music therapist might ask a few patients to continue playing one rhythmical pattern while another small group plays a distracting pattern. Finally, patients need to learn to switch between multiple stimuli at will. The MACT chapter in the “Handbook of Neurologic Music Therapy” by Thaut and Hoemberg (2014) provides a comprehensive description of the technique. In that the prisoners struggle most with selective and sustained attention, SMAART only focuses on developing the first two attentional control levels.

The fifth principle to implementing SMAART

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is repetition. Retraining the brain requires repeated practice over time to create and strengthen the new neural pathways or what is termed neuroplasticity (Schneck & Berger, 2006; Thaut & Hoemberg, 2014). Therefore, ther-apists need to repeat techniques throughout the implementation of SMAART and give homework assignments to encourage further repetition outside of the music therapy sessions.

The sixth and final principle is based on the clinical practice of monitoring patients’ progress. Besides helping the prisoners monitor their stress levels, the therapist also needs to administer a modified weekly version of the PSSI-5 (Foa, McLean, Zang, Zhong, Rauch, Porter, et al., 2016). This measure was adjusted to track changes in the prisoners’ PTSD symptoms, that is to check-in with how each patient is progressing. In the feasibility study conducted by Macfarlane, Masthoff, and Hakvoort (in review), results suggest that pivotal changes in a prisoners’ responses were pinpointed at the moment when the prisoner was able to differentiate between arousal symptoms associated with his PTSD and arousal symptoms associated with his surroundings (e.g., noisy neighbors). Techniques of the SMAART

The techniques used in the SMAART protocol are a combination of: (a) low and slow abdominal breathing practiced and applied throughout sessions, (b) body percussion to provide the rhythmic entrainment and promote hemispheric integration (Tinnin & Gantt, 2014), and (c) the first steps of the MACT (Thaut & Gardiner, 2014) to improve selective and sustained attention. Singing also can be used to demonstrate and practice deep abdominal breathing. During music therapy sessions, the bilateral movements of the body

percussion component can be accomplished by playing the xylophone, which in turn offers auditory scaffolding (Thaut & McIntosh, 2010) to the body percussion movements. Table 1 is a schematic representation of the phases, goals, and techniques used in SMAART. The speed at which therapists progress through the phases, however, needs to be dictated by the neural strengths and needs of each patient, principle three. Revisiting Case A. After the six SMAART sessions A. reports that his nightmares have practically vanished and that he is no longer is afraid to go to sleep. On the ward, the decrease in hyperarousal is noticeable in the absence of aggressive behavior towards others. Staﬀ on the ward report that A. can now be seen regulating his breathing pattern when tension rises and even encourages other prisoners to do so. A. is really happy that his children notice that he can follow and remember conversations he has with them, and he is pleased that this has a positive impact on their relationship. After this successful experience with SMAART, he has decided that therapy just might be a viable treatment option after all and has put in a request to continue trauma treatment with EMDR.

Summary-Focus on Brain Before Behavior

With limited understanding of the neural impact of past traumatic experiences, many people often interpret the responses of the prisoner, such as in the case descriptions, as unfocused, aggressive, and typical of someone with an antisocial personality disorder. Instead, the responses of the patients in the PPC need to be understood as someone who’s brain functioning has been negatively changed and cannot be controlled. Their brains are “in

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TABLE 1. Schematic representation of SMAART—phrases, goals, and techniques.

Phase

Sub goal 1 Psychoeducation

Sub goal 2 Improve attention

Sub goal 3 Regulate breathing pattern

Session

Techniques

a) breath control b) body percussion step 1 & 2 c) xylophone step 1&2

Phase 1

Pt1 is introduced to psychoeducation

Pt focuses attention

Pt is introduced to strategies to regulate breathing pattern

1&2

Phase 2

Pt describes the brain’s stress response

Pt sustains attention

2-5

a) breath control b) body percussion step 2 - 6 c) xylophone steps 2-6

Phase 3

Pt describes stress response and how to act to calm the brain

Pt maintains sustained attention during distraction

a) Pt practices abdominal breathing and uses during sessions b) Pt provided in situ training of abdominal breathing

5&6

a) breath control b) body percussion step 6. c) xylophone steps 7-9

Pt = patient

a) Pt provided in situ training of abdominal breathing b) Pt identiﬁes & describes his breathing pattern and c) applies breathing strategies to regulate

stress”, constantly hyperaroused, and responding to triggers throughout the experiences of each day. Therefore, calming the brain and providing self-regulatory skills are critical and the main focus of the SMAART protocol. However, SMAART was specifically designed as a first step intervention and should not be offered continuously or as a single trauma treatment solution.

Instead, music therapists will ﬁnd the SMAART protocol provides a systematic means for not only helping patients learn to self-regulate but also monitoring treatment progress.

When working with the patients in the prison, music therapists need to be constantly aware of signs suggesting neuro-dysregulation (Behrens, 2017); these responses become key to tailoring the protocol within each music therapy session. By observing and understanding the disrupted behaviors of the men, music therapists develop a perspective that creates eﬀective neural-based treatment strategies. Monitoring changes in behavior also become indicators of treatment progress; some of these responses include muscle tension, ability to focus and sustain attention, breathing patterns, emo-

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tional responses, verbal cues, and body language and facial expressions. Through the power of music therapy, therapists can provide a music enriched environment for the brain to experience neural plasticity. As a result of opportunities to practice regulating stress responses in the brain through the use of SMAART and music experiences, music therapists can help prisoners begin to experience an ability to focus and control their dysregulated responses. Acknowledgements

The author would like to thank the music therapy participants for allowing use of their case material in an anonymous manner. References

American Psychological Association (2017). Clinical practice guideline for the treatment of PTSD. Retrieved from https:// www.apa.org/ptsd-guideline/ Ardino, V. (2012). offending behaviour: The role of trauma and PTSD. European Journal of Psychotraumatology, 3, 18968. doi.org/ 10.3402/ejpt.v3i0.18968 Ardino, V., Milani, L., & Blasio, P. di (2013). PTSD and re-offending risk: The mediating role of worry and a negative perception of other people’s support. European Journal of Psychotraumatology, 4, 21382. doi.org/ 10.3402/ejpt.v4i0.21382 Aupperle R., Melrose A., Stein M., & Paulus, M. (2012). Executive function and PTSD: Disengaging from trauma. Neuropharmacology, 62(2), 686–694. doi: 10.1016/ j.neuro pharm.2011.02.008 Badura-Brack, A., Naim, R., Ryan, T., Levy, o., Abend, R., Khanna, M., McDermott, T., Pine, D., & Bar-Haim, y. (2015). Effect of attention training on attention bias variabi-

lity and PTSD: Randomized controlled trials in Israeli and U.S. combat veterans. Am J Psychiatry, 172, 1233-1241. doi: 10.1176/appi.ajp.2015. 14121578 Baranyi, G., Cassidy, M., Fazel, S., Priebe, S., & Mundt, A. (2018). Prevalence of posttraumatic stress disorder in prisoners. Epidemiologic Reviews, 40, 134-145. Bardeen, J., Tull, M., Daniel, T., Evenden, J., & Stevens, E. (2016). A preliminary investigation of the time course of attention bias variability in posttraumatic stress disorder: The moderating role of attentional control. Behaviour Change, 33(2), 94-111. http://doi: 10.1017/bec.2016.5 Barret, E. L., Teesson, M., & Mills, K. L. (2014). Associations between substance use, post-traumatic stress disorder and the perpetration of violence: A longitudinal investigation. Addictive Behaviors, 39 (2014),1075–1080.doi.org/10.1016/j. addbeh.2014.03.003 Behrens, G. A. (May, 2017). A neurobiology of trauma lens, using a trauma-informed approach to music therapy. Presentation NVvMT & EMTC Music Therapy and Trauma symposium. Ede, The Netherlands. Bonta, J. & Andrews, D. A. (2007). Risk-Need-Responsitivity Model for Oﬀender Assessment and Rehabilitation. Public Safety Canada. Centraal Bureau voor de Statistiek (CBS). https://www.cbs.nl accessed on December 20th 2018 for data on number of male prisoners in the Netherlands. Cornet, L. J. M., van der Laan, P. H., Nijman, H. L. I., Tollenaar, N., & De Kogel, C. H. (2015). Neurobiological factors as predictors of prisoners’ response to a cognitive skills training. Journal of Criminal Justice, 43(2), 122-132. Crasta, J., Thaut, M., Anderson, C., Davies, L., & Gavin, W. (2018). Auditory priming improves neural synchronization in auditorymotor entrainment. Neuropsychologia

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117, 12-112, doi: 10.1016/j.neuropsychologia.2018.05.017 DeGutis, J., Esterman, M., McCulloch, B., Rosenblatt, A., Milberg, W., & McGlinchley, R. (2015). Posttraumatic psychological symptoms are associated with reduced inhibitory control, not general executive dysfunction. Journal of the International Neuropsychological Society, 21, 1-11. Foa, E. B., McLean, C. P., Zang, y., Zhong, J., Rauch, S., Porter, K., . . . Kauffman, B. y. (2016). Psychometric properties of the Posttraumatic Stress Disorder Symptom Scale Interview for DSM-5 (PSSI-5). Psychological Assess, 28(10), 1159-1165. Francati, V., Vermetten, E. & Bremner, J. D. (2007). Functional neuroimaging studies in posttraumatic stress disorder: Review of current methods and findings. Depression and Anxiety, 24, 202–218. Hopper, J. W., Frewen, P. A., van der Kolk, B. A. & Lanius, R. A. (2007). Neural correlates of re-experiencing, avoidance and dissociation in PTSD: Symptom dimensions and emotion dysregulation in responses to script-driven trauma imagery. Journal of Traumatic Stress, 20(5), 713-725. Hull, A. M. (2002). Neuroimaging findings in post-traumatic stress disorder. British Journal of Psychiatry, 181, 102-110. Koelsch, S. (2009). A neuroscientific perspective on music therapy. Annals of the New York Academy of Sciences, 1169, 374–384. Kolassa, I. T., & Elbert, T. (2007). Structural and functional plasticity in relation to traumatic stress. Current Directions in Psychological Science, 16(6), 321-325. Lazarov, A., Suarez-Jiminez, B., Abend, R., Naim, R., Shvil, E., Helpman, L., …Neria, y. (2018). Bias-contingent attention bias modification and attention control training in treatment of PTSD: A randomized control trial. Psychological Medicine, 1-9. doi: 10.1017/s0033291718003367

Macfarlane, C., Masthoff, E., & Hakvoort, L. (in review). Short-term Music Therapy Attention and Arousal Regulation Treatment (SMAART) for prisoners with posttraumatic stress disorder: A feasibility study. Nozaradan, S., Peretz, I., Mouraux, A. (2012). Selective neuronal entrainment to the beat and meter embedded in a musical rhythm. Journal of Neuroscience, 32(49), 17572-17581. Pettus-Davis, C., Renn, T., & Motley, R. (2016). Conceptual model to guide practice and research in the development of trauma interventions for men releasing from incarceration. Institute for Advancing Justice Research and Innovation. Quereshi, S. U., Long, M. E., Bradshaw, M. R., Pyne, J. M., Magruder, K. M., Kimbrell, T., Hudson, T. J., Jawaid, A., Schulz, P. E., & Kunik, M. E. (2011). Does PTSD impair cognition beyond the effect of trauma? Journal of Neuropsychiatry and Clinical Neurosciences, 23(1), 16-28. Rauch, S. L., van der Kolk, B. A., Fisler, R. E., Alpert, N. M., orr, S. P., Savage, C. R., .. ., Ptman, M. D. (1996). A symptom provocation study of posttraumatic stress disorder imagery in Vietnam combat veterans. Archives of General Psychiatry, 53(5), 380-387. Rolvsjord, R., Gold, C., & Stige, B. (2005). Research rigour and therapeutic flexibility: Rationale for a therapy manual developed for a randomized controlled trial. Nordic Journal of Music Therapy, 14, 15-32. Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: What it is and what it isn't. BMJ (Clinical research ed.), 312(7023), 71-72. Sadeh, N. & McNiel, D. E. (2015). PTSD increases risk of criminal recidivism among justice-involved persons with mental disorder. Criminal Justice and Behavior, 42(6), 573–586. doi: 10.1177/ 009385481455 6880

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Sarapas, C., Weinberg, A., Langenecker, S., & Shankman, S. (2017). Relationships among attention networks and physiological responding to threat. Brain & Cognition, 111, 63-72. Schneck, D., & Berger, D. (2006). The Music Eﬀect, Music Physiology and Clinical Applications. Philadelphia, PA: Jessica Kingsley. Shucard J., McCabe D., Szymanski H. (2008). An event-related potential study of attention deﬁcits in posttraumatic stress disorder during auditory and visual Go/NoGo continuous performance tasks. Biological Psychology; 79(2), 223–233. doi: 10.1016/ j.biopsycho.2008.05.005 Sommer, J., Hinsberger, M., Elbert, T., Holtzhausen, L., Kaminer, D., Seedat, S., . . . Weierstall, R. (2017). The interplay between trauma, substance abuse and appetitive aggression and its relation to criminal activity among high-risk males in South Africa. Addictive Behaviors, 64, 29-34. Thaut, M. H. & Gardiner, J. C. (2014). Music attention control training. In M. H. Thaut,

& V. Hoemberg, Handbook of neurologic music therapy (pp. 257-269). oxford, United Kingdom: oxford University. Thaut, M. H., & Hoemberg, V. (2014). Handbook of neurologic music therapy. oxford, United Kingdom: oxford University. Thaut, M. H., & McIntosh, G. C. (2010). How music helps to heal the injured brain: therapeutic use crescendos thanks to advances in brain science. Cerebrum. Retrieved from https://dana.org/Cerebrum/ 2010/ How_Music_Helps_to_Heal_the_Injured_ Brain__Therapeutic_Use_Crescendos_ Thanks_to_Advances_in_Brain_Science/ van der Kolk, B. A.(2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New york, Ny: Penguin Group. Wahlstrom, L. C., Scott, J. P., Tuliao, A. P., DiLillo, D., & McChargue, D. E. (2015). Posttraumatic stress disorder symptoms, emotion dysregulation, and aggressive behaviour among incarcerated methamphetamine users. Journal of Dual Diagnosis, 11(2), 118-127.

About the Author

Clare Macfarlane, MA, SRMTh, NMT-F,has a long history of work with various populations, but now specializes in forensic psychiatric work. She pioneered the music therapy program in the Penitentiary Institution Vught, Vught, The Netherlands, where she has worked since 2010.

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Music Therapy, Neurology, and Somatosensory-Informed Trauma Treatment Kristen Stewart, MA, MT-BC, LCAT, SEP

VA – Hudson Valley Healthcare System, Montrose, New York, United States kristen.stewart@va.gov

Abstract

Mental health treatment, whether approached through pharmacotherapy, psychotherapy, complementary, alternative, and/or integrative means, aims to restore natural balance in the nervous system (Simpkins & Simpkins, 2016). Music and music therapy have long been identified as effective tools in addressing an overwhelmed nervous system that results from acute stress and trauma. Music is now known to access all regions of the brain that have currently been mapped (Levitin, 2013), and it’s applications in the treatment of trauma are receiving growing attention. The value of understanding the impact of music on the brain and body is particularly heightened when considering its application in a body-centered, trauma-informed music therapy practice. Traumatic experiences resulting in post-traumatic stress disorder (PTSD) are linked to advanced neurological impairment and abnormalities implicated in the stress response (Bremner, 2007). More specifically, a somatic emphasis in trauma treatment can be used to help bypass inhibitory frontal cortex mechanisms and access the emotional brain. By integrating the use of body-centered techniques in a music therapy practice, therapists can deepen and expand treatment across multi-dimensional layers and levels of process to enhance trauma renegotiation in a safe and non-threatening way. This article will explore current neuroscience-based evidence in support of a somatosensory music therapy approach in trauma treatment and its implications across stages of trauma renegotiation. Resumen

El tratamiento de la salud mental, esté basado en farmacoterapia, psicoterapia, terapias complementarias, y/o medidas integradoras, tiene como objetivo restaurar el equilibrio natural del sistema nervioso (Simpkins & Simpkins, 2016). La música y la musicoterapia se reconocen desde hace mucho tiempo como herramientas efectivas para equilibrar un sistema nervioso sobrecargado como resultado del estrés y de los traumas. Se conoce actualmente que la música accede a todas las regiones del cerebro que han sido mapeadas (Levitin, 2013), y su aplicación en el tratamiento de los traumas recibe una atención creciente. Cuando se realizan prácticas de musicoterapia diseñadas para tratar traumas centradas en el cuerpo, se descubre la importancia de entender el impacto de la música sobre el cerebro y sobre el cuerpo. Las experiencias traumáticas

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resultantes de un trastorno de estrés postraumático (PTSD) están relacionadas con el deterioro neurológico y las anomalías implicadas en la respuesta al estrés (Bremner, 2007). Más especíﬁcamente, enfatizar el aspecto somático en el tratamiento del trauma puede ser utilizado para facilitar un bypass que inhiba los mecanismos del córtex frontal y su acceso al cerebro emocional. Integrando la utilización de técnicas centradas en el cuerpo en prácticas de musicoterapia, los terapeutas pueden profundizar y desarrollar tratamientos mediante capas y niveles del proceso multidimensionales para favorecer la renegociación del trauma de forma segura y no amenazante. Este artículo explora la neurociencia actual basada en la evidencia en apoyo de la musicoterapia somatosensorial aplicada al tratamiento de traumas y sus implicaciones a lo largo de las etapas del tratamiento del trauma. Music Therapy, Neurology, and Somatosensory-Informed Trauma Treatment

as the ﬁeld of music therapy continues to mature, there is a need for ongoing expansion that delves into ever deeper lines and levels of exploration. This innate need for growth has led the music therapy profession to better understand, conceptualize, execute, verify, and communicate what music therapists know intuitively and experientially about the power of music to heal. Signiﬁcant advances in neuroscience have fostered this growth and, as such, have rightfully received much attention in the music therapy community. This article aims to explore how advancements in neuroscience can provide important insight into how a bottom-up approach to music therapy and trauma treatment can enhance the process of stabilization and renegotiation for those dealing with trauma.

Trauma renegotiation is a term used in the somatosensory approach to trauma healing called Somatic Experiencing® created by Dr. Peter Levine (1997), and is integral to the paper that follows. In Somatic Experiencing, trauma renegotiation is identiﬁed as the process by which the therapist supports a client’s creative adaptation to restore homeostasis1 to the traumatized nervous system. This process occurs by freeing energy stuck in the

body due to trauma and directing this energy to an organic, regulated completion (Levine, 2010). Foundations in Neuroscience

Fortunately, much is now known about the structure and organization of the nervous system in the human body (Levitin & Tirovolas, 2009). a growing body of research also supports music as a link to the body’s senses, it’s biology and chemistry, and its complex organic nature (Thaut, McIntosh & Hoemberg, 2014). as such, it is becoming increasingly clear that the stimulating effect of music goes well beyond early applications of promoting general well-being. Thaut, McIntosh, and Hoemberg (2014) emphasize the connection of music and physiology, stating that “… music [is] a biological language whose structural elements, sensory attributes, and expressive qualities engage the human brain comprehensively and in a complex manner” (p. 6). according to Levitin (2013), neuroimaging now shows that music stimulates all areas of the brain explored to date. Research also supports the clinical perception of music’s capacity to entrain neurophysiological systems, including heart rate, respiratory rate, vocalizations, and movement (Miendlarzewska &

1. Homeostasis is the process by which physical and chemical conditions within the internal environment of the body are maintained within tolerable ranges even when the external environment changes (Homeostasis, 2019).

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Trost, 2013; Müller & Lindenberger, 2011), as well as to synchronize brain responses across listeners (abrams et al, 2013).

This capacity of music to engage a broad and diverse scope of neural networks suggests a unique opportunity for music to meet the complex biological and physiological systems impacted by trauma. yet evidence applying the understood potential of music to promote neuroplasticity, when used in the context of music therapy treatment, remains limited. Using evidence gleaned from studies in related ﬁelds provides important and relevant insight to help bridge this gap.

It is hoped that developments in neuro-science also can help to re-conceptualize current deﬁnitions of trauma. as research suggests, therapists need to move past a purely pathological perspective, as implied by the term post-traumatic stress disorder (PTSD), to one that reframes awareness of trauma as a nonpathological, natural response of the body’s nervous system that affects survivors in uniquely individual ways (Payne, Levine, & CraneGodreau, 2015). according to Levine (1997; 2010), trauma involves “a long-term dysregulation in the autonomic and core extrapyramidal nervous system,” noting that “trauma is in the nervous system and body, and not in the event…” (p. 5). Surprisingly, some of the earliest deﬁnitions of PTSD described trauma as a physioneurosis and pointed to the physicality of its symptoms (van der Kolk, 1994).

The extensive work of Dr. Stephen Porges (1995; 2001; 2003; 2004; 2011) has resulted in the development of the Polyvagal Theory, which oﬀers a clear depiction of the expansive, evolutionary-based brain-body connection and the impact of these connections following trauma. He states, “after experiencing life-threat, neural reactions are retuned towards a defensive bias and resilience to return to a state of safety is lost,” (Porges, 2018a, p. xx).

Traditionally, the autonomic nervous system (aNS) is discussed as involving the sympathetic nervous system (SNS) and the parasympathetic nervous system (PSNS). according to Porges, however, the aNS is comprised of three parts rather than two. These parts include (a) the SNS, responsible for a person’s mobilization and arousal or fight/flight responses, (b) the dorsal vagus pathway of the PSNS, responsible for a person’s immobilization and de-escalation of arousal – or freeze responses, and (c) the ventral vagus, a second vagal pathway of the PSNS, and the last in the evolution of the vagus nerve (Porges, 2018b). as previously stated, the dorsal vagal branch of the PSNS is responsible for the “freezing” survival response and remains dormant until triggered in the face of life-threatening experiences. Porges suggests that the ventral vagal pathway emerged during the evolution of mammals. This newer route of the vagus nerve changed the regulating pathway from involving just the heart to a face-heart connection. Therefore, the ventral vagus pathway allows social interactions to regulate physiology, specifically one’s visceral state, through a Social Engagement System (SES) (Porges, 2018b). The SES allows humans the capacity to regulate an over-activated SNS, thereby, promoting balance and a return to homeostasis (Porges, 2018b). From his polyvagal perspective, Porges (2018b) defines trauma as “the disruption of the social engagement system, its management of defense reactions, and its contribution to co-regulation and cooperative behaviors, including intimacy and play.” (p. 52). The SES is responsible for face-to-heart/lungs connections that foster the de-escalation of arousal and support the calm state necessary for social engagement to occur. as the SNS is aroused to address the body’s needs in response to perceived danger and threat, the visceral states of mobilization are activated and the SES is inhibited. once the perceived alert is resolved, non-traumatized people can eventually re-en-

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gage their SES through the process of homeostasis while people dealing with unresolved trauma are stuck in their reactive SNS or may withdraw into their dorsal ventral system. Therefore, to change the aﬀective states associated with trauma symptomatology, Porges (2018b) states that treatment must ﬁrst address the inner visceral, tactile, and motoric sensations latent in the body. as such, the goal of treatment becomes reframed as a restoration of the “dynamic balance between the [three pathways of the] sympathetic and parasympathetic branches of the aNS” (Levine, 2018, p. 22).

In addition to the now widely accepted capacity of music to (a) create homeostasis in the body and (b) promote relaxation and support social networks, music can be used to speciﬁcally target the SES without the need for direct, face to face contact (Porges, 2010). Porges identiﬁes that one of the sensory inputs to the SES ventral vagus nerve occurs within the muscles of the middle ear. Because melodies use the same frequency band, volume, and musical phrasing as the human voice, Porges (2010; 2018b) asserts that melodic lines can replicate vocal prosody and provide neural regulation through input at middle ear muscles. Therefore, music experiences that are perceived as safe, he adds, have the potential to regulate all aspects of the SES, thereby balancing autonomic states.

Thaut & Wheeler (2010) describe the scope of music’s impact on the brain and body as follows: “Because music can access affective/motivational systems of the brain, it can influence and modify affective states and also access the totality of a patient’s cognitions and perceptions, feeling states, and behavior organization,” (p. 334). The use of music to improve state regulation has long been observed both casually and clinically. as the study of the nervous system expands, identifying and understanding the neural mechanisms and responses involved in this process

is becoming increasingly clear. Roth (2014) emphasizes that the rhythmic capacity of music to create a felt sense of pulse occurs through the perception of equidistant spacing between each beat; this perception in turn cues feelings of safety that are interpreted as stability, predictability, and comfort. Tracking this felt sense experience is a key feature of a somatosensory approach to trauma treatment that provides a moment-by-moment attunement to one’s embodied inner, visceral, and sensory landscape (Levine, 1997).

While research documenting the impact of music and music interventions on the brain is young, it is important that music therapists gather and integrate all available related neuroscience research to build sound and scientifically validated treatment plans. Research-based music experiences support the value and role of music therapy amidst treatment approaches receiving more scientiﬁc attention. Establishing and maintaining high standards of treatment that are scientiﬁcally supported helps to fortify therapeutic foundations and safeguard the quality of interventions used to serve those coping with the impact of trauma.

Applications across Stages of Trauma Treatment

advancement in neuroscience research has opened a new road to trauma recovery and treatment by deﬁning trauma as a natural neurophysiologic response in the body (Payne, Levine & Crane-Godreau, 2015). The neurobiology of trauma research reminds clinicians that (a) trauma presents with distinctly personal symptoms, (b) surface in a context of unique client histories, and (c) are assessed and perceived through individualized experiences of overwhelming life threat. Consequently, each client comes to treatment with understandably diverse and speciﬁc desires, goals, and interests for recovery. The client’s framework for recovery must

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then guide applications within a music therapy treatment plan to include an assessment and awareness of whether the active processing of traumatic material is desired by the client, or if the client feels that the renegotiation of the traumatic experience/s will demand a level of processing that is not desired or considered unbearably overwhelming. In this case, treatment that focuses solely on restoring stability and maintaining state regulation may be preferred to provide suﬃcient relief and improved resiliency in meeting the desired recovery goals of the client.

open and honest dialoguing with clients prior to treatment that aims to identify client-centered needs and goals while maintaining the client’s window of tolerance will support a collaborative treatment plan, build trust in the therapeutic relationship, and provide an orientation period that is critical for a traumatized nervous system. Preparation for and treatment through each phase of recovery should be designed to help the client to embody a new pacing of experiences that counters the overwhelmed states of arousal activated due to sensory system overload. The use of a slower pacing within the clinical process helps to better target the visceral state of somatic memories created from the uncontrollable autonomic response to traumatic events experienced as “too much, too fast, too soon,” (Levine, 1992).

Therefore, orientation to music therapy and trauma treatment should go beyond a traditional intake interview and assessment. Music therapists also need to include opportunities for the client to prepare for therapy, such as by: (a) helping the client to identify a resource base of preferred music that evokes and supports regulation and resiliency across domains and (b) providing psycho-education that illustrates the biophysiologic nature of trauma and helps to normalize and reframe antiquated and stigmatizing perceptions of trauma responses and symptomatology. ad-

ditionally, an ongoing use of assessment and re-orientation within the treatment process is critical to constantly regulate the pacing of therapy to ﬁt the needs of clients responding to traumatic experiences. a slow, deliberate, and regulated pacing will help ensure that interventions remain within the client’s window of tolerance (Siegel, 1999) and avoid exposing the client to vulnerable states that can be re-traumatizing (Fattner, 2018).

Herman (1992) categorized trauma recovery into three primary stages: 1) safety and stabilization, 2) remembrance and mourning, and 3) reconnection and integration. These original stages have evolved over time into expanded versions with additional delineation of phases (Cook et al, 2005; Fattner, 2018; Levine & Poole-Heller, 2002; Luxenberg, Spinazzola & van der Kolk, 2001; Macy et al, 2004; van der Kolk, 2001; van der Kolk, McFarlane & van der Hart, 1996). Stewart (2009; 2018) has synthesized the phases across these versions as follows: 1. Safety and Stabilization, 2. Self-regulation, 3. Integration, 4. Reconnection, 5. Restoration, and 6. Self-care and Maintenance

Each stage of recovery is described below to examine treatment objectives and explore applications within a body-centered, bottomup trauma-informed approach to music therapy backed by neuroscience. This integrated and expanded version of the stages of trauma recovery is part of a dynamic model of music therapy and trauma treatment that continues to evolve with advances in neuroscience and related ﬁelds of inquiry. Phase One: Safety & Stabilization

as previously discussed, trauma treatment needs to ﬁrst target the rebalancing of the

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aNS; this approach is best achieved using a visceral, tactile, proprioceptive, kinesthetic approach to therapy (Levine, 2018; Porges, 2018b). By directing attention to felt sense experiences, such as bottom-up processing and interoception (one’s felt sense of the body), music therapists can engage the inner somatic and autonomic states that cue a perception of safety and danger (Levine, 2018). Developing a sense of safety and an ability to balance movement among the three vagal pathways are key concepts of stabilization and overall wellness. Porges (2004, 2018a) has deﬁned the body’s capacity to perceive and evaluate states of safety and danger as neuroception, which he deﬁnes “as a neural process, distinct from perception, that is capable of distinguishing environmental (and visceral) features that are safe, dangerous, or ‘life threatening’” (Porges, 2007, p. 14). Neuroception occurs spontaneously and without conscious thought, and therefore, is not changed by mental processing. Based on the Polyvagal Theory, cues of safety become the treatment, and these cues “need to be available and detected via the process of neuroception (Porges, 2018b, p. 56).

Eﬀective interventions, as such, involve strategies that engage neuroceptive and interoceptive processing by helping clients become aware of felt sense experiences and identify their somatic resources. These resources serve as a base from which to develop positive feelings associated with embodied experience and build the client’s sensory window of tolerance. Based on the Polyvagal Theory, this stage of establishing safety and stability results in improved symptom management and is critical to the success of all phases of recovery. according to van der Kolk (2018), making connections with others through the SES are what provides “the ability to feel safe, physiologically calm, mentally clear, and socially engaged…” (p. 31).

Mounting neuroscientiﬁc evidence further

supports the need for treatment strategies that release stuck, habituated muscular and visceral states within the process of trauma recovery (Payne, Levine, & Crane-Godreau 2015; Porges, 2011; Simpkins & Simpkins, 2016). With their focus on enhancing a calm embodied state of experience, researchers are turning their attention to the use of coping strategies such as yoga, t’ai chi, qi gong, and meditation along with other clinical treatments. Consequently, these mind-body practices have become a significant part of a recent Veteran affairs (Va) whole health initiative. Interest in the benefits of creative arts therapies, including music therapy, has also been on the rise at the Va (americans for the arts, 2013), with the stated intention of increasing veteran access to integrative approaches, especially for PTSD populations (U.S. Department of Veteran affairs, 2018).

The capacity of music to create homeostasis in the body (abrams et al., 2013; Fifer & Moon, 1995; Levitin & Tirovolas, 2009; Porges, 2010) by fostering feelings of release, calm, pleasure, predictability, and constancy points to the vast potential of music to stimulate, establish, and deepen the interoception of somatic and autonomic states of stability. oﬀering tailored music therapy interventions that promote homeostasis in the context of a therapeutic relationship can enable traumatized clients to perceive and evaluate enough feelings of safety and stability to continue the often diﬃcult and frightening journey of recovery (ogden, 2018; Porges, 2018b). Phase Two: Self-Regulation

When not in a state of safety, the aNS works to support strategies of defense – ﬁght, ﬂight, and freeze. on a continuum of phase-oriented trauma recovery that supports a bottomup approach, the self-regulation phase involves (a) developing increased access to somatic states of stability and (b) activating the ventral vagal system through the building

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of consistent and reliable connections with a physiologic state of calm. This second phase requires repeatedly orienting clients to felt sense experiences to enable and nurture a “bidirectional communication between the brain and the body” (Porges, 2018b). Repetition of felt sense experiences is key to strengthening clients’ ability to monitor their interoceptive responses with relative ease and regularity. as communication between the brain and body grows, the client’s somatic resource base expands, thereby cultivating an independent capacity to down-regulate during observed states of defense.

Therefore, a polyvagal perspective highlights the signiﬁcance of supporting a client’s capacity for self-regulation. Learning to self-regulate is key to disrupting the prolonged states of dysregulation that have become habituated autonomic responses to triggering events (ogden, 2018). By serving to increase the client’s window of tolerance, self-regulation also helps clients improve symptom management and prepare for trauma renegotiation.

Phase Three: Integration

Integration, from a neurophysiologic standpoint, can be described by exploring a Somatic Experiencing® technique called pendulation. Somatic Experiencing is a body-centered trauma treatment model developed by Dr. Peter Levine (1992). The technique of pendulation involves moving between states of regulation and dysregulation to renegotiate an interrupted natural process within the nervous system in the wake of life threat. Pendulation is used to restore equilibrium by guiding clients in and out of states of immobility/freeze that are experienced in response to dorsal vagal collapse. The technique is designed to move clients through activation of their PSNS and the SNS without the attachment of fear, as fear maintains a client’s state of immobilization (ogden, 2018). “Parasympathetic dominance [of the dorsal path-

way] appears to override high sympathetic activation… Therefore, treatment is aimed to help the SNS break through the override (freeze) by completing a meaningful course of action: escape.” (Levine, 2018, p. 10)

This renegotiation of the nervous system is difficult to manage without the guidance of a practitioner trained in body-centered psychotherapy. a client emerging from a frozen state of immobilization will naturally begin to release the interrupted completion of a fight or flight response in the SNS. Without the expertise of the therapist, a client moving from a frozen state into one of high sympathetic charge can easily become overwhelmed and revert back to a state of immobility rather than resolution (Levine, 2018). This common trap of continuously looping from immobilization to high sympathetic charge and back to immobilization leaves traumatized clients caught in a trauma vortex that re-enforces the habituated and highly symptomatic system and makes them highly vulnerable to re-traumatization. Levine (2018) describes the initial sensation of a released freeze response as “a re-encounter with the high sympathetic charge that was present prior to the onset of immobility” (p. 7).

Integration achieved as hyper- and hypoarousal states are used to develop adaptive mobilizing and immobilizing defensive strategies (ogden, 2018, p. 36). This adaptation and renegotiation process titrates the release of the stored charge (frozen activation) so that it may be broken down into tolerable and mannageable pieces and then released. Through this process of integration, previously halted discharges of activated energy are released to support a biological completion and a restoration of the nervous system to a balanced state (Levine, 2015). In the context of music therapy and trauma treatment, this integration process can be facilitated in several ways. Music can:

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1. provide containment for the disorganized and dysregulated energy; 2. constructively direct the release of stored energy; 3. guide the controlled release of energy through a pendulation of musical elements; 4. support movement that safely replicates defensive mobilization and immobilization strategies; 5. help maintain active engagement without necessitating verbalization of the trauma narrative; 6. cue and deepen reconnection with somatic resources and avoid prolonged states of defense; and 7. manipulate the elements of music to reduce auditory hypersensitivities and target stimulation of the SES.

Promoting renegotiation of traumatic experiences through bottom-up strategies does not necessarily negate all reference to a trauma narrative. Traumatized clients often ﬁnd sharing their trauma story important if they choose to pursue this phase of treatment. However, leading the treatment process by asking a client to share this story will almost inevitably lead the client into a dysregulated and overwhelmed state due to the consequent arousal of the corresponding high charge that has been stored in the nervous system. Trauma renegotiation and integration is better served by recognizing and adhering to the needs of the human system, by listening to the pacing of the body, honoring a person’s evolutionary heritage, and respecting the neuroanatomical and neurophysiological patterns of reactivity that are an inherent and natural part of this evolution. Phase Four: Reconnection

as a traditional phase of trauma treatment, reconnection is imbedded with many broad layers, such as reconnection to a new sense

of self, to hope, and to supportive social resources. From a neuro-centered perspective, reconnection is viewed as the reactivation of the Social Engagement System (SES). Because the SES supports physiologic regulation and helps contain mobilized arousal, Porges (2018b) believes that features of the SES need to be employed throughout treatment and should not be isolated to one phase of treatment.

Before continuing this discussion, however, it is important to differentiate the SES from the more general sense of social support that is a person’s perception of being cared for and helped by other people. While social supports may be helpful, they do not guarantee the interactive prosody that cues safety. In fact, ineffective supportive efforts of caring people may unintentionally trigger adverse SNS or dorsal PSNS responses in the receiving person. additionally, “If receptors for human kindness are blocked, we cannot take it (social support) in or reciprocate,” (van der Kolk, 2018, p. 30). However, when the SES is engaged, a self-regulating, bidirectional communication occurs between the brain and body. This bidirectional communication allows connections to be influenced as they travel both to and from social interactions (Porges, 2018b). In other words, the SES is influenced by both the primitive visceral sensory connections and the higher order brain structures of thought and action that are further connected to affective states and emotions (Porges, 2018b, p. 56).

Speciﬁc music interventions for the SES emphasize vocal prosody and the use of music that replicates the frequency bands associated with calming vocal cues of safety and feelings of connection and reciprocity. These acoustical characteristics mirror the nurturing musical qualities of lullabies in many cultures. additional music elements that help create nurturance and feelings of safety include low dynamics, slow tempos, simple structures

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and arrangements, repetitive phrasing, and a rocking meter (Loewy, 2000). For those coping with developmental trauma and attachment issues, the manipulation of preferred melodies to emulate a lullaby form may simulate the fetal sound environment and help rekindle innate feelings of connection. as such, lullabies appear to provide a gentle acoustic frame of reference to the protective prenatal time when co-regulation occurred through the mother’s heartbeat, respiratory rate, and vocal patterns (Fifer & Moon, 1995; Loewy, 2000; McKenna & Mosko, 1990; Schwartz et al., 1998).

In fact, Stegemöller (2014) reports that “sung text is more easily processed in the brain than spoken text,” (p. 219). She goes on to describe that the more consonant quality of singing and song, by its nature, contains less acoustic noise. This research may help to explain why stimulation of the SES through vocal prosody can be enhanced by singing melodies that resemble lullabies. Moreover, music therapists, particularly those trained as professional musicians, have a distinct advantage in supporting spontaneous social engagement, as both the speaking and singing voice of a professional musician are shown to have exaggerated vocal prosody (Porges, 2018c; Stegemöller, 2008).

Co-regulation, deﬁned as “the mutual regulation of physiological state[s] between individuals” or groups (Porges, 2017, p, 9), is another important principle in the reconnection phase; in therapy, it is achieved between the client and therapist. If a client’s system is traumatized, the client may rely on this coregulation, both musically and interpersonally, to initially experience homeostasis. Fisher (2009) clariﬁes this concept by describing the trauma therapist as a neuro-biological regulator. In addition to tracking cues of regulation related to the aNS, clinicians need to observe the quality and extent of social engagement through movements of the face,

head, and body of their clients and themselves. “When a client experiences reliable coregulation, the potency of transitory shifts in state [that potentially act] as triggers of defense is reduced and self-regulation spontaneously emerges,” (Porges, 2018, p. 62). Phase Five: Restoration

Restoration in the context of bottom-up proc-essing involves the use of restorative experiences to create new, corrective, habituated responses to daily life. While seeking to help traumatized clients maintain a sensory window of tolerance, interventions may be designed to further explore attuned, broadened, and embodied states that accompany feelings across a spectrum of happiness and heightened states of arousal/excitation. as such, music interventions may build on the previously described applications for increasing dynamic variance and energetic, interactive music play. Sessions also may be designed to spark this interaction in an everincreasing invitation for social engagement— from dyads to small groups or family, treatment, and community groups—as capacities for neuroplasticity improve with exposure to progressively increasing challenges (Lövdén et al, 2010). Phase Six: Self-Care & Maintenance

Self-care and maintenance can be relatively synonymous with the generalization of skills acquired in treatment to independent, everyday living. Within a neuro-physiologic context, skills are separated to create a distinction between self-care as a functional state and maintenance as the set of practiced behaviors by which self-care is sustained. amidst standard definitions of self- care, such as “care for oneself,” (Merriam-Webster, 2019) and “the practice of taking action to preserve or improve one's own health, (oxford University Press, 2019), Segal and Goldstein (1998) define self-care as a func-

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tion: “In health care, self-care is any necessary human regulatory function which is under individual control, deliberate and selfinitiated,” (p. 279). Segal and Goldstein’s definition goes on to distinguish self-care from the daily behavior and moment-by-moment decision-making involved in the management of self-care, (p. 279).

Promoting independence to restore and maintain an improved, acceptable, and best possible quality of life remains the pinnacle goal in most treatment processes. From a bottom-up approach to trauma recovery, this goal marks the development and accumulation of new sensory signals and the development of new re-enforced neural connections through which neuroplasticity can occur. This is a stage of empowerment for clients during which their accomplishments can be strengthened and celebrated.

However, brain or neural plasticity is experience driven (Thaut, 2014). Therefore, the literal training and re-training of the brain involves skills that are achieved during treatment and then must be replicable independently by recovering clients. Through the replication of those skills, clients maximize the training process and allow the transference of beneﬁts beyond the clinical environment. While working with clients throughout the phases of recovery, music therapists can constantly add to their toolbox of skills for resourcing and regulating the aNS. This toolbox of music skills can help clients form maintenance plans that are achievable, practiced, and individualized for each client.

The frequency and consistency of achieved homeostasis helps clients to feel successful in their self-regulatory capacity, and each success helps trigger motivation for continued maintenance (Chanda & Levitin, 2013). additionally, the steady strengthening of neural connections through the repetition of regular maintenance promotes the transference of

skills achieved through music and music therapy interventions to non-music-based tasks and behaviors (Stegemöller, 2014). While ideal timeframe parameters that would help to ensure lasting change, such as frequency and duration of maintenance practices, remain unclear, the above mentioned neural science research suggests a potential ripple eﬀect of resiliency for clients that could have a signiﬁcant impact on meeting diverse needs for the best possible quality of life. Conclusion

To restore natural balance in the nervous system within the aftermath of traumatizing life experiences, research recommends that treatment ﬁrst address the inner visceral, tactile, and motoric sensations latent in the body; it is the sympathetic nervous system that has trapped a client in these stored, hyper-aroused responses (Porges, 2018b). By placing emphasis on somatic/bottom-up processing across phases of trauma treatment, it is possible to restore equilibrium and resiliency in the nervous system through stimulation of the ventral vagal, SES (Levine, 2018; Porges, 2011). Stimulation and activation of the SES can create physiologic homeostasis, expand the sensory window of tolerance, regulate extreme emotional states, increase mental clarity, and foster meaningful social engagement (ogden, 2018; Porges, 2018b; van der Kolk, 2018). It is important to remember that while illustrated phases of treatment may appear sequential, processing typically moves organically between the phases. Monitoring and following the vagal responses of the client as well as those of the therapist is key to successful treatment. From a neurophysiologic, polyvagal perspective, the phases are integrally intertwined, as all involve the re-activation of the SES in retraining the nervous system to process cues of safety (Porges, 2011; Porges, 2018). Each of the discussed six stages of recovery attemp-

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ted to examine treatment objectives and applications that exemplify theoretical insight supported by the ever-expanding body of neural science research. advances in perspective and treatment supporting a body-centered/bottom-up music therapy and trauma approach will continue to evolve as technology and research further develops.

These descriptions of music therapy, Somatic Experiencing, and the Polyvagal Theory continue to formalize a developing, dynamic model for music therapists engaged in trauma treatment; it is important that the model be responsive to the ever growing advances in neuroscience and related fields of inquiry. as in other areas of music therapy practice, multiple interacting factors can influence treatment outcomes, and more research is needed to better understand the complexity of these interactions and their influences. Fortunately, the exponential growth in neuroscience continues to shed valuable light on the role of the body’s response to music, to traumatic experience and human resiliency, and thus guide treatment interventions to maximize these transformational forces. references

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ory: The emergence of polyvagal-informed therapies (pp. 3-26). New york, Ny: W. W. Norton. Levitin, D. J., & Tirovolas, a. K. (2009). Current advances in the cognitive neurosciences of music. annals of the New York Academy of Sciences: The Year in Cognitive Neuroscience, 1156, 211-231. Levitin, D. J. (2013). Neural correlates of musical behaviors: a brief overview. Music Therapy Perspectives, 31(1), 15-24. Loewy, J. V. (2000). Music therapy in the neonatal intensive care unit. New york, Ny: Satchnote Press. Lövdén, M., Bäckman, L., Lindenberger, U., Schaefer, S., and Schmiedek, F. (2010). a theoretical framework for the study of adult cognitive plasticity. Psychology Bulletin 136, 659–676. doi: 10.1037/a0020080 Luxenberg, T., Spinazzola, J., van der Kolk, B. a. (2001). Complex trauma and disorders of extreme stress (DES-NoS) diagnosis: Part 1: assessment. Directions in Psychiatry, 21 (25), 373-392. Macy, R. D., Behar, L., Paulson, R., Delman, J., Schmidt, L. (2004). Community-based, acute posttraumatic stress management: a description and evaluation of a psychosocial-intervention continuum. Harvard Review of Psychiatry, 12, 217-228. McKenna, J. J., & Mosko, S. (1990). Evolution and the sudden infant death syndrome (SIDS): Part III: Infant arousal and parentinfant co-sleeping. Human Nature, 1, 291330. Merriam-Webster. (2019). Self-Care. Retrieved January 6, 2019, from Merriam-Webster: https://www.merriam-webster.com/ dictionary/self-care ogden, P. (2018). Polyvagal Theory and sensorimotor psychotherapy. In S. W. Porges & D. Dana (eds), Clinical applications of the Polyvagal Theory: The emergence of polyvagal-informed therapies (pp. 34-49). New york: W. W. Norton & Company. oxford University Press. (2019). self-care. Retrieved January 6, 2019, from oxford Li-

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cations of the Polyvagal Theory: The emergence of Polyvagal-informed therapies (pp. xix-xxv). New york, Ny: W. W. Norton. Porges, S. W. (2018b). Polyvagal Theory: a primer. In S. W. Porges & D. Dana (eds), Clinical applications of the Polyvagal Theory: The emergence of Polyvagal-informed therapies (pp. 50-69). New york, Ny: W. W. Norton. Roth, E. a. (2014). Clinical improvisation in neurologic music therapy. In M. H. Thaut & V. Hoemberg (eds), Handbook of neurologic music therapy (pp. 24-46). oxford, UK: oxford University Press. Schwartz, F. J. (2000). Music and sound eﬀect on perinatal brain development and the premature baby. In J. V. Loewy, Music therapy for premature and newborn infants (pp. 21-37). New york, Ny: Satchnote Press. Schwartz, F. J., Ritchie, R., Sacks, L. L., & Phillips, C. E. (1998). Music, stress reduction, and medical cost savings in the neonatal intensive care unit. In R. R. Pratt & D. E. Grocke (eds), MusicMedicine 3 (pp. 120130). Melbourne, aU: The University of Melbourne. Segall, a. & Goldstein, J. (1998). Exploring the correlates of self-provided health care behaviour. In D. Coburn, a. D'arcy, and G. M. Torrance (eds.). Health and Canadian Society: Sociological Perspectives (pp. 279– 280). Toronto, Ca: University of Toronto Press. ISBN 978-0-8020-8052-3. Siegel, D. J. (1999). The developing mind: How relationships and the brain interact to shape who we are. New york, Ny: Guilford Press. Simpkins, C. a. & Simpkins, a. M. (2016). Neuroscience for clinicians: Brain change for stress, anxiety, trauma, moods and substance abuse. Neuroscience for clinicians. White Plains, Ny. Stegemöller, E. L., Skoe, E., Nicol, T., Warrier, C. M., & Kraus, M. (2008). Music training and vocal production of speech and song. Musical Perception, 25, 419-428.

Stegemöller, E. L. (2014). Exploring a neuroplasticity model of music therapy. Journal of Music Therapy, 51(3), 211-227. Stewart, K. (2009). PaTTERNS - a model for evaluating trauma in NICU music therapy: Part 1 - Theory and design. Music and Medicine, 1(1), 29-40. Stewart, K. (2018). all roads lead to where I stand: a veteran case review. Music and Medicine, 10(3), 130-141. Thaut, M. H. (2014). assessment and the transformational design model (TDM). In M. H. Thaut & V. Hoemberg (eds), Handbook of neurologic music therapy (pp. 60-68). oxford, UK: oxford University Press. Thaut, M. H., McIntosh, G. C., & Hoemberg, V. (2014). Neurologic music therapy: From social science to neuroscience. In M. H. Thaut & V. Hoemberg (eds), Handbook of Neurologic Music Therapy (pp. 1-6). oxford, UK: oxford University Press. Thaut, M. H. & Wheeler, B. I. (2010). Music therapy. In P. Juslin and J. Sloboda (eds.) Handbook of Music and Emotion (pp. 819-848). oxford, UK: oxford University Press. U. S. Department of Veterans aﬀairs. (n.d.). PTSD. Retrieved March 31, 2018, from National Center for PTSD: https://www.ptsd. va.gov/public/ptsd-overview/basics/howcommon-isptsd.asp van der Kolk, B. a. (1994). The body keeps the score: Memory and the evolving psychobiology of posttraumatic stress. Harvard Review of Psychiatry, 1(5), 253-265. van der Kolk, B. a. (2002). The assessment and treatment of complex PTSD. In R. yehuda (ed), Traumatic stress: Treating trauma survivors with PTSD (pp. 127-156). Washington, DC: american Psychiatric Press. van der Kolk, B. a. (2018). Safety and reciprocity: Polyvagal Theory as a framework for understanding and treating developmental trauma. In S. W. Porges & D. Dana (eds), Clinical applications of the Polyvagal

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Theory: The emergence of polyvagal-informed therapies (pp. 27-33). New york, Ny: W. W. Norton. van der Kolk, B. a., McFarlane, a. C., & van der Hart, o. (1996). a general approach to treatment of posttraumatic stress disorder. In B. M. van der Kolk, Traumatic stress: The

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About the Author

Kristen Stewart, Ma, MT-BC, LCaT, SEP, is a music therapist and trauma specialist in the Va-Hudson Valley Healthcare System and a CertiďŹ ed Somatic Experiencing practitioner. She is pursuing her PhD in music therapy and trauma and has presented and written often on this subject.

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Rhythm-to-Beat Trauma:

A Trauma-informed Approach for Music Therapy with a Japanese Internment Camp Survivor Laurien Hakvoort, PhD, SRMTh, NMT-F

ArtEZ University of the Arts, Music Therapy Department, Enschede, The Netherlands L.Hakvoort@ArtEZ.nl

Abstract

This article describes key moments from the ﬁrst year of music therapy treatment with an 83year old Indo-European male survivor of the Japanese internment camps in the Dutch East Indies who is diagnosed with psycho-trauma. The client will be referred as Thomas. Observations by the music therapist and verbal reports from Thomas suggest that music therapy treatment helped to reduce the PTSD symptoms that were present in Thomas’ body and brain after more than 75 years of living with complex trauma. He reported several sources of trauma in his life including attachment issues during his early years, three years of living in Japanese internment camps during the second world war, forced immigration to the Netherlands after the war, and denial by Dutch society for more than 25 years about the harshness of the Japanese camps.

With the explicit consent of the client, this case study will describe how music therapy is helping Thomas regain control over his body and mind and the hyperarousal states that have limited his ability to function in social life. The trauma-informed music therapy treatment involved rhythm and voice to encourage Thomas to change his 80-year-old ingrained patterns of avoidance and anxiety. Thomas learned to apply the rhythmic exercises and body percussion to reinforce body awareness. His nervous system made him alert to all intrusions in his surroundings and leading a constant shift of his attention; he found focusing on a task very threatening. As a result of music attention control training (Thaut & Gardiner, 2014), he increased his ability to sustain his concentration attention without spiraling into anxiety. Both breathing and singing exercises in which he engaged and his desire to make music helped him to express his longing for aﬀection and to share emotions—two of the most precarious responses to show in the Japanese camps. Resumen

Este artículo describe los momentos clave del primer año de tratamiento de musicoterapia de un hombre de 83 años de edad, indoeuropeo, superviviente de un campo de internamiento japonés en las Indias Orientales Holandesas y diagnosticado de psicotrauma. Lo llamaremos Thomas. Las observaciones del musicoterapeuta y las manifestaciones verbales de Thomas sugieren que la musicoterapia realmente le ayudó a reducir los síntomas de PTSD que estaban presentes en el

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cuerpo y en el cerebro de Thomas después de más de 75 años de vivir con un complejo de trauma. Ha explicado varios episodios traumáticos en su vida, incluyendo problemas de integración en su juventud, tres años de vivir en un campo de internamiento japonés durante la segunda Guerra Mundial, inmigrante forzado a Holanda después de la guerra, e inadaptado a la sociedad holandesa durante más de 25 años a causa de la dureza de los campos japoneses.

Con el consentimiento explícito del cliente, este estudio de caso describe como la musicoterapia ayuda a Thomas a recuperar el control de su cuerpo y de su mente y de los estados de hiperexcitación que han afectado su capacidad vital. El tratamiento de musicoterapia dirigido al trauma incluye ritmo y voz para animar a Thomas a cambiar 80 años de patrones de ocultación y de ansiedad arraigados. Thomas ha aprendido a realizar los ejercicios de rítmica y de percusión para reforzar su conciencia corporal. Su sistema nervioso le alerta de todas las intrusiones a su alrededor y desplaza constantemente su atención ya que la focalizaba en tareas muy amenazantes. Como resultado del entrenamiento para control de su atención a la música (Thaut & Gardiner, 2014), ha aumentado su capacidad para mantener su atención sin caer en una espiral de ansiedad. Los ejercicios de respiración y de canto que ha realizado y su deseo de hacer música le ayudan a expresar su anhelo de afecto y de compartir emociones, dos de las respuestas más inusuales en los campos japoneses. Pre-therapy Process – Client Background

Thomas contacted me through email in the summer of 2017 with a request to help him deal with his traumatized past before he would be too old to be able to process his memories. Music therapy would be his only treatment. He had pursued several other treatments during the course of his life, including verbal psychotherapy and art therapy. In the seventies, he actually trained to become a Gestalt therapist but was not able to verbally express his needs or fears and deal with the horrific nightmares that prevented him from sleeping at night. He insisted on starting music therapy with me, even though my private practice was more than an hour away from his hometown.

During our ﬁrst encounter I met an elderly, active, and highly intelligent gentleman who had severe problems talking about his past and present state of functioning. He shared with me that he, from an early age, had at-

tempted suicide multiple times and was a spiritual person who had gone through multiple near-death experiences. I realized that if music therapy was the only treatment for him at that time, I needed to ensure he had a good support network at home which I learned did not exist. His partner was not capable of giving him the necessary support, nor were his grandchildren. He also acknowledged that he lacked good friends. To see whether he was capable of initiating a therapeutic process, I asked him to find at least three people in his direct vicinity who could form a support network for him. If he was able to establish this network and still willing to continue the music therapy treatment, we could collaborate. I felt his hesitation. I was rather surprised when he called me four weeks later to make an appointment for his first music therapy session, confirming that he had asked four people to become his support network. He was unhappy with the contract I sent him that explained I would work

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alongside him, develop a professional relationship prior to the start of the treatment, but not become a friend. Again, I sensed Thomas’ hesitation, yet he decided to start music therapy. We would meet bi-weekly for 1.5hour music therapy sessions. Client’s anamneses

Thomas was born as the third child and first son of a coffee-planters family on Java Island in the mid-1930s. At that time Java was a part of the Dutch East Indies colony. He grew up in a tropical climate with relative wealth and was adored by his father and “babu” (the Dutch East Indies name for nanny). His mother had a difficult past herself and seemed to have difficulties connecting to her three children.

Historical events also impacted Thomas’ past. The Netherlands were at war with Germany, and the government had ﬂed to London. In December 1941, this Dutch government in exile declared war on Japan. In January and February 1942, Japan attacked the Dutch East Indies to free the Indonesians from Dutch colonization (“NIOD; Dutch Institute for War Documentation,“ n.d.). In March 1942, the Dutch East Indies Army surrendered, and all European and Euro-Indonesian inhabitants of the Dutch East Indies were declared prisoners of war. Men and teenage boys were separated from their families.

As a result of the surrender, Thomas was imprisoned with his mother and sisters. Thomas was certain that his father gave him the assignment to take care of his mother and sisters which he took very serious as any 6-year -old would have done. First, the family was jailed in a county prison and later transported to one of the female internment camps. Along with suﬀering from starvation and suppression by the internment camp guards,

Thomas witnessed punishments like physical torture and other extreme cruelties during their incarceration. Mothers and children were forced into submissiveness by the Japanese camp staﬀ and their Indonesian guards as they stood in the burning sun for many hours a day causing frequent sunstrokes and hallucinations. Around 20 percent of the women and children died during their imprisonment in the internment camps (“NIOD; Dutch Institute for War Documentation,“ n.d.).

After the Japanese surrender in August 1945, the Dutch government decided to evacuate the camp-survivors to the Netherlands. During the winter 1945/46, Thomas was shipped at the age of almost 10 with his entire family to the Netherlands—the ‘homeland’ he did not know. Besides dealing with the cold of winter, most camp-survivors were met with a “cold denial” of their war and camp experiences by the Dutch government and people. By then, Thomas had become a submissive, hyper-aroused, constantly alert, introverted child. Trauma-informed Approach to Music Therapy Based on Neuroscience

As a music therapist, I chose to work from a trauma-informed approach that was supported by the neurobiology of trauma research. Recent brain scan studies suggest unresolved trauma can trigger neural changes in the brain (Bremner, 2007; Perry, 2009; Tinnin & Gantt, 2013; Van der Kolk, 2014). People dealing with traumatic stress respond to everyday situations as if each experience is a threat. Most anything can become a trigger and reinforce the re-experiencing of a trauma state. Due to the negative impact of trauma responses in different regions of the brain, people experience a diminished ability to react or effectively cope. Trauma-informed

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music therapists use “the neurobiology of trauma theory and research to understand the impact of clients’ experiences, interpret observed symptoms and responses, and then design and deliver individualized treatment” (p. 389, Behrens, 2011; translated).

A trauma-informed approach implies that trauma symptoms are observed as inadequate coping responses that need modiﬁcation through experiential treatment (Van der Kolk, 2014). To work from a trauma-informed music therapy perspective, Behrens suggests balancing treatment around four components: (1) neural-goals, (2) psycho-social goals, (3) eﬀective coping strategies, and (4) basic treatment steps (Behrens, 2011; translated). Since trauma is stored in the body and alters how the brain functions, music therapists also need to be aware of physiological responses that might trigger re-experiencing trauma. It is important to not unnecessarily expose and re-traumatize the client, to assure treatment progress.

Several of the neural goals became a part of Thomas’ music therapy sessions. One goal focused on modulating his perception of himself and others, which implied helping him develop his inner resources and creating positive musical experiences. It also was important to enhance neural integration across his brain. This goal involved music assignments that encouraged Thomas to use both sides of his body together. For example, body-percussion and making music with drums provided him with neural integration as well as direct tactile and auditory feedback. Helping clients calm the hyper-aroused areas of their brain and decrease perceived threats is at the center of all the neural goals. As a music therapist this meant using musical exercises to help Thomas relax, such as abdominal breathing, singing, and music listening. Finally, repetition was key to successful progress, that is stimu-

lating Thomas’ neuroplasticity and creating new neural pathways that bypass trauma responses. If Thomas would make progress within these three neuro-goals, he and I could aim for higher order processing, that is, verbalizing and integrating the traumatic experiences in his life history. Because discussions to integrate his past would bring up his multiple layers of unpleasant memories, this processing only would take place once he was able to use coping skills to calm his responses and keep his memories from triggering trauma responses.

The psychosocial goals of the sessions encompassed: 1) cognitive skills such as, reframing Thomas’ perception; 2) developing emotional coping skills, such as, linking various emotional responses with diﬀerent situations; and 3) learning adaptive responses to stress-triggering situations. My basic treatment strategies were to stay in the here and now through musical exercises involving body-oriented assignments. I had to establish a safe therapeutic alliance and predictable musical structures. I observed Thomas’ past experiences using indirect methods, rather than asking him directly. It was important to encourage Thomas’ self-regulating responses and de-condition his engrained trauma responses. Music Therapy Process – Assessment and Initial Treatment Plans

To begin, I provided Thomas with some psycho-education about the neurology of a traumatized brain. I explained that according to recent research trauma could have altered his brain responses and “engraved trauma responses” throughout his body. When any physiological trauma-linked response was triggered, this stimulus could cue trauma-related stress responses in Thomas. Since he had trouble verbally sharing his history with

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me, I had the impression that at those moments the left side of his brain, responsible for verbal responses, seemed to somewhat shut down. This verbal challenge left him with the feeling that he was struggling to ﬁnd words to share his experiences. In addition, the right side of his brain probably became hyper-aroused at these moments. His thalamus, the relay and initial organizational center, was unable to categorize his experiences and instead sent fragmented pieces of information to his pre-frontal cortex and amygdala. Van der Kolk (2014) suggests that though the pre-frontal cortex tries to mediate, when dysregulated it is incapable of calming the amygdala. The amygdala and other areas of the brain release high levels of stress hormones and neurotransmitters (e.g., norepinephrine, cortisol, and adrenaline) as a reaction to this perceived threat. This release contributes to Thomas’ feelings of extreme tension and anxiety.

Thomas reported that the psycho-education helped him reframe his perception. He ﬁnally was able to understand why his body and mind always reacted so extreme when encountering even just the smallest event. Actually, he was upset that not a single person in the last 45 years of searching for a treatment had provided him with this neurological explanation of his traumatic stress reactions. I explained to him that as a result of new brain scan technology, we only recently developed an understanding of how trauma impacts the brain. This research has challenged therapists to consider how the brain and body react given early onset traumata and how to adjust their treatment accordingly. I advised him to read van der Kolk (2014) to understand more about his trauma-process and my treatment approach. During our ﬁrst meetings, I assessed Thomas

for Post-traumatic Stress Disorder (PTSD) using: (a) the Dutch version of the PTSD Symptom Scale – Interview for DSM 5, PSS-I5, (Foa et al., 2016) and (b) the Bourdon Wiersma Dot Cancelation test (Bourdon et al., 1977) that evaluates visual selective and sustained attention. During the PSS-interview, I registered several PTSD symptoms, such as cognitive and behavioral avoidance, psychogenic amnesia, detachment from others, emotional numbness, sleep difficulty, irritability, and concentration problems. He did not verbalize re-experiencing symptoms or flashbacks. I had the feeling Thomas was not entirely open, but still he received a score of 35, 12 points above the PTSD-cutoff score of 23. His sustained and selective attention was extremely weak; this test took him more than 17 minutes and he missed 106 groups of dots he had to cancel out.

In addition to the cognitive symptoms, Thomas demonstrated several physical indicators of trauma. His breathing was shallow, and he stopped inhaling when he grasped for words or became emotionally distressed when telling his story. His upper-body was tensed, and he constantly moved his hand or foot up and down. He clamped his hands to cover his eyes and mouth and trembled with fright tremors when talking about his experiences. He had chronic kidney-pains and suffered from calf spasms during the night. He seemed to find it difficult to find words for his emotions. It took about four months to collect the entire described anamnesis.

Based on the ﬁrst parts of the anamnesis and assessments, I determined it was initially important to help Thomas ease his hyperarousal. Therefore, I started with some abdominal breathing exercises and then began by singing calm, easy songs. I created the songs so I was sure they did not have any speciﬁc con-

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notations. Thomas eagerly participated in all the assignments. In addition, I introduced the use of rhythmic exercises with Thomas to enhance neural integration. I set a metronome to 60 bpm and requested him to tap along with both hands on his upper legs. When he succeeded, I added a subdivision in both hands, then only his left hand, again in both hands, and then only his right hand (SMAARTprotocol Macfarlane, 2019). Subsequently, I asked him to say words with every movement he made, such as “both, left, both, right”. The use of verbal labels further activates the orbitofrontal cortex and the expressive-receptive language areas of the brain. Thomas reported feeling liberated and at ease when tapping and singing. We downloaded a metronome on his cellphone, and I assigned him to practice these rhythmic assignments and several variations as homework when he felt at ease at home.

Along with the rhythmic exercises and singing during subsequent sessions, I introduced new instruments to Thomas and assessed which instruments he preferred and which ones he disliked. We searched for instruments that had a pleasant sensory component either through sound or tactile input so as to stimulate positive body-experiences. He liked to improvise on the pentatonic scale of the piano and loved most string instruments. When I played along using my flute, the music moved him to happy tears; he reported feeling cradled and supported. He disliked most percussion and wind-instruments, with the exception of the large djembés and the tenor-xylophone. His responses to the various instruments helped me deﬁne which ones we would use for future musical exercises. I offered structured musical assignments and was supportive in my accompaniments to establish safety, trust, and predictability.

After each session, I wrote an extensive report and sent it to Thomas. The reports helped him recall the details of the sessions and reflect on meaningful moments. Since I only saw Thomas every other week, he often wrote me an email about his experiences during the intermediate weeks. I read not only how he struggled to meet the assignments I gave him, but also how his nightmares intensified. He described how he increasingly avoided triggering situations and felt hopeless, was flooded by emotions, frightened, or completly numbed. I referred him to his general practitioner and to his friends that formed a support network. I urged him to use the rhythmic exercises to help calm himself and promised to work on his attention the next meeting. Thomas assured me that the rhythmic exercises helped him during the day. He grew into a state of relaxation when performing the exercises and could keep breathing deep and slowly. At night, however, the nightmares kept occurring and were more terrifying and intense. I had to provide him with more structural coping skills to help him be less vulnerable. PTSD and Attention Problems

After six assessment and introduction sessions, I next chose to work on his focused and sustained attention using Musical Attention Control Training (Thaut & Gardiner, 2014). I expected it to be an ‘easy’ next step in the treatment process. Thomas chose to play the diatonic xylophone, while I played the piano. I invited him to play along with my music. The piano was standing in the corner of the room, and Thomas was seated in the middle of the room where we previously had done the rhythmic exercises. I played a clear rhythmic pattern with slow moving melodic lines. I observed how Thomas seemed to enjoy the melody, a second before he joined me. However, his facial expression changed completely as

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soon as he started playing along on the xylophone. His eyes shot from one side to the other, his breathing became entirely unregulated, he quit playing, and he placed his hands in front of his mouth and eyes to sob soundlessly. He was entirely rigid and shivered from head to toe. Because I had expected that the exercise would be easy, I was confused and shocked. It appeared that I had retraumatized him by simply asking him to follow the piano improvisation. To help Thomas calm his hyper-aroused brain, I gently touched his shoulders and sang about how he could breath in and out.

I did not fully understand what had happened. How could I have retriggered such a severe trauma-response by simply asking him to follow the piano? In supervision, I discussed the situation with a trauma-expert. She made me aware that when I asked him to play along with the piano, I challenged his highly developed alternating attention. By forcing him to sustain his attention, I apparently had triggered his ‘camp-survival’ warning system of mandatory alternating awareness. To make it worse, I had positioned Thomas in the middle of the room with doors on his back and the windows left and in front of him. Unwittingly, I had forced his alternating attention-system to let go of a life-time engraved pattern. He mastered this alternating attention pattern during his campyears and unconsciously continued this response in all his surroundings. The exercise I gave Thomas required him to focus on the piano to play along with my music; and I placed him in in the middle of the room, the most vulnerable position. His mind and body reacted, thus, with extreme fear. I discussed this unexpected negative experience with Thomas during the next session. Rather than blaming me for the event, Thomas was relieved when I provided an explanation for what could have happened to him. He wanted to retry

the exercise but now seated against the wall.

Thomas also reported having difficulty connecting with people. He always felt extremely cut-off in these relationships as he was afraid to be too intense around others, but at the same time was in need of other people’s warmth and attention. He wanted to support others but needed a lot of reassurance himself. During his camp-time, he never wanted to burden his mother and these feelings often still existed in his present relationships. It wasn’t until nine months into treatment when Thomas told me that two years after immigration to the Netherlands his parents relocated back to Indonesia and only took their two new born children. His parents left him and his two older sisters behind, placing them with different families across the Netherlands. This abandonment left him feeling very unwanted and it made him even more submissive in his relationships with others.

After ﬁve treatment-sessions, a re-assessment revealed that indeed Thomas was encountering more trauma symptoms; he now scored 44 compared to his previous score of 35 on the PSS-I-5. His focused attention was very unstable. It took him over 20 minutes, compared to his previous 17, to complete the dotcancelation test; but interestingly, his number of missed dots dropped from 106 to 19. He was perceiving more inner turmoil as ‘things were coming to the surface’. To increase his resilience, I decided to put more emphasis on the exercises that would help him feel calm and safe, and those that would rehearse breathing, singing, and rhythmic patterns, along with experiences to sustain attention. The combination of music relaxation and sustained attention exercises worked well for Thomas.

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I decided to introduce more drumming exercises to draw upon his strengths. Because he sometimes had problems joining the drumming experiences, I often requested that he started playing. Sometimes he sensed my support right away and could experiment with tempi and volume, allowing himself to play as loud as his hands could bear. He clearly enjoyed those moments and always allowed me to provide a rhythmic grounding to intensify or calm the improvisations and thus adjust to possible hyperarousal of his brain. Sometimes I initiated vocalizations as part of the improvisation, to break the circles of silence that were habitual to Thomas every time he expressed his emotions. During these improvisations, Thomas demonstrated his power and resilience. However, when he had problems getting into the ﬂow of the music, he did not respond to my music improvisations and seemed to obstruct his own rhythms. At those moments he reported feeling confronted with the fear of his own anger and violence that echoed in his musicking as well. After each musical improvisation and experience, Thomas tried to verbalize his experiences and thoughts. His verbalizations were introspective as he attempted to understand what happened and how his musical experiences related to him and his past.

For his birthday, he asked his family for a djembe. He brought his newly developed skills literally to his home. Thomas kept repeating the rhythmic exercises at home and during the music therapy sessions. The exercises helped him become calm at moments when his emotions ﬂooded or numbed him. These were skills he learned to apply automatically and they functioned as helpful tools. The music therapy appeared to be eﬀective, and when I reassessed him after four months, his

scores improved. His trauma symptom score was back to 35 on the PSS-I-5 scale. Stepping Back from Avoidance

While he was teaching his nervous system to calm his trauma responses during music therapy, Thomas’ weekly reports suggested that he was attempting to face many more situations he previously avoided or from which he ran. He dared to enroll and confront himself with difficult situations and shared them with me for possible solutions or coping strategies. The most unexpected difficult situation was a vacation on a cruise-ship to the Fjords in Norway. He recalled many dreadful memories of the boat journey as he immigrated from the Dutch East-Indies to the Netherlands: standing in line for food; endless fear and boredom; an extremely hot, packed ship filled with hammocks; anxiety related to being left behind; and arriving in the extreme cold winter. The closer the vacation date came, the more stress Thomas encountered.

In addition, his sustained attention and his ability to consciously keep breathing when in distress seemed to diminish slightly during this time. Since I was doubtful how I could support his needs related to the impending trip, I decided to help him strengthen his newly developed coping skills and refrain from adding another part to his treatment. We practiced diverse drumming assignments to gain experience in releasing and controlling. The sessions were similarly structured to optimize repetition. During verbal openings to sessions, we discussed Thomas’ meaningful moments of the past weeks. Next, we practiced the neural-integration and relaxation exercises involving rhythm and voice work. Subsequently, we musically improvised starting from calm, followed by a more confrontive experience, and ending with either a verbal reﬂection or a mu-

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sical closure. After most music therapy sessions, Thomas departed with a feeling of empowerment. He often commented that he had gained new coping skills and openly discussed how engaging in new experiences confronted his old anxieties and fears. A reassessment showed that the PSS-I-5 score went up to 39 after nine months of treatment.

To our shared relief, the vacation was quite successful from several perspectives, even resolving some of his trauma-related fears. Satisﬁed with his newly developed ability to distinguish between anxiety in unexpected daily situations versus trauma-induced anxieties, he was ﬁnally ready to deal with new trauma-induced situations with some help. Thomas requested me to support him as he confronted his ‘demons’ in the music therapy sessions. More precisely, he wanted to get in touch with his ‘incapacity to feel’. Although during most of the sessions our improvisations led to Thomas experiencing strong emotional reactions, he still perceived that he could not connect to the grief, pain, and sorrow surrounding his traumatic youth. I discussed with him that I was not sure whether he could emotionally cope with such pain. I was very concerned that I would retraumatize him by exposing him to such emotions. Confronting the ‘Demons’

Regardless of my concerns, Thomas insisted we could confront his fears. I decided to provide him with a safe music experience as I surrounded and guided him consciously through the process to prevent any retraumatization responses. Thomas sat at the piano, while I accompanied him on the guitar. He really wanted to experience grief, but finding a proper musical connection was difficult. The musical ‘miss-fits’ seemed to mirror his problems with relating to others. However, as

soon as I was able to establish a musical connection, Thomas started to react emotionally. I observed him gasp for air, cry sound- less, express feelings of intense despair and fear while covering his face. I decided to sing to make him aware that he should breathe, knowing by now that he would join me in the breathing exercise through my melodic lines. He slowly calmed down and while I sang, he regained control—able to use his breathing and body movements to return to the here-and-now.

Then, just before a session around the first year of treatment, a sudden event made us realize that while Thomas had changed, he still had severe difficulties dealing with his trauma. He shared in an email that he had had one of his most frightening nightmares; a situation in which he was forced to choose between the life and death of others. He could not give me any details and was too scared to even think about it. I realized that he had to verbalize the dream in a safe manner supported by music therapy. I had to make sure he would be able to disentangle this extreme fear from his daily reality. In music therapy, I initiated the most basic rhythmic exercise we had practiced in the very first sessions. With the metronome on 60 bpm, we tapped both hands on our upper legs followed by the right hand on the right upper leg, while I mirrored the movement with my left hand, saying, “Both, right, both, right”. Next, I invited Thomas to replace these words with the description of his dream. He started slowly to share his nightmare, adjusting to the 60 bpm. At two moments he was too overwhelmed and speechless to continue. As these responses occurred, I exaggerated my movements and returned to “both, right” while encouraging Thomas to continue his movement and story. After sharing the details of his horrific nightmare, he ended his story and stopped the rhythmic exercise. He

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was astonished to experience that the extreme fears had gone. He could now retell the nightmare without feeling any extreme fear. This perceptual catharsis helped Thomas to separate his more common fears that almost all people experience as humans from his particular fears triggered by his trauma responses.

We discussed other experiences during the next therapy sessions and were able to diﬀerentiate between general, human fears and fears deriving from his ‘camp-survival-warning-system’—a system that Thomas needed to learn to ignore. Thus, he made a major step in unlearning his dysregulating responses.

We designed rhythmic exercises with lummi sticks (Wentling & Behrens, 2018) to add interactive elements to the repeating patterns and help him stay focused on other people while in distress. Breathing consciously when in distress was sometimes still hard for him. However, Thomas started to notice differences when by himself. For example, he discerned the difference between difficulty breathing due to physical problems versus psychological distress. Making such distinctions really helped Thomas facilitate changes in how he perceived his panic-attacks. Perceiving such differences, made him feel less fearful.

From that session and onward, Thomas searched for similar moments as opportunities to restore ‘damaged feelings’ and disconnect pain from fear, sadness from anxiety, and anger from terror. Even though it was hard for him to acknowledge, Thomas realized that he was allowing himself to live; he was encountering moments of internal tranquility during which he could almost admit that he was “enjoying that he lived”. He realized that these positive emotions frightened

him, and in re-sponse, he also had major moments of extreme solitude. Awareness of such moments of insecurity and isolation were the unfortunate counterparts of his positive developments. In neurological terms, his newly acquired higher-order processing capabilities, such as the activation of his orbitofrontal cortex, provided him with thoughtful considerations, both positive as well as unpleasant.

Rather than talking about his experience, I invited Thomas to improvise using the higher register of the piano á quatre mains. Again, it appeared to be diﬃcult to get connected with him, even though we both played the black keys. This time, I observed how Thomas was flooded by sadness, and I started to sing and took his left hand while we both continued playing with our free hand. I gently tapped the pulse with our hands. Thomas squeezed my hand while sad tears fell from his eyes. He showed no fear, but relaxation and intense grief. After the improvisation we sat for a while before Thomas shared how he sensed the sadness—fearful during the first improvisation and sad supported by the second improvisation. The connection he made between grief and fear was still strong, although he really wished to disconnect them. To ensure that he would be able to drive home safely, we wrapped-up doing rhythm exercises that quickly helped stabilize his emotions. Thomas had learned to modify his perceptions through enhanced neural-integration, sometimes even reframing an experience with only my indirect help. Therefore, he was able to reduce his perceived threats which helped calm himself down after hyper-aroused responses. He acquired new emotional coping skills and developed adaptive reactions to stress-triggering responses. A

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one-year-reassessment to support observations during therapy sessions revealed that Thomas now scored 29 points on the PSS-I-5, only 6 points away from the cut-oﬀ score for PTSD. He completed the dot cancelation test under 14 minutes with 26 misses. These scores suggested that his sustained attention skills were improving. However, despite these positive changes, Thomas still needed to further incorporate, control, and master all the new coping skills he had learned. Since the key to successful music therapy treatment of trauma is sustained repetition, we are not done with his treatment sessions. But his progress in such a short time is inspiring—not only for Thomas and his family, but also for the music therapy community at large as professionals continue to learn how to best meet the needs of clients diagnosed with PTSD.

References

Behrens, G. A. (2011). Musiktherapie zur Behandlung von traumatischem Stress. Zu Theorie und Forschung. Musiktherapeutische Umschau, 32(4), 384-393. Bourdon, B., Wiersma, E. D., van der Ven, A. H. G. S., Hofhuizen, J. W. M., Weis, C., Hofhuizen-Hagemeyer, J. W. M., & Mesker, P. (1977). Bourdon-Wiersma Test. Utrecht: Instituut voor Clinische en Industriële Psychologie (ICIP). Bremner, J. D. (2007). Neurobiology of posttraumatic stress disorder. In G. Fink (Ed.), Encyclopedia of stress (2nd ed.), (pp.152157). San Diego, CA: Academic Press.

Foa, E. B., McLean, C. P., Zang, y., Zhong, J., Rauch, S., Porter, K., ... & Kauﬀman, B. y. (2016). Psychometric properties of the Posttraumatic Stress Disorder Symptom Scale Interview for DSM–5 (PSSI–5). Psychological Assessment, 28(10), 1159 -1165. Macfarlane, C. (2019) Short-term Music Therapy Attention and Arousal Regulation Treatment (SMAART) for PTSD. Music Therapy Today. Retrieved from https:// www.wfmt.info NIOD; Dutch Institute for War Documentation. (n.d.) Retrieved from https://www.NIOD. nl/en Perry, B. (2009). Examining Child Maltreatment Through a Neurodevelopmental Lens: Clinical applications of the Neurosequential Model of Therapeutics. Journal of Loss and Trauma, 14, 240–255. Thaut, M. H., & Gardiner, J. C. (2014). Musical attention control training. In M. H. Thaut, & V. Hoemberg (Eds.), Handbook of neurologic music therapy (pp. 257-269). Oxford, United Kingdom: University Press. Tinnin, L., & Gantt, L. (2013). The instinctual trauma response dual-brain dynamics. A guide for trauma therapy. Morgantown, WV: Gargoyle van der Kolk, B. (2014). The body keeps the score: Mind, brain and body in the transformation of trauma. London, United Kingdom: Penguin Books. Wentling, B., & Behrens, G. A. (2018). Case study of early childhood trauma using a neurobiological approach to music therapy. Music Therapy Perspectives, 36(1), 131-136.

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About the Author

Laurien Hakvoort, PhD, SRMTh, NMT-F, is a lecturer and co-developer of the bachelor and master music therapy program as well as researcher at ArtEZ University of the Arts, Enschede, The Netherlands. She runs a private practice and previously worked in forensic psychiatry.

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How Neuroscience Research Supports Music Therapy with Children Who Have Experienced Sexual Abuse Dr. sc. mus. Gitta Strehlow, Dipl. Music-Therapist (Germany)

Clinic for Psychiatry and Psychotherapy Bethesda Hospital Hamburg-Bergedorf, Glindersweg 80, 21029 Hamburg, Germany. Email: Gitta.Strehlow@t-online.de

Abstract

This article focuses on the use of neuroscience to support music therapy in the treatment of children who are sexually abused. Four areas related to trauma work with children who are sexually abused are presented. The ﬁrst part focuses on music therapy with children, especially those dealing with sexual abuse. The second part provides information on the brain and neurological consequences of attachment trauma. Music therapists need to monitor the arousal level and then attune interventions based on observations during sessions. The third part focuses on insecure attachment responses related to trauma that often are manifested as hypersensitivity to stress, hyperactivity of the attachment system, and impairment in mentalizing. Neuroscience also will be used to support the concepts about mentalization. The fourth part involves a case example of a 7-year-old boy. The music therapy approach is psycho-dynamically-orientated and is supported by knowledge about the neurobiology of trauma and Fonagy’s concept of mentalization (Bateman & Fonagy, 2019). The paper concludes with a summary of diﬀerent concepts related to using music in music therapy with sexually abused children. Resumen

Este artículo se focaliza en la utilización de la neurociencia como apoyo a la musicoterapia en el tratamiento de niños que han sufrido abusos sexuales. Se presentan cuatro áreas relacionadas con el tratamiento del trauma en niños que sufrieron abusos sexuales. La primera parte está centrada especialmente en los niños que se están tratando por abusos sexuales. La segunda parte aporta información sobre el cerebro y las consecuencias neurológicas del trauma. Los musicoterapeutas deben monotorizar el nivel de excitación y sintonizarlo con las intervenciones basadas en la observación durante las sesiones. La tercera parte se centra en las respuestas inseguras relacionadas con el trauma que con frecuencia se maniﬁestan como hipersensibilidad al estrés, hiperactividad y deﬁciencias en la mentalización. La neurociencia también se utilizará como apoyo a los conceptos de mentalización. La cuarta parte describe el caso de un niño de 7 años como ejemplo. El enfoque de la musicoterapia tiene una orientación psicodinámica y se apoya en el

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conocimiento de la neurobiología del trauma y en el concepto de mentalización de Fonagy (Bateman & Fonagy, 2019). El artículo concluye con una relación de distintos conceptos relacionados con la utilización de la música en musicoterapia con niños que sufrieron abusos sexuales. Part One. MuSiC THERAPy AND CHiLDREN DEALiNG WiTH SEXuAL ABuSE

In music therapy, the topic of sexual abuse begins to appear more often in publications around the 1990’s (Montello, 1998, Tüpker, 1996, Ventre, 1994). Several music therapists report using different approaches and working successfully with clients who have experienced sexual abuse. The publications that focus on children (Bray Weslay, 2003, Clendenon-Wallen, 1991, Frank-Bleckwedel, 2000; Lorz, 1994; Robarts, 2006; Rogers, 1992; Strehlow, 2009a; Tompson, 2007) are roughly half of the number that focus on adults experiencing sexual abuse during childhood (Curtis, 2016; day et al., 2009; Edwards & McFerran, 2004; Lindberg, 1995; Montello, 1999). In recent years, an increasing number of publications now emphasize the general topic of traumatized clients, mostly adults, and sexual abuse is a subtopic (ahonen, 2016; Maack, 2012; Sutton & Mcdougall, 2010). only a few research studies specifically examine music therapy with children who have been sexually abused (decker-Voigt, 2005; Kim, 2015; Strehlow, 2009a). This article presents neuroscience findings and how this knowledge can inform music therapy practice with sexually abused children. Music Therapy with Children

Working with children as a music therapist presents many diﬀerent challenges than working with adults. Children are still in a developmental process and are dependent on their parents, family members, and/or caregivers. additionally, brain development is strongly in-

tertwined with early childhood experiences. Schore (2009) points out the impairments of child development when trauma is involved— “It is commonly accepted that early childhood abuse specifically alters limbic system maturation, producing neurobiological alterations that act as a biological substrate for a variety of psychiatric consequences, including affective instability, inefficient stress tolerance, memory impairment, psychosomatic disorders, and dissociative disturbances” (p. 123). young children have not developed a concept of time which has a significant impact on their experience of time in therapy. Weeklong gaps between therapy sessions can become a very long time, in which the child cannot hold on to the relationship with the therapist.

Because trust is built upon secure attachment experiences, disturbances in early child-parent interaction have a great inﬂuence on the child’s future development. In-family sexual abuse is an attachment trauma whereby trust is destroyed precisely by those people who should be responsible for the protection of the child (Luyten & Fonagy, 2019). The world becomes unpredictable and not safe for the child. as a result, traumatic experiences such as sexual abuse in childhood impact and inﬂuence many developmental processes and milestones. Quite often the experience of being sexually abused in childhood becomes apparent as a serious problem from puberty onwards. Children and inner Family Sexual Abuse

Trauma due to sexual abuse also presents unique challenges for therapists, especially

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when the perpetrator is a family member. Common to most all deﬁnitions of sexual abuse is the gap that exists between perpetrators and victims in terms of age, maturity, or power; and that the sexual assault usually is against the will of the child (Engfer, 2016). The perpetrator is satisfying himself at the expense of the child; and the child is not allowed to talk about the abuse. In many cases, sexual abuse is a desperate attempt by a parent to escape personal issues. Sexual abuse occurs quite often not only to one family generation but often is a trans-generational problem. Frequently, mothers or fathers were sexually abused and never dealt with the trauma. There- fore, mothers and fathers who are victims themselves are often unable to protect their children who then also become victims (Seiffge-Krenke & Petermann, 2016).

Nevertheless, the experience of child abuse does not automatically mean that the child needs therapy. How the child experienced the abusive situation and what issues or problems surfaced as a result is an important consideration. Sexual abuse is categorized according to intensity levels from mild, such as, no physical contact or observing while bathing, to intense abuse, such as attempted or executed rape (Engfer, 2016). The ‘damage’ from being sexually abused depends on the child’s age, the frequency, the intensity, the degree of severity, and if any helping figures were involved. In the majority of cases, sexual abuse is a one-time assault. Usually it is not an attempted or consummated sexual intercourse, but mostly an exhibitionist experience or sexual touch (Engfer, 2016). There are no specific symptoms that go along with sexual abuse, although feeling numb, self-harm, anxieties, withdrawal, aggression, depression and dissociation are some possible symptoms. The only symptom

that can be strongly indicated with sexual abuse is sexualised behaviour in childhood (Engfer, 2016). Engfer (2016) also suggests a gender speciﬁc patterns exists for children who are victims of sexual abuse. Boys are more often abused by outsiders to the family, (i.e., the neighbor or a best friend.). Girls on the other hand are more often abused by someone within the family, (i.e., by the uncle, stepfather, or grandfather). Girls also are six times more likely to be victims of sexual abuse than boys, and 90% of the perpetrators are male.

Two important factors inﬂuence how the trauma is processed—whether the child could speak about the incident afterwards and whether the child was believed. Children in my practice as a music therapist frequently did not talk about their abuse after it happened. often there was not even enough trust to tell their mother about the abuse. In this instance, the child is not only traumatized by the perpetrator but by the mother’s silence and failure to protect the child. In addition, it is more challenging for children to cope with the experience of sexual abuse when they are blaming themselves. Coming to terms with the experience of sexual abuse also is especially difficult when ambivalent feelings exist, negative or positive, which is most often the case (Engfer, 2016).

The dependency of children on their parents also can lead to special problems. Children very often do not speak about their abuse because they want to stay loyal to their attachment ﬁgures. The exposure of sexual abuse within the family often leads to a break-up of the family, something children have experienced for themselves and are therefore naturally reluctant to address in therapy. one big advantage in music therapy is that the

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therapist and client can interact with each other without words.

In addition, children experiencing sexual abuse may demonstrate hypersexuality as well as feelings of shame and guilt. Hypersexuality may be evident as one of two symptoms—the child engaging in sexualized behavior or being noticeably avoidant of sexual behavior. The sexual assault on a child by an adult perpetrator sexualizes a young child’s needs. This result is especially disastrous for children experiencing or feeling neglected; the sexual act satisﬁes their need for attachment and connection and is the only way children can experience themselves as important and meaningful to the adult. The child often has no choice but to adapt his or her need for tenderness to the passionate sexual needs of the adult; and as result his or her actual childhood needs for tenderness are not fulﬁlled. This also is problematic since healthy sexuality is important to feel vital and helps with resiliency. When working with sexually abused children, the therapist must be prepared to deal in therapy with sexual topics and to find ways to help the child develop healthy sexual behaviour (Ziegler, 2015).

The adverse Childhood Experience study (aCE) (Felitti et al., 1998) shows a clear connection between childhood trauma and the development of health issues in adulthood. The study highlights the impact of stressful childhood experiences. The more types of adverse and traumatic childhood events one experiences, the greater the negative inﬂuence on health throughout adulthood. Sexual abuse is one of the signiﬁcant events, along with physical abuse, addiction problems, and separation of the parents. It is important for the therapist to be aware that sexual abuse often is not the only traumatic experience, but rather it is one event in a far more complex series.

Part Two. NEuROSCiENCE AND TRAuMA NEuROBiOLOGy AND BRAiN DEVELOPMENT

although neurobiology is often a complicated topic, recent literature is important to therapists working in the area of sexual abuse. While music therapists are not neuroscientists, it is important to understand the brain and its response to traumatic experiences when working with traumatized patients. This section focuses on outcomes from the neurobiology literature and how to transfer and integrate the results into music therapy practice. due to the advancement of brain scan technology starting in the 1970s, it is now possible to investigate and understand the brain without surgical interventions (Roth & Strüber, 2017).

While there are several ways to divide up the brain, I would like to discuss the functions of the brain based on a developmental perspective, that is based on the order of its development which includes the three layers of hindbrain, midbrain, and forebrain. due to its importance, I also will separately discuss the limbic system.

development begins with the first layer, the hindbrain, which involves the brain stem (the pons and cerebellum), the reticular formation, and the cerebellum. These brain areas are formed during the first several weeks of pregnancy, with the brain stem developing first and then the cerebellum. The areas are responsible for autonomic-sensory input and responses including elementary energy management and body perception.

The second layer includes the midbrain which sits between the hindbrain and the forebrain. The upper areas of the midbrain regulate sensory networks, and the lower areas regulate motor functions and provide a pathway for

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motor and sensory information from the forebrain. This area basically acts as a relay centre.

The limbic system and the cerebral cortex are a part of the third layer, the forebrain. Sequentially, the limbic system develops next before the cerebral cortex. The limbic system is not one speciﬁc area in the brain but a complex network involving several diﬀerent areas all over the brain. The components of the limbic system partially reside within the diencephalon or “the forebrain”, that is the thalamus and hypothalamus, and within the forebrain itself, that is the amygdala, basal ganglia, and cingulate gyrus. These brain areas are responsible for autonomic-sensory input and responses related to elementary energy management and body perception. The hypothalamus is a regulation centre for vegetative functions such as respiration, heartbeat circulation, arousal, food balance, heat balance, sleep patterns, explicit memory, and immunological reactions (Roth & Strüber, 2017, p. 57). The sympathetic and parasympathetic nervous systems, part of autonomic nervous system, also are regulated by the hypothalamus with input from the amygdala; they are key within the area of stress. The limbic system regulates various aspects of the psyche such as fear or anxiety, joy, aggression, compassion or impulse inhibition. The limbic system also is responsible for emotional and motivational processing such a person’s expectations of emotions expressed during interactions.

The sequence of development from limbic system to forebrain is key as it means that the brain stores and process emotional information before it can talk about and consciously process the information. In part, the system develops based on how emotional needs are met early in life, if safety and trust are experienced, and whether people accept or resist

help. Therefore, the limbic system helps people internalize emotional relationships such as those experienced with parents, siblings and friends. While the complete role of the amygdala is still unclear, one of its roles is to evaluate the valence and intensity of the emotional content of sensory input.

The forebrain, the third layer involves the prefrontal cortex and other areas that developed last. as previous stated, this area involves then the diencephalon, which includes thalamus, subthalamus, hypothalamus, and epithalamus, as well as the cerebrum or telencephalon. The forebrain is responsible for rational thinking, imagination, and reﬂective functions. a person’s capacity to mentalize is related to reﬂective functions. Traumatic experiences often negatively impact a person’s capacity to mentalize. Neurobiology and Trauma

It also is important for a clinician to understand the fear and panic responses and the systems that control them when working with clients who are dealing with stress. The panic and fear systems are connected to the diencephalon and the limbic system, both a part of forebrain or the third layer. again, these areas develop before the cerebral cortex. The fear system is connected to ﬁght or ﬂight reactions which is regulated by the sympathetic nervous system and involves reactions such as pulse acceleration, dilation of the pupil, an increase in adrenalin, and faster breathing. The panic system is regulated by the dorsal vagal portion of the parasympathetic nervous system and involves reactions such as slower pulse, narrowing of the pupils, and decreases in adrenalin and breathing. Both systems are needed to deal appropriately with stress. When infants react to distress triggers they begin to cry, the sympathetic or fear system

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responds; and then as infants are comforted, their nervous system calms. However, if needs are not consistently met infants enter the dorsal parasympathetic or panic system and withdraw. Within the fear system, infants learn to cry, or at a later age children and adults ask for help. Therefore, with comfort and support people learn to deal with problematic situations and manage their fear and panic systems.

However, the development of response patterns is very different in the case of a child who has been traumatized. Schore (2009) uses the term “attachment trauma” to define when trauma involves an attachment figure relationship. Schore describes two different types of attachment trauma based on two components, the type of trauma and how the body responds. The first is “abuse attachment trauma” which occurs when the reaction of overstimulation and hyperarousal is connected with the activity of the sympathetic autonomic nervous system. “Neglect attachment trauma” is the second type and occurs when the reaction of hypo-arousal or freeze occurs as a result of activity within the dorsal parasympathetic autonomic nervous system. Withdrawal from the outside world to avoid triggers and block or minimize pain is called dissociation. as an emergency reaction related to neglect attachment trauma, dissociation often occurs as a result of very high, on-going arousal within the sympathetic system that remains unresolved. Therefore, withdrawal and eventual de-attachment is a dorsal parasympathetic regulation strategy that occurs in stressful situations that are experienced as helpless and hopeless. These responses also can be a state of retreat to gain strength (Schore, 2009, p. 120).

Henceforth, when the autonomic nervous system is not balanced and unable to return to homeostasis after a stressful event, the

brain responds very diﬀerently. due to the partial shutdown of the left hemisphere, the right prefrontal cortex becomes more crucial for coping with and regulating self-functions. Schore (2014) points out that the right brain hemisphere often is the main area of that brain that is processing in psychotherapy.

The amygdala plays a key role in emotion, attention, and memory (denny & ochsner. 2018, p. 97). In the case of a highly stressful event, the amygdala becomes hyperaroused. Van der Kolk (2014) calls the amygdala the “smoke detector” as this area of the brain assesses arousal, fearful expressions, threatening, unpleasant experiences, as well as the perception of positive experiences (denny & ochsner, 2018). Therefore, the amygdala is quite active when experiencing or later remembering terrible traumatic experiences.

optimally, as the same sensory information is simultaneously sent to the prefrontal cortex, this area of the brain begins mediating responses to the stress event and eventually sends messages to exert some inhibitory control over the intense arousal of the amygdala. However, when extreme stress is perceived, the prefrontal cortex, including the orbitofrontal area, is unable to modulate the fear responses of the amygdala (Sachsse, 2004, p. 44). “Early relational trauma manifests in dysregulated autonomic hyperarousal associated with sympathetic-dominant aﬀects (panic/terror, rage, and pain), as well as dysregulated autonomic hypoarousal and parasympathetic-dominant aﬀects (shame, disgust, and hopeless despair)” (Schore, 2009, p. 130). Neurobiology and Trauma Related to the Application of Music Therapy

From a neurobiological perspective, attachment trauma can be understood as a se-

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quence of events. When social attachment relationships are experienced as rewarding, dopamine and oxytocin become key biological mediators released through a series of neural network connections. In contrast, insecure attachment experiences resulting from attachment trauma can lead to an increased susceptibility to stress, indicated by the HPa axis and the reward system. In the case of attachment trauma, a person’s attachment experiences are associated with reward as well as anxiety, anger, and frustration.

according to Habibi and damasio (2014), there is “unequivocal evidence that the emotive states induced by music and the feelings states that follow them, engage homeostasisrelated neural systems of the human brain and prompt physiological changes in several sectors of the body” (p. 99). as any other sensory input, music can stimulate both comfortable or threatening feelings and moods. Habibi and damasio reviewed a number of studies and concluded that a strong connection exists between the limbic system and pleasurable feelings evoked by music. Pleasurable music activates the dopaminergic reward system. In addition, music of any kind can become a stressor and be experienced as overwhelming. Habibi and damasio also concluded that the amygdala and the hippocampus are involved in unpleasant responses to music (p. 97).

When working with children diagnosed with trauma, music therapists need to create safe, predictable settings to meet the clients’ needs. Rather than confronting children with challenges, music experiences need to stabilize and motivate them while supporting their resources (Keller et al., 2018). Van der Kolk (2014) discusses several examples of how music and rhythm play an important role in the healing process. He discusses the use of making music in groups but does not provide

any particular experiences or advantages of music therapy.

The increasing number of articles on trauma by music therapists, however, does provide suggestions for the speciﬁc use of music and instruments to support the needs of children dealing with trauma. For example, to further develop trust and a sense of mastery, music therapists might place music instruments on the ﬂoor in the same order from which the child can select. By maintaining the same order and allowing the child to make selections, the child may develop a sense of safety and predictability and a personal sense of control over the room and instruments. Variations on similar session structure can contribute to a sense of mastery.

Therefore, to meet the needs of children’s nervous systems, music therapists need to constantly monitor the child’s arousal and adapt music interventions to adjust to their needs. For example, the choice of music generally needs to follow the preferences or interests of the child. Children often express concerns, wishes, and hopes though playing and acting rather than using words. Some of the cues to observe changes in arousal include: how they move their body, breathe, the tempo and sound of their speaking, and their ability to concentrate. additional clues about their arousal level also can be inferred from how the children make music.

While a certain amount of arousal is needed to interact and make music with children, care must be taken so that the arousal does not get too high or too low. If the arousal (anxiety) level is too high, the child is overwhelmed, the amygdala is too active, and learning is not possible. Interventions then are needed to help the child calm down. If the arousal level (anxiety) is too low, the child might not

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be able to respond to the therapist’s music interventions and again cannot learn because the therapeutic activity has no meaning for the child. during hypoarousal, the child appears to be absent, petriﬁed, or lost in reverie. The child continues to play, but does not appear to be even attending to the created sounds. The music responses hardly change and often are mechanical and monotonous, and therapists have the feeling they cannot reach the child. Children may seem dreamy, and the music may then stop. all of these responses can be cues that the child has dissociated (Strehlow & Spitzer, 2019).

during the first phase of the therapy, stabilization, I offer children several songs that support the use of specific music components. Because of the songs’ periodicity and use of verses and refrains, the music has the advantage of presenting reliable patterns that are predictable and repetitious. When closely attuned to children, music therapists are aware of how preferred music supports important events in their lives, such as highlights from school. I choose songs that become ritualistic and therefore, provide safety and reliability.

Sometimes children only choose songs that support an ergotropic tendency, that is a response to music that involves accented rhythms and a rigid time structure that accelerates over the course of the piece of music (decker-Voigt, 1991; Gembris, 1985). This music most often involves major keys and dissonances and is played at higher decibel levels. To further clarify, the term "ergotrop" does not refer to the music, but to the child’s reactions to this type of music. Therefore, as a result of this music and an ergotropic reaction, the child’s sympathetic nervous system will be triggered and increase various bodily responses, such as blood pressure, respiratory rate and pulse, and rhythmic muscle contractions.

In response to children’s ergotropic reaction and resulting music, I often offer songs that will produce a “trophotropic tendency”, that is a reaction to music that triggers the parasympathetic nervous system. as a result of stimulating a parasympathetic response, the child’s blood pressure drops, pulse and respiratory rate decrease, muscles relax, pupils narrow, skin resistance drops and calming occurs possibly associated with a feeling of pleasure. This type of music tends to have fewer accentuated rhythms, is predominantly in minor keys, and includes consonant sounds and lower decibel levels. Similarly, if a child displays symptoms of dissociation, I instead offer music that may trigger ergotropic tendencies. Using these two approaches to music, therefore, allows me to choose songs that are familiar and have a stimulating or calming effect for a hypoaroused or hyperaroused child, respectively. For example, I might select songs in a duple meter to stimulate or a triple meter to calm a child.

above all, my music choices need to help hyperaroused children regulate their emotions, that is help them find ways to calm down. In addition, to providing opportunities for positive, lively feelings, I tend to use music interactions that are experience-centred, involve physical responses, and are in the hereand-now. For some children, playing rhythms with their hands using drums can be very helpful to calm down. Providing opportunities to play on the skin of a drum or the bars of a slit-drum using their hands enhances the physical experience; using music instruments that offer several different ways to play may motivate children to actively problem solve. Children also like guessing games where one person closes his eyes and the other plays an instrument for the child to identify based on the sound produced. These exercises are used to practice alertness and perception.

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I also need to present music interactions that support the strength and self-efficacy of children. Self-efficacy is defined as believing in one’s ability and resources to successfully implement tasks and goals. an example of selfefficacy might involve allowing a child to decide how loud to play a drum after modelling the range. It also is important that the music feels alive, as Stern emphasised with his well-known concept of vitality forms (2010). The use of varying dynamics such as, “crescendo”, “diminuendo”, “surging,” “fading away,” “fleeting,” and “explosive,” are some examples. These vitality forms can help children to become more involved with the music and ultimately help them experience more liveliness and courage to deal with difficult problems.

another key aspect to my work is promoting the togetherness of music experiences. Very often people with traumatic experiences feel lonely and isolated. Music oﬀers a bridge to feel close and connected again. This need to feel connected with people is particularly true for children who have experienced sexual abuse; more importantly, they need to feel close again but without a sexual atmosphere. Musical improvisation oﬀers a unique way to experience togetherness. By combining the various principles discussed, the “music” in music therapy becomes an important means for developing hope, which is essential in surviving traumatic experiences. Part Three. ATTACHMENT TRAuMA AND iMPAiRED MENTALiZATiON The Capacity to Mentalize and Attachment Trauma

Strategies that require children to mentally conceptualize and process relationships and

emotions involve activating the prefrontal cortex of the forebrain. These higher-order processes often are referred to as a capacity to mentalize—that is “the ability to perceive and understand actions by both other people and oneself in terms of thoughts, feelings, wishes and desires” (Bateman & Fonagy, 2016, p. 3).

Mentalization theory emerged out of psychoanalytical thinking and is a progressive concept because of the connections among psychoanalysis, neurobiology, theory of mind, systemic theory, evolution, developmental theory, and attachment theory (Bateman & Fonagy, 2019). For 25 years, Fonagy and his colleagues, Bateman and Luyten, have been developing the concept of mentalization. The capacity to mentalize is crucial for the development of self-awareness, perception of relationships, ability to cooperate and work as a team, and understand oneself and others. Mentalizing involves the ability to reflect on oneself and others, to recognize that internal thoughts and feelings are connected with the outside world. Therefore, mentalization is both self-reflective and interpersonal. Without this reflexive function to process, people become overwhelmed by emotions such as anxiety, anger, and shame. at the most elementary level, mentalization allows attachments to develop with people who are important in one’s life and to be maintained even in their absence. as skills develop, people learn to see the world from different angles and change perspectives while attending to and maintaining one’s needs. Because the capacity to mentalize can act as a protection against the effects of traumatic experiences, it is important to involve strategies in therapy that help children enhance this capacity (Luyten & Fonagy, 2019, p. 83). acquiring a capacity for mentalizing, howe-

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ver, involves a developmental process (Bateman & Fonagy, 2019) and a safe and secure relationship established through "congruent marked mirroring” between attachment figures and the infant. Congruent marked mirroring can be defined as interactions “between a parent and infant whereby when a baby shows an affect, the care-giver responds by reflecting back to the baby that affect but in such a way that the baby knows that it is a reflection of its own affect” (Gillies, 2010, p. 79). Bateman and Fonagy (2019) further add that marked mirroring “is a process by which the adult means represents the child’s affect in a manner that conveys recognition and understanding of the child’s state at the same time as communicating a sense of coping with, rather than merely reflecting back, the child’s affect” (p. 4). as a result of these interactions, the capacity to mentalize develops through “pre-mentalizing modes” during childhood from birth to around age 6. Prementalizing modes (or modes of thought defined as how people tend to think or process based on that person’s past experiences, beliefs, reasoning style) are described as normal stages in the evolution of one’s ability to mentalize. If not developed by age 6, different perspectives need to be taken to develop the capacity.

Therefore, disturbances in early child-parent interaction, such as attachment trauma due to sexual abuse or the lack of congruent marked mirroring, can lead to deﬁcits in a child’s capacity to mentalize. Marked contingent mirroring experiences create an ability to regulate emotions. Following Fonagy, I often use the phrase “children need to experience a mind that has the child’s mind in mind”; that is, caregivers need to be aware of their own capacity to mentalize to provide this experience for their children (Bateman & Fonagy, 2019, p. 4). as a result of these experiences, children develop the ability to reﬂect

on feelings and intentions, or in other words, the child can mentalize. during stressful situations however, it is normal that the ability to mentalize is temporarily impaired.

Therefore, the experience of extreme distress simultaneously inhibits the development of mentalizing and the development of a capacity to regulate the distress. Children who experience early trauma due to abuse or neglect fail to develop an ability to regulate the intensity of their feelings. Instead of modulating stimulation for their children, the caregivers of traumatized children induce extreme levels of arousal. In the case of sexual abuse, the caregiver also becomes the perpetrator who induces through sexual stimulation high levels of arousal. These children are confronted with attachment figures who are not helping them learn how to deal with high arousal; instead, their attachment figures become a source of threat. Because “th[is] caregiver provides no interactive repair, the infant’s intense negative affective states last for long periods of time” (Schore, 2009, p. 119). Therefore, children are not only traumatized as a result of abuse experiences, but because they cannot learn how deal with extreme emotions. These children essentially become emotionally handicapped. In the case of early traumatisation within the family, children are compelled to avoid entering the inner world of the attachment figure; otherwise, these children would imagine that the attachment figure would want to harm them on purpose. Without developing a mentalizing capacity, children create a distance between themselves and the traumatic situation. From this perspective, children might appear to be using their hyperactivity to connect and find security with others, while actually believing that others are unable to provide security and support. Unfortunately, children

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only can learn from a person when they believe that person has something valuable to oﬀer. For treatment to move forward, the child needs to believe the music therapist has something to oﬀer the child, that the child can develop a trusting relationship with the music therapist.

To support this treatment need, Bateman and Fonagy (2016) introduced the concept of Epistemic trust as a fundamental component in therapy. Epistemic trust “emphasizes the social and emotional signiﬁcance of the trust we place in information about the social world that we receive from another person…” (Bateman & Fonagy, 2016, p. 23). For children to learn from social situations, they emphasize the need to rekindle the potential of relationships with children. Therefore, the development of trust in a relationship is a key component in music therapy.

attachment trauma also can be conceptualized as the repeated experience of being left psychologically alone in an unbearable state (Bateman & Fonagy, 2016, p. 87). From this perspective, the absence of social support itself also creates trauma. When unbearable emotional states repeatedly are not mentally processed, they become traumatic. often survivors of trauma refuse to think about their experience, because thinking about the experience means having to relive it. Therefore, therapy aims to help patients establish a more regulated mentalizing self which in turn allows them to mentalize their trauma and conﬂict and develop more secure attachments. Mentalizing puts the breaks on overwhelming emotions and impulsive actions by placing a buﬀer between feelings and actions. Mentalization Dimensions

Individuals with traumatic experiences have

specific impairments when it comes to mentalizing. To better understand the complexity of mentalization, four pairs of contrasting mentalizing dimensions were identified: (1) automatic (implicit) versus controlled (explicit) mentalizing, (2) mentalizing about oneself versus others, (3) mentalizing with regard to internal versus external features, and (4) cognitive versus affective mentalizing (Fonagy & Bateman 2019). Mentalizing takes place within all four dimensions along a continuum defined by the two terms identifying each of the dimensions. as an example, for individuals with attachment trauma, it is more common to be able to reflect on others than to reflect on themselves; and in situations of danger, individuals will protect their mentalization of the external features of those experiences more than reflecting on their internal experiences. Further, Luyten and Fonagy (2018) believe individuals with attachment trauma will reflect on the cognitive content of experiences than on the affective content of experiences. The medial prefrontal cortex has a central role in processing during affective mentalizing, and the prefrontal cortex is involved during cognitive mentalizing (p. 124).

It is important to understand the moment when a person’s mentalizing capacity switches between the two extremes of the four dimensions. For example, if arousal is too high and the amygdala too active, the person is not able to use controlled mentalizing anymore and switches to automatic mentalizing. a person with secure attachment strategies can maintain controlled mentalizing longer and use the process more eﬀectively compared to individuals with insecure attachment strategies (Luyten & Fonagy. 2018, p. 121). The therapeutic goal is to help traumatized individuals regulate when they switch and become aware of the emotional features that inhibit or facilitate their ability to mentalize.

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of the four dimensions, most neurobiology research focuses on the fourth dimension, automatic or implicit versus controlled or explicit mentalizing. automatic mentalizing facilitates survival, involves faster processing, and best serves the fight or flight response of the sympathetic system in threatening situations. In less threatening situations, automatic mentalization is helpful when processing things that are familiar, known, and require limited attention. automatic or implicit mentalizing involves a network including the amygdala, basal ganglia, ventromedial prefrontal cortex, lateral temporal cortex, and the dorsal anterior cingulate cortex areas of the brain. Controlled mentalizing is a relatively slow serial process which is typically verbal and involves reflection, attention, awareness, intention, and effort. Some of the brain areas involved in the processing of controlled mentalization include the lateral prefrontal cortex, the lateral parietal cortex (complex causal reasoning), and the medial parietal cortex (perspective-taking) (Luyten & Fonagy. 2018, p. 118). Mentalization in Relation to Music Therapy

In their new handbook, Bateman and Fonagy (2019) included for the ﬁrst time a separate chapter written by Havsteen-Franklin (2019) discussing how the creative therapies can foster the ability to mentalize. Bateman and Fonagy believe that mentalizing and the use of creative arts therapies are connected due to their common creative nature and focus on imagination (p. 4). In fact, exploring aﬀect is one of the great advantages to using arts therapies. despite the focus on art therapy rather than music therapy, Fonagy's mentalization approach provides a valuable perspective for music therapists due to its focus on the relationship between therapist and child and the child's attachment patterns (Bateman et al., 2019, p. 105).

When using improvisation, music therapists approach the child’s attachment problems from a music perspective. Because musical improvisation is communication with sounds, music therapists are trained to hear intention when creating and listening to music. For example, getting louder when playing together or playing in an alternating dialogue results in many music cues for interpretation. depending on how the therapist uses music cues, children can feel supported and understood, and henceforth, the relationship with clients using music develops. In music therapy, deep emotional involvement is established through music experiences, which leads to trust, and eventually helps children open up to new experiences.

Besides epistemic trust, the mentalization approach also focusses on affect elaboration and identifying emotions as another component (cognitive vs. affective mentalizing) within the four dimensions (Bateman & Fonagy, 2016, p. 250). Because music is an excellent way to explore emotions, music therapy also supports this dimension during treatment. However, when working with children dealing with trauma, it is important to work carefully with difficult emotions so as to not overwhelm the child (Strehlow, 2009a). Using composed or pre-composed songs or improvisations, music therapists can help children express and differentiate emotions. In particular, when children are unable to find the words and the topics are difficult to discuss, the emotions and content can be expressed and explored through the nonverbal phenomena of music. Therapists need to assess when the music is necessary to provide a nonverbal avenue of expression and avoid harm; then when words may become safe, help children find words to express their emotions. Music also provides therapists with unique

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opportunities to be with the child, especially when difficult and unbearable emotional states might arise, and children feel psychologically alone in an unbearable state. Music played during sessions for example might sound overwhelming, express feelings of shame and guilt, or reflect sexual behaviour. Interacting with children through improvisations allows children who were sexually abused to safely express these feelings, their sense of being used, helplessness, and powerlessness. In turn, music therapists can use the music to support, preserve, and modulate unbearable experiences. The therapist’s task is to find a way to support children throughout carefully planned music interactions and use words so that children can overcome the traumatic feelings.

Musical marked mirroring (Gergelys, 1996) is another mentalization concept that can be used within music therapy. Music often is used to mirror children’s emotions while at the same time frame and contain their emotions (Strehlow, 2009b). The technique both reﬂects and contains emotions, thereby, helping patients experience high arousal states that often include diﬃcult and unbearable emotions. The therapist’s role is to help children deal with the intolerable emotional states without them becoming overwhelmed again.

However, music alone does not promote mentalization. Therefore, music therapists need to recognize when children are losing their capacity to mentalize. To do this, therapists need to be aware of their own music, the child’s music, and how the child and therapist create music together. Strehlow and Hannibal (2019) discuss several options within music therapy to enhance the capacity to mentalize and how to deal with failure in mentalizing. When working with traumatized

children, it also is important to monitor, recover, and maintain the therapist’s own mentalizing capacity. analyzing countertransference can help therapists regain their mentalizing capacity (Strehlow & Lindner, 2016).

Therefore, mentalization can be elicited through the implicit way music is used to develop relationships and music interactions. To reﬂect traumatic emotions and provide an avenue to nonverbal expressions through musically marked mirroring, music therapists also need develop their own mentalization skills. Part Four. CASE EXAMPLE: DAViD, THE “LiTTLE WHiRLWiND”

To demonstrate how these concepts can be applied within a clinical practice, the ﬁnal section of this article focuses on a case example of david, “the little whirlwind”. david is a 7year-old child who presents as a pleasant, likeable, but agitated young boy. due to neglect and sexual abuse by his biological mother, he lives with his foster mother. This case emphasizes the need among therapists to be aware of sexual abuse not only among young girls but also boys.

david showed several symptoms of sexual behaviour in various settings prior to starting therapy. For example, he touched his teacher’s breast and backside and persuaded his schoolmates to take their clothes off. on examining david’s history, he had a type of sexual relationship with his mother. The teachers observed david and his mother kissing intensely. There were suspicions of abuse by the mother and her partner. Eventually, it was discovered that they were taking videos of sexual activity with david.

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When david entered the music therapy room, he wanted to play all the instruments at the same time. He began by hitting many of the instruments; then made a beeline for the big drums, playing them loudly for a short time; and then moved on to hitting a variety of drums. He then ran to the piano and repeatedly opened the piano top, played some notes and closed it. Finally, he ran to the string instruments and strongly plucked the strings. I tried to keep up with him, but he was very fast and was already at the next instrument before I could even reach him.

This chaotic start of david’s session is typical of music therapy treatment with sexually abused children. The theme of danger and high tension was immediately apparent in the room. I felt overwhelmed by the tempo and fearful that the instruments would be damaged. He established his own form of security by being in charge and leaving me no space or room to enter the experience. His playing, which excluded me, showed that closeness and a relationship were not allowed. For me, david’s behavior demonstrated his fear about what could happen when alone in a room with a therapist. david also avoided me as a musical partner. He was basically running away in the session. I understood his behaviour as primarily being a result of his fear of becoming a victim again. according to Fonagy’s theory (Luyten & Fonagy, 2019), he was demonstrating that entering into another person’s world was perceived as threatening and must be avoided.

Because david was very highly aroused, the first step was to find a way to help him calm down and to diffuse the overpowering tension. I began by dividing the room into two halves; he played in one half and I played in the other with limited instruments. We also arranged an order in which the instruments

could be played by him. The distance between us and the clear order of the instruments helped david to calm down. The structure created in the therapy space and the use of the instruments provided a sense of safety and security that allowed david to settle into the space and the experience.

In session eight, david began demonstrating seductive piano playing. david asked me to relax, to feel comfortable, and to listen to music that he wanted to play for me on the piano. He also asked me to close my eyes. I followed his instructions. He used the pedal and played with both hands moving from the low tones up to the high tones. The sound was very soft and the tones ﬂowed into each other in waves. during his song, I felt very uncomfortable. I had the impression that he was trying to seduce me with his piano playing. It sounded sexual to me, I felt ashamed, and did not know what to do. The music communicated an overwhelming relationship.

I was surprised and irritated that a boy of 7years old could play in a way that felt seductive. I felt very awkward, even strange. I started to become highly stressed and at ﬁrst did not know what to do. although I could not hear stress in his playing, I assumed david also was experiencing a very high level of stress. as I was able to acknowledge my stress experience, I was able to calm myself down. I remembered that confusion between adult and child sexuality is very common in children who have been sexually abused. My hypothesis was that david wanted closeness and excitement but no adult sexuality. I decided to stop “only listening”, stood up, and went to the congas to accompany what he was playing. at ﬁrst, david was irritated when I started to play with him. However, I began to sing as I

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continued to play expressing happiness that he was here, that we could make music together, and we could have a good time together. My music communicated that he did not have to “play for me”, but that we can make music together. My goal was to allow him to experience and recognize that we could be in a relationship together, without it being sexual. david smiled when I made it clear that it was good to be together and there was no need for him “to do something for me”. Here the music helped to have a close relationship without the presence of sexualized feelings.

For the next session, I looked for songs that could keep david in a calmer state of arousal and connect to a sense of safety, comfort, and reliability. I wanted the music to support and communicate positive experiences. These included German children songs in which animals were engaged in enjoyable experiences, for example, “Häschen Hüpf” or “Bunny Jump”. as we sang these songs together, he also had the option of engaging in the body actions for the songs, such as, “If you’re Happy and you Know it Clap your Hands”. We also found a song in ¾ meter that had a calm tempo and was about a frog that needed help because the frog was ill. I learned which specific songs had meaning for david and helped him feel safe and comfortable with me. Generally, the songs I selected were ergotropic (accented rhythms, rigid time structure, accelerando) as well as trophotropic (fewer accentuated rhythms, predominantly in minor keys, consonant sounds, lower decibel levels). I also used a song that included a bit of danger. This was a song about dracula, titled, “Who is afraid of dracula?”. It is very lively song, with a dancing melody and rhythm. david liked this song a lot as the song provided an opportunity for feelings of fear to be in the

room in a way that was not overwhelming or threatening, but tolerable.

The next series of sessions illustrate how a traumatic experience can begin to be modulated through marked mirroring. Music improvisation was used during sessions to express traumatic emotions such as disgust and shame. For example, one day david was singing into plastic pipes with a very deep voice, and I was singing into a pipe as well. He began to sing, “hey, you horny bastard”. His voice sounded disgusting, dirty, and dangerous. I was shocked when I heard this voice. I felt uncomfortable and again ashamed. david was showing me an unknown and dangerous part of himself. I supported and expressed these feelings of disgust by singing the vocal “eeh” in a very high-pitched tone. I was exaggerating the feeling of disgust, so that it would be clear that it was his emotions that I was singing about. Later, I extended the play by singing that I would go away and get help, thus communicating that I would not stay in a situation that was harmful and disgusting. david initially was surprised by my responses, but by the end we both were making sounds of pushing someone away and looking for help. This session with the pipes was significant for several reasons. I, as the therapist, experienced these dominant feelings of shame and disgust. These feelings then were modulated; and the idea to ask for, get help, and accept help was implemented. The significant experience that occurred in this session also was reflected upon in subsequent sessions, further illustrating the pivotal nature of the experience.

after working through those difficult emotions, david’s sessions again began to focus on developing his resources. david started

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to think about his gender and how being a boy was important to him. The few men in his life were very disappointing for david. For example, his father was in prison. I mentioned my gender as a woman and how difficult it must be for him to be mostly surrounded by women. I was showing him that it is possible to reflect, mentalize, in a critical way about myself. It was important for david to experience that thinking about himself did not need to lead to something dangerous, but instead he could use thoughts from the sessions for a new musical play. david began singing “cowboys and Indians songs” and used these to identify with the male gender. We were collecting positive male role models and behaviors through the use of songs. In our music making, we were playing together on the congas in very rhythmic and ergotropic ways. david was playing the musical instruments using strong, rhythmic patterns—he had developed his own powerful music that expressed what it was and felt like to be a smart boy.

Summary

Throughout the case example of david’s experiences in music therapy, the sessions illustrate how music can be used to respond to highly arousal, sexualized behavior and the need for creating safety and security in sessions, and to deal with feelings that are overwhelming. These are issues commonly associated with and experienced by children who have been sexually abused. Music therapists need to be prepared to meet these complex needs through music. It is important to recognize and understand the various ways in which music and the therapist play a signiﬁcant role in this work.

In summary, I present the following principles for eﬀectively working with children who

have been sexually abused through music therapy.

1. Maintain an active stance to eﬀectively monitor the client’s arousal level. 2. Recognize that music oﬀers a way out of silence and secrets. 3. Focus on and enhance good musical experiences. 4. Recognize that music can be comfortable and safe because of high predictability. 5. Use music as a space for pleasurable experiences with no sexual connection. 6. Understand that music can develop the capacity to mentalize to protect against new traumatisation. 7. Be aware of feelings of guilt, shame, and disgust, which can be sometimes inaudible. 8. Be open-minded towards dangerous inner voices. 9. Recognize that music can modulate unbearable emotions. 10. Use music as a space for experimenting with new relationships and related experiences and to enhance epistemic trust. References

ahonen, H. (2016) adult trauma work in music therapy. In J. Edwards (Ed.) The Oxford handbook of music therapy, (pp. 268288), New york, Ny: oxford University. Bateman, a. W., & Fonagy, P. (2016). Mentalizing-based treatment for BPD–A practical guide. New york, Ny: oxford University. Bateman, a.W., & Fonagy, P. (2019). Handbook of mentalizing in mental health practice. (2nded.). Washington, dC: american Psychiatric association. Bray Weslay, S. (2003). The voice from the cocoon: Song and imagery in treating trauma in children. In S. Hadley, (Ed.), Psychodynamic music therapy case studies. (pp. 106– 122), Gilsum, NH: Barcelona Press.

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Clendenon-Wallen, J. (1991). The use of music therapy to influence the self-confidence and self-esteem of adolescents who are sexually abused. Music Therapy Perspectives, 9, 73-81. Curtis, S. L. (2016) Music therapy for women who have experienced domestic violence. In J. Edwards (Ed.) The Oxford handbook of music therapy, (pp. 289-298), New york, Ny: oxford University. day, T., Baker, F., & darlington, y. (2009). Experiences of song writing in a group programme for mothers who had experienced childhood abuse. Nordic Journal of Music Therapy, 18(2), 133-149. decker-Voigt, H. H. (Ed.) (2005). Der Schrecken wird hörbar: Musiktherapie für sexuell missbrauchte Kinder [The horror becomes audible. Music therapy for sexually abused children]. Eres Verlag, Lilienthal. decker-Voigt, H.-H. (1991). Aus der Seele gespielt [Played from the soul]. München, Germany: Goldmann. denny, B. T. & ochsner, K. N. (2018). Minding the emotional thermostat. In C. Schmahl, K. Luan Phan, R. o. Friedel, & L. J. Siever, (2018). Neurobiology of personality disorders (pp. 95-109). New york, Ny: oxford University. Edwards, J. & McFerran, K. (2004). Educating music therapy students about working with clients who have been sexually abused. The Arts in Psychotherapy, 31, 335348. Engfer, a. (2016). Formen der Misshandlung von Kindern- definitionen, Häufigkeit und Erklärungsansätze [Forms of abuse of child definitions, frequency and explanatory approaches]. In U. T. Egle, P. Joraschky, a. Lampe, I. Sieffge-Krenke, & M. Cierpka (Eds.), Sexueller Missbrauch, Misshandlung, Vernachlässigung [Sexual abuse, maltreatment, neglect] (pp. 3-23). Stuttgart, Germany: Schattauer.

Felitti, V. J., anda, R. F., Nordenberg, d., Williamson, d. F., Spitz, a. M., Edwards, V., Koss, M. P., & Marks J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse Childhood Experiences (aCE) Study. American Journal of Preventive Medicine, 14, 245-258. Frank-Bleckwedel, E. (2000): ...dass ich ernst genommen werde mit meinem Erlebnissen.“ Szenen einer Musiktherapie mit sexuell traumatisierten Kindern. [...that I am taken seriously with my experiences." Scenes of a music therapy with sexually traumatized children]. Musiktherapeutische Umschau, 21(1), 30-42. Fonagy, P. Bateman, a. W. (2019). Introduction. In a. W. Bateman & P. Fonagy. Handbook of mentalizing in mental health practice (2nd ed.) (pp. 3-20). Washington, dC: american Psychiatric association. Gergely, G., & Watson, J. (1996). The social biofeedback model of parental aﬀect-mirroring. International Journal of Psychoanalysis, 77, 1181-1212. Gembris, H. (1985). Musikhören und Entspannung [Listen to music and relax]. In H. de la Motte-Haber (Ed.), Beiträge zur Systematischen Musikwissenschaft, 8, Hamburg, Germany: Karl dieter Wagner. Gillies, F. (2010). Being with humans: an evolutionary framework for the therapeutic relationship. In M. Milton (Ed.). Therapy and beyond counselling psychology contributions to therapeutic and social issues (pp 7-87). oxford, United Kingdom: WileyBlackwell. Habibi, a., & damasio, a. (2014). Music, feelings, and the human brain. American Psychological Association. 24(1), 92-102. Havsteen-Franklin, d. (2019). Creative arts therapies. In: a. W. Bateman & P. Fonagy. Handbook of mentalizing in mental health

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practice (2nd ed.) (pp.181-196). Washington, dC: american Psychiatric association. Keller, J., Strehlow, G., Wiesmüller, E., Wolf, H. G., & Wölf, a. (2018). Methodische Modiﬁkationen für die musiktherapeutische Behandlung von Patientinnen mit Traumafolgestörungen [Methodical modiﬁcations for the music therapeutic treatment of patients with post-traumatic disorders]. Musiktherapeutische Umschau, 39(1), 12-22. Kim, J. (2015). Music therapy with children who have been exposed to ongong child abuse and poverty: a pilot study, Nordic Journal of Music Therapy, 24(1), 27-43. Lindberg, K. a (1995). Songs of healing: Song writing with an abused adolescent. Music Therapy, 13(1), 93-108. Luyten, P., & Fonagy, P. (2019). Mentalizing and trauma. In. a. W. Bateman & P. Fonagy. (Eds.), Handbook of mentalizing in mental health practice (2nd ed.) (pp.7999). Washington, dC: american Psychiatric association. Luyten, P., & Fonagy, P. (2018). The neurobiology of attachment and mentalizing: a neurodevelopmental perspective. In C. Schmahl, K. Luan Phan, R. o. Friedel, & L. J. Siever (Eds.). Neurobiology of personality disorders (pp.111-130). New york, Ny: oxford University. Lorz, a. (1994). Musiktherapie bei sexuell missbrauchten Kindern und Jugendlichen [Music Therapy with sexually abused children and adolescents]. Musik- Tanz- und Kunsttherapie 5, Göttingen, Germany: Hogrefe Verlag, Maack, C. (2012). outcomes and processes of the Bonny Method of Guided Imagery and Music (GIM) and it‘s adaption and psychodynamic imaginative trauma therapy (PITT) for women with complex PTSd, http://vbn.aau.dk/files/68395912 /Carola_Maack_12.pdf Montello, L. (1998). Relational issue in

psychoanalytic music therapy with traumatized individuals. In K. Bruscia (Ed.): The dynamics of music psychotherapy. (pp. 299-314) Gilsum, NH: Barcelona Press. Montello, L. (1999). a psychoanalytic music therapy approach to treating adults traumatized as children. Music Therapy Perspectives, 17, 74-81. Robarts, J. (2006) Music Therapy with sexually abused children. Clinical Child and Psychiatry, 11(2), 249-269. Rogers, P. (1992). Issues in child sexual abuse. British Journal of Music Therapy, 7(2), 515. Roth, G., & Strüber, N. (2017) Wie das Gehirn die Seele macht [How the brain makes the soul]. Stuttgart, Germany: Klett-Cotta. Sachsse, U. (2004). Traumazentrierte Psychotherapie [Trauma-centered psychotherapy]. Stuttgart, Germany: Schattauer. Schore, a. N. (2009). Right brain affect regulation: an essential mechanism of development, trauma, dissociation, and psychotherapy. In d. Fosha, d. Siegel, & M. Solomon (Eds.), The healing power of emotion: Affective neuroscience, development, & clinical practice (pp. 112144). New york, Ny: W.W. Norton Schore, a. N. (2014). The right brain is dominant in psychotherapy. Psychotherapy (Chic.) 51(3), 388-97. Seiﬀge-Krenke, I., & Petermann, F. (2016). Kinder und Jugendliche als Täter und opfer [Children and adolescents as perpetrators and victims]. In U. T. Egle, P. Joraschky, a. Lampe, I. Sieﬀge-Krenke & M. Cierpka (Eds.), Sexueller Missbrauch, Misshandlung, Vernachlässigung [Sexual abuse, maltreatment, neglect] (pp. 263-282). Stuttgart, Germany: Schattauer. Stern, d. (2010). Forms of vitality. New york, Ny: oxford University. Strehlow, G., & Spitzer C. (2019). dissoziative Störungen [dissociative disorder]. In U.

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Schmidt, T. Stegemann, & C. Spitzer (Eds.): Musiktherapie bei psychiatrischen und psychosomatischen Störungen. München, Germany: Elsevier Urban & Fischer (in press) Strehlow, G., & Hannibal, N. (2019). Mentalizing in improvisational music therapy. Nordic Journal of Music Therapy, 28(4), 333-346. Strehlow, G., & Lindner, R. (2016). Music therapy interaction patterns in relation to borderline personality disorder (BPd) patients. Nordic Journal of Music Therapy, 25(2), 134-158. Strehlow, G. (2009a). The use of music therapy in treating sexually abused children. Nordic Journal of Music Therapy, 18(2), 167-183. Strehlow, G. (2009b). Mentalisierung und ihr Nutzen für die Musiktherapie. [Mentalization and its beneﬁts in music therapy]. Musiktherapeutische Umschau, 30(2) 89101. Sutton, J. & Mcdougall, I. (2010). The roar of

the other side of silence. Thoughts about silence and the traumatic in music therapy. In: K. Stewart (ed.). Music therapy and trauma. bridging theory and clinical practice (pp 88-100). New york, Ny: Satchnote. Tompson, S. (2007). Improvised stories in music therapy with a child experiencing abuse. British Journal of Music Therapy, 21(2), 43-52. Tüpker, R. (1996). Sexueller Missbrauch [sexual abuse]. In H. H. decker-Voigt, P. Knill, & E. Weymann (Eds.) Lexikon der Musiktherapie (pp 336-338). Göttingen, Germany: Hogrefe. van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New york, Ny: Penguin Books Ventre, M. (1994). Healing the wounds of a children abuse: a guided imagery music case study. Music Therapy Perspectives, 12, 98-103 Ziegler, d. (2015). Sexual issues with children. Jasper, oregon: Createspace Independent.

About the Author

Dr. Gitta Strehlow, dipl. Music-Therapist, works with adults at the Clinic of Psychiatry and Psychotherapy (Bethesda Hospital Hamburg-Bergedorf) and with sexually abused children. She also is a part-time lecturer at Hamburg University of Music and Theatre and Swiss Forum Further Education Music Therapy.

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Considerations for Music Therapy in Long-term Response to Mass Tragedy and Trauma Jennifer M. Sokira, MMT, LCAT, MT-BC

Resiliency Center of Newtown; Connecticut Music Therapy Services, LLC jen@ctmusictherapy.com

Abstract

Drawing from experience in providing music therapy to the Newtown/Sandy Hook, Connecticut community since the 2012 school shooting, this paper will outline the trajectory and psychological phases of community trauma, providing considerations for music therapists serving survivors through all phases. Advocating for therapist attunement to the neurobiological brain and bodily changes which trauma survivors experience, recommendations will be made regarding resilience as prevention, education and training, networking, and therapist vicarious resilience. Resumen

Aprovechando la experiencia en la prestación de musicoterapia en la comunidad de Connecticut Newtown/Sandy Hook, desde el tiroteo que hubo en la escuela en 2012, este artículo describe la evolución y las fases del trauma psicológico de la comunidad, aportando consideraciones a los musicoterapeutas que trabajan con los supervivientes en todas las fases. Con referencia a la sintonía del terapeuta con los cambios neurológicos en el cerebro y en el cuerpo que sufren los supervivientes, se hacen recomendaciones relativas a la resiliencia como prevención, a educación y entrenamiento, a pautas de trabajo, y a la propia resiliencia del terapeuta. Introduction

On December 14, 2012, after shooting his mother at close distance in their home, a shooter opened fire in Sandy Hook School in Newtown, Connecticut, USA, killing 20 first grade students and six educators. The resulting constellation of individual and community trauma has had a major, long term influence on the lives of thousands of people in the immediate

geographic area, in addition to signiﬁcant impact on a vast number of individuals throughout the world who became aware of these events. In subsequent years, many mass shootings in schools, places of worship, and other public places have occurred in the United States creating ripples of impact and unique but connected individual and community needs. These are the needs that music therapists may be called to serve in a long-term capacity.

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This article will discuss the importance of music therapists’ understanding of masstragedy trauma and its effect on the whole individual and community, describing the trajectory of community trauma and clinical needs as they emerge in the days, months, and years following. Grounded in a clientcentered, neuroscience-informed perspective of trauma as a whole body experience (van der Kolk, 2014; Levine, 1997), this article will (a) highlight clinical examples that illustrate assessment, treatment, and therapeutic relationships in each phase of trauma recovery (Zunin & Myers 2000), and (b) provide recommendations for future consideration in the ﬁeld.

Please note that the terminology used throughout this article to reference the speciﬁc tragedy on 12/14/12 may include “Sandy Hook”, “Sandy Hook School” and “Newtown”, consistent with the ways in which it is addressed within the community.

understanding Mass Tragedy Trauma

According to the American Psychological Association, trauma is an emotional response to a terrible event like an accident, rape or natural disaster. Immediately after the event, shock and denial are typical. Longer term reactions include unpredictable emotions, flashbacks, strained relationships and even physical symptoms like headaches or nausea. While these feelings are normal, some people have difficulty moving on with their lives (2019). Individual trauma may stem from natural events, like a ﬂooded home or house ﬁre, and human-caused events, for example, harassment, assault and murder. Trauma also may impact many individuals at once, for example, large scale natural disasters such as hurri-

canes, ﬂoods, or wildﬁres. Mass or collective trauma also can be caused by large humancaused events like school shootings and acts of mass terrorism (Myers, 1994). Trauma Response in the Body and Brain

While it is not within the scope of this article to fully outline the complex processes of the brain as it responds to trauma, it is now widely accepted that trauma is not simply an emotional reaction, but a full body reaction that has long term consequences if not addressed. Therefore, a brief overview of these processes is warranted, especially as this viewpoint has been signiﬁcantly inﬂuential in the music therapy response in Newtown/ Sandy Hook.

When a trauma occurs, information enters the individual’s brain through the senses, and is processed in the limbic system. The neocortex becomes overwhelmed and higher order functions, such as the ability to speak, think clearly, and perceive time, become impaired. The autonomic nervous system then activates, moving the body quickly into survival mode as the reptilian brain takes over the body’s functioning. Adrenaline is released activating the body to get out of danger and impacting the heart rate, breathing, and digestion. The individual may experience a ﬁghtﬂight-freeze response that is intended to preserve the individual’s existence; and eventually the person may move back into a level of homeostasis and regulated bodily functions.

This bodily memory is then stored and can be re-activated when a sensory experience (e.g., a sound, color, or smell) or a physiological response (e.g., a heart rate or blood pressure) reminds the body of the previous fight, flight or freeze. Re-traumatization can occur through this reactivation. Whether it

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is one trauma memory or many, when actuated by the senses via the limbic system the client re-experiences their trauma. This triggering or activation of the trauma experience by the body causes the individual to relive the trauma through the ﬁght/ﬂight/freeze response, which causes dissociation, hyperarousal, or a myriad of other symptoms. (Levine, 1997; Rothschild, 2000; van der Kolk, 2014).

Post Traumatic Stress Disorder (PTSD) is diagnosed when multiple symptoms are observed over an extended period of time with significant, negative impact. These symptoms might include intrusive thoughts, nightmares, flashbacks, emotional and/or physical distress in response to trauma reminders, avoidance of trauma-related thoughts or reminders, difficulty recalling the event, negative thoughts about self or world, self-blame, changes in interests, feelings of isolation, and difficulty experiencing positive emotions (National Center for PTSD, 2018). In addition, individuals also display a variety of other symptoms related to the negative effect of trauma on the body, such as difficulty making decisions; responding with empathy; trusting others; responding to social cues; maintaining relationships; regulating emotions, thoughts, and/or responses; problem-solving; and calming themselves (van der Kolk, 2014).

Until this body-based trauma memory is processed and integrated, the body will continue the potential to become activated and triggered into responding (Perry & Pollard, 1998; van der Kolk, 2014). Music therapy provides an embodied approach to trauma treatment. Harris (2016) outlines rationale for the use of embodied creative arts therapy interventions with trauma. In embodied interventions, “bottom-up” processing meets the needs of clients who have experienced trauma by intervening with the bo-

dily symptoms experienced by the client. This method differs from “top-down” approaches used in “traditional” psychotherapeutic methods that address neocortical processing (Levine, 1997; Ogden et al, 2005; Rothschild, 2000; van der Kolk, 1994, 2014). Many music psychotherapy models, such as Vocal Psychotherapy (Austin) and Analytical Music Therapy (Priestley), include specific techniques and interventions that involve embodied experiences (Harris, 2016).

Among children and adults who have experienced a mass tragedy, approximately 15% may go on to develop PTSD and may benefit from embodied music therapy experiences. Others will improve or maintain functioning without intervention (Adams & Boscarino, 2006; Novotney, 2018). Risk factors for developing PTSD include severity of exposure, gender, perceived parental stress (in children), previous trauma exposure, perception of social support, self-esteem, and perception of being in danger (U.S. Dept. of Veterans Affairs, 2019). Protective or resilience factors that may limit the likelihood of an individual developing PTSD include social support, selfesteem, sense of hope, and sense of confidence in coping ability (Adams & Boscarino, 2006; Smith, 2015; U.S. Department of Veterans Affairs, 2019). Potential music therapy clients who have been exposed to mass tragedy trauma may not meet the diagnostic criteria for PTSD but may nonetheless show or report signs and symptoms of trauma. Therefore, it is important for music therapists to remember and be aware of potential signs and symptoms in initial and ongoing assessment across populations and settings.

Additionally, in mass tragedy settings, many people experience trauma symptoms concurrently. Therefore, a complex constellation of needs arises requiring additional clarity and

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assessment over time as to how these group and individual needs may be addressed therapeutically (Myers & Wee, 2005). As individuals experience symptoms within different timings, further conflict may arise among community members who hold contrasting experiences, perspectives, and opinions (Becker, 2014). It is in this activated setting then, that the music therapist must evaluate timing and appropriateness of response and intervention so as to identify where music therapy is both needed and may effectively help.

Responses Speciﬁc to Mass Tragedy

In the United States, mass shooting tragedies have become frequent events that signiﬁcantly impact individuals and communities, those directly and vicariously involved, especially survivors, helping professionals, teachers, and first responders. Erikson (1976) describes the concept of collective trauma as, “a blow to the basic tissues of social life that damages the bonds attaching people together and impairs the prevailing sense of communality” (p. 194). Further, collective trauma may present difficulty with individual healing processes within a community should that community’s collective trauma not be addressed. Following the 12/14/12 tragedy at Sandy Hook School, both direct and secondary trauma exposures were experienced by thousands, resulting in many significant and ongoing effects in the community. Some examples include: • Sense of loss/change of community identity • Sense of loss of or invasion of privacy • Signiﬁcant grief for individuals who died • Loss of sense of safety • Loss of privacy or sense of anonymity • Secondary trauma due to media exposure or overexposure

• Frequent trauma reminders within the community • Disconnection from “outside” viewpoints as the community experience is not accurately captured by the media • Loss of trust in the media and sense of invasiveness • Anger towards exploitation from celebrities, media, others • Re-traumatization due to additional mass shooting events • Re-traumatization due to false stories purporting that the tragedy did not occur • Sense of additional loss due to inadequate responses by lawmakers • Sense of fracturing within the community based on competing or conﬂicting needs in the healing and rebuilding process • Continued threats to the community (i.e., bomb threats, death threats) • Losses or reductions in funding sources that support healing • Vicarious trauma and burnout of helping professionals.

Among immediate survivors and others close to the event, the myriad of individual healing processes within the greater community trauma may diﬀer, collide, and frequently feature more complexity as compared to the presentation of an individual traumatic experience or loss in which the client may engage in therapy and daily business with relative anonymity (Myers, 1994). Trajectory of Community Trauma

Zunin and Myers (2000) oﬀer a helpful framework for understanding the long-term trajectory of a community’s response after a mass tragedy not only during the disaster re-sponse, but also during intermediate and long-term phases. They describe the following phases: Pre-Disaster, Impact, Heroic, Honeymoon/

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Community Cohesion, Disillusionment, and Reconstruction, This framework may help music therapists understand preparedness, initial and long term responses, and the nuances within and between these phases (Else, 2010). Consideration for community and individual music therapy are included within each phase to illustrate examples of potential clinical needs and responses.

Pre-Disaster/Warning/Threat Phase

During the pre-disaster/warning/threat phase it is not apparent that a disaster is going to take place, although signs may be present. With regard to disaster planning for natural disasters, individuals and communities may take action to mitigate potential negative eﬀects to themselves (DeWolfe, 2000). Within the U.S. music therapy community, two examples of this include AMTA’s disaster response network (AMTA, n.d.) and disaster preparedness courses (Lagasse, n.d.). When mass-violence events occur, communities must consider working towards de-stigmatization of mental (brain) health disorders to (a) mitigate the potential for isolation or reduced access to treatment and (b) increase funding for community-based brain/mental health support and treatment. Individuals with previous trauma experiences of course are most at risk during disasters or mass-violence events. Within their own communities, music therapists may fulﬁll an important role in engaging individuals; networking with other providers; and creating environments and systems that will support engagement, reduce isolation, and possibly reduce the potential for violence. For example, art therapists and music therapists at the Resiliency Center support suicide and violence prevention programs and socialemotional learning programs internally and in

collaboration with town, school, and community agencies. Impact Phase

The impact phase starts at the time during which the disaster is known to be happening based on initial stages of reaction. At this time a wide variety of reactions may be observed ranging from confusion, to shock, to hysteria depending on each person’s past trauma history and their individual nervous system response. Within the impact phase of a mass violence incident, individuals may experience difficulty and anxiety, survivors and family members attempt to reunite, and first responders and law enforcement secure the scene and begin investigations. During this time survivors move to safety as survivor families of loss are notified of the death of their loved ones. The community learns the details of the event in the context of multiple and frequent reports that can have an additive, retraumatizing impact. In Newtown specifically, in the week following the tragedy, traffic was difficult to navigate due to an influx of media and interested, curious outsiders of various intentions.

In the days following the mass tragedy at Sandy Hook School in Newtown, CT, additional events added to the traumatic experiences for direct and indirect survivors and community members. From a long-term perspective of assessment and case conceptualization, the music therapists working in long term response to mass-tragedy need to remember that the impact phase might include more than one aspect of the tragedy. For example, an immediate witness to the trauma might be grieving multiple losses while also experiencing harassment by media reporters. When considering direct responses within this disaster phase, music therapists also need to ﬁrst

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and continually evaluate the impact of the disaster on themselves and their own family and network. Additionally, music therapists should consider their own training within the modality of Psychological First Aid (PFA) or similar disaster response intervention. If therapists have this training or similar experience and feel able, they may consider responding within the disaster recovery agency as appropriate, not necessarily in the role of “music therapist” to provide music therapy but as an aid worker (Else, 2010).

At this point in the disaster cycle, therapist self-evaluation also is recommended regarding ability to respond competently and to understand potential personal impact and secondary trauma exposure. In some cases the therapist, local to the area of disaster, is a recipient of psychological ﬁrst aid themselves rather than a provider, as was the case with the present author and her local colleagues after the tragedy at Sandy Hook School. PFA in this instance served to ensure that the therapists’ community was safe and supported to continue responding to their normal clinical caseload (B. Else, personal communication, July 10, 2013). Heroic

The heroic phase of the disaster cycle takes place following initial impact and may be characterized by high activity and low productivity fueled by adrenaline. Decision making within the community may be impaired due to the negative neural impact and diﬃculty recovering from the trauma, and altruism may be high both among survivors and disaster responders. DeWolfe also notes that during this time the risk assessment of responders may be impaired (2000). Music therapists may be involved with com-

munity responder activities, for example volunteering in a shelter or assisting Red Cross. In the days following the events in Sandy Hook, music therapists participated in vigils, engaged in networking while actively attuning to the needs of the community, and worked to establish trust—a diﬃcult response for those dealing with trauma. The high activity and attention to the tragedy also attracts media attention and well-meaning helpers. Therefore, a high potential for exploitation exists. Music therapists need to remain vigilant in monitoring their integrity to stay grounded in ethical responses, knowing that the full picture of therapeutic needs has yet to develop.

Honeymoon/Community Cohesion

The Honeymoon/Community Cohesion period takes place over the initial weeks and months following the tragedy and is characterized by a community bonding around the tragedy and a sense of optimism and support of the survivors. Community members may be observed rallying together. During this phase, DeWolfe (2000) notes that “[w]hen dis-aster mental health workers are visible and perceived as helpful…they are more readily accepted and have a foundation from which to provide assistance in the diﬃcult phases ahead” (p. 11).

In Newtown during this time, a large number of recovery eﬀorts, foundations, and advocacy groups began; however, some did not maintain their original form and others did not continue in the long term. During this phase, music therapists were requested to attend various community events as a result of their supportive, attuned networking. Some examples included working with a new children’s organization to provide music as part of a community support day, assisting with a

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children’s programming at the library, and attending a Girl Scout troop meeting to discuss how music can help in wellness and mindfulness.

Through these events, strong consideration was given to both the psychological and neurobiological impact of music and music therapy on the individuals participating in these interventions. Music therapists actively incorporated preferred, familiar music that was attuned to the individuals and space in which the experience was taking place. With attunement to trauma’s impact on their nervous systems, the iso principle was used to guide improvisation or song selection. Great care was given in selecting instruments as to avoid auditory activators for re-traumatization, such as loud surprising drum beats which could mimic the sound of gunﬁre. Interventions included improvisation, song discussion, group music making, and conscious drumming (Borzon, 2012; Borling & Miller, 2007). Through connections made during these events, music therapy came to the attention of the newly established Resiliency Center of Newtown, which oﬀered space for clients to receive grant-funded music therapy services with the objective of aiding in long-term healing. Disillusionment

As the honeymoon phase ends, public and media attention to the event begins to wane, and previously helpful funding and donations slow in pace. Some initial volunteers, including disaster workers, therapists from afar, and other helpers and consultants may leave the area, which leaves the community faceto-face with their needs and new reality. During this phase, which may extend over years, members in the community may experience stress, trauma symptoms, anger, frustration,

and a myriad of other feelings. Individuals experience continued grief for those who were killed and for the loss of the community. A focus on critique of initial response and the handling of the recovery might be present. Critiques of many aspects related to recovery may initiate a “disaster after the disaster” creating community fracturing or alienating survivor groups (DeWolfe, 2000; Becker, 2014). During this phase in Newtown, music therapy was established and made available to anyone impacted by the trauma as a part of the greater response to the psychological needs that arose. Sessions were provided at the Resiliency Center of Newtown (RCN) funded by grants secured by private, state, and federal entities. At this time, several other traditional counseling groups as well as a local government-based referral agency were established or expanded. RCN’s specific mission focused on providing “non-duplicative” trauma therapies and treatments. In addition to music therapy, art therapy; play therapy; Brainspotting (a somatic approach in which the therapist and client are neurophysiologically attuned and address the processing of trauma experiences and symptoms) and Masgutova Neuro-Sensory-Motor Reflex Integration (MNRI, an approach that focuses on developing healthy reflex responses for use in protection and development) were provided. All of these therapeutic modalities were linked by their common focus on the brain and body’s physiological responses to trauma and that they were not easily accessible, available, or reimbursable through private insurance.

During this phase individuals initially presented with anxiety, depression, and diﬃculty coping; however, some of these clients were uncertain as to whether these symptoms were a result of the recent tragedy. During this ﬁrst year, many individuals within the initial wave of clients seeking treatment were

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among those most affected by the tragedy but not necessarily the closest to it, that is not immediately impacted. In fact, this initial group of clients often reported dealing with symptoms previous to the tragedy such as anxiety and depression; difficult divorces; or other trauma-related responses reflecting additional past tragedies (e.g., September 11, 2001) (Adams & Boscarino, 2006; Novotney, 2018).

To work with this group of clients, therapists, including the present author, also participated in a great deal of continuing education during this phase to help people consider additional trauma-speciﬁc interventions, such as, Brainspotting (Grand, 2013) and Complicated Grief Treatment (Shear, 2015). As a result of this intense learning phase, this diverse group of therapists beneﬁted from the growing network and opportunities to collaborate that arose among privately practicing clinicians and those working within agencies. This collaboration also resulted in increased referrals and a continuum of care. Clinically, psychoeducation became an important aspect of helping clients better understand their own experiences and to reduce the stigma they felt blocked them from seeking treatment.

During this stage, Herman’s Phase Oriented approach (1992) was used to guide music therapy assessment and treatment. The ﬁrst two phases involve establishing safety, stabilization and processing experiences. To establish safety in music therapy, structure and support were provided through a supportive, attuned therapeutic relationship (Herman, 1992; Rothschild, 2000). Using a variety of interventions, such as musical grounding, music and mindfulness, and supportive music and imagery, clients were encouraged to regulate their bodies and brains which assisted with

sleep, self-care habits, communication, and relational issues. With the critical step of safety and stability established, treatment then moved into the processing phase during which anger and grief trauma stories and experiences were processed. The music therapy interventions during the processing phase included singing, improvisation, musical autobiography, songwriting, GIM, and, receptive experiences (Borzon, 2012; Borling & Miller, 2007; Lowey & Frisch-Hara, 2002; Stewart, 2010). Reconstruction

During the reconstruction phase the community begins moving towards it’s “new normal” by integrating the experiences that occurred. However, not all individuals or subgroups within a community will recover at the same rate. Because integrating experiences sometimes involves the re-experiencing of grief reactions and triggering events, this phase creates new challenges for some individuals, possibly re-traumatizing them and causing them to seek therapy for the ﬁrst time. Those who have moved through the integration process may experience post-traumatic growth and “recognize strengths [and] reexamine life priorities.” (DeWolfe, 2000, p. 12).

While it is unclear exactly when a community as a whole moves from disillusionment to reconstruction, a clinician may observe clients seeking therapy for the ﬁrst time. This delayed request for support may be due to a variety of trauma responses, such as, (a) initial survivor guilt or hesitation in taking resources from others “more aﬀected”, (b) dissociation of memories, or (c) a denial of trauma-related symptoms. Some clients also may be coming back to therapy despite previously resolving their

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symptoms. Perry and Pollard (1998) report that the developmental trajectory of trauma processing indicates that while a traumatic experience may have been adequately processed at one developmental phase, this traumatic experience then needs to be reprocessed as the client moves into another developmental phase. From a neuroscience perspective, important changes in myelination, neural proliferation and sloughing occur in the brain from birth through early adulthood along with changes in hormones and neurotransmitters. This principle supports the need for long-term availability of appropriate therapy options. In the case of Newtown, many clients seen as children benefitted from being able to return to a familiar therapist to reprocess and re-understand their trauma experiences as adolescents. Reentering into the therapy process with someone with whom they had previously established a relationship allowed the adolescents to more safely explore new insights, to better understand bodily reactions and symptoms and to re-conceptualize their story using their changing hormonal brains. This re-experiencing of the therapy process with a familiar therapist also extends to clients who are developing from adolescents to adults.

Conversely, during this phase clinicians may also observe a shift among clients as they move into a more integrated or future-focused perspective. While setbacks, activators/ triggers, or experiencing re-traumatizing events may still occur, clients may begin to independently incorporate the strategies that allow their nervous system to “bounce back” with resilience. As impacted children in the Newtown Community moved from childhood to adolescence, as expected, they displayed a variety of developmentally appropriate responses—some of which suggested (a) a

sense of integration among their experiences and (b) a better understanding the tragedy as part of their personal story.

In music therapy this reconstructive phase includes supporting clients as they prepare to tell their story to others in new settings and begin to question their identity—that is, to what extent is their survivor identity going to be present as a part of their lives. For music therapists, the task involves validating the myriad of client responses that emerge. Some clients desire minimizing exposure to and impact with other clients who have entered a public advocate/supporter role. For others, this process involves supporting clients who move into work or volunteerism that “pays it forward”. Clients who experience post-traumatic growth may support the development of strong communities and good, non-stigmatized brain health. They may even become involved in suicide prevention or gun violence prevention. This wide variety of client needs therefore requires therapists to be open, supportive, and attuned to the individualized past, current, and future strengths and challenges of clients as they move forward into continued healing or maintenance. emerging Resources and Recommendations

Prevention and preparedness are important considerations for music therapists who work in any community. It is unfortunate but clear that mass tragedy can happen unexpectedly and change the course of many lives and careers. Within the music therapy community, therefore, it is recommended that on-going education be available for therapists to be proactive and prepared. I have found the following four recommendations to be most important in my practice as I continue to work as a music therapist among a community of healthcare workers supporting the healing

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process among the residents of Sandy Hook. 1) Resilience as Prevention: Anecdotally I observed, and research supports that the clients who responded best to the longterm healing process were those who had developed more resilient coping skills prior to the tragedy. Music therapists must be continually mindful of the importance of resilience and support and bolster client resilience across populations.

2) Education and Training: Music therapists may consider advancing their education to include music therapy modalities and methods which are safe and appropriate for addressing various levels of trauma. This training may include psychological ﬁrst aid or other courses that provide information about trauma, adaptations to increase sensitivity to a neural perspective, and competence as an initial responder. A trauma informed approach (SAMHSA, n.d.) can provide a helpful starting point and framework for music therapists working in both disaster response and in the long term with clientele of all clinical populations who are recovering from trauma. While bachelors-level education and training in music therapy may prepare clinicians for supportive work in establishing safety in disaster response and initial phases of therapy, music therapists need to pursue (a) advanced music psychotherapy training or cross-training with other modalities and (b) supervision and personal therapy to eﬀectively navigate the complex dynamics of trauma in the mind and body. Each music therapist is ethically responsible for ensuring that they work within a supported scope of practice which also ensures clients are not inadvertently exposed to re-traumatization.

3) Networking: A strong network of disaster response has been established within the U.S. under the leadership of the American Music Therapy Association. Clinician-responders and trauma-trained therapists are now networking regionally to (a) evaluate disaster needs; (b) increase the pool of trained, initial disaster responders; and (c) provide support to clinicians who are working in these environments. I strongly recommend that therapists familiarize themselves with this network. Further, as music therapy trauma-treatment moves into long term phases, I also suggest continual peer support and supervision are needed to maintain competency and provider resilience, which can be met, in part, through networking (van Dernoot Lapinsky & Burke, 2009). 4) Therapist self-care and vicarious resilience: In the current state of the country in which many vulnerable individuals have become survivors of natural or human-made disasters, a vicarious toll occurs for all of those in caring roles, including music therapists, regardless of their proximity or direct connection to speciﬁc events. Key to this is awareness of one’s personal responses, and choosing a path forward that considers one’s own wellbeing while serving others. While many self-care options exist, these should evolve with one’s needs and be consistent with one’s own values. Ultimately, it is possible that through this balanced approach, both survivors and caregivers may grow through the overwhelming experience of disaster.

As the music therapy community continues to grow and evolve, there is a movement among those in the profession to develop and train therapists in disaster preparedness and long-term trauma-informed music therapy

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service provision. This approach to the current increase in disasters and violence will provide current clients with the opportunity to receive treatment options that accommodates their life experience and future clients with music therapists who are ready to respond both initially and long term when disaster strikes. This approach requires music therapists to move beyond current models of practice and to incorporate and integrate a deeper understanding of the eﬀects of the neuroscience of trauma into their practices and theoretical approaches. This understanding of the eﬀects of trauma on our clients’ brains can usher a positive shift towards truly meeting our clients where they are and more accurately assessing and intervening as music therapists. Further growth, collaboration, and networking in this area will provide music therapists with greater awareness of their training needs and skills within trauma work, encourage the longevity of competent practices, and ultimately sustaining therapists in remaining available to those who will be affected by tragedy in the future.

References

Adams, R. & Boscarino, J. (2006). Predictors of PTSD and Delayed PTSD after disaster: The impact of exposure and psychological resources. The Journal of Nervous and Mental Disease, 194(7): 485-493. AMTA (n.d.). AMTA's disaster response and relief eﬀorts: A message to music therapists about preparedness. Retrieved 1/15/ 2019 from https://www.musictherapy. org/about/relief/. APA (2019). Trauma. Retrieved 1/1/2019 from https://www.apa.org/topics/trauma/ Becker, K (2014). Community Connections. Keynote Presentation to the Newtown Community Connections Conference, May 31, 2014; Walnut Hill Church, Bethel, CT.

Borling, J., & Miller, R. (2007). Conscious drumming: Drumming from the heart: In B. Matney (ed.), Tataku: The use of percussion in music therapy (pp. 226-232). Topeka KS: Sarsen. Borzon, R. (2013). Survivors of catastrophic event trauma. In L. Eyre (ed.), Guidelines for music therapy in mental health (pp. 1118-1230). Gilsum, NH: Barcelona Press. DeWolfe, D. (2000). Training manual for mental health and human service workers in major disasters, (2nd Ed.). Rockville, MD: SAMHSA. Else, B. (2010). Perspectives and priorities in disaster response. In K. Stewart, (ed.). Music therapy and trauma bridging theory and clinical practice (pp. 16-35). New york, Ny: Satchnote Press. Erikson, K. (1976). Everything in its path: The destruction of community after the Buﬀalo Creek ﬂood. New york, Ny: Simon & Schuster. Grand, D. (2013). Brainspotting. Boulder, CO: Sounds True. Harris, B. (2016). Embodied creative arts therapy interventions with trauma: A qualitative study. Expressive Therapies Dissertations 9. Retrieved on 12/17/2018 from https://digitalcommons.lesley.edu/expressive_dissertations/9/? utm_source=digitalcommons.lesley.edu%2Fexpressive_dissert ations%2F9&utm_medium=PDF&utm_ campaign=PDFCoverPages Herman, J. (1992). Trauma and recovery. Philadelphia, PA: Basic Books. Lagasse, B. (n.d.) Preparing for disaster: a guide for music therapist. Retrieved on 1/15/2019 at https://www.mtned.com/ courses-online/free-preparing-for-disaster/ Levine, P. (1997). Waking the tiger- Healing trauma. Berkeley, CA: North Atlantic Books. Lowey, J. & Frisch-Hara, A. (Eds.) (2002). Caring for the caregiver: The use of music

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and music therapy in grief and trauma. Silver Spring, MD: AMTA. Myers, N. (1994). Disaster response and recovery: A handbook for mental health professionals. US Dept. of Health and Human Services; Washington DC: SAMHSA. Myers, N. & Wee, D. (2005). Disaster mental health services: A primer for practitioners. Great Britain: Brunner-Routledge. National Center for PTSD (2018). PTSD and DSM-5. Retrieved on 1/30/2019 from https://www.ptsd.va.gov/professional/tre at/essentials/dsm5_ptsd.asp. Novotney, A. (2018). What happens to the survivors? Monitor on Psychology, 49(8). Retrieved on 12/1/2018 from https: //www.apa.org/monitor/2018/09/survivors.aspx Ogden P., Pain, C., Minton, K. & Fisher, J. (2005). Including the body in mainstream psychotherapy for traumatized individuals. Psychologist-Psychoanalyst, 25(4), 19-24. Perry. B., & Pollard, R. (1998). Homeostasis, stress, trauma and adaptation. Child and Adolescent Psychiatric Clinics of North America, 7(1) pp. 33-51. Rothschild, B. (2000). The body remembers: The psychophysiology of trauma and trauma treatment. New york, Ny: WW Norton. SAMHSA (n.d.). Trauma informed approach and trauma speciﬁc interventions. Retrieved from https://www.samhsa.gov/nctic/ trauma-intervention

Shear, K. (2015). Complicated grief treatment. New york, Ny: Columbia Center for Complicated Grief. Smith, A. J., Donlon, K., Anderson, S. R,, Hughes, M., & Jones, R. T. (2015). When seeking influences believing and promotes posttraumatic adaptation. Anxiety, Stress, & Coping: An International Journal, 28 (3), 340-356. Stewart, K., (Ed.). (2010). Music therapy and trauma: Bridging theory and clinical practice. New york, Ny: Satchnote. U. S. Department of Veterans Affairs (2019). Effects of disasters: Risk and resilience factors. Retrieved on 1/13/2019 from https: //www.ptsd.va.gov/understand/types/disaster_risk_resilence.asp van der Kolk, B. (1994). The body keeps the score: Memory and the evolving psychobiology of posttraumatic stress. Harvard Review of Psychiatry, 1(5), 253-265. van der Kolk, B. (2014). The body keeps the score. New york, Ny: Viking/Penguin. van Dernoot Lipsky, L. & Burk, C. (2009). Trauma stewardship: An everyday guide to caring for self while caring for others. San Francisco, CA: Berrett-Koehler. Zunin, L. & Myers, D. (2000). Phases of disaster. In D. DeWolfe (Ed.) Training Manual for mental health and human service workers in major disasters (2nd ed). Rockville, MD: SAMHSA.

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About the Author

Jennifer Sokira, MMT, LCAT, MT-BC is Founding Director of Connecticut Music Therapy Services, LLC and Clinical Director at the Resiliency Center of Newtown. Her primary clinical and professional interests include trauma informed music therapy, disaster response, and ethics.

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The Startle Reﬂex: Implications in Trauma and Music Therapy Elizabeth L. Stegemöller, PhD

Associate Professor. Department of Kinesiology. Iowa State University. 534 Wallace Rd. Ames, Iowa 50011, United States esteg@iastate.edu

Abstract

Understanding how the brain controls movement and how this process might differ across individuals who experience trauma may provide a deeper understanding of how to apply music therapy for this population. One such example is the auditory startle reflex in persons diagnosed with trauma. The purpose of this manuscript is to first provide a general overview of the auditory startle reflex and how this reflex may differ in those who have experienced or been diagnosed with trauma. Suggestions of how music therapy may be applied are provided. Resumen

La comprensión de cómo el cerebro controla el movimiento y cómo este proceso puede resultar alterado en individuos que han experimentado traumas, puede aportar una comprensión más profunda de cómo aplicar musicoterapia a este colectivo. Un ejemplo es el reﬂejo de Moro auditivo en personas diagnosticadas de haber sufrido trauma. El propósito de este artículo es, en primer lugar, aportar una visión general de cómo el reﬂejo de Moro auditivo puede ser distinto en los que han experimentado o han sido diagnosticados con trauma. Se sugiere cómo se puede aplicar la musicoterapia. Why Movement?

When working with individuals dealing with stress trauma, the relevance of understanding how the brain controls movement and the effects of music on movement may not seem initially apparent. However, clinicians base the development and implementation of music therapy on observations of how their client moves. Music making involves movement, and movement is behavior. Thus, understand-

ing how the brain controls movement (i.e., motor control) and how this process might differ in individuals who experience trauma may provide a deeper understanding of how to apply music therapy for traumatized clients.

How the brain controls movement is complex, and limited research exists on movement impairment in trauma. However, a growing body of research is available on the auditory startle reﬂex in persons who are traumatized. The

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purpose of this manuscript is to provide a general overview of the auditory startle reflex and how this reflex may differ for those dealing with trauma symptoms. Suggestions of how music therapy may be applied are provided, but the examples are meant to spur continued thought, as the suggested experiences do not encompass the whole of what is possible with music therapy for persons diagnosed with trauma. Reflexes

Reflexes can be divided into two main groups, spinal reflexes and brainstem reflexes. For spinal reflexes, the neural circuitry lies in the spinal cord. a common example is the knee jerk response. a tap on the patellar tendon leads to a small kick. The second group of reflexes includes the brainstem reflexes. Examples of brainstem reflexes include the blink reflex and vestibular ocular reflex. Indeed, the control of eye movement, whether reflexive or not, occurs mainly in the brainstem and other lower cortical regions such as the basal ganglia. Both types of reflexes are influenced by other higher brain regions. For example, the cerebral cortex can inhibit a reflex (i.e., a persons can suppress a blink) to accurately carry out other movements. Likewise, the cerebral cortex can excite the reflex circuitry. Moreover, reflexes also are often adapted which may be controlled by the cerebellum or other subcortical regions. Thus, observing reflexes and how they change or are different in individuals dealing with trauma may provide information regarding the brain region that may or may not be impaired (Purves et al., 2018). The Auditory Startle Reflex

For individuals who are diagnosed with trauma, one of the most interesting clinical

and experimental applications of reflexes is the auditory startle reflex. This reflex consists of a rapid sequential muscle contraction in response to an abrupt and intense auditory stimulation (i.e., a loud sound). The circuitry for this reflex lies in the brainstem. Sound enters and stimulates the cochlear root neuron, which then sends the signal to the giant neurons of the caudal pontine reticular nucleus (i.e., part of the reticular activating system). From here, the signal is sent to the spinal cord via motor neurons that activate the muscles involved in the reflexive movement (figure 1). The entire reflex occurs in 6-10 milliseconds (Lee et al., 1996; Gomex-Nieto et al., 2014). The sternocleidomastoid, a muscle that originates at the sternum and clavicle and inserts at the mastoid process of the temporal bone of the skull is the most prominent muscle that is activated.

In addition to the muscle activation, there is also an eye blink response. The purpose of this reflex is thought to be for facilitating the flight reaction and/or to protect the body from sudden attack. Interestingly, the auditory startle reflex is evident across animal and human species. However, while the movement pattern initiated by the auditory startle reflex is the same across humans, the amplitude (i.e., size), of the motor response changes depending on the internal state of the system (Grillon & Baas, 2003).

Indeed, the auditory startle reflex can be modulated by aversive states, such as fear, verbal threats, or darkness (Baas et al., 2002; davis, 1986). In all three examples, size of the auditory startle reflex response is increased. affect also can modulate the auditory startle reflex (Vrana et al., 1988). The startle response is enhanced in subjects viewing unpleasant stimuli (i.e., pictures, movies) and reduced when viewing pleasant stimuli (Bradley & Lang, 2000;

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FIGURE 1. Startle reﬂex circuitry.

TERMS: amygdala, part of the limbic system and responsible for evaluating valence and intensity of emotions; BNST (bed nucleus of the stria terminalis) an extension of the amygdala and part of the limbic system; caudal pontine reticular nucleus, part of the reticular activating system that itself regulates consciousness; cochlear root neuron, initial portion of nerve leaving cochlea; sternocleidomastoid, a muscle that originates at the sternum and clavicle and inserts at the mastoid process of the temporal bone of the skull.

Ehrlichman et al., 1995). This change due to the perceived influence of stimuli suggests that the startle reflex may be a measure of general affective valence (Grillon & Baas, 2003). However, results remain conflicting as to whether pleasant stimuli truly reduce the startle response, as some research results suggest that both arousal and affective valence play a role in modulating the auditory startle reflex (Witliet & Vrana, 2000).

Given the suggested role of aﬀective valence, it is not surprising that the amygdala is a primary brain region implicated in the modulation of the auditory startle reﬂex (Figure 1) (Walker et al., 2003). In humans, research suggests that left lateralization of amygdala acti-

vation is involved in regulating the auditory startle reflex, in particular during a fear-potentiated startle (Funayama et al., 2001; Phelps et al., 2001). However, research also implicates the bed nucleus of the stria terminalis (BNST) in the regulation of the auditory startle reflex. The BNST is thought to be an extension of the amygdala and is part of the limbic system. Less is known about the exact function of BNST brain region. Thus, given the breadth of knowledge regarding the underlying circuitry of the auditory startle reflex, observing the startle response in various populations, such as those diagnosed with trauma, may provide information about how the underlying neurophysiology may be impacted.

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The Startle Reﬂex and Trauma

Research has long shown that the auditory startle reflex is exaggerated, (i.e., more easily triggered and the response is larger) in posttraumatic stress disorder (PTSd), and is linked to trauma exposure (Grinker and Spiegel, 1945). However, there are many factors, such as the length of time and severity of PTSd that can affect the auditory startle reflex. More specifically, individuals with a more recent and/or complex PTSd demonstrate a more exaggerated startle response. Research reveals that the cause of the exaggerated response is due to the progressive sensitization of the reflex caused by severe or prolonged trauma-induced stress (yehuda, 1997; Grillon & Baas, 2003). While the startle reflex should return to baseline given enough time after trauma, some individuals with long-lasting PTSd will still experience this exaggerated response. Grillon and Baas (2003) suggest that a continued display of the exaggerated reflex may be due to episodes of increased state anxiety experienced as generalized anxiety disorder and also may result in an exaggerated startle response.

While the auditory startle reflex is exaggerated in PTSd, there also are some cases in which the response is not modulated or different. Research shows that the startle response is not affected by the common medication, clonazepam. Untreated patients show the same exaggerated response as treated patients (Shalev & Rogel-Fuchs, 1992). This drug is often used to treat anxiety disorders and panic disorders. another interesting finding is that children who have experienced trauma also may demonstrate a reduced startle response. This reduction may reflect a cognitive or behavioral shut down or depression (Ornitz & Pynos, 1989; Medina et al., 2001). In all these varying cases, it is important to note that

the auditory startle reﬂex is still being modulated; either increased or inhibited suggesting that other brain structures, such as the amygdala or BNST, are modulating/adapting the response due to the trauma experience.

Thus, in reviewing the general exaggerated startle response in persons with PTSd, there are two types, a tonic exaggerated response that will fade over time, and a phasic response in which the response is brought on by trauma-related stimuli or stressful environments. Research suggests the amygdala is involved in the tonic response, while the BNST is implicated in the phasic response (Hitchcock & davis, 1986; Marshall & Garakani, 2002). Thus, by observing the startle reﬂex and understanding the (a) length of time since trauma, (b) severity of trauma, (c) current environmental conditions, (d) medication, and (e) age, insight may be gained in developing treatment strategies for individuals responding to traumatic experiences. Music Therapy Application

For music therapy, there are at least two potential applications of the auditory startle reflex. The first is that the auditory startle reflex may be a way to monitor and measure treatment effectiveness. For example, if the goal of the music therapy intervention is to reduce anxiety, then in theory the startle response should reduce after an effective intervention. The music therapist may simply observe the amplitude (i.e. size) of the movement response and eye blink from an auditory startle before and after an intervention. However, this task may be challenging to observe due to the subtle changes in the startle response. as an alternative, therapists might use a simple questionnaire that asks clients how many times during the past week they experienced a startle and how would they rate their stress

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and anxiety. Monitoring clients’ occurrence of startle responses may provide useful information when evaluating the eﬀectiveness of the music therapy intervention.

according to the polyvagal theory (Porges, 2018), evolution has resulted in distinct neural pathways, involving the vagus nerve that inﬂuence the control of the heart, lungs, and digestive tract during a response to stress and/or trauma. The myelinated pathway is a fast, tonic pathway that is linked to social communication and self-soothing calm behaviors. In contrast, the unmyelinated pathway is linked to immobilization behaviors such, as freezing, and vigilance. Those who have experienced trauma often use the unmyelinated pathway, and this pathway has been linked to the exaggerated response to the auditory startle in adults and the lack of startle response in children (Porges, 2018). Thus, a second potential application of music therapy would be to purposely use unexpected music components or instrumental sounds within various stages of music therapy to (a) “safely” alert clients, especially children, who are withdrawn or (b) provide a means for rehearsing how to recover from an auditory startle.

Children who have experienced trauma often do not have a response to auditory startle and may be dissociated or withdrawn. Carefully planned, low level changes in tempo or dynamics or the introduction of unusual instrumental sounds could be used to alert and potentially engage clients. However, music therapists need to carefully use the startle response only when a safe and predictable relationship is established with a client or the client’s startle response is at a low level.

Conversely, clients who are beginning to use coping skills and can engage in social commu-

nication and self-soothing behaviors may beneﬁt from higher level, systematic auditory interruptions to rehearse active recovery skills from a startle response. a music therapist can provide an auditory startle and then guide the client through music supported self-soothing practices to rehearse recovering from startle events. The length of time it takes for the client to recover can serve as a measure of progress. It is important to note, though, that research suggests that those who demonstrate a very large startle response have the poorest treatment outcome (Grillon & Baas, 2003). again, therapists would need to use caution and make sure a safe, predictable relationship is established. Moreover, it is suggested to consult with other medical professionals who are working with the client before including auditory startle into the intervention.

While these are potential examples, they are of course not inclusive. There may be other ways to use the auditory startle reflex within music therapy with clients recovering from trauma; it is very possible that the auditory startle reflex is contraindicated for some clients or a viable option for other clients. More importantly, having a better understanding of the auditory startle response and implications for traumatized clients will help music therapists purposefully use music components and musical instruments to best benefit each client and their startle response. If an unintentional startle response is observed during a music therapy session, the therapist has a basic understanding of what might be causing this response, which further allows the music therapist to tailor the intervention and use other techniques to reduce stress and anxiety, and/or reduce the arousal state for the client.

In conclusion, the auditory startle reﬂex has

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been extensively studied in animal and human models, both healthy and those who are diagnosed with trauma. Music therapists can beneﬁt from understanding the underlying neurophysiology of the auditory startle response and the startle response of their clients with PTSd. Continued research in the area of the startle response may inform the development and implementation of music therapy interventions for those diagnosed with trauma. References

Baas, J. M., Grillon, C., Bocker, K. B., Brack, a. a., Morgan, C. a., III, Kenemans, J. L., & Verbaten, M. N. (2002). Benzodiazepines have no effect on fear-potentiated startle in humans. Psychopharmacology (Berl), 161, 233–47. Bradley, M. M., Lang, P. J., & Cuthbert, B. N. (1993). Emotion, novelty, and the startle reflex: Habituation in humans. Behavioural Neuroscience, 107, 970–980. davis, M. (1986). Pharmacological and anatomical analysis of fear conditioning using the fear-potientiated startle paradigm. Behavioral Neuroscience, 100, 814–824. Ehrlichman, H., Brown, S., Zhu, J., & Warrenburg, S. (1995). Startle reflex modulation during exposure to pleasant and unpleasant odors. Psychophysiology, 32, 150–154. Funayama, E. S., Grillon, C., davis, M., & Phelps, E. a. (2001). a double dissociation in the affective modulation of startle in humans: Effects of unilateral temporal lobectomy. Journal of Cognitve Neuroscience, 13, 721–729. Gomex-Nieto, R., Horta-Junior J de, a., Castellano, O., Millian-Morell, L., Rubio, M. E., & Lopez, d. E. (2014). Origin and function of short-latency inputs to the neural substrates underlying the acoustic startle reflex. Frontiers in Neuroscience, 8, 216. Grillon, C., & Baas, J. M. P. (2002). Comments

on the use of the startle reﬂex in psychopharmacological challenges: Impact of baseline startle on measurement of fearpotentiated startle. Psychopharmacology, 164, 236–238. Grinker, R. R., & Spiegel, J. P. (1945). Men under stress. Philadelphia, Pa: Blakiston. Hitchcock, J. M., & davis, M. (1986). Lesions of the amygdala, but not of the cerebellum or red nucleus, block conditioned fear as measured with the potentiated startle paradigm. Behavioural Neuroscience, 100, 11–22. Lee, y., Lopez, d., Meloni, E., & davis, M. (1996). a primary acoustic startle pathway: Obligatory role of cochlear root neurons and the nucleus reticularis pontis caudalis. Journal of Neuroscience, 16, 3775–3789. Marshall, R. d., & Garakani, a. (2002). Psychobiology of the acute stress response and its relationship to the psychobiology of post-traumatic stress disorder. Psychiatric Clinics of North America, 25, 385–395. Medina, a. M., Mejia, V. y., Schell, a. M., dawson, M. E., & Margolin, G. (2001). Startle reactivity and PTSd symptoms in a community sample of women. Psychiatry Research, 101, 157–169. Ornitz, E. M., & Pynoos, R. S. (1989). Startle modulation in children with posttraumatic stress disorder. American Journal of Psychiatry, 146, 866–870. Phelps, E. a., O’Connor, K. J., Gatenby, J. C., Gore, J. C., Grillon, C., & davis M. (2001). activation of the left amygdala to a cognitive representation of fear. Nature Neuroscience, 4, 437–441. Porges, S. W. (2018b). Polyvagal Theory: a primer. In S. W. Porges & d. dana (eds), Clinical applications of the Polyvagal Theory: The emergence of Polyvagal-informed therapies (pp. 50-69). New york: W. W. Norton & Company. Purves, d., augustine, G., Fitzpatrick, d., Hall,

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W., Lamantia, a. S., & White, L. (2018). Neuroscience (8th ed.). Sunderland, Ma: Sinaur associates. Shalev, a. y., & Rogel-Fuchs, y. (1992). auditory startle reﬂex in post-traumatic stressdisorder patients treated with clonazepam. Israel Journal of Psychiatry and Related Sciences, 29: 1–6. Vrana, S. R., Spence, E.L., & Lang, P. J. (1988). The startle probe response: a new measure of emotion? Journal of Abnormal Psychology, 97, 487–491. Walker, d. L., Toufexis, d. J., & davis, M.

(2003). Role of the bed nucleus of the striaterminalis versus the amygdala in fear, stress, and anxiety. European Journal of Pharmacology, 463, 199–216. Witvliet, C. V., & Vrana, S. R. (2000) Emotional imagery, the visual startle, and covariation bias: an aﬀective matching account. Biolological Psychology, 52, 187–204. yehuda, R. (1997). Sensitization of the hypothalamic-pituitary-adrenal axis in post traumatic stress disorder. Annals of the New York Academy of Sciences, 821, 57– 75.

About the Author

Dr. Stegemöller is an associate Professor in the department of Kinesiology and is the director of the Graduate Program in Neuroscience at Iowa State University. She is a music therapist and neuroscientist with expertise in motor control.

Book Reviews

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The body keeps score: Brain, mind and body in the healing of trauma Written by Bessel van der Kolk

Viking Peguin, New York, New York; ISBN 978-0-78593-3 (443 pages)

Reviewer: Annie Heiderscheit, Ph.D., MT-BC, LMFT

Associate Professor and Director of Music Therapy at Augsburg University Minneapolis, Minnesota, United States

This comprehensive text is divided into five sections, encompassed in twenty chapters. These sections include: The rediscovery of trauma, this is your brain on trauma, the minds of children, the imprint of trauma, and paths of recovery. The book begins with the discoveries ascertained from Vietnam veterans, to new developments and understandings of how trauma impacts the brain, exploring attachment and developmental trauma, the challenges with traumatic memories, and finally a focus on healing trauma.

Part One of the book addresses the rediscovery of trauma. In Chapter 1, Dr. van der Kolk begins by describing his early experiences working with Vietnam veterans and the realization that his psychiatric training did not prepare him to deal with any of the challenges these patients were experiencing. Additionally, little existed in the literature to provide any insight or direction in how to help these patients. As a result, Dr. van der Kolk began his research endeavors. In trauma. This began with understanding their experiences and the impact of these experiences. One important discovery was how veterans experi-

enced emotional numbing, in order to avoid experiencing the intense emotions associated with their traumatic experiences. However, this also impacted their ability to experience deep emotions of love and compassion, keeping them isolated emotionally. Understanding the veteranâ&#x20AC;&#x2122;s experiences, provided awareness that their traumatic experiences reorganize their perceptions. This may be represented by the sound of a crying baby reminding a veteran of children dying in Vietnam. These changes in perception can foster an individual getting stuck in the trauma, as Dr. van der Kolk and his colleagues discovered in their early research. The lived challenges the veterans experienced, further complicated the fact that they were then labeled with various mental health diagnoses, as well as the treatments associated with those diagnoses. Unfortunately, these treatments proved ineffective, leading clinicians and veterans to call for change, starting with the inclusion of the diagnosis of post-traumatic stress disorder. The inclusion of this framework and the cluster of symptoms associated with it served as a platform for radical change to begin. Chapter 2 focuses on understanding

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how the mind and the brain respond to trauma. This is explored through Dr. van der Kolk’s observation of patients, the behaviors they demonstrated and the stories of their trauma that they shared with him. These experiences early in his career, helped him discover how medical and psychiatric care was failing to understand and treat patients with trauma. This also led to the exploration of the impact of human suffering and prolonged stress, and shock on the brain. Understanding the brain’s response to stress and trauma fostered discoveries of the role of serotonin in the process and insights into how pharmacology may help Chapter 3 delves into the role of neuroscience and the use of neuro-imaging technology. The images of the brain’s response to trauma provided a deeper understanding of what was happening in the brain and how this is manifested in a person’s behavioral responses.

Part Two takes an in-depth focus on the impact of trauma on the brain. In Chapter 4, this is explored through case illustrations from various traumatic events. These provide insights to how the nervous system is changed as a result of traumatic experiences and survival. This important responsibility of the brain to ensure survival, requires an understanding the brain structure from bottom to top including the brainstem, the limbic system, and the prefrontal cortex. When the amygdala signals danger, stress hormones are released and physiological symptoms are also impacted. When the danger passes, the body returns to a normal state. When this recovery is blocked, as is the case for individuals with PTSD, the body continues to defend itself, causing arousal and agitation. Chapter 5 focuses on the body and brain connections, providing an overview of the autonomic nervous system, parasympathetic nervous system, and heart rate variability. Polyvagal Theory is

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introduced exploring how the pneumogastric nerve connects to various organs in the body, providing the basis for the body’s sophisticated understanding, and experience of safety and danger. This then introduces the reader to levels of safety, including social engagement, fight or flight, and freeze or collapse. Our response to the level of safety triggers the ventral vagal complex activating the muscles to respond to our experience. The importance of understanding this theory and the body’s response to defend or relax is vital to helping clients coping with trauma. Restoring a sense of safety and security is critical to addressing trauma. Chapter 6 focuses on the loss of one’s body from trauma and how this creates a sense of ongoing danger. The author suggests that in order heal, the client needs to reclaim a sense of agency, developing an awareness of the subtle sensory and body-based feelings they experience. Understanding what we feel is the first step to knowing why we feel that way. This then helps the client to befriend their body.

Part Three shifts to a focus on how this relates to children by addressing attachment and the impact of developmental trauma. Chapter 7 explores the importance of having a secure attachment in childhood, as we learn to care for ourselves is based on how we were cared for. Additionally, mastering our skills in self-regulation are dependent upon our early interactions with caregivers. Whether our attachment is secure or insecure is based on emotional attunement. Attunement begins with subtle physical interactions between infants and caregivers, giving the infant the sense of being acknowledge and understood. Chapter 8 explores the impact and cost of trauma, identifying how it influences behavior and emotional development from childhood into adulthood, as well as relationships. Trauma(s) from childhood can be triggered and replay even into

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adulthood, if unaddressed. Chapter 9 addresses the issue of the power and importance of diagnosis, recognizing there are differences in children that had been victims of abuse compared to adults that survived a natural disaster. In order to provide optimal treatment, diagnosis must be appropriate for the symptoms the client is experiencing. The Adverse Childhood Experiences (ACEs) study is reviewed in this chapter to support this premise. In exploring the ACEs study, the author goes onto identify the challenge of when the problem serves as the solution. Such as how weight is used as a means of protection for a client that has been abused and that seeing the weight as their problem, when they have used it as their solution can cause a client to fail in treatment. Chapter 10 addresses the issue of developmental trauma and the impact this has on society. This is demonstrated through case illustrations that explore how a child that experiences trauma early in life may then present behaviors in school, then engage in at risk behaviors that result in the involvement of law enforcement, and the legal system. The impact of not treating the trauma, the issue underlying the behaviors, results in a significant burden on society. As a result, understanding the impact of this, lead to the development of the National Child Traumatic Stress Network, a think tank to work to address this public health issue.

Part Four addresses the imprint and specifically the challenges of traumatic memory and the pain of remembering. Case illustrations is Chapter 11 help to clarify and explore the unusual nature and complexities of traumatic memories. These memories can be incoherent and fragmented. The high arousal experienced during a traumatic event, disconnect areas of the brain necessary for the proper storage of information, and as a result trauma

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experiences are organized in fragmented sensory and emotional ways. These include images, sounds and physical sensations. This has led traumatic memory to be on trial, leaving repressed memories as generally not accepted within the scientific community. Chapter 12 identifies how the interest in trauma as fluctuated over the past 150 years and how denial of the consequences of trauma have not only negatively impacted trauma survivors, but society as well. This highlights the important of recognizing the difference between normal and traumatic memory.

Part Five encompasses a significant portion of the book as it focuses on the pathways to recovery. Chapter 13 focuses the process of owning oneâ&#x20AC;&#x2122;s self to begin the process of recovery. This begins with recognizing and resolving traumatic stress by understanding the bodyâ&#x20AC;&#x2122;s response. This involves befriending the emotional brain, dealing with hyperarousal, practicing mindfulness, fostering safety and connection within relationships, and choosing a therapist. To support this therapeutic work. The chapter concludes by addressing aspects of the therapeutic process including integrating traumatic memories, desensitization, as well as recommended therapeutic approaches. Chapter 14 addresses breaking the cycle of silence around trauma and striving to speak the truth, as there have been traumas that have historically been silenced. This is a process of dual awareness because language has limits regarding trauma. Chapter 15 is entirely focused on eye movement desensitization and reprocessing (EMDR) and its application in the treatment of trauma. While EMDR does not focus on revisiting the trauma, it does focus on the associative process. Chapter 16 addresses learning to inhabit the body and doing this through the use of yoga. yoga has been implemented

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to foster self-regulation from the bottom up. The use of yoga in trauma treatment has been implemented to help trauma survivors learn self-regulation and self-awareness. Chapter 17 explores the issue of dissociation as it relates to trauma and the use of internal family systems therapy (IFS) to address these parts of the trauma survivor in their process of treatment. IFS works to empower the trauma survivor to identify and understand their internal landscape. This process allows the client to understand the role each of these parts has played and develop self-compassion. Chapter 18 includes several case illustrations addressing how to create structure to foster rebuilding oneâ&#x20AC;&#x2122;s life in their recovery process. This process of rescripting oneâ&#x20AC;&#x2122;s life to honor the truth, change the inner landscape, and work through the experiences held in the body. Chapter 19 explores rewiring the brain through the use of neurofeedback. The chapter provides an overview of neurofeedback and how this relates to trauma. This reviews how trauma changes the brainwaves and how this information can be helpful tool in the recovery and healing process. Chapter 20 focuses on the use of theater and community projects in helping trauma survivors find their voice. The chapter shares examples of several different theater productions, creative and improv projects in schools and community settings. These projects provide a way for survivors to gather as

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a community, work collectively in a safe setting.

The book includes an appendix of proposed criteria for developmental trauma disorder submitted by the National Child Traumatic Stress Network (NCTSN)- affiliated task force. These criteria were proposed to for consideration in the DSM in 2009, while it was not accepted for use in the revised DSM, these criteria have continued to guide field trials. A list of resources including organizations, websites, and suggested readings on various topics related to trauma is also provided in the appendix.

The book is a comprehensive overview of trauma from historical analysis, clinical observations, neuroscience, and therapeutic tools. The text is filled with historical information, clinical research, and case illustrations that help the reader understand impact of trauma. The authorâ&#x20AC;&#x2122;s passion is clearly embedded in the writing, and as a result the moments of challenges he has experienced in championing trauma recovery and care are also evident. While the research and practice surrounding trauma is moving at a fast pace, this text does provide an important context in the process and journey of the emerging field of trauma recovery and the importance of understanding the connections of the brain, mind, and body in this process.

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The Pocket Guide to the Polyvagal Theory: The Transformative Power of Feeling Safe Written by Stephen W. Porges

W. W. Norton & Company, New York, New York; ISBN 9780393707878 (254 pages)

Reviewer: Annie Heiderscheit, Ph.D., MT-BC, LMFT

Associate Professor and Director of Music Therapy at Augsburg University Minneapolis, Minnesota, United States

Polyvagal Theory emerged from Dr. Stephen Porges’ research. He first presented and published these findings in the mid-1990’s. The model and theoretical implications he presented at this time provided explanations for the neurophysiological responses of individuals that have experienced trauma. The theory provided an understanding for clinicians and clients of how the body is retuned in response to a life threat and the loss of resilience to return to a state of safety. While the theory was quickly embraced by clinicians, there was increased interest and demand to understand how to incorporate this theory into clinical practice. The Pocket Guide to Polyvagal Theory: The Transformative Power of Feeling Safe is the culmination of Dr. Porge’s collaboration with colleagues who treat clients with trauma, including Peter Levine, Bessel van der Kolk, and Pat Ogden. Their collaboration helped Dr. Porges understand the disruptive effects of trauma, the process involved in experiencing, and recovering from trauma. The insights they developed moved his theory into their treatment models. The book includes a glossary of terms at the start of the book. This is a unique design fea-

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ture to the book. This does allow the reader to develop a familiarity with the various terms associated with polyvagal theory, brain structure, mental health diagnoses, and trauma experiences and responses. The glossary provides thorough definitions and descriptions to ensure the reader has a clear understanding of the terminology before engaging in regarding Polyvagal Theory.

Chapter 1: The neurobiology of feeling safe explores the important role that feeling safe plays in our lives. While the concept of safety may be intuitive, the assumptions we hold about safety demonstrate inconsistencies between how our bodies experience it and how we describe it. One of the challenging aspects of this is the value our culture places on thoughts over feelings, resulting in negating the feelings one experiences in response to trauma. The advent of research in heart rate variability provided a new mechanism for understanding how the body is responding to stimulus. The recognition that breathing impacted the vagal control of the heart. The vagus connects the brainstem areas with structures throughout the body, including the neck, thorax and abdomen, thus serving as a

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primary nerve in the parasympathetic nervous system. Understanding this fostered insight that these neural circuits support social behavior and emotional regulation. As a result, they are only available when the nervous system experiences the environment as safe. This awareness of the need to create a feeling of safety is vital in the clinical setting in order to allow the therapist and client to develop a trusting relationship, and doing so is a biological imperative.

Chapter 2: Polyvagal theory and the treatment of trauma is a dialogue between Dr. Ruth Buczynski, a clinical psychologist and Dr. Stephen Porges. Their dialogue is focused on trauma and the nervous system. One of the issues addressed in this chapter is focused on one of the challenges in understanding the neurophysiological responses to trauma is that trauma has been conceptualized as a stress-related disorder. As a result, many of the important attributes specific to trauma are lost in the dialogue on the cause and treatment. This has also fostered the assumption that the human nervous system responds to danger and life threats with one common stress response and that the nervous system has a single defense. Polyvagal Theory emphasizes that danger and lifethreatening situations elicit different defensive response profiles. While we are familiar with the fight/flight response, the response to life threats elicits a second defense system, which includes immobilization and dissociation. The lack of awareness of the full range of these adaptive biological reactions have contributed to the challenges in treating clients with trauma.

Attachment is also explored in this chapter and the important role that safety places in developing secure attachments. Our sense of safety moderates our ability to develop se-

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cure attachments in our relationships, as well as our vulnerability to trauma. Porges and Buczynski discuss how music supports intimacy and cues safety. They discuss how the prosodic (intonation of the voice) features of a singerâ&#x20AC;&#x2122;s voice can trigger the neuroception circuit that helps one feel safe. This sense of safety then diffuses our defensiveness and helps us to feel more open to physical contact with others.

Chapter 3: Self-regulation and social engagement continues with a dialogue between Dr. Ruth Buczynski and Dr. Stephen Porges. In this chapter they explore the relationship between heart rate variability and self-regulation. Heart rate variability provides a window into observing how the nervous system is regulating our bodies. When our heart rate is demonstrating nice periodic oscillations, it is telling us that we are in a comfortable state and regulating well. As we encounter warmth and kindness in others we have a physiological response. These cues we experience from a safe individual foster a sense of safety and decrease defensiveness. When we experience this sense of safety, it is the vagal pathway that communicates this information to the brain. It is signaling the body that the environment is safe and thus calming the body. Dr. Porges discusses the vagal paradox in this chapter, recognizing the vagus nerve is involved in the body shutting down (e.g. fainting) and it is also involved in calming down. This is best understood through evolution, as our vagal pathway differs from our ancestors. The new vagal pathway that evolved has the capacity to dampen the sympathetic nervous system, helping us to calm down and regulate our mammalian fight/flight responses. When individuals experience immobilization with fear, they are engaging an ancient neural circuitry. When someone is then stuck in this state, it does not promote social interaction

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or a sense of safety. To move from this state, a therapist needs to help the client to feel a physiological of safety. When the therapist can empower the client to negotiate safety, it enables the nervous system to experience the environment as safe. Porges highlights how vocal music can cue to nervous system that the environment is safe. Low frequencies and vocal intonation efficiently trigger the neural circuit that responds to prosodic voices, which in turn stimulates social engagement.

Chapter 4: How polyvagal theory explains the consequences of the trauma on brain, body, and behavior. In this chapter Dr. Ruth Buczynski and Dr. Stephen Porges continue their dialogue exploring the origins of polyvagal theory. Our understanding of polyvagal theory emerged from the concept of social behavior that is based on the behavioral adaptations that distinguish reptiles from mammals. The evolution process demonstrated a change in the structure and function of the autonomic nervous system. This change issued in a system that could support two different types of defenses, one being the fight/flight and the other to immobilize. Our higher brain functions inform the brainstem structures about the safety or threats present in our environment. Within this structural set up, it is important to understand that the vagus is a cranial nerve that emerges from the brainstem, involved in regulation of striated muscles of the face, head, and regulating cardiac muscle. It is helpful to think of the vagus as connecting the brain with the body. Vagal tone is influenced and impacted by emotion, as respiration rate as emotions are a cluster of physiological constructs. Chapter 5: Cues of safety, health, and polyvagal theory continues with ongoing discussion between Dr. Ruth Buczynski and Dr.

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Stephen Porges. In their dialogue they reiterate that the vagus is a cranial nerve that connects directly to the heart and to other visceral organs. As a result, it is involved in the regulation of physiological processes involving the heart and the gut. The bidirectional nature of the vagus is and import feature. While it is sending signals from the brain to the visceral organs; it is also sending signals from the visceral organs to the brain. An important aspect of Polyvagal Theory is to help those that have been traumatized, understand that their symptoms are a functional product of a neural system that allowed them to adapt and survive. As they gain insight into their bodyâ&#x20AC;&#x2122;s processes were enacted to protect, they can become empowered in their process of treatment and recovery.

Their discussion also explores that if an individual has developed secure attachments in their relationships, that this can serve as a buffer to trauma. Striving to help individuals to develop secure attachments in their relationships does not mean they can avoid trauma, but it may help to minimize the impact of trauma, because they have already experienced a sense of safety and security in their world.

Chapter 6: The future of trauma therapy: A polyvagal perspective shifts between a conversation between Lauren Culp and Dr. Stephen Porges. One of the key insights to influence trauma therapy is the understanding of the immobilization and developing a respect for this involuntary reaction of the nervous system. While the response of the nervous system, allowed the individual to survive the trauma, it also created problem. The state that saved them is also the state it is difficult to get out of. Treatment of trauma needs to shift from categorizing these adaptive sym-

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ptoms and moving toward respecting them as an extraordinary protect system. Therefore, in order to treat trauma effectively therapeutic techniques need to help the client calm and self-regulate, addressing the brainbody nervous system.

Chapter 7: Some perspectives on psychotherapy includes a dialogue between Dr. Stephen Porges and Serge Prengel. They focus their discussion on how Polyvagal Theory can help to inform clinical treatment of trauma. They include several recommendations for clinicians; reducing low frequency noises and unpredictability in the environment, and increasing proximity to people with whom a client feels safe, respect the bodyâ&#x20AC;&#x2122;s reactions to experiences rather than reject it, engage clients in experiences that help them to regulate their autonomic nervous system and calm down their system, and foster social engagement when it is safe. En-

gaging clients in these types of experiences will help them to develop greater flexibility in the world, help them to efficiently dampen their defenses in safe settings, and experience positive outcomes.

Each chapter strives to build on information from the chapter before. The style of conversation utilized throughout much of the book helps the reader to process the information in a less formal fashion, which makes it more approach and easier to comprehend overall. There are moments where information is repeated in from one chapter to another, which can feel redundant at times. Some readers may find it helpful to review information within the context of another chapter. Overall, the book provides a very good introduction to Polyvagal Theory and bring the information to the reader in a way that can allow them to begin to incorporate these concepts into clinical practice.

About the Author

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Review Article

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Music Interventions for Integrating Loss Based on Buddhist Psychology Practice Reviewer Puchong Chimpiboon, M.A. (music). Music Therapy Major

Academic Occupational Therapist, Siriraj Palliative Care Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand Email: puchongmsmu@gmail.com

Dr. Pornpan Kaenampornpan. Lecturer

Faculty of Fine and Applied Arts, Khon Kaen University Email: pornpan@kku.ac.th

Assoc. Prof. Dr. Dena Register, MT-BC.

Director of Music Therapy Program, School of Music, West Virginia University Email: Dena.Register@mail.wvu.edu Abstract

While music is not a universal language, it is a universal force in helping people of various social, cultural, and spiritual backgrounds to connect with others; to cope with the various challenges that life brings; and to communicate both what they are experiencing and how they perceive the world around them. To that end, music plays an integral role in helping individuals cope with grief and loss, and in developing an individualâ&#x20AC;&#x2122;s sense and understanding of spirituality. Because there is very little information regarding how music therapy and Buddhist Psychology may overlap, the purpose of this review article is to identify how music interventions for integrating loss can be incorporated into Buddhist Psychology Practice in order to better understand the role that music therapy plays in the primarily Buddhist, Thai society. Studies from both electronic databases and electronic journals were collected for analysis. This article presents music listening and songwriting as music interventions which can help grieving people to integrate loss in a manner similar to Buddhist Psychology Activities. Music listening can combine with mindfulness practice, and it is beneficial in reducing depression and empowering participants to meditate. Songwriting is less confronting than speaking when dealing with a difficult topic. Thus, the use of music is recommended to facilitate the expression of the emotions, feelings, thoughts, and memories associated with loved ones. Keywords: music interventions, integrating loss, Buddhist psychology practice Resumen

Aunque la mĂşsica no es un lenguaje universal, es una fuerza universal que ayuda a personas de varias clases sociales, culturales y espirituales a conectar con los demĂĄs; a afrontar los distintos de-

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safíos que brinda la vida; y a comunicar lo que han experimentado y como perciben el mundo que les rodea. Con este objetivo, la música juega un papel integral en ayudar a los individuos a afrontar dolor y pérdida, y en desarrollar la personalidad individual y la comprensión de la espiritualidad. Debido a que existe muy poca información relativa a la relación entre la musicoterapia y la Psicología Budista, el objetivo de este artículo de revisión es identificar como las intervenciones musicales para soportar las pérdidas pueden incorporarse a la práctica de la Psicología Budista, para comprender mejor el papel que la musicoterapia juega en una sociedad principalmente Budista de la sociedad Thai. Se han recogido estudios para su análisis tanto de las bases de datos electrónicas como de las publicaciones electrónicas. Este estudio presenta las audiciones musicales y la composición de canciones como intervenciones musicales que pueden ayudar a las personas a procesar un duelo y a aceptar su pérdida en una forma similar a la actividad psicológica del Budismo. La audición musical puede combinarse con la práctica de la atención plena (mindfulness), lo que es beneficioso para reducir la depresión e inducir a los participantes a la meditación. La composición de canciones significa menor confrontación que la palabra cuando se trata de un tema difícil. Así, el uso de la música se recomienda para facilitar la expresión de las emociones, sentimientos, pensamientos y recuerdos asociados con las personas queridas.

Palabras clave: intervenciones musicales, aceptación de pérdidas, práctica psicológica Budista. Introduction

Grief is defined as the normal reaction of loss, which all human beings must face. It includes many aspects, such as psychological, social, behavioral, and cognitive responses, based on an individual’s perceptions (Rando, 1984; Worden, 2002). There are two types of loss people experience: physical and symbolic. Physical loss is tangible, such as the loss of a loved one or personal possessions, while symbolic loss is more abstract and can include a loss of status, social role, or identity (Scrutton,1995). Both physical and symbolic losses can prompt grief in an individual.

Parkes (1965) divided grief into four phases. These comprised (1) numbness, whereby a person is stunned and appears non-reactive when faced with a loss; (2) yearning and searching, which may present manifestations such as anger, restlessness, irritability, disbelief, tension, and tearfulness; (3) disorganization and despair, whereby a person appears

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to have given up the attempt to recover and accept loss; and (4) reorganization, when the individual detaches from the loss, starts to initiate new relationships, and displays renewed interest in life (Parkes, 1965).

Grief is a vital process for helping people accept loss and move forward with their lives (Rando, 1984). Previous studies have demonstrated the benefits of using interventions to help people integrating grief and loss. Cognitive-behavioral therapy and counseling have been used to reduce symptoms of prolonged grief disorder (PGD) in children (Spuij et al., 2013). For example, the “Growing through Loss” program was developed for adolescents who had multiple losses. This program focused on the value of support, education, and therapeutic groups for grieving adolescents. When established, it started by determining goals, objectives, and session activities. There were twelve sessions, covering the topics of antisocial attitudes, values, and beliefs; interpersonal skills; the dangers of alcohol and drugs; and

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dealing with adverse families. Examples of the session exercises were role playing and handson activities. The results indicated that the program addressed the core issues of grief rather than just treating the symptoms of destructive behaviors (Walker and Shaffer, 2007).

Another approach combined parental counseling with the cognitive-behavioral treatment of prolonged grief in children and adolescents. This method provided substantial improvements in self-rated prolonged grief disorder and post-traumatic grief, while smaller changes were found in depression and parent-rated internalization and externalization (Spuij et al., 2013). Moreover, this cognitive behavioral therapy also assisted the elderly in confronting emotional drain and grief acceptance, and increased their spiritual well-being and emotional intelligence (Khashab, Kivi, and Fathi, 2017).

A systematic review of complicated grief therapy (also known as traumatic grief therapy) found that interpersonal therapy and cognitive-behavioral therapy have been used for the treatment of complicated grief (Enez, 2017). In terms of interventions, the review indicated that various psychotherapy-based interventions were able to be applied, such as supportive counseling, writing therapy, group therapy, and narrative intervention. Additionally, it has been reported elsewhere that creative arts therapy (or the therapy of art) was able to help with self-expression by providing a safe space, and psychodrama assisted in resolving personal issues and encouraging individuals to move forward with their lives (Count, 2000; Dayton, 2005).

In addition to the aforementioned interventions, a study by Phra Panot Gunavaddho (Isarasakul) (2011) described how Buddhist Psychology Practice formed part of an inter-

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vention to help integrate loss. The hybrid-program combined Buddhist teaching and Buddhist-psychological group counseling, and it was based on the concepts of the Four Noble Truths and Threefold Training. The program provided four days for bereaved people to participate in Buddhist Psychological Practice, such as chanting, discussing doctrine, meditation, Buddhist counseling, and the pouring of water of dedication. The grief scales of the 19 participants in the program demonstrated a significant decrease in negative behaviors in the post-test and two-week follow-up test.

The Buddha’s teaching states that, “In order to build a pure land, the Bodhisattvas make use of beautiful music to soften people’s hearts, as with their hearts softened, people’s minds are more receptive, and thus easier to educate and transform through the teaching”. This indicates the reason for developing music as one type of ceremonial offering to be made to the Buddha (Misra and Shastri, 2014).

Buddhist music can be described as being relaxing and having an easy pace. It has a soft tone and a dignified, solemn manner. Listening to Buddhist music may reduce bodily fatigue, confusion, forgetfulness, and mental weariness, and may promote personal expression and communication (rumination of music). It also provides space to express the deepest feelings of the human soul through sincere chants of praise (Xingyun, Bell, and Miao, 2001).

Many music-therapy research studies have reported on the benefits of music interventions, especially for bereaved people. For example, creating original songs through songwriting assists patients and family members in understanding the experience of terminal illness, death, and loss (Heath and Lings, 2012). Moreover, the use of precomposed songs, music listening, and lyrical analysis provides

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space for bereaved people to express their feelings of grief and loss (Magill, 2009), while group music therapy creates opportunities for participants to be joyful and express their grief alongside other group members (McFerran, 2010). In addition, the use of Orff-based music therapy interventions significantly reduces behavioral problems and grief symptoms (Hilliard, 2007), and music-therapy-based bereavement groups experience reduced grief symptoms (Hilliard, 2001).

These studies indicate that music interventions help grieving people to integrate loss in a manner similar to Buddhist Psychology Practice. Therefore, it may be valuable to integrate these two interventions and measure outcomes in order to further the evidencebased practice of music therapy techniques coupled with Buddhist Psychology Practice. This could also help develop guidelines for the use of music interventions in Buddhist Psychology Practice for the integration of loss (Walker and Shaffer, 2007). Understanding Buddhist Psychology Practice

Buddhist Psychology Practice for integrating loss are based on the application of Buddhist principles and the underpinnings of Buddhist Psychology. The Buddhist principles consist of the Four Noble Truths and the Threefold Training (Gunavaddho, 2011).

The Four Noble Truths are the four main truths which are derived from Lord Buddha enlightenment. These lessons aim to free people from suffering (Tsering, 2005). The first is the truth of suffering (dukkha), which acknowledges the existence of suffering in life. Birth, aging, illness, and death are all suffering. Feelings such as grief, anger, jealousy, anxiety, and disappointment are also expres-

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sions of suffering. Separation from loved ones, enmity, and avidity are other forms of suffering. The second of the four truths relates to the cause of suffering (samudaya). All suffering does not happen by itself; there must be a reason why the suffering occurs, such as sensual desire, craving for existence, or craving for self-annihilation. The third truth relates to the end of suffering (nirhodha); it means that an individual has come to understand the concept that if suffering has occurred, it can disappear. The fourth truth is concerned with the path, or the way, to free a person from suffering (magga). The way to end the suffering is known as the “Noble Eightfold Path”. It consists of (1) right understanding; (2) right thought, which means having the intention or commitment to cultivate the right attitudes; (3) right speech, in order to speak truthfully and avoid slander, gossip, and abusive speech; (4) right action, in order to behave peacefully and refrain from stealing and killing; (5) right livelihood, so that one can live properly and not harm oneself or others; and (6) right effort, to achieve a positive attitude in a balanced way. A metaphorical example of this is the strings of a musical instrument and the amount of effort put upon them; they should not be too tense, nor too slack. Next is (7), right mindfulness, which means to be aware of the moment and to be focused in that moment; and lastly (8), right concentration, which is to train one’s mind to become totally focused (Tsering, 2005).

Threefold Training, another principle underlying Buddhist Psychology Practice, consists of morality, concentration, and wisdom. Morality relates to the practice of developing the right speech, right action, and right livelihood. Concentration means to develop consciousness, or the mind, in order to achieve the right effort, right mindfulness, and right concentra-

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tion. The third relates to wisdom, which is to train to develop the right understanding and the right thought through concentration (Olsen and Braseth, 2015; Thera, 2010). Activities in Buddhist Psychology

The Activities in Buddhist Psychology consist of the use of Buddhist precepts, chanting, meditation, discussions of the Doctrine, the pouring of water of dedication, and Buddhist counseling. Buddhist Psychology Practice requires 15 to 20 participants to stay at a peaceful place for four days and three nights. Each day starts with chanting, meditation, discussion, and counseling (Gunavaddho, 2011). The schedule of the Buddhist Psychology Practice is illustrated in the following table.

Music Interventions in Buddhist Psychology Practice

One precept in Buddhism suggests that Buddhists should refrain from dancing, singing, and listening to music; going to see entertainment; wearing garlands; using perfume; and beautifying the body with cosmetics. However, the precepts in Buddhism are not commandments; rather, they are moral guidelines Day 1

The application of music interventions within Buddhist Psychology Practice does not mean that the interventions will replace or disturb any process in the activities. Instead, the authors aim to use the music interventions as a tool to deliver the principles of both the Four Noble Truths and Threefold Training to clients. Based on their literature review, the authors recommend that music listening and songwriting can be readily applied to the schedule of Buddhist Psychology Practice.

Music Listening

Mindfulness is an important element in Buddhist lessons. It helps people to focus on the here and now (Lesiuk, 2008; Lesiuk, 2016). People who experience loss may find it ex-

TABLE 1. Schedule of Buddhist Psychology Practice

Early Morning 5 am

Late Morning 9 am

Greeting

Chanting

Meditation

Chanting

Buddhist counseling (Cause of suffering)

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to follow so that one may maintain healthy practices for oneself and not harm others. Given that, music interventions are applied to those Buddhist Psychology Practices which aim to help people who have experienced a loss. There have been many studies on the use of music therapy for people who have experienced a loss, and some have provided details of music interventions that can be applied to Buddhist Psychology Practice.

Pouring water of dedication

Afternoon 1 pm

Discussed Doctrine (Merit) Buddhist counseling Discussed Doctrine (Belief in birth) Discussed Doctrine (Karma)

Evening 6 pm

Discussed Doctrine (Kindliness & Love) Buddhist counseling (the suffering)

Buddhist counseling (the end of suffering)

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tremely hard to be fully in the present as thinking of the past is probably the only way to remind them of the loved ones they have lost. When people concentrate on the past or the future, it can lead to feelings of anxiety and depression. Various studies have demonstrated the positive effects of music listening on alleviating mood. For instance, Echardt and Dinsmore (2012) conducted a study combining mindfulness practice and music listening to treat depression. The results showed that this combination can be helpful for depression, and the participants felt it was a nonthreatening approach. Moreover, the technique encouraged the clients to choose music that expressed their feelings, which in turn allowed them to be able to understand their feelings. In addition, there is extensive literature regarding music and concentration. Listening to music mindfully can increase a listener’s engagement (Diaz, 2011). Music listening can also be used as a “highly convenient, effective, and tolerable means of achieving the goal of more mindful functioning” (Graham, 2010). Therefore, during Buddhist Psychology Practice, listening to music can be very beneficial to empowering participants to do meditation.

Songwriting

In the healing process, songwriting is a useful music intervention to facilitate the expression of emotions, feelings, thoughts, and memories regarding loved ones, and to help patients and family members understand the experiences of terminal illness, death, and loss (McFerran-Skewes, 2000; Roberts, 2006; Heath and Lings, 2012; Clements-Cortés, 2004). When communicating about a difficult topic such as death, songwriting is less confronting than speaking (Derrington, 2005). Moreover, the lyrics from songwriting can represent coping strategies. The study by Dal-

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ton and Krout (2006) reported that understanding, feeling, remembering, integrating, and growing were the coping strategies of bereaved adolescents, which were identified through an analysis of songwriting.

Many studies have demonstrated the process of using songwriting. As an example, the study by Roberts and McFerran (2013) represented the seven-steps of songwriting as (1) introducing songwriting; (2) brainstorming ideas for the song; (3) determining the song structure; (4) lyrical composition; (5) musical-accompaniment composition; (6) finalizing the musical features and recording the song; and (7) making covers for the CD and song-lyrics folder.

Additionally, by using a familiar melody in order to write new lyrics, it is possible to express emotions and memories relating to loved ones. This process requires that (1) the song is currently popular (as in presently played on the radio) or was popular within the past year; (2) the lyrics of the song either relate to bereavement or are easily modified for the bereavement setting; (3) the melodies are easy to sing and/or learn with few skips; and (4) the song has predictable, rhythmic timing (Fiore, 2016). After the songwriting is completed, a music therapist provides the opportunity for participants to share their memories and thoughts about their songs and their loved ones. Conclusions

While there are currently no published articles that discuss the specific use of music therapy techniques with Buddhist Psychology Practice, some music interventions can be applied within Buddhist Psychology Practice. These music intervention activities should be used as a tool to deliver the principles of the Four Noble Truths and Threefold Training.

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This article presents music listening and songwriting as music interventions which can help grieving people to integrate loss in a manner similar to Buddhist Psychology Practice. Music listening combined with mindfulness practice shows benefits in terms of reducing depression and encouraging the expressing and understanding of feelings. Songwriting is less confronting than speaking when dealing with a difficult topic. Thus, the use of music is recommended to facilitate the expression of the emotions, feelings, thoughts, and memories related to the loved ones, and to assist patients and family members in understanding the experiences of terminal illness, death, and loss.

Acknowledgments

The authors are grateful to Phra Panot Gunavaddho (Isarasakul), who devised and refined the Buddhist Psychology Practice to help integrate loss. Moreover, we thank Assistant Professor Givivann Veerakul MD for her awareness of the importance of employing various interventions, including music therapy, to cope with loss and grief. She also introduced the authors to Buddhist Psychology Practices and encouraged us to develop and incorporate music interventions for integrating loss into Buddhist Psychology Practice.

References

Clements-Cortés, A. (2004). The use of music in facilitating emotional expression in the terminally ill. American Journal of Hospice and Palliative Medicine, 21(4), 255–260. https://doi.org/10.1177/1049909104021 00406 Count, D. L. (2000). Working with ‘Difficult’ Children from the Inside Out: Loss and Bereavement and how the Creative Arts can Help. Pastoral Care in Education, 17–27.

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Dalton, T. A., Krout, R.E. (2006). The grief song-writing process with bereaved adolescents: An integrated grief model and music therapy protocol. Music therapy perspectives, 24, 94–107. Dayton, T. (2005). The use of psychodrama in dealing with grief and addiction-related loss and trauma. Journal of Group Psychotherapy, Psychodrama, and Sociometry, 15–34. Derrington, P. (2005). Teenagers and songwriting: supporting students in a mainstream secondary school. In F. Baker, T. Wigram, and E. Ruud (Eds.), Songwriting methods, techniques and clinical applications for music therapy clinicians. London and Philadelphia: Jessica Kingsley Publishers. Diaz, F. M. (2011). Mindfulness, attention, and flow during music listening: An empirical investigation. Psychology of Music, 41(1), 42–58. https://doi.org/10.1177/ 0305735611415144 Eckhardt, K. J. and Dinsmore, J. A. (2012). Mindful Music Listening as a Potential Treatment for Depression. Journal of Creativity in Mental Health, 7(2), 175–186. https://doi.org/10.1080/15401383.2012. 685020 Enez, Ö. (2017). Effectiveness of Psychotherapy-Based Interventions for Complicated Grief: A Systematic Review. Psikiyatride Güncel Yaklaşımlar—Current Approaches in Psychiatry, 9(4), 441–463. Fiore, J. (2016). Analysis of Lyrics from Group Songwriting with Bereaved Children and Adolescents. Journal of Music Therapy, 53(3), 207–231. https://doi.org/10.1093/ jmt/thw005 Graham, R. (2010). A cognitive-attentional perspective on the psychological benefits of listening. Music and Medicine, 2(3), 167–173. Gunavaddho, P. (2011). Effects of Grief reducing program for the Bereaved people

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using Buddhist practices combined with Buddhist Psychological Counseling. Journal of Psychiatry Association of Thailand, 56(4), 403–412. Heath, B. and Lings, J. (2012). Creative songwriting in therapy at the end of life and in bereavement. Mortality, 17(2), 106–118. https://doi.org/10.1080/13576275.2012. 673381 Hilliard, R. E. (2007). The effects of orff-based music therapy and social work groups on childhood grief symptoms and behaviors. J Music Ther, 44(2), 123–138. Hilliard, R. E. (2001). The effects of music therapy-based bereavement groups on mood and behavior of grieving children: a pilot study. Journal of Music Therapy, 38(4), 291–306. Hudgins, K. D. (2007). The effect of music therapy on the grief process and group cohesion of grief support group. The Ohio University. Khashab, A. S., Kivi, H. G., and Fathi, D. (2017). Effectiveness of Cognitive Behavioral Therapy on Spiritual Well-Being and Emotional Intelligence of the Elderly Mourners. Iranian Journal of Psychiatry, 12(2), 93–99. Lesiuk, T. (2008). The effect of preferred music listening on stress levels of air traffic controllers. Arts in Psychotherapy, 35(1), 1–10. Lesiuk, Teresa. (2016). The development of a mindfulness-based music therapy (MBMT) program for women receiving adjuvant chemotherapy for breast cancer (Vol. 4, p. 53). Presented at the Healthcare, Multidisciplinary Digital Publishing Institute. Magill, L. (2009). The Meaning of the Music: The Role of Music in Palliative Care Music Therapy as Perceived by Bereaved Caregivers of Advanced Cancer Patients. American Journal of Hospice and Palliative Medicine, 26(1), 33–39. https://doi.org/

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10.1177/1049909108327024 McFerran, K. (2010). Tipping the scales: A substantive theory on the value of group music therapy for supporting grieving teenagers. Qualitative Inquiries in Music Therapy, 5, 1–42. McFerran-Skewes, K. (2000). From the mouths of babes: The response of six younger, bereaved teenagers to the experience of psychodynamic group music therapy. Australian Journal of Music Therapy, 11, 3–22. Misra, S. and Shastri, I. (2014). Rumination of Music on Buddhism and Hinduism. Sport and Art, 2(3), 30–40. https://doi.org/ 10.13189/saj.2014.020301 Olsen, J. and Braseth, D. A. (2015). Morality, Meditation, and Wisdom: An Exploration of the Buddhist Foundation of Mindfulness-Based Stress Reduction. Universitas Bergensis. Parkes, M. (1965). Bereavement and mental illness (Part 2): A classification of bereavement reactions. British Journal of Medical Psychology, 38(1). Rando, T. A. (1984). Grief, dying, and death: Clinical investigations for caregivers. Champaign, IL: Research Press Company. Roberts, M. (2006). “I Want to Play and Sing My Story”: Home-based Songwriting for Bereaved Children and Adolescents. Australian Journal of Music Therapy, 17, 18. Roberts, M. and McFerran, K. (2013). A Mixed Methods Analysis of Songs Written by Bereaved Preadolescents in Individual Music Therapy. Journal of Music Therapy, 50(1), 25–52. Scrutton, S. (1995). Bereavement and grief: Supporting older people through loss. London: Edward Arnold. Spuij, M., Londen-Huiberts, A. V., and Boelen, P. A. (2013). Cognitive-Behavioral Therapy for Prolonged Grief in Children: Feasibility

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and Multiple Baseline Study. Cognitive and Behavioral Practice, 20. Spuij, M., Dekovic, M., and Boelen, P. A. (2015). An open trial of ‘Grief-Help’: A cognitive-behavioural treatment for prolonged grief in children and adolescents. Clinical Psychology and Psychotherapy, 22, 185–192. Thera, P. (2010). The Threefold Division of the Noble Eightfold Path. London: Rider and Company. Tsering, G. T. (2005). The Four Noble Truths: The Foundation of Buddhist Thought. (G. McDougall, Ed.) (1st ed., Vol. 1). Somerville, MA: USA: Wisdom Publications.

Walker, P. and Shaffer, M. (2007). Reducing Depression among Adolescents Dealing with Grief and Loss: A Program Evaluation Report. Health and Social Work, 32(1), 67–68. Worden, W. (2002). Grief counseling and grief therapy: A handbook for the mental health practitioner. (Third ed.). New York: Springer. Xingyun, Bell, C., and Miao, H. (2001). Sounds of the Dharma : Buddhism and music = fo jiao yu yin yue. Hacienda Heights: CA: Buddha’s light international Association.

About the Author

Puchong Chimpiboon Puchong Chimpiboon, MA, Music Therapy Major is a music therapist from Siriraj Palliative Care Center, Faculty of Medicine Siriraj Hospital, Mahidol University - Thailand. He is the assembly student delegate from South East Asia in 2014.

About the Author

Pornpan Kaenampornpan Pornpan Kaenampornpan is currently working as a lecturer at the Faculty of Fine and Applied Arts, Khon kaen University – Thailand. She finished her Master Degree in music therapy from new Zealand School of Music and completed her PhD in music therapy at Anglia Ruskin University-England. Her clinical experience includes elderly, patients with dementia and children with special needs and their family.

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About the Author

Dena Register Dena Register is an associate professor of music therapy and consultant to Mahidol University College of Music in Bangkok, Thailand. She helped established clinical music therapy programs and the first graduate music therapy degree program in Southeast Asia.

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Original Research

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Does a Customized Musical Song Promote a More Positive Experience Vs. Rhythmic Auditory Stimulation when Used to Enhance Walking for People with Parkinson’s Disease? Authors Kristen Barta, PT, PhD, DPT, NCS – Assistant Professor

University of St. Augustine for Health Sciences. 5401 La Crosse Ave. Austin, TX 78739. kbarta@usa.edu

Carolyn P. Da Silva, PT, DSc, NCS – Professor

Texas Woman’s University. 6700 Fannin. Houston, TX 77030. cdasilva@twu.edu

Shih-Chiao Tseng, PT, PhD – Assistant Professor

Texas Woman’s University. 6700 Fannin. Houston, TX 77030. steng@twu.edu

Toni Roddey, PT, PhD, OCS, FAAOMPT – Professor

Texas Woman’s University. 6700 Fannin. Houston, TX 77030. troddey@twu.edu Abstract

External auditory cueing has been shown to improve gait for individuals with Parkinson’s disease (PD). Rhythmic Auditory Stimulation (RAS) uses a fixed beat while other strategies rely on a musical composition. Despite the extensive research on mobility with auditory cues, there has been little research that addresses the perceived benefits of music and the preferred method of stimulation. The Synchronized Optimization Auditory Rehabilitation (SOAR) tool is a new approach to simulate auditory cueing in the form of music. The purpose of this study was to answer the question, “Do participants report a higher level of satisfaction and motivation when using the SOAR tool as compared to RAS or no auditory cue during ambulation?” Participants ambulated with no auditory cueing, metronome, and music customized by the SOAR tool. The investigator asked open-ended questions during a semistructured face-to-face interview session with each participant after the training. All participants preferred music to RAS and felt music best impacted walking. The emerging themes were auditory effects and utility that included the subthemes of motor impact, nonmotor impact, and issues within the testing and home environment. The perception was that music contributed to improved spatio-temporal parameters, balance, coordination, motivation, and happiness.

Keywords: Parkinson’s disease, rhythmic auditory stimulation, pattern sensory enhancement, perception, gait.

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Resumen

Se ha demostrado que la percepción de la señal auditiva mejora la marcha en las personas con le enfermedad de Parkinson (PD). La Estimulación Auditiva Rítmica (RAS) utiliza un ritmo fijo mientras que otras estrategias se basan en una composición musical. A pesar de la extensa investigación disponible sobre movilidad con señales auditivas, existe poca investigación dirigida a los beneficios percibidos de la música y a los métodos de estimulación preferidos. La herramienta Optimización de la Rehabilitación Auditiva Sincronizada (SOAR) es un nuevo enfoque para simular señales auditivas en forma de música. El objetivo de este estudio fue dar respuesta a la pregunta: ¿Reportan los participantes un nivel más elevado de satisfacción y motivación cuando utilizan la herramienta SOAR en comparación con el RAS o sin señal auditiva durante la marcha? Los participantes caminaron sin señal auditiva, metrónomo, y música personalizada por la herramienta SOAR. El investigador formuló preguntas abiertas durante una entrevista semiestructurada con cada participante después del entrenamiento. Todos los participantes prefirieron música a RAS y encuentraron que la música tiene un impacto mejor para la marcha. Los temas que aparecieron fueron los efectos de la audición y su utilidad, que incluyó otros temas como el impacto sobre el movimiento, impacto sobre otras áreas no motrices y otros aspectos durante las pruebas y en el hogar. La percepción fue que la música contribuyó a mejorar parámetros espacio-temporales, equilibrio, coordinación, motivación y felicidad.

Palabras clave: enfermedad de Parkinson, estimulación auditiva rítmica, modelo de mejora sensorial, percepción, marcha. introduction

External cueing has been shown to be an effective strategy for individuals with Parkinson’s disease (PD) to improve spatio-temporal parameters and functional gait (Thaut et al., 1992; McIntosh et al., 1997; Thaut et al., 1996; Morris et al., 1994; Behrman et al., 1998; Howe et al., 2003; Kadivar et al., 2011; Spaulding et al., 2013; Harro et al., 2014; Bukowka et al., 2016; Lirani-Silva et al., 2019). The pathophysiology of PD results from a progressive disruption of dopamine within the basal ganglia. Dopamine reduction leads to the four cardinal signs of PD: bradykinesia, tremor, rigidity, and postural instability (Ta-rakad & Jankovic, 2017). As the disease progresses, and production of dopamine is further reduced, these characteristics increase in severity, resulting in safety issues, loss of independence and a decline in quality of life.

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In individuals with PD, the reduced ability to create appropriate motor responses are due to the overactivation of pathways that inhibit movement, leading to timing deficits within the motor system. However, the auditory system remains relatively intact, and can properly receive information from the enviroment. The auditory stimulus provides an additional method to activate the motor system, by using a loop to the cerebellum and thalamus, which indirectly activates the premotor cortex through the temporal and parietal lobes (McIntosh et al., 1997; Freeland et al., 2002; Grahn & Brett, 2007; Petzinger et al., 2013; Stegemöller, 2014; Dalla Bella et al., 2015). In theory, predictable auditory cues promote temporal expectations resulting in more normalized movements. When the somatosensory system provides information to the brain these cues can potentially help regulate timing by influencing the basal ganglia-supplementary motor cortex-premotor cortex circuit

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which could assist in planning and ultimately executing a motor function (Ashoori et al., 2015).

Individuals without hearing impairments use cues from surrounding sounds for a variety of functional activities. Whether an auditory stimulus alerts a person of a car approaching, soothes a distressed infant or motivates one during recreational exercise, it is a tool that can be used to adjust motor actions. Individuals in a comatose state underwent music therapy for eight twelve-minute sessions and physiological changes occurred. When a therapist sang a wordless song, changes in heart rate and respiratory rate corresponded with the tempo of the song. Another interesting observation of the study found that these participants did not have the same response to talking, indicating that the body systems possibly respond more to rhythm rather than spoken sound (Aldridge et al., 1990). In individuals with an intact central nervous system, functional magnetic resonance imaging (fMRI) revealed that areas of the brain were activated when introduced to auditory stimuli (Chen et al., 2008). As individuals listen to a musical rhythm in a static position, with or without anticipation of the upcoming required motor task, the supplementary motor cortex, mid-premotor cortex and cerebellum have been shown by fMRI to be stimulated. This finding, in combination with previous work showing involvement of the basal ganglia and these structures in response to a motor task, points to the potential impact auditory stimulus can have on the areas of the brain that control motor movements (Zatorre et al., 2007).

Auditory cues have been shown to be an effective strategy to improve the spatio-temporal parameters of gait in individuals with PD. These cues can be delivered in the form

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of rhythmic auditory stimulation (RAS) or patterned sensory enhancement (PSE). RAS is an auditory cue in the form of a repetitive beat or sound, such as a metronome, and PSE is the use of harmony and melodies to impact movement and quality (Thaut et al., 2014). Improvements have been found in velocity, cadence, step length, single and double limb support, and muscle activation when RAS and PSE have been used during gait in individuals with PD. The most commonly studied intervention is RAS with a tempo set at a slightly higher percentage of preferred walking speed. Individuals with PD have shown improvements in various gait functions immediately after feedback and with training, suggesting the powerful impact auditory cues can have on mobility (Thaut et al., 1992; Morris et al., 1994; McIntosh et al., 1997; Behrman et al., 1998; Thaut et al., 1996; Howe et al., 2003; FernĂĄndez-del-Olmo & Cudeiro, 2003; Hausdorff et al., 2007; Bryant et al., 2009; Thaut et al., 2010; Kadivar et al., 2011; Spaulding et al., 2013; Harro et al., 2014; Dalla Bella et al., 2015; Bukowka et al., 2016; Lirani-Silva et al., 2019). Despite the research on mobility with RAS and music in the PD population, there has been little research that addresses the emotional aspect of music and the preferred method of stimulation. In a randomized controlled trial, Pacchetti el al. (2000) compared music therapy and physical therapy over a three-month intervention period in individuals with idiopathic PD. The music therapy group showed significant improvements in the motor subsection of the Unified Parkinsonâ&#x20AC;&#x2122;s disease rating scale and Happiness Measure after intervention, while the physical therapy group did not. Findings also report that music can improve perception of motor improvement after listening sessions

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in individuals with PD (Nombela et al., 2013). The theory that music has an emotional effect in addition to motor effect is noteworthy. Incorporating music into therapy has also been shown to increase adherence to a program and improve quality of life measures (Pohl et al., 2003). At the current time, the authors found no other research that assesses the user’s perception of how music or auditory cues impacts ambulation in the PD population.

The Synchronized Optimization Auditory Rehabilitation (SOAR) tool incorporates an approach that simulates techniques used by a music therapist during sessions with patients who have gait dysfunctions. The SOAR tool, created by a music therapist, uses playback methodology through Ovation1 that allows a therapist to move beyond simple metronome type strategies and create musical pieces individualized to the person’s needs in real time. This new process encourages the auditory system to facilitate movements that improve stepping strategies and thus impact the quality of the gait pattern. The theory relies on the concept that musical cueing is more complex than the repetitive clicks of RAS, which is not music. Potential improvement is possible because the SOAR tool allows customization to the specific issues of each person. The technique integrates music technologies using a new process in recording and playback. These are specifically designed so that the music therapist can manipulate PSE through a computerized software system (Barta et al., 2016). The software system could potentially allow a physical or occupational therapist to stimulate the auditory drivers for the motor system more specifically by customizing the sensory input using the SOAR tool to facilitate more 1. Merging Technologies, 82 Gilman St., Portland, ME 04102

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predictable gait parameter improvements during treatment sessions.

The SOAR tool uses a digitally recorded instrumental composition of a generic genre. The instrumental tracks include the trombone, piano, guitar, clarinet, upright bass, and saxophone. Each PSE track, in theory, corresponds with a specific portion of the gait cycle. The varying tempos are initiated through a single drum beat to establish the pace, serving the purpose of RAS. The remaining instrumental tracks can be started and stopped through a touch screen, allowing immediate real-time adjustments during gait assessment and training. The instrumental tracks were recorded separately, resulting in the composition being heard as a melody, regardless of the number of tracks played. This technology makes it possible to customize a melody depending on the impairments presented, as well as to modify it in real time based on a person’s reaction to the auditory cue (Barta et al., 2016).

The purpose of this study was to assess participants’ (with PD) perception of his or her experience using RAS and the SOAR tool during ambulation. The research question was, “Do participants report a higher level of satisfaction and motivation when using the SOAR tool as compared to RAS or no auditory cue during ambulation?” Methods

Participants

Convenience sampling was used to recruit people from local physicians’ offices, local PD support groups, community exercise groups, and word of mouth. Information regarding the study was distributed through flyers and

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informational announcements. The inclusion criteria included persons with a diagnosis with PD, Hoehn and yahr classification of I to IV, and ability to walk independently for at least 10 minutes over a level tiled surface without an assistive device (Hoehn & yahr, 1967). The exclusion criteria were individuals with a deep brain stimulator, an acute orthopedic injury or surgery within two months of data collection, a hearing impairment not corrected by a hearing aid, complete dependence on an assistive device for walking any distance, or those who had used the SOAR tool in a previous pilot study. All participants and caregivers signed an informed consent form approved by the Institutional Review Boards of Texas Woman’s University and University of St. Augustine prior to starting data collection. Equipment

The SOAR tool provided the music that was played through a desktop computer using Ovation software. Two speakers were attached to the computer to play the music at an appropriate volume wherever the participant was in the room. The same computer used a free metronome program to provide the other auditory cue. Research design

This study utilized a qualitative research approach using coding and triangulation to assess the participants’ and caregivers’ perception of the SOAR tool and RAS. The investigator asked open-ended questions during a semi-structured face-to-face interview session with each participant (Patton, 2015). If the caregiver was present and willing to be interviewed, the investigator asked separate questions of him or her. The interview occurred simultaneously with another data collection and within one to five days after

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each participant completed gait training using RAS and the SOAR tool by a music therapist. The two types of auditory cues were given in a random order, and the tempo was determined by the participant’s cadence during a measured walk across a computerized walkway system (Bilney et al., 2003; Egerton et al., 2014). The participants walked to RAS and the SOAR tool five to 10 minutes to become accustomed to the cue and develop a walking pattern in synchrony with the tempo. Modifications to the SOAR tool track combination were made until the most optimal gait pattern was determined through observational gait analysis by the music therapist. Music therapists are trained professionals in movement analysis pertaining to auditory cueing. The combination of instrumental tracks used for each participant was different based on the individual’s clinical presentation during gait (Thaut et al., 2014).

The focus of the questions was on self-perception of functional change during walking, enjoyment while using each intervention (SOAR tool and RAS), and feelings about which would more likely be used for independent exercise. The caregiver was asked about his or her perception of the participant’s level of enjoyment and likelihood of compliance at home, as well. The interview questions are listed in Appendix A.

All interviews were audio recorded and transcribed verbatim. The transcriptions were emailed or mailed, depending on participants’ preference, for member checking to confirm that the report accurately portrayed their perceptions and intended meaning (Patton, 2015).

Data Analysis

Qualitative data were analyzed using a content analysis approach. Independent coding

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occurred first by KB and CDS of the transcripts of three participants, to facilitate consistency and trustworthiness coding (Patton, 2015). The rest were completed by KB through lineby-line coding to identify codes of the remaining 17 interviews. Index cards were created with the coded words and phrases for sorting. Together, KB and CDS used the individual note cards to complete the sorting process and identify categories, subthemes, and themes by visually laying all cards into columns on a large table. The notecards were clustered by similar participant responses and then compared to determine how the groups were related. As like tendencies emerged, possible subthemes and categories were written on a dry-erase board. Comparison of the categories that emerged lead to the overarching themes, or major elements, that developed from the qualitative data. (Creswell, 2018; Patton, 2015; Smith & Furth, 2011; Elo & KyngĂ¤s, 2008). KB and CDS determined that data saturation had occurred after reviewing the 20 transcripts of the participants (Fusch & Ness, 2015; Guest et al., 2006). Results

The participants consisted of 20 individuals with PD. The mean age of the participants was 72.9 years old, the mean years since diagnosis was four, and there were 10 females and 10 males. Three caregivers participated in the interview process, two wives and one daughter. The participants were typically able to answer in a short period of time, averaging seven minutes. All three caregivers provided more information than their loved one, providing more detailed descriptions of how the auditory cue impacted movement. Seventeen of the participants reported that they preferred the music to the metronome. The other three individuals stated that they preferred no auditory cue, and no one reported

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a preference to the metronome. All three caregivers reported they liked the music better and felt that it impacted walking the most of the three conditions.

The questions that were most difficult for some participants to answer involved reflecting on the change in walking pattern or quality of movement. Most participants discussed how a particular auditory cue impacted how they walked but some could not differentiate or were not able to verbalize what they felt. If a participant provided a non-descriptive answer, the investigator would ask for clarification without providing additional prompts. For example, if the response was â&#x20AC;&#x153;better,â&#x20AC;? then the investigator would ask how it was better. The investigator was cautious to not influence thoughts or responses of the participants.

The two themes that emerged through data analysis were auditory cues and utility. The two themes evolved from reports of how RAS and SOAR were perceived to change motor and emotional elements and the feasibility of using the auditory cues. Within these two themes were two sub-themes for auditory cues: motor impact on walking and nonmotor impact, and two sub-themes for utility: testing issues and home issues. These led to several categories and sub-categories. Figure 1 illustrates the results of the qualitative data.

The larger sub-theme within the theme auditory effects was impact on the motor system. The influence of music was the category that was reported to have the greatest impact by the participants and the caregivers. While the metronome was reported to help with stepping strategies during walking, by increasing the length and speed, walking with the music was what people reported to change the

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AUDiTORy EFFECTS Motor impact on Walking • Metronome Influence - Stepping • Music Influence - Balance and stability - Quality and fluidity - Speed - Step length • Neutral Impact - No difference with either cue • Family Report - Better walking pattern - More automatic movements Nonmotor impact • Cognitive - Body awareness - Past memories • Emotional - Mood elevation - Motivation

UTiLiTy Testing issues • Clinician - Minimal verbal instruction - No feedback on performance • Physical Space - Cords to step over - Frequent turns - Too small Home Use •Ease of use • Disruption of family activities • Risk of boredom • Safety

FIGURE 1. Data Analysis results with auditory effects and utility as themes and related sub-themes, categories and sub-categories. quality of movement with one participant clearly stating, “Music improves quality of gait.” Another participant described this change by stating,

“…I felt like after a minute or so it changed everything about my body. It [music] helped with rigidity. It helped with fluidity. It changed everything about the way I was moving.”

One participant even stated, “Actually, it [music] kind of pulled me along,” suggesting that the music gave her a sensation of forward movement to facilitate her gait progression. The motor impact of music even moved beyond simple stepping strategies with some participants reporting perceived improvements in balance, stability and co-

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ordination during walking. Walking is a complex task that incorporates balance and the ability to reciprocally move the lower extremities. The ability of the participant to potentially increase step length and speed could be in combination with perceived improvements in these areas. The caregivers also perceived a difference in the walking pattern and automaticity of the movements. One participant’s wife said,

“I think his walking was smoother, if there is such a thing. He looked more natural with the music. With the metronome, and maybe it’s just my perception, was that it was too rigid.” The daughter, who stated during the walking sessions that she is constantly reminding her dad to move his arms, said,

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“…that without the music he was barely moving his arm, his arm was basically straight. And after that [music] he did it automatically without me saying anything!”

The reported changes of the participants were consistent with previous research using auditory cues to influence walking. Most participants reported that the cues were helpful and changed their walking pattern. Objectively measured improvements in spatio-temporal parameters of gait in individuals with PD is documented in the literature and the categories within the motor impact on walking subtheme of the qualitative data are in alignment. (Thaut et al. 1996; Howe et al. 2003; Hausdorff et al., 2007; Lohnes & Earhart, 2011, Dalla Bella et al., 2015; Benoit et al., 2014). The uniqueness of this study was that the participants were not aware of the measured changes from the computerized walkway and were only reporting on how they felt their walking changed.

Despite the positives perceived by most participants, there were four people who did not notice a difference in walking between the two auditory cues. They reported noticing a difference from no auditory input to RAS or SOAR, but they did not perceive improvements of the music over the metronome or vice versa. Most were open to the idea that there might have been a change in their walking pattern; any change, if present, was just not noticeable to them.

The nonmotor impact was an interesting result found during the analysis process. The questions were meant to target the participants’ perception of how the spatio-temporal parameters of gait changed with each auditory cue. The two categories that emerged from the sub-theme of nonmotor impact were cognitive and emotional, although the

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interview did not directly address these areas. In the cognitive category, participants discussed having a past knowledge of music, whether it be from marching band, military or dance. The music was stated to be easier to follow or made them remember a past life experience. Some participants stated that the music gave them more awareness of their body in general. One participant said that the music had a lasting effect that she felt for a while after testing. She stated, “After a bit on the music I actually felt myself kind of internally in my head almost singing to the rhythm.” Another reported, “The music makes me want to get into the rhythm more.” The other main category that emerged under the nonmotor impact was the emotional component. Ten individuals reported that the music was motivating and made them feel better. For example, two individuals stated the following, suggesting that music could be a more positive experience for the user.

“Music makes it more interesting, more entertaining. And it sort of lifts your spirits to hear a melody line or harmony line.”

“So the music actually made me feel, you are going to laugh, but the music made me feel happy. you know, it was like a light, airy melody that made me kind of want to skip along!”

The benefits of music therapy have been reported in healthcare across other populations such as psychiatric conditions, depression, and pain management. The use of music has facilitated improvements in these conditions on participant subjective reports (Silverman, 2006; Godi et al., 2016; Magee, 2002; Krout, 2001). Pacchetti el al. (2000) reported improvements in the Happiness Measure after three months of music therapy including singing and playing musical instruments in individuals with PD. While these studies indi-

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cate the positive effect music can have on the emotional state of a person, none focused on the perceived impact of physical mobility during ambulation in the PD population.

The other theme was utility and participants’ ability and motivation to incorporate auditory cues into their walking programs. Some participants discussed the limitations of the lab testing environment. The room, 20 feet in length, caused the participants to have to make frequent turns. The limited space may have decreased participants’ ability to focus on the auditory cue when walking because of the external distractions. Additionally, due to the nature and purpose of the study, there was no formal training or verbal instruction given on how to walk with the auditory cue. The investigators did not provide any instruction other than “walk with the beat/music” and some participants stated they did not know if they were doing it correctly. Similarly, the investigators did not give any feedback on how well or poorly participants walked with either auditory cue. This lack of feedback was done purposefully so as not to sway the individual’s perception of either cue before the interview occurred. This deliberate withholding of information could have led to some participants not having a good understanding of how their walking changed with each cue.

The final sub-theme was the auditory cues’ ability to be incorporated into home use. Despite most participants preferring the music, there was a reported risk of boredom if the musical piece was the same day after day. Boredom, along with the music being difficult or potentially unsafe to use, were limiting factors to incorporating music into a home exercise program. One participant highlighted an area of concern when discussing the practicality of using an auditory cue in the community. Her statement below

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sheds light on issues that would need to be addressed before issuing an auditory cue as a home program.

“It concerns me a little bit about traffic if I’m outside. I kind of want to have my senses going, but you know, you can find better places to walk too. The trail, for example.”

Discussion

This study aimed to assess if individuals with PD perceived walking with a customized musical piece to be a better experience than walking with a metronome or without any auditory cues. Although there is ample research to support the use of auditory cueing during ambulation in the PD population, there is little to no documented research indicating how these interventions are perceived or preferred. RAS has been shown to increase velocity, step length and cadence in individuals with PD (Behrman et al., 1998; Morris et al., 1994; Thaut et al., 1996; Howe et al., 2003; Hausdorff et al., 2007; Picelli et al., 2010). Likewise, there is supporting research of using PSE, melodies and harmonies, to have similar impacts on walking in this population (Wittwer et al., 2013; Bukowska et al., 2016). While researchers have acknowledged that these interventions serve a valuable role in rehabilitation, there is inconclusive evidence as to if these methods are perceived as beneficial from the user’s end.

The participants in this study reported positive experiences using an auditory cue during ambulation from a motor standpoint, with music being the preference of most. The music added not only perceived motor benefits to spatio-temporal gait parameters, but also benefits to balance, coordination and continuity of movement. The responses of the participants and their caregivers aligned with what is

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typically observed during walking with auditory cues in the presentation of longer step lengths, faster velocity, and improvements in stability and overall quality of movement. The results of this study suggest that individuals with PD and their caregivers perceived a positive change in these parameters, as well.

Another aspect of the music that may make it superior to RAS is its impact on a patient’s motivation. A participant stated in an interview that “the music motivates people to move,” indicating music’s potential to support compliance with home exercise programs. In the field of rehabilitation, noncompliance is an issue that clinicians deal with often (Sluijs et al., 1993). Adherence to a home exercise program is influenced by how helpful a client feels the program is as well as the program being able to fit into their everyday schedule (Sluijs et al., 1993; Campbell et al., 2001). Having a tool or intervention that improves motivation to move and be active could improve compliance. The statement “it definitely makes me feel happier” supports the notion that a patient may be willing to exercise because the music has a positive emotional impact. Cavanaugh et al. (2015) found that individuals with PD have difficulty maintaining the recommended daily steps for physical activity. Results of this study are promising because research has shown that individuals with PD can be successful in using auditory cues in a home-based intervention program. Significant improvements in gait speed and stride length have been demonstrated in this population when RAS or another form of musical cue was used on a home basis during daily activities (Bryant et al., 2009; Ginis et al., 2016). In the RESCUE trial, patients with PD received external cueing in the form of auditory, visual or vibratory cues in the home environment during functional tasks and showed significant improvements after training, and at a three month follow up, in velocity, step

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length, and fear of falling (Nieuwboer et al., 2007). Providing a motivational and enjoyable method for encouraging activity could lead to better outcomes in compliance and overall activity level.

There were limitations to this study. The first is that the interviews occurred one to five days after the initial use with the music therapist. This delay could have resulted in some individuals not accurately remembering how they felt when using each auditory cue. The questions focused on how participants perceived each cue to change gait pattern. With the delay in questioning, some participants may have provided less detailed responses. Another limitation was the questions. The purpose of the study was to determine if individuals with PD perceived a higher level of satisfaction and motivation in walking with the metronome or a customized musical piece, and the questions focused on changes in walking pattern with each auditory cue. The weakness of the questions became apparent after a few interviews because participants were reporting an emotional improvement as well with the music over the metronome. Due to the lack of qualitative research experience of the interviewer, the questions were not modified midway through data collection, and the same format of questioning continued for all participants. More questions could have been developed to assess this domain further to potentially capture more detailed and productive emotional responses to the music.

Conclusion

Auditory cues, administered through RAS and PSE, have demonstrated improvements in the spatio-temporal parameters of gait in individuals with PD. To the authors’ knowledge there is no current research that specifically assesses the perceived improvements in am-

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bulation, with the use of auditory cues, in individuals with PD. Most of the participants in this study indicated a preference to auditory cues given in a musical form over RAS. The perception of most of the participants was that music contributed to improved spatiotemporal parameters, along with balance, coordination, motivation and overall happiness. The findings from this study suggest that this music tool could offer improvements to intervention beyond physical performance. Since individuals with PD perceive music as more motivating and better than RAS, it could lead to improved outcomes in ambulation and compliance in home exercise programs. Music could be the catalyst to stimulate motivation as well as motion. Appendix A: interview Questions

Participant Questions

1) Tell me how you felt when using the metronome during walking? 2) Tell me how you felt when using the music during walking? 3) Tell me how you walked differently when using the metronome as compared to the music? 4) Which method would you be more likely to use when exercising at your own home? 5) Can you think of any reasons why the metronome/music would be hard to use when exercising at home? Caregiver questions

1) Tell me how (name of participant) walked differently when using the metronome as compared to the music? 2) Which method (either metronome or music) do you think would be more motivating for (name of participant)? 3) Can you think of any reasons why the metronome/music would be hard to use when exercising at home for (name of participant)?

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et al., Lim, I. (2007). Cueing training in the home improves gait-related mobility in Parkinson’s disease: the RESCUE trial. Journal of Neurology, Neurosurgery, and Psychiatry, 78: 134-140. Nombela, C., Rae, C.L., Grahn, J.A., Barker, R.A., Owen, A.M., & Rowe, J.B. (2013). How often does music and rhythm improve patients’ perception of motor symptoms in Parkinson’s disease? Journal of Neurology, 260:1404-1405. Pacchetti, C., Mancini, F., Aglieri, R., Fundarò, C., Martignoni, E., &Nappi, G. (2000). Active music therapy in Parkinson’s disease: an integrative method for motor and emotional rehabilitation. Psychosomatic Medicine, 62: 386-393. Patton, M.W. (2015). Qualitative Research and Evaluation Methods. 4th ed. (pp. 115118,525) Los Angeles, CA: SAGE Publications, Inc. Petzinger, G.M, Fisher, B.E., McEwen, S., Beeler, J.A., Walsh, J.P., & Jakowec, M.W. (2013). Review: Exercise-enhanced neuroplasticity targeting motor and cognitive circuitry in Parkinson’s disease. Lancet Neurology, 12: 716-726. Picelli, A., Camin, M., Tinazzi, M., Vangelista, A., Cosentino, A., Fiaschi, A., & Smania, N. (2010). Three-dimensional motion analysis of the effects of auditory cueing on gait pattern in patients with Parkinson’s disease: a preliminary investigation. Neurology Sciences.;31: 423-430. Pohl, M., Rockstroh, G., Rückriem, S., Mrass, G., & Mehrholz, J. (2003). Immediate effects of speed-dependent treadmill training on gait parameters in early Parkinson’s disease. Archives of Physical Medicine and Rehabilitation, 84: 1760-1766. Silverman, M.J. (2006). Psychiatric patients’ perception of music therapy and other psychoeducational programming. Journal of Music Therapy, 42(2):111-122.

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Sluijs, E.M., Kok, G.J., van der Zee, J., Turk, D.C., & Riolo, L. (1993). Correlates of exercise compliance in physical therapy. Physical Therapy, 73(11): 771-800. Spaudling, S.J., Barber, B., Colby, M., Cormack, B., Mick, T., & Jenkins, M.E. (2013). Cueing and gait improvement among people with Parkinson’s disease: a meta-analysis. Archives of Physical Medicine and Rehabilitation, 94: 562-570. Stegemöller, E.L. (2014). Exploring a neuroplasticity model of music therapy. JMT. 51(3): 211-227. Tarakad, A. & Jankovic, J. (2017). Diagnosis and management of Parkinson’s disease. Seminar in Neurology, 37: 119-126. Thaut, M.H. & Abiru, M. (2010). Rhythmic auditory stimulation in rehabilitation of movement disorders: a review of current research. Music Perception, 27(4): 263-269. Thaut, M.H. & Hoemberg, V. (2014). Handbook of Neurologic Music Therapy. (pp.

70, 80-85, 106) Oxford, UK: Oxford University Press. Thaut, M.H., McIntosh, G.C., Prassas, S.G., & Rice, R.R. (1992). The effect of rhythmic auditory cueing on temporal stride and EMG patterns in normal gait. Journal of Neurologic Rehabilitation, 6:1 85-190. Thaut, M.H., McIntosh, G.C., Rice, R.R., Miller, R.A., Rathbun, J., & Brault, J.M. (1996). Rhythmic auditory stimulation in gait training for Parkinson’s disease patients. Movement Disorders, 11(2): 193-200. Wittwer, J.E., Webster, K.E., & Hill, K. (2013). Music and metronome cues produce different effects on gait spatiotemporal measures by not gait variability in healthy older adults. Gait and Posture, 37: 219222. Zatorre, R.J., Chen, J.L., & Penhune, V.B. (2007). When the brain plays music: auditorymotor interactions in music perception and production. Neuroscience, 8: 547-558.

About the Author

Kristen Barta, PT, PhD, DPT, NCS. Kristen a physical therapist, board certiﬁed in Neurology, studies locomotor training of individuals with balance dysfunction. She worked with a music therapist studying the use of specialized delivery of auditory cues to impact gait in people with Parkinson’s disease.

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Commission Report

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Moving the Profession Forward: Governmental Recognition, Increased Access, and Competitive Pay Authors Petra Kern, Ph.D., MT-BC, MTA, DMtG

University of Louisville, KY Music Therapy Consulting, Santa Barbara, CA

Daniel B. Tague, Ph.D., MT-BC

Southern Methodist University, TX World Federation of Music Therapy

Correspondence concerning this article should be addressed to

Petra Kern, Ph.D., MT-BC, MTA, DMtG. Email: petrakern@musictherapy.biz

Abstract

Music therapy seems to be developing around the world; yet it continues to be a small field. Data from the international survey study (Kern & Tague, 2017) indicated financial issues, governmental regulations, advocacy efforts, and educational/professional development offerings as barriers to a more rapid growth. Despite the challenges the profession faces, practitioners remain positive about the future development of the field.

This report, provided by the Chair of WFMT’s Commission of Clinical Practice in collaboration with the 2008-2011 WFMT President, is based on an in-depth exploration of the previously presented qualitative survey data. It reveals regional information about the prediction of the future, impact of a potential global certiﬁcate, and educational/professional development needs. Findings from the survey data also suggest three major assertions about music therapists representing characteristics (who we are), key standards (what we believe), and aspirational values (why we are committed).

Focusing on three key standards identiﬁed by the survey respondents, this article proposes basic legislative, professional, and self-advocacy initiatives to address the deﬁned lack of governmental recognition, limited access to music therapy services, and inadequate competitive pay. Example initiatives and resources from music therapy organizations, businesses, and practitioners around the world supplement the content. Keywords: music therapy; ongoing barriers; assertion; advocacy initiatives.

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Resumen

La musicoterapia parece que se está desarrollando por todo el mundo; pero aún sigue siendo un campo reducido. Los datos obtenidos en el estudio de una encuesta internacional (Kern & Tague, 2017) señalan aspectos económicos, regulaciones gubernamentales, esfuerzos legales, y desarrollo educacional/profesional que constituyen barreras para un crecimiento más rápido. A pesar de los retos a los que se enfrenta la profesión, los profesionales son positivos sobre el desarrollo futuro de la musicoterapia.

Este informe, impulsado por el Director de la Comisión y Práctica Clínica de la WFMT en colaboración con el Presidente de WFMT de 2008 a 2011, se basa en una exploración profunda de los datos presentados previamente en una encuesta cualitativa. Los resultados proporcionan información regional sobre la predicción del futuro, del impacto de un potencial certiﬁcado global, y de las necesidades de desarrollo educacional/profesional. Los resultados de la encuesta también sugieren tres aﬁrmaciones principales sobre las características de los musicoterapeutas (quien somos), normas clave (que creemos), y aspiraciones (por qué estamos comprometidos).

Basándonos en tres claves estándar identiﬁcadas por las personas que respondieron a la encuesta, este artículo propone iniciativas básicas legislativas, profesionales e iniciativas de promoción para corregir la falta de reconocimiento gubernamental, el acceso limitado a servicios de musicoterapia, y los honorarios competitivos inadecuados. Como ejemplo, iniciativas y recursos de organizaciones de musicoterapeutas, empresas, y profesionales de diversas partes del mundo complementan el contenido.

Palabras clave: musicoterapia; barreras existentes, asertividad; iniciativas de autodefensa. Commission Report Moving the Profession Forward: Governmental Recognition, Increased Access, and Competitive Pay Food for Thought

Since its inception in the 1940s in the U.S., the profession of music therapy has been introduced in all regions of the world; professionals serve a wide variety of populations globally, and basic standards of practice exist worldwide. Most music therapists feel wellrespected, well-trained as clinicians and musicians, and have an optimistic outlook on the future of the profession (Kern & Tague, 2017). yet, there seem to be ongoing barriers for the

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exponential growth in size and employer demand of the ﬁeld not meeting client demands worldwide.

Growth in Size Looking at sample growth rates of certiﬁed or registered music therapists in ﬁve of the World Federation of Music Therapy’s (WFMT) regions reveals a steady but slow growth in the size of the profession. For example, the British association of Music Therapy established in 2011 lists 704 Health and Care Professions Council (HCPC) registered music therapists in 2012 and 1,038 in 2017 (L. Patridge, personal communication, June 27, 2018). another European organization, Österreichische Berufsverband der MusiktherapeutIn-

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nen (ÖBM), was established in 1984 with 9 therapists and reported growing to 288 therapists by 2018 (E. Puchner, personal communication, November 8, 2018). although there is no published data to indicate the initial number of professional therapists in South america and australia, current numbers indicate very slow average growth over the last 40-50 years as well. The asociación argentina de Musicoterapia (aSaM) was founded in 1966 and indicates 680 registered music therapists in 2018 (G. Federico, personal communication, November 14, 2018). The australian Music Therapy association (aMTaaus, 2018) was established in 1975 and lists 545 registered music therapists as of September 2018. Finally, in the U.S., the number of certiﬁed music therapist grew from 2,626 certiﬁcates to 8,008 between 1985 and 2018 (J. Schneck, personal communication, october 19, 2018). Similarly, the Japanese Music Therapy association reports a growth from 433 to over 3,000 registered music therapists between the years 2000-2018 (M. Kato, personal communication, June 21, 2018). Given the number of university degree programs and their cohort sizes in these sample countries, this growth rate is not surprising.

Employer Demand Employer demand is typically defined by the number of job openings for a specific job title. While market researchers provide customized assessments of the labor market in specific geographical regions for corporate clients, educational institutions, or the government, no music therapy labor market report is available to the general public. yet, only a few music therapy organizations included in their workforce analyses job market trends by investigating the number of jobs created over time. For example, the american Music Therapy association (aMTa, 2019a) reports a total of 1,113 net jobs created between 1998-

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2018. In 2016, the australian Music Therapy association (aMTaaus) notes in their first workforce analysis that 46% of respondents indicated an increase in referrals and 36% mentioned that new jobs had been added since the previous year. In the country-specific reports of the European region (Ridder & Tsiri, 2015), no specific labor data is available. However, a statement in the Swiss country report seems to reflect a steady increase in job opportunities as well as the challenges of the music therapy labor market: “During the last 30 years many new work opportunities for music therapists have been created. Nevertheless, music therapists who qualify from training courses frequently have to find innovative and creative ways to begin work, as jobs are still rare” (Kandé-Staehelin, 2015, p. 185-186). Without any reliable labor market data for each geographical region, the professions’ growth will be difficult to define. organizations should hire market researchers to assess current and future job market trends in music therapy.

Client Demand In contrast, the United Nations’ Department of Economics and Social aﬀairs (UN DESa, 2017) projects that the current world population of 7.6 billion people will reach 8.6 billion in 2030, 9.8 billion in 2050, and 11.2 billion in 2100. This is an upward trend in population size of approximately 83 million people per year. By 2050, India, China, and Nigeria respectively are expected to be the most populous countries – regions where music therapy as a profession is currently in its development (WFMT, 2017a). according to reports of the World Health organization (WHo), the global population also is aﬀected by an increased prevalence of disabilities and healthcare issues such as autism spectrum disorder (aSD), depression, and dementia – three populations frequently served by music

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therapists worldwide (Kern & Tague, 2017). Currently, the global estimate of aSD is 1 in 160 persons or 0.3% of all global diseases (WHo, 2017a); over 300 million people or 4.4% of the world’s population are estimated to suﬀer from depression (WHo, 2017b); and 5 to 8 in 100 persons aged 60 and older or 50 million people worldwide have dementia (WHo, 2017c). Estimates of the proportion of a general population aﬀected by disabilities or health issues are indicators for healthcare services needed and should be considered by the music therapy profession. Unfortunately, the present rate of growth of the music therapy profession cannot meet the current nor future demands of clients worldwide.

Ongoing Barriers In 2017, Kern and Tague (2017) published the results of a survey study that determined the demographics, practice statuses and trends of music therapy worldwide. Included in this study were 2,495 professional music therapists from 19 organizations aﬃliated with WFMT who resided in seven regions of the world. The infographic poster displayed in Figure 1 provides an overview of the study’s background, method, results, and conclusions.

Responses to three open-ended questions on the 30-item questionnaire provided insights into possible barriers and potential global development of the profession. In short narrative reports, respondents identified financial issues, governmental regulations, advocacy efforts, and educational/professional development offerings as the major barrier for a more rapid growth of the profession. While a possible global certificate that supports common standards of clinical practice might lead to professional recognition and provide mobility to accept employment worldwide, multiple approaches inherent in music therapy practice and cultural differences were identi-

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fied as potential obstacles. Not surprisingly, advanced clinical practice/training, specific information about clinical approaches and specific populations, supervision and mentorship as well as how to establish formal degree programs were cited as desirable topics for music therapy training offerings. although respondents listed many crucial risks and barriers, most remained positive about the overall future development of the profession.

The purpose of this report is three-fold. First, to provide additional insights into the potential ongoing barriers spotlighting regional survey data of the three open-ended questions. Second, to present an assertion of characteristics, key standards, and aspirational values shared by music therapists worldwide. and third, to propose key action steps that may be taken by organizations and dedicated individuals to move the profession forward. Spotlight on World Regions

I think music therapy could continue to grow, but we are not positioning ourselves well as a profession at the moment (wages too low, too many short-term/freelance employment contracts).

Supporting the Kern and Tague (2017) research outcomes, respondents of the seven participating regions identiﬁed the key issues of lack of jobs/insuﬃcient pay, funding, and reimbursement. Full-time employment (36+ hours per week) was mainly reported in the North american region while music therapy practitioners in all the other regions predominantly worked between 1-9 hours per week. only the European region split between those working almost full-time (mainly 20-29 hours per week) and part-time (mainly 1-9 hours per week). Hourly rates for individual and group sessions ranged from $10-59

FIGURE 1. Evaluating Music Therapy Practice Statuses and Trends Worldwide.

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with the lowest rates cited in the Latin american, Southeast asian, and Western Pacific regions; the highest reported rates were in the North american, European and australian/ New Zealand regions. Funding and reimbursement for music therapy sessions varied across the regions: Facility/hospital budget (North america and Western Pacific), governmental funds (Europe and Southeast asia), private/client pay (Latin america and australia/New Zealand). overall, all respondents expressed major concerns about financial issues, especially noting the need for competitive pay that would negate the necessity of working a second job.

I would hope that music therapy moves to a licensed ﬁeld so that we will be better recognized by other professional healthcare organizations.

In contrast, recognition and licensure issues appear to greatly diﬀer across the regions. While in North america, Europe and australia/New Zealand governmental regulations are in place or targeted, respondents from the Southeast asia region and most of the Latin american countries reported that music therapy is not yet recognized as a health profession. These observations are in alignment with data from regional reports (e.g., Jack, Thompson, Hogan, Tampli, Eager, & arns, 2016; Myers, 2015; Ridder & Tsiris, 2015; Saji, okazaki, Igari, Bando, Saito, 2010) and updates from the Commission on accreditation and Certiﬁcation of WFMT (2017a). In general, respondents believe that governmental recognition is the key for improved access to music therapy services.

The general public […] needs to be educated about music therapy and its value. This will increase our job opportunities and encourage more students to look at music therapy as a viable career option.

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Respondents across all seven regions mentioned the importance of public awareness, marketing, and networking/mentoring to communicate the value and impact of music therapy services for clients, families, communities, and societies at-large. Especially cited was educating the public about the scope of practice of music therapy versus related health professions. Mainly, respondents believe that governmental recognition will create employment opportunities and encourage students to consider music therapy as an attractive career option.

We still do not have music therapy training [programs…], which aﬀect the status and future of the profession.

The lack of university programs is especially evident in the Southeast asia and Latin america regions. The European and North american regions more frequently cited degree issues. Largely, respondents see education and professional development as the doorway to growing the profession in size and depth. Table 1 displays example quotes sorted by respondents residing in the seven regions that oﬀer their insights and predictions on the future of the profession.

a global certiﬁcate might bring more professional respect but we have to be careful in not losing the rich heterogeneity in music therapy practice.

In the 2017 research report (Kern & Tague, 2017) 40.8% of the respondents thought it would be worthwhile to explore a global certiﬁcate given the common standards of clinical practice, a potential increase of recognition worldwide, and the global mobility leading to greater employment opportunities. Twentyfour percent of the respondents expressed that a global certiﬁcate would not be a good

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idea given the variety of approaches as well as cultural differences around the world; 15.5% were undecided and 19.8% had no opinion. Interestingly, there have been regional differences. Respondents from the australia/New Zealand, Latin america, Southeast asia, and Western Pacific regions indicated that they would welcome the exploration of a global certificate; respondents from the European and North american regions tended more to shy away from the idea. Commonly, respondents agreed that more unified practices while honoring cultural values could be beneficial for the development of the field. Table 2 provides regional opinions on the importance and impact a global certificate could have.

[..] set the bar high in regards to musical, clinical, and research expectations.

as reported by Kern & Tague (2017) music therapy professionals clearly voiced a desire and need to engage in professional development activities of various topics, delivery methods, and lengths. Respondents from all the regions tended to seek information about advanced clinical practice and how to work with specific populations. overall, respondents were committed to staying informed to provide high-quality services to their clients. Table 3 displays regional professional development topics.

TaBLE 1. Participants’ Predictions About the Future of Music Therapy Practice by Region.

Theme (1,407 respondents)

Theme 1: Financial Issues

Region

africa

australia/ New Zealand Europe

Latin america North america

South East asia Western Paciﬁc

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Example Quotes

[…] other Healthcare Professionals (i.e., oT's and Psychologists) who use the arts in their practices, are becoming a problem for the appropriately trained and qualiﬁed arts Therapists. Especially in private healthcare where their services are covered under their disciplines by the medical insurance companies, but ours are not.) Funding for music therapy remains precarious. However, there is growing awareness and understanding of its beneﬁts and value.

It is growing, but ﬁnancial challenges remain so the promotion of the professional role is still very important particularly into new ﬁelds of work. There is still a lot to do. We are very few and jobs are hard to get.

Music therapy is at rough place in the U.S., where insurance, government funding, licensure and other things are clashing at times…and we are trying to sort it all out.

[…] funding remains a challenge in providing services to people who simply can't aﬀord to pay. We cannot make a living only with music therapy.

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Theme 2: Government Regulation

africa australia/ New Zealand

Europe

[…] we fight...for acceptance of music therapy as a profession that is registered. […] there needs to be a better connection and recognition of music therapy certificates. Still, it is difficult to be able to just start working in one country as a music therapist, when having studied in the other.

I hope that this year the law for legal and national execution of music therapy will be approved.

South East asia

…it will be more accepted as a profession and eventually be supported by the government.

Western Paciﬁc

africa

australia/ New Zealand Europe Latin america North america

South East asia Western Paciﬁc

141

The range of client populations is expanding as the awareness of the profession and its beneﬁts grow. I predict an increase in evidencebased research emerging from (our country). The need to lobby government and education will continue regarding funding of music therapy at this level and for professional recognition in the form of salaried positions […]. It is an exciting time in this country!

Latin america North america

Theme 3: advocacy Eﬀorts

I believe music therapy will grow dramatically…if we can get international support to boost our practice.

We need more than psychotherapy regulation… we need government regulation of our profession in order to be recognized as a profession. We need title protection.

To be recognized as a profession.

I believe music therapy will grow dramatically…if we can get international support to boast our practice.

among the professional services that offer music therapy our worth is recognized but there is still the need for music therapists to prove themselves. There is a real need for music therapists to be strong advocates and talk confidently about what music therapy is, its effectiveness and the difference it can make to care pathways. It is necessary that the music therapist is recognized and valued in clinical, educational, and community settings.

The importance of advocacy for music therapy is helping get the word out. as more opportunities arise, music therapy will be recognized by the media and public eye in an accurate and positive way, increasing opportunities for music therapists and services for citizens. To have a legal certiﬁcation, and music therapy could be well known in society. although many music therapists are working very hard, recognition of music therapy is poor for the general people.

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Theme 4: Education and Professional Development

africa

australia/ New Zealand Europe

N/a

With Music Therapy courses closing it is unfortunate, but we will run out of students and professionals.

I think, that the academic qualiﬁcations of the therapists will become more and more important, because there are many people with no degree in music therapy, who none the less think they can practice it.

Latin america

I wish for my country more university courses (pre- and postgraduate) in music therapy.

South East asia

Increasing diverse training and cultural backgrounds of professionals coming to work in my country.

North america

Western Paciﬁc

Need to tighten the qualiﬁcation and standards, starting within academia…re-evaluate the standards incorporated for bringing in students with diverse musical abilities and cultural experiences…assure that graduates are highly qualiﬁed both musically and clinically.

Education and training standards are not consistent, so there are huge gaps in training, knowledge, and experiences between therapists. Setting up consistent clinical and educational standards is important.

TaBLE 2. Pros and Cons of a Global Music Therapy Certiﬁcate by Region.

Theme (1,442 respondents)

Pro Theme 1: Common Standards of Clinical Practice

Region africa australia/ New Zealand Europe

Latin america

I think it would draw us together which would be very positive and informative. Great idea – bring a global standard to the profession.

It might help to unify the profession globally – consolidate or standardize music therapy practices. It will create a basic standard for practice.

North america

Some degree of standardization of education and training across borders would be beneﬁcial to the profession.

Western Paciﬁc

I think that it is desirable that there is a worldwide standard in the qualiﬁcation of music therapy.

South East asia

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Example Quotes

It is important to have an equal standard all over the world, and help music therapists to do professional works in other countries as well.

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Pro Theme 2: Professional Recognition

africa australia/ New Zealand Europe

Latin america North america South East asia Western Paciﬁc

Pro Theme 3: Global Mobility

africa australia/ New Zealand Europe Latin america

North america

South East asia

Con Theme 1: Variety of Clinical approaches

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It would need to be regulated carefully so that we don't have more "music therapists" that are actually not qualiﬁed or registered. It may enhance the proﬁle of music therapy as a profession and allow it to gain increased recognition.

I think it would be a helpful uniﬁcation for music therapies to raise awareness and support in our profession. It will make our discipline well-known globally.

I think this is very important, because if music therapy means something diﬀerent in every country, we are never going to be taken seriously as a profession. Put all therapists on the same note and increase recognition of music therapy as a profession.

a protected label "music therapist" (Diplom/ Master) with certiﬁcate is very important for acceptance, better pay and working with state health insurance.

Global music therapy would help to develop music therapy in african countries.

It would be good to have global recognition to ensure a standardized quality of practice and an ease to take our work around the world and be recognized for our training and abilities regardless of the location.

Would be useful for those wanting to travel. Could be beneﬁcial to unite MT practice globally.

It would be important for those professionals who wish to live in other countries.

This is a mobile, global world and standards that can translate will improve access for clients and freedom for therapists to relocate.

If this certiﬁcate would be recognized worldwide, I would be able to work anywhere I would love to.

Western Paciﬁc

Present as a music therapist anywhere, anytime.

australia/ New Zealand

It would be a big job to narrow down all the different frameworks and cultural influences into one certificate.

Latin america

I think it would be difficult to evaluate who is qualified to have a global certificate, considering the different clinical approaches.

africa

Europe

N/a

Potentially interesting though unclear how this would work with the number of diﬀerent approaches within the profession.

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North america

South East asia Western Paciﬁc Con Theme 2: Cultural Differences

africa

australia/ New Zealand Europe

Latin america North america South East asia Western Paciﬁc

Theme (1,442 respondents)

Theme 1: advanced Clinical Practice/ Training

144

Given the diversity in training and clinical practice, I am uncertain about what role a global music therapy certificate would play. I think it has value in understanding how music therapy functions in different countries, but would need more information on the practical application of the certificate before I would support it.

It would […] lead to increased opportunities for training, although with the diﬀerent approaches and theories, gaining consensus may be a challenge. We should respect each other to recognize customs or particular specialty of each country. We should know that it may be that any method doesn't match for other country’s people. N/a

Whilst I see the benefits of such a document, I believe it may be difficult to balance the values of different countries and cultures.

I think this could be really diﬃcult, given the vastly diﬀerent cultural contexts that music therapy is practiced in, and at what point in its development the profession is. I think it should recognize the conditions and history of music therapy in each country.

I feel that there are far too many variables spanning spiritual, cultural, self-identity, musical dimensions involved for a global MT certiﬁcate to be worth the additional expenses.

Not a priority for me and I don't think global music therapy certiﬁcation is necessary because each country has diﬀerent focus/ needs/ laws.

Because of the country specific situations, especially the difference in language and culture, a global standardization seems to be difficult.

TaBLE 3. Regional Professional Development Needs. Region

africa australia/ New Zealand Europe

Example Quotes

[…] therapeutic discussion techniques, NMT training, song writing with the aid of technology (not only live), group improv techniques. Certiﬁed training for particular frameworks of practice.

It would be nice to have 'refresher' training about certain topics and modules that we initially did on our training, albeit at a more in-depth level, especially if we are then working in that particular area of expertise.

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Latin america

Improve training intensity/time professionals specialize in each area…

South East asia

For me to develop ability doing music therapy needs a formal training. It will help me to understand more and learn diﬀerent techniques.

North america

Theme 2: Clinical approaches

Western Paciﬁc

I want the opportunity to learn knowledge and practice for each specialized ﬁeld.

australia/ New Zealand

Improvisational techniques.

africa

Europe

Latin america North america South East asia

Theme 3: Information/ Training for Specific populations

Western Paciﬁc

N/a

Development and maintenance of particular approaches (e.g. mentalization based arts therapies approach, short term therapy, interpersonal therapy). I want more information about community music therapy area.

Evidence-based approaches and current trends in and outside of our profession that relate to our work with individuals with aSD and other intellectual/developmental disabilities. N/a

Music therapy approaches used in foreign countries.

africa

N/a

Europe

opportunities for specialist training in speciﬁc domains would be welcome.

australia/ New Zealand

Latin america

Practical experience to work with diﬀerent populations.

[…] about music therapy in patients with addictions.

North america

Information about current research ﬁndings separated by populations.

Western Paciﬁc

Current eﬀective approaches of music therapy for disease – speciﬁc [populations].

South East asia

145

I would like to see training speciﬁc to certain needs (e.g. procedural support) that incorporate the theoretical frameworks of other disciplines (psychology, child life) and link these to the clinical decision-making process of music therapy.

N/a

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Theme 4: Supervision and Mentorship

africa

N/a

Europe

More peer observation, support, and supervision.

North america

online peer supervision.

Western Paciﬁc

Supervision.

australia/ New Zealand

N/a

australia/ New Zealand Latin america

Theme 5: Establish Formal Degree Programs

N/a

South East asia

N/a

africa

…degree program is oﬀered as modules with three contact blocks per year (9 days each), as well as skype lectures, self-study, and group and individual supervision of practical work (on site and on skype after viewing recordings of sessions) which makes it more accessible for students throughout the country, and also results in more mature students with life experience being able to apply.

Europe

Latin america North america South East asia

Western Paciﬁc

146

Supervision training for professionals.

International working groups (online communication platforms); Study Exchange (e.g., Erasmus program); summer schools. […] postgraduate training and recognized magister training are necessary.

[…] courses to maintain skills and awareness of new research is necessary to keep the professional abreast of current best practices. These courses should be ﬂexible in scheduling. N/a

Concrete practical introduction at workshops.

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Assertion of Music Therapists

Based on the themes and topics discovered in the three-open ended survey questions, assertions about characteristics (who we are), key standards (what we do), and aspirational values (why we are committed) of music therapists can be drawn. It should be noted that outcomes from the quantitative data set also support the assertion (Kern & Tague, 2017). Ultimately, the following three core statements might contribute to a better under-standing of the current status of music therapy worldwide and provide clues for needed actions and initiatives to overcome the existing barriers.

Who We Are ● Music therapists are educated and certiﬁed professionals, dedicated to high standards of clinical practice, and conﬁdent in providing music therapy services in an ever-expanding world of opportunity.

What We Believe ● Music therapists believe that the profession should be recognized by governments, access to services should be available to all who could beneﬁt, and adequate competitive pay should be standard.

Why We are Committed ● Music therapists are optimistic about the future of the profession, passionate about the impact of their work, and dedicated to their clients/patients.

Music therapists’ aspirational values of optimism, passion, and dedication seem to thrive in the profession. Based on their overall competence, high standards, and conﬁdence levels, music therapists are well equipped to face the identiﬁed barriers of governmental recognition, increased access, and competitive pay. The question is how to achieve the stated goals.

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Moving Forward

Moving the profession forward means that music therapy organizations and dedicated individuals need to address the three major barriers for growth of the profession: Lack of government recognition, improved access to services, and inadequate competitive pay. To achieve successful outcomes, music therapy professionals should consider eﬀective strategies related to legislative advocacy, professional advocacy, and self-advocacy. The intention of the following proposed actions is to educate, explain, and encourage music therapists to take an active role in growing the profession by adopting the content to their regional circumstances.

Legislative Advocacy addressing the first identified and defined issue, governmental recognition of music therapy in public regulations, policies, and laws, requires careful planning and systematic actions to be successful and eventually increase employer demand. The following step-by-step outline provides a basic concept for starting or continuing legislative advocacy initiatives as describe by various entities (e.g., Bolder advocacy, 2018; CBMT & aMTa, 2018; Voyles, 2016). Example initiatives and documents from music therapy organizations around the world supplement the content.

Prioritize your goals. For legislative advocacy, music therapists need to review existing regulations, policies, or laws of their country to deﬁne short-term, intermediate, and longterm goals. additionally, understanding the issues in political, social, and economic context is essential for successful advocacy. For example, the Certiﬁcation Board for Music Therapists (CBMT) and american Music Therapy association (aMTa) have prioritized licensure procedures for each of the 50 states and

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developed a “State action ToolKit” for their members (CBMT & aMTa, 2018). What needs to change to aﬀect the issue in your country?

Research the issue. advocates need to know about facts and numbers, available resources, assets, and available community support related to the status, practices, and trends of music therapy practice in their country. Preparing a summary report that addresses the problem, possible solutions, and anticipated results is a crucial step in the legislative advocacy process. For example, the worldwide music therapy survey (Kern & Tague, 2017), and country-specific report and workforce analyses (e.g., aMTa, 2018; Jack, Thompson, Hogan, Tampli, Eager, & arns, 2016; Myers, 2015; Ridder & Tsiris, 2015; Saji, okazaki, Igari, Bando, Saito, 2010) are excellent resources to obtain data-based information.

What is the current status and trends of music therapy practice in your country?

Develop a strategy. In this phase, advocates need to recruit supporters of the established goals from various fields/organizations and form a team that assigns each person a specific role based on his or her expertise, network, and possible impact. It is important to clarify scopes of practice to avoid conflicts of interests. For example, a white paper created by aMTaaus brought together interested parties to better inform, clarify and spotlight music therapy services as part of the australian National Disability Insurance Scheme (NDIS; McFerran, Tamplin, Thompson, Lee, Murphy, & Teggelove, 2016).

Who can support your endeavors in your country?

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Establish a plan of action. Before scheduling a meeting with legislative key players, it is crucial for advocates to convey a clear message with supporting materials. Speciﬁc tactics pertaining to how, when, where, and who should contact which key players needs to be discussed. For example, the CBMT and aMTa State Task Forces hold regular conference calls to discuss with all supporters the next steps of actions (D. Register, personal communication, october 18, 2018). What is the best way to meet legislative representatives in your country?

Build your base of support. Mobilizing communities and starting grassroots movements by conveying goals and the vision supports advocates in their efforts. News articles, interviews with local media, advocacy days, or social media campaigns are effective strategies to convey the message. For example, the aMTaaus (2016b) started the “RMTs Change Lives” campaign to communicate the impact of music therapy interventions for specific populations and WFMT (2018) organizes a World Music Therapy Day every March to advocate for music therapy around the globe (WFMT, 2018).

Which community-based initiative could support the identiﬁed goals and vision in your country?

Get to know people and key players. Before any meeting, advocates should inform themselves about the persons’ roles and tasks. Knowing which causes they have supported before, what they stand for, and with whom they are professionally aﬃliated also can be helpful. For example, aMTa provides links to federal and state legislators (aMTa, 2019b).

What do the people and key players stand for in your country?

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Know the process. When it is time to sponsor or co-author a bill that might become law, music therapy advocates should seek help from legislators, lobbyist, or attorneys to develop legislative language and collaborate with governmental committees. overall, legislative advocates need to be familiar with the country-speciﬁc process of creating laws. For example, the ÖBM (2008) worked with governmental representatives to develop a speciﬁc austrian music therapy labor law. What is the process to create laws in your country?

Monitor legislative action. Finally, advocates need to monitor the progress of the legislative action and be ready to testify or provide additional information while maintaining the grassroots movements. Evaluating and regrouping, or eventually celebrating successful legislative advocacy concludes the process. For example, CBMT’s (2011) Government Regulation interactive State Task Force Map monitors the recognition status of all states.

What is the status of the legal action you co-sponsored in your country?

Professional Advocacy Focusing on the second identified and defined issue, increased access to high quality music therapy services for those who could benefit from it, calls for professional advocacy initiatives. While governmental recognition is fundamental for access to music therapy services, public education is crucial for increased client demand. The following action items represent simple professional advocacy initiatives drawn from various sources (e.g., Kennedy, 2015; Kern, 2016). Examples of documents and resources from music therapy organizations around the world complement the content.

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Educate clients/patients/caregivers. as professional advocates, music therapists must support their clients, patients, or their caregivers in understanding their rights and options related to their unique circumstances; and enable them to make informed decisions and speak up for themselves to receive music therapy services. additionally, professionals should offer complete, unbiased, and clientfriendly information about the benefits of music therapy, the therapeutic process, and reimbursement options. For example, tailored to specific populations, the British association for Music Therapy (BaMT, 2017a) offers leaflets, aMTaaus (Bibb et al., 2018) a booklet, and aMTa (2019b) fact sheets. What do clients, patients, or caregivers need to know about music therapy services in your country?

Collaborate with related service providers. Professional advocates can greatly beneﬁt from establishing collaborative relationships with other experts (e.g., healthcare providers, educators, administrators, occupational ther-apist, speech-language pathologists, or physical therapists) who might open the gateway to music therapy services. Therefore, sharing similarities and diﬀerences in scope of practice as well as data-based information about the impact of music therapy interventions through in-services, webinars, conference presentations, or print materials is strongly encouraged. For example, many music therapy organizations have scope of practice documents (e.g., aMTa & CBMT, 2015; Canadian association of Music Therapy, CaMT, 2019) available and offer peerreviewed research journals (e.g., British Journal of Music Therapy, Canadian Journal of Music Therapy, Journal of Music Therapy, Music Therapy Perspectives, Music Therapy Today, Nordic Journal of Music Therapy) or

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research briefs (aMTa, 2019c; Bibb et al., 2018) that can be utilized to prepare for advocacy eﬀorts. What do related service providers need to know about music therapy practice in your country?

Develop a referral system. To improve access to music therapy services, music therapy advocates must address referral criteria and clearly outline the rationale for considering music therapy as an intervention option for specific populations. Distributing simple forms or contact lists to collaborators or being listed as a service provider at major internet sites and healthcare systems is essential. For example, various music therapy publications describe the referral process that can be used as a model (e.g, Gooding, 2016; Hanser, 1999; Schwartzberg, 2016; Waldon, 2015) and several organizations offer an online directory to search for qualified music therapists in their country (e.g, aMTa, aMTaaUs, BaMT, CBMT, ÖBM).

What do various stakeholders need to know about the music therapy referral process in your country?

Be familiar with reimbursement options. advocates must be well-informed about funding sources and processes that lead to successful compensation of music therapy services. Being informed and active in creating funding avenues (e.g., facility/hospital budget government funds, private/client pay, donations/ sponsors, insurance plans) supports clients, patients, or caregivers to ﬁnance music therapy services. For example, several reimbursement guides, private practices, or music therapy networks oﬀer advice about best practices and procedures of covering music therapy services (Simpson & Burns, 2004;

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Guy & Neve, n.d.; The George Center for Music Therapy, 2013). What do music therapists need to know about reimbursement options for services in your country?

Engage in intervention research. Professional advocates need to contribute to building the knowledge-base of the music therapy profession. Data-based informed approaches and music therapy interventions are more likely accepted, referred to, and reimbursed than those that lack scientiﬁc evidence. Given the vast amount of intervention options, it is imperative to demonstrate treatment eﬀects to various decision-makers. For example, aMTa started the Music Therapy Research 2025 initiative bringing together researchers and practitioners to improve access and quality of music therapy services (aMTa, 2015).

What do music therapists need to know about current and future music therapy treatment eﬀects?

Support training students. Professional advocates need to support educating and mentoring students to become competent practitioners, organizational leaders, and future advocates. Raising the number of music therapy students and retention eﬀorts means increasing the number of potential service providers and therefore access to music therapy services. For example, university-based degree programs and organizations invite practitioners to oﬀer guest lectures, practicum and internship opportunities, mentorship programs, and leadership opportunities (e.g., Great Lakes Region-aMTa, 2018; Kern, 2015; WFMT, 2017c).

What do music therapists need to know about supporting music therapy students?

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Self-Advocacy Pondering the third identified and defined issue, competitive pay for music therapy services, requires rigorous self-advocacy. Government recognition and access to music therapy services increase employer demand and client demand; higher demand results in higher pay. The following action items offer rudimentary ideas for self-advocacy initiatives as outlined by various authors (e.g., Knoll & Henrey, 2014; Moore, 2008; Pizzi & Guy, 2015; Silverman, Furman, Schwartzberg, Leonard, Stephens, & McKee, 2013; The Career Development Center, 2016; Thomas & abad, 2017). Example resources from organizations and businesses around the world enrich the content.

Research potential demands. advocates negotiating competitive pay need to determine the demand of music therapy services and potential competition in their geographical region. Estimated caseloads, potential market growth, and how music therapy services could improve prospective employers’ business goals are vital for successful negotiations. For example, reviewing the incident rates of the targeted population (e.g., WHo, 2017a, b, c) and corresponding workforce and trend analysis in the geographical region resources (e.g., Jack, Thompson, Hogan, Tampli, Eager, & arns, 2016; Kern & Tague, 2017; Myers, 2015; Ridder & Tsiris, 2015; Saji, okazaki, Igari, Bando, Saito, 2010) as well as the employers’ mission and vision can be useful. What is the demand for your service in your geographical region?

Communicate your value. Music therapy selfadvocates need to be able to articulate the value of their services and time. Educating employers about the impact of music therapy interventions and what is involved in

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providing services is central to payment discussions. Emphasizing experiences and accomplishments, individualization of services, and ﬂexibility in adjusting to employers’ needs add value as well. For example, providing research briefs (e.g., aMTa, 2019b; Bibb et al., 2018), case examples (e.g., aMTaaus, 2016; BaMT, 2017b), and a resumé can be used to prepare for meetings. Why are you worth the investment?

Calculate realistic payment. advocating for competitive payment requires that music therapists consider benchmark rates and salary ranges for music therapy and related services in their geographical region when calculating a desired income. For successful negotiations with potential employers, costeﬀective analyses should be quoted, and realistic fee structures presented. For example, cost-effectiveness studies for medical procedures (Chlan, Heiderscheit, Skaar, & Neidecker, 2018; Walworth, 2005), salary structures and comparisons (Silverman, Furman, Schwartzberg, Leonard, Stephens, & McKee, 2013; The Career Development Center, 2016), and various online resources (GlassDoor.com; salary.com) are available for preparing realistic payment proposals.

How will you help an employer save or make money?

Achieve your financial goals. When advocating for competitive pay, music therapy selfadvocates might not always be immediately successful in achieving their financial goal. asking for benefits in lieu of a higher salary or requesting a performance review for potential additional compensation in the following year might be alternate ways to approach the set financial goal. For example, asking for health insurance, retirement funds, life insu-

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rance, an annual bonus, or a professional development budget adds monetary value (e.g., The Career Development Center, 2016). The poster displayed in Figure 2 summarizes the research questions, spotlights world regions, notes the assertions of music therapists, considers the barriers, and suggests actions. What annual income would you like to have?

Conclusion

although music therapy is an established profession in many regions of the world, it remains a relatively small profession of welltrained individuals who are passionate about

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the impact of their work and dedicated to providing high-quality services to their clients/ patients. Mutual barriers for growth are lack of governmental recognition, limited access to services, and inadequate competitive pay. Suggested legislative, professional, and self-advocacy initiatives that are already implemented in a few countries might support the growth of the profession globally. However, it will take a collective vision of music therapy organizations and dynamic individuals to move the profession forward into a positive and sustainable future direction. In the words of a survey respondent, â&#x20AC;&#x153;We have dedicated people pulling everything together and, with a lot of eďŹ&#x20AC;ort, I believe we will end up in a good place.â&#x20AC;?

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References

american Music Therapy association. (2019a). Descriptive Statistical Profiles. Retrieved from https://www.musictherapy.org/ members/jobcenter/resources/ american Music Therapy association. (2019b). Find my legislators. Retrieved from https: / / w w w. m u s i c t h e ra p y. o r g / p o l i c y / findlegislators/ american Music Therapy association. (2019c). Music therapy with specific populations: Fact sheets, resources and bibliographies. Retrieved from https://www.musictherapy.org/research/factsheets/ american Music Therapy association. (2018d). 2018 AMTA member survey and workforce analysis: a descriptive statistical profile of the aMTa membership and music therapy community. Silver Spring, MD: author. american Music Therapy association & Certification Board for Music Therapists. (2015). Scope of Music Therapy Practice. Retrieved from http://www.musictherapy. org/about/scope_of_music_therapy_prac tice/ american Music Therapy association. (2015). Improving access and quality: Music therapy executive summary and conclusions. Retrieved from https://www.musictherapy. org/music_therapy_research_2025_ summary/ australian Music Therapy association. (2018). About us. Retrieved from https:// www.austmta.org.au/content/about-us australian Music Therapy association. (2016a). My profession, my voice: Results of the Australian Music Therapy Association’s 2016 workforce census. Melbourne, australia: author. australian Music Therapy association. (2016b). RMTs Change Lives… Retrieved from http: //www.rmtschangelives.com.au Bibb, J., Bower, J., Murphy, M., Baker, F. a.,

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Hogan, B., abad, V., Eager, R. Butcher, K., & Tamplin, J. (2018). Music therapy in disability: Information booklet. Melbourne, australia: australian Music Therapy association. British association for Music Therapy. (2017a). BAMT information leaflets. Retrieved from https://www.bamt.org/british-association-for-music-therapy-resources/bamtinformation-leaflets.html British association for Music Therapy. (2017b). Music therapy on video. Retrieved from https://www.bamt.org/british-association-for-music-therapy-resources/musictherapy-on-video.html Bolder advocacy. (2018). Advocacy Capacity Tool (ACT!). Retrieved from www.bolderadvocacy.org Canadian association of Music Therapy. (2019). About music therapy. Retrieved from https: / / w w w . m u s i c t h e r a p y. c a / a b o u t -camt-music-therapy/about-music-therapy/ Certification Board for Music Therapists. (2011). State Task Force Map. Retrieved from http://www.cbmt.org/advocacy/ state-task-forces-map/ Certification Board for Music Therapists & american Music Therapy association. (2018). Music Therapy Advocacy. State Action ToolKit. Retrieved from http:// www.musictherapy.org/assets/1/18/aMT a_CBMT_advocacy_Toolkit.pdf Chan, l. l., Heiderscheit, a., Skaar, D. J., & Neidecker, M. V. (2018). Economic evaluation of a patient-directed music intervention for ICU patients receiving mechanical ventilator support. Critical Care Medicine. 2018, May 4 [Epub ahead of print]. Retrieved from https://www.ncbi.nlm.nih.gov/ pubmed/29727366 Gooding, L. (2016). Music therapy: an overview of the therapeutic process. imagine 7(1), 30-35. Great Lakes Region-american Music Therapy

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association. (2018). GLR-AMTA Mentorship Program. Retrieved from http:// www.glr-amta.org/about-glr/glr-amtamentoring-program/ Guy, J. & Neve, a. (n.d.). Additional funding sources. Retrieved from http://www.themusictherapycenter.com/wp-content /uploads/2016/07/funding.pdf Hanser, S. B. (1999). The new music therapist’s handbook (2nd ed.). Boston, Ma: Berklee Press. Jack, N., Thompson, G., Hogan, B., Tamplin, J., Eager, R., & arns, B. (2016). My profession, my voice: Results of the Australian Music Therapy Association’s 2016 workforce census. Melbourne: australian association of Music Therapy. Kandé-Staehelin, B. (2015). Switzerland: Country report on professional recognition of music therapy. In H. M. Ridder & G. Tsiris (Eds.), Approaches 7(1), Special Issue, 185-186. Retrieved from http: //approaches.gr/special-issue-7-1-2015/ Kennedy, R. (2015). Music therapy in the 21st century: an interview with Dr. Petra Kern. Music Therapy Today, 11(1), 142-149. Kern, P. (2016). Early childhood music therapy advocacy: Demonstrating our passion for young children and their families. [Editorial]. imagine, 7(1), 5-4. Kern, P. (2015). organizational leadership development: Investing in students. Music Therapy Today, 11(2), 95-104. Kern, P., & Tague, D. (2017). Music therapy practice status and trends worldwide: an international survey study. Journal of Music Therapy, 54(3), 255-286. doi: 10.1093/jmt/thx011 Knoll, C., & Henry, D. (2014). You’re the boss! Self-employment strategies for music therapists. Stephenville, TX: MusicWorksPublication.com. McFerran, K. S., Tamplin, J., Thompson, G., Lee, J., Murphy, M., & Teggelove, K.

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(2016). Music therapy and the NDIS: Understanding music therapy as a reasonable and necessary support service for people with disabilities [White Paper]. Retrieved from https://www.austmta.org.au /content/ndis-white-paper Myers, K. (2105). Current status of music therapy in africa. Music Therapy Today, 11(1), 50-59. Moore, K. S. (2008). The therapy business blueprint: A 7-step approach to starting your own private practice. available at http://www.musictherapyebooks.com/pr oduct/therapy-business-blueprint/ Österreichischer Berufsverband der Musiktherapeutinnen. (2008). Bundesgesetzblatt fure die Republik Österreich [Federal Law Record for austria]. Retrieved from https://www.oebm.org/ﬁles/musiktherapiegesetz.pdf Pizzi, M., & Guy, J. (Eds.) (2015). Leading the way – music therapy business of the future: A workbook. Silver Springs, MD: american Music Therapy association. Ridder, H.-M., & Tsiris, G. (Eds.) (2015). Music therapy in Europe: Path of professional development. Approaches 7(1), Special Issue. Retrieved from http://approaches. gr/special-issue-7-1-2015/ Saji, N., okazaki, K., Igari, y., Bando, H., & Saito, T. (2010). Report on asian music therapy symposium 2009 Tokyo. Tokyo: Japanese Music Therapy Association Schwartzberg, E. T. (2016). Music therapy for children with autism spectrum disorder: developing sustaining professional relationships with pediatricians. imagine 7(1), 93-95. Silverman, M. J., Furman, a. G., Schwartzberg, E. T., Leonard, J., Stephens, E., & McKee, R. (2013). Music therapy salaries from 1998-2012: a comparative and descriptive study. Music Therapy Perspectives, 31(4), 181-188.

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Simpson, J., & Burns, D. S. (2004). Music therapy reimbursement: Best practices and procedures. Silver Spring, MD: american Music Therapy association. The Career Development Center. (2016). Music careers in dollars and cents. Boston, Ma: Berklee College of Music. The George Center for Music Therapy. (2013). The ultimate guide to paying for therapy in Georgia. Roswell, Ga: author. Thomas, D., & abad, V. (2017). The economics of therapy. London and Philadelphia: Jessica Kingsley Publishers. United Nations. (2017). World population prospects: The 2017 revision. Retrieved from https://www.un.org/development/ desa/publications/world-population -prospects-the-2017-revision.html Voyles, K. (2016). 9 steps to advocacy planning. Retrieved from http://www.communityaction.org/9-steps-advocacy-planning/ Walworth, D. (2005). Procedural-support music therapy in the healthcare setting: a cost-eﬀectiveness analysis. Journal of Pediatric Nursing, 20(4), 276-284. Waldon, E. G. (2016). Clinical documentation in music therapy: Standards, guidelines, and laws. Music Therapy Perspectives 34(1), 57–63. doi.org/10.1093/mtp/miv040 World Federation of Music Therapy. (2018). World Music Therapy Day. Retrieved from

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https://www.wfmt.info/world-music-therapy-day-approaches/ World Federation of Music Therapy. (2017a). Regional Liaisons’ Blog. Retrieved from https://www.wfmt.info/leadership/regional-liaisons-blog/ World Federation of Music Therapy. (2017b). Commission: Accreditation & Certification. Retrieved form https://www.wfmt. info/commission-accreditation-certification-2017-2020/ World Federation of Music Therapy. (2017c). WFMT for Students. Retrieved from https://www.wfmt.info/wfmt-for-students-2017-2020/ World Health organization. (2017a). Meeting report: Autism spectrum disorder and other developmental disorders: From raising awareness to building capacity. Geneva, Switzerland: author. Retrieved from http://apps.who.int/iris/bitstream/10665/ 103312/1/9789241506618_eng.pdf World Health organization. (2017b). Depression and other common mental disorders: Global health estimates. Retrieved from http://apps.who.int/iris/bitstream/ handle/10665/254610/WHo-MSD-MER2017.2-eng.pdf World Health organization. (2017c). Dementia. Retrieved from http://www.who.int/ news-room/fact-sheets/detail/dementia

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About the Author

Petra Kern Petra Kern, Ph.D., MT-BC, MTa, DMtG is the owner of Music Therapy Consulting, professor at the University of Louisville and editor-in-chief of imagine. She is a former President of WFMT and currently serves on CBMTâ&#x20AC;&#x2122;s Board of Directors.

About the Author

Dr. Daniel Tague Dr. Daniel Tague, MT-BC, is Chair and assistant Professor of Music Therapy at Southern Methodist University. He is the current Chair of the Clinical Practice Commission of the WFMT.

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Book Reviews

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Adolescents with autism spectrum disorder: A clinical handbook Edited by Nicholas W. Gelbar

Oxford University Press, Oxford, United Kingdom (337 pages) Reviewer: Lindsay Markworth, MMT, MT-BC

Minneapolis, Minnesota, United States

Adolescence is a transitional stage of development involving many challenges for people of all abilities. Individuals with autism may experience additional challenges due to needs in areas such as social skills, executive functioning, communication, and emotional expression. In addition, many individuals with autism experience co-occurring mental health disorders, which are often under-diagnosed and not properly supported. While there is a large body of literature investigating therapies, supports, and needs of individuals with autism, most of this research is focused on children. Therefore, this book is a thorough and valuable resource for practitioners working specifically with adolescents and young adults with autism. This resource outlines the unique needs of adolescents with autism, evidence-based therapy practices, information about transition programs within the education system, and highlights areas for future research. While written by psychologists and special educators, this text is a valuable resource for music therapists working with adolescents and young adults with autism as a resource for understanding the unique needs of this population, and frameworks for supporting development through goal-based work.

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PART I: Diagnosis and Treatment of Adolescents with Autism Spectrum Disorder

Chapter 1: The Challenge of Entering Adulthood for Individuals with Autism Spectrum Disorder By Nicholas W. Gelbar and Daniel T. Volk Chapter 1 provides an overview of autism as a diagnosis, prevalence, and research trends while highlighting the unique challenges of individuals with autism who are moving through these transitional stages of development into adulthood.

There are two stages predating adulthood: adolescence and emerging adulthood. This period of development presents many challenges for all individuals, as it is a transitional time when young people are exploring options for careers and relationships. Individuals with autism are twice as likely to have a cooccurring mental health diagnosis than their neurotypical peers. Adolescents with autism also report an experience of loneliness due to challenges establishing and maintaining social relationships. Another challenge within this demographic is low employment rates

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and completion of post-secondary education compared to neurotypical peers. In addition, young adults with autism may not able to live independently, often requiring supports for daily living skills into adulthood.

Chapter 2: Efficacious Treatments for Common Psychiatric Challenges in Adolescents with Autism Spectrum Disorder By Lisa A. Nowinski, Alyssa Milot, Alanna Gold, and Christopher J. McDougle

Chapter 2 provides a thorough overview of the most common, co-occurring psychiatric disorders with autism, and the most effective pharmacological and therapy treatment options for each category of diagnoses. Included in this chapter were, mood disorders (Major Depressive Disorder, Persistent Depressive Disorder, and Disruptive Mood Dysregulation Disorder), Anxiety Disorders (Generalized Anxiety Disorder, Social Anxiety Disorder, phobias, and obsessive Compulsive Disorder), and Attention-Deficit/Hyperactivity Disorder. The chapter also looks into common psychiatric challenges of adolescents with autism including disruptive behavior, sleep difficulties, sexuality, gender identity, adaptive and vocational skills.

Common themes within this chapter are the challenges of identifying and treating individuals with co-occurring mental health diagnosis and autism. Many of the symptoms of these mental health disorders could also be related to an individualâ&#x20AC;&#x2122;s autism diagnosis. In addition, many of the diagnostic tools rely on self-report measures, which can present challenges for individuals with autism who may have limited verbal communication skills, or who struggle with identifying, expressing emotions, as well as social and communication deficits commonly experienced by individuals with autism may exasperate the

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symptoms of anxiety. For example, some individuals with autism may develop social anxiety because they are aware of their social deficits and develop anxiety within certain social contexts.

The chapter provides literature supporting pharmacological treatments and therapy treatments for each category of co-occurring mental health diagnoses for individuals with autism. A common theme was the need for more research to specifically understand the effectiveness and potential risks for pharmacological treatments. It is especially important to be aware of the potential risks and side effects for individuals with autism who may have a limited ability to communicate negative side effects of these drugs. Recommendations for therapy treatments included adapted Cognitive Behavior Therapy and Applied Behavior Analysis. Chapter 3: Executive Functions in Adolescents with Autism Spectrum Disorder By Yael Dai and Inge-Marie Eigsti

Chapter 3 explores executive functions and how deficits in this domain impact the lives adolescents with autism. Adolescence is a time of rapid development in the regions of the brain that support executive functioning; therefore, it is especially important to consider how these areas can be supported during this critical time. Current research suggests that children and adolescents with autism demonstrate limitations in executive functioning across five domains. The deficits were most consistently found when the assessment involved arbitrary rules, or complex information out of routine.

It is important to be mindful of potential deficits in executive functioning when working with adolescents with autism because

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these skills are essential for independence with daily living skills and the ability to be successful in educational and vocational settings, and should be prioritized during adolescents and young adulthood.

Chapter 4: Anxiety in Adolescents and Adults with Autism Spectrum Disorder By Micah O. Mazurek

Chapter 4 focuses on autism and anxiety disorders. Anxiety can impact the ability of individuals with autism to function effectively and can negatively impact quality of life; however, it often goes undiagnosed and untreated separately from the autism diagnosis. Anxiety can manifest as internal or external symptoms. Individuals with co-occurring autism and anxiety present with these symptoms as well as atypical symptoms such as anxiety related to sensory experiences, changes in routine, or fears related to restricted patterns of behavior. Some studies suggest anxiety is a result of stress related to challenges with employment, ability to live independently, and maintain relationships. It was also suggested that not only deficits in social functioning, but awareness of these deficits may cause increased anxiety. Individuals with autism often have difficulty expressing emotions, which may lead to an increased experience of anxiety and distress internally. Assessment of anxiety in adolescents and adults can be challenge because there is often an overlap in symptoms of these diagnoses. In addition, while there are assessments available for evaluating anxiety in children with autism, there are no assessments available for adults with autism. This is a critical area where additional research is needed in order to better discern whether symptoms are related to autism or anxiety. It is recommended that assessments of anxiety

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in adults begin with an interview including checklists and direct questions about the experience of anxiety.

Available treatment for co-occurring anxiety and autism includes psychopharmacological and cognitive behavioral treatment. There is limited evidence supporting the use of SSRIs with individuals with autism. Coupled with the risk for side effects, the available psychopharmacological treatments are not recommended for treating anxiety in people with autism. Instead, Cognitive-behavioral therapies are considered recommended treatments for anxiety disorders. There is evidence supporting the use of Cognitive-behavior therapy interventions with children and adolescents with autism, and a few studies supporting these strategies for adults with autism. The predictability, structure, and repetition of traditional cognitive-behavioral approaches have been reportedly helpful for individuals with autism and anxiety. However, some adaptations have been suggested including: caregiver involvement, visual supports, and executive functioning supports. In addition, additional CBT interventions have been developed to address social skill training. Some other adaptations include a focus on the clientâ&#x20AC;&#x2122;s specific interests, and incorporating technology into treatment. Chapter 5: Cognitive Behavioral Approaches for Treating Adolescents with Autism Spectrum Disorder By Caitlin M. Conner, Lindsey Devries, and Judy Reaven

Chapter 5 builds upon recommendations of therapeutic intervention for individuals with co-occurring anxiety and autism. Cognitive Behavior Therapy (CBT) is built on the premise that thoughts impact feelings and behaviors. Research supports the use of CBT to address

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a wide array of mental health issues and diagnoses, utilizing a structured approach. The brief nature of CBT is focused on helping clients better understand their diagnosis, develop coping and problem solving skills, and address negative and maladaptive thoughts

The chapter explores how modifications can be made to traditional CBT in order to support the needs of adolescents with autism and co-occurring mental health conditions. This can include utilizing visual tools and parent engagement in sessions. Social skills instruction has also been included in CBT when working with this population. These interventions have been used to help clients practice and develop social and communication skills, learn how to develop friendships, and to identify and name their emotions

CBT is recommended for clients who have some verbal and literacy skills. There is also a higher success rate when clients have positive relationships with parents or caregivers who can support progress in therapy. This therapy is especially effective when clients have motivation or desire to change. When met with resistance, the it is recommended the CBT therapist take additional time to establish rapport and highlight the clientâ&#x20AC;&#x2122;s strengths and special interests. PART II: Supporting the Educational Needs of Adolescents with Autism Spectrum Disorder

Chapter 6: Self-Determination and the Transition to Adulthood for youth and young Adults with an Autism Spectrum Disorder. By Michael L. Wehmeyer and Karrie Shogren Chapter 6 outlines theories, methods and assessment tools for promoting self-determina-

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tion and student involvement in their process of transitioning out of the school setting into adulthood. Self-determination is essential for developing independence into adulthood, and ability to find and maintain work and relationships

The Self-Determination Theory (SDT) suggests competence, autonomy and relatedness are three basic needs that are either met or areas of deficit impacting intrinsic motivation and healthy psychological development. Causal agency theory builds upon SDT to explore actions and beliefs required for individuals to be self-determined.

Research has shown that adolescents with autism are less self-determined than typically developing adolescents. A meta-analysis of studies found strong evidence that adolescents with autism are able to learn skills and behaviors to increase self-determination. The positive outcomes associated with increased self-determination include enhanced academic achievement, positive employment and independent community living, higher rate of goal attainment, and more positive quality of life.

There are several evidence-based methods to support development of self-determination. The Self-Determined Learning Model of Instruction (SDLMI), Self-Directed IEP (SDIEP), and Whose Future Is It Anyway (WFA). Research has suggested that interventions strengthening areas such as problem-solving, self-regulation, self-advocacy and awareness result in greater self-determination.

Students with autism scored the lowest for self-determination among three groups assessed including individuals with learning disabilities and intellectual disabilities. Further research suggests this may be due to the so-

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cial context of self-determination. Deficits in social and communication skills may present challenges in expressing preferences, needs and goals. There is a need for further research on individuals with autism and self-determination in order to better understand the benefits of promoting self-determination.

Chapter 7: Supporting Strong Transitions for Adolescents with Autism Spectrum Disorder By Erik Carter

Chapter 7 reviews recommended transition services for adolescents and young adults with autism, and how these supports may help to increase independence and employment outcomes. The Individuals with Disabilities Education Improvement Act which was enacted in 2004 and emphasizes the importance of providing educational and extracurricular experiences to promote independence with skills required for individuals with disabilities to thrive in adulthood.

Evidence-based practice consistently emphasizes the importance of the following components to transition services: strengths and interests-based supports, collaboration within treatment team, family involvement, and a focus on fostering self-determination.

The author defines best practices for transition services as including 1) transition assessment, 2) transition planning, 3) rigorous instruction, 4) relevant educational experience, 5) relationship formation, 6) linkages and partnerships, and 7) program evaluation (p. 174). The transition assessment involves obtaining information about a studentâ&#x20AC;&#x2122;s areas of interest, strengths and needs in relation to vocation and independent living. It is important to foster individual interests to engage the student in becoming self-motivated to achieve goals for learning, daily living and employment.

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Transition plan then becomes the road map for how the students can achieve their postsecondary goals. These goals are derived from the transition assessment, and are measurable. It is important that the transition services in the studentâ&#x20AC;&#x2122;s Individualized Education Plan are directly related to these postsecondary goals. It is also recommended that the student, parents and any other key service providers be invited to actively engage in creating the transition plan.

In addition to having a thorough transition assessment and plan, there are several other factors that can support positive transition outcomes. Research has shown that individuals with autism who work during adolescence are more likely to be employed as adults. Exposure to a variety of extra-curricular and community activities during adolescence can also support the development of a myriad of skills while helping the student to identify specific areas of interest. It is also essential for adolescents with autism to focus on building social skills and fostering relationships in order to prepare for work environments and cultivate a social network into adulthood. Building relationships between individuals with autism and community programs and support networks is also very important as the educational and vocational services provided by the school system come to a close. It is important for graduates and families to understand where to go to seek out continued services and supports.

overall, it is recommended that practitioners hold high standards of expectation for students with autism, seek out the most current evidence-based strategies, and use a data-driven approach to determining the efficacy of the transition services provided.

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Chapter 8: Employment Training for young Adults with Autism Spectrum Disorder By David test, Debra Holzberg, Kelly Clark, Misty Terrell, and Dana Rusher Chapter 8 reiterates the unfortunate statistics showing that individuals with autism consistently demonstrate lower post-school outcomes than their typically-developing peers. These results show that individuals with autism are employed at lower rates, with lower pay, fewer hours and with less engagement in their communities.

IDEA requires that transition planning begin at 16 years of age or earlier to ensure effective strategies are integrated into the students IEP for successful transition into adulthood. From this age, the IEP must have goals focused on the areas of 1) training, 2) education 3) employment and 4) independent living skills (when appropriate).

There are some clear factors influencing the successful employment of individuals with autism. High school graduates who demonstrated strong social skills, received career counseling, and attended schools with a relationship between the high school and postsecondary vocational training programs all positively impacted the post-secondary employment statistics.

In order to promote employment outcomes for young adults with autism, practitioners must conduct a transition assessment in the form of checklists, ecological assessments, and person-centered planning in order to determine meaningful post-secondary goals. The information obtained through the assessment process must be integrated into the students Individualized Education Plan in the form of measurable goals and objectives. The transition team must also articulate evi-

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dence-based services and interventions to support the studentâ&#x20AC;&#x2122;s ability to achieve their goals and objectives.

Chapter 9: Teaching Skills to Adolescents Using Applied Behavior Analysis By John Molteni

Chapter 9 explores how the principles of Applied Behavior Analysis (ABA) can be used to strengthen functional skills and promote independence for adolescents with autism. ABA is an evidence-based practice that can be used to teach a variety of skills throughout the lifespan. The focus of ABA is creating an effective environment for learning isolated skills with an emphasis on using data to intentionally structure the antecedents and postcedents to teach skills and shape behaviors.

For adolescents with autism, programs for ABA begin with an ecological assessment to gather information about the skills the student will need in their educational or work environments. The assessment process illuminates specific skill areas that the student needs to develop in order to be successful in each environment. The data derived from the assessments are translated into measurable goal areas, which are then broken down by a task analysis process, breaking down all of the relevant components of each skill area.

It is essential to have a reliable and valid system for measuring progress within an ABA program. In addition, it is important to assess the studentâ&#x20AC;&#x2122;s interest in reinforcement used during the ABA instruction, and which reinforcements are best paired with each environment or skill area.

There are several factors to consider with implementing an ABA program with adolescents

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with autism. The environment where the skill will be required must be considered when creating programs to integrate sensory conditions, natural antecedents/postcedents, and variations of stimuli. Chapter 10: Managing Challenging Behavior in Adolescents with Autism Spectrum Disorder By Maya Matheis, Jasper Estabillo, and Johnny Matson Chapter 10 explores challenging behaviors and outlines strategies to support adolescents with autism who have significant behavioral challenges. Some examples of challenging behavior include aggression, selfinjurious behavior (SIB), stereotypical behavior, pica and vomiting/rumination. It is clear how aggression or SIB may cause physical harm to a person with autism, or their caregivers, however, the author points out how stereotypical behaviors (in addition to aggression or SIBs) may result in exclusion from events in the community. The author provides strategies for the person with autism to decrease these behaviors; however, nothing is mentioned about the importance of advocacy for neuro-diversity, changing communities by promoting awareness and acceptance of neuro-differences, related to stereotypical behaviors.

Functional Behavior Assessments are an essential process of gaining understanding of the context and function of a behavior to inform intervention and treatment. Interventions with a focus on the function of a behavior have been more effective in shaping behaviors than interventions focused only on the behavior itself. By understanding the function of a behavior, it becomes possible to identify and teach a more socially appropriate

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behavior in its place. For example, increasing communicating skills so that a person can say â&#x20AC;&#x153;all doneâ&#x20AC;? instead of having an aggressive behavior when they need a break.

Several behavioral treatment methods are described within this chapter. Extinction of a behavior is when the reinforcement of the challenging behavior is removed from the environment in order to eliminate the challenging behavior. Differential Reinforcement involves two-part focus on 1) extinction of a challenging behavior, and 2) reinforcement of an alternative behavior. Differential Reinforcement of Incompatible Behavior (DRIB) and Differential Reinforcement of Alternative Behavior (DRAB) are focused on reinforcement of behaviors outside of the challenging behavior, to increase rates of acceptable behaviors, promote adaptive functioning and learning of skills. Differential Reinforcement of other Behavior is using reinforcement when the challenging behavior has not occurred. Differential Reinforcement of Low Rates is used to increase the length of time of appropriate behaviors (shortening the duration of challenging behaviors). Functional Communication Training is a form of DRAB and focuses on reinforcing the use of communication as the target alternative behavior. Restraints are sometimes used by practitioners to keep a client safe from harming others or selfharming. It is recommended restraints (holds or mechanical devices) only be used after all other methods have been exhausted and when done so by a trained professional. Medication is another method that has been used with significantly challenging behaviors as a method to limit a clientâ&#x20AC;&#x2122;s movement; however, there is limited evidence supporting this method when addressing challenging behaviors. The author outlines some important ethical considerations to keep in mind when navigat-

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ing challenging behaviors with individuals with autism. It is essential to consider the level of risk, both physically and psychologically these treatment methods my pose for individuals with autism. other considerations include the individual’s right to provide permission for behavior management, protection of the client’s dignity, and use of the least restrictive methods—especially when using physical restraints, medications and environmental modifications. PART III: Special Populations of Adolescents with Autism Spectrum Disorder

Chapter 11: Supporting College Students with Autism Spectrum Disorder By Nicholas Gelbar

Chapter 11 highlights the unique challenges for young adults with autism who are pursuing a 2 or 4-year college degree, and the supports available for these students. It is important to note that once students enter the post-secondary education system, supports are no longer mandated through IDEA. Instead, college students are covered through The Rehabilitation Act of 1973. This act requires postsecondary institutions to provide necessary accommodations for individuals with disabilities; for example, having more time to take exams and accessibility of classroom locations. Students may also receive minor accommodations to their degree curriculum, including waiving some courses when not essential for the student’s major focus of study.

A primary difference between these two laws is the responsibility for seeking out accommodations and supports rests with the students rather than the institution. Another difference is students may also be responsible for paying for additional services not typically covered

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through the college or university. For example, some institutions offer free counseling services to all students while others go through the student’s health insurance or charge out of pocket fees. It is not mandated, through the Rehabilitation Act, for post-secondary institutions to pay for accommodations and supports for students with disabilities like it is within IDEA for K-12 education.

The privacy of students in post-secondary education settings is protected by Family Education Rights and Privacy Act (FERPA) (1974). Educators are not able to disclose information to any individual over the age of 18, including to parents/guardians, unless given permission by the student.

The experiences of individuals with Autism in post-secondary educational settings vary greatly. There is little research on this age group, as much of the research is focused on autism in children. It is common for individuals with autism to struggle with executive functions including problem solving and time management. Many case studies revealed that it was common for individuals with autism to experience feelings of loneliness, depression and anxiety while working on postsecondary education.

Further research suggested that many individuals with autism wish they had more support with the process of disclosing their disability, and to learn self-advocacy skills before they got to college. Additional challenges reported include, difficulty with adapting to changes in environment (course cancellations) and the dramatic increase in independence (academic demands and managing assignments across courses). It was also noted that group work could be especially challenging for students with autism, often causing anxiety. Although students with autism face a range of addi-

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tional challenges in a post-secondary educational setting, they also face the same challenges as their neuro-typical peers during this significant transition into a more independent learning environment.

Chapter 12: young Women on the Autism Spectrum By Meng-Chuan lai, Stephanie Ameis, and peter Szatmari Chapter 12 questions the accuracy of diagnosing females with autism, and explores unique challenges experienced by these young women. There seems to be a trent of under-recognizing autism in females, and is predominately diagnosed in males with a male-female rational of 4-5:1. There is emerging evidence that these statistics may not be entirely accurate suggesting a male-female ration of 3:1.

There are some differences in abilities between male and females with autism. The presentation of social-communication deficits can be less obvious in females. Females can have lower scores in imaginative play, and preoccupations or rigid interests, higher ranges of expressive affect, drawing and self-injurious behaviors. It was also discovered that females with autism are better able to compensate for their social deficits to blend in with peers. In addition, narrow interests are more likely to include topics on people and animals rather than obscure objects and things.

Some challenges uniquely faced by women with autism include: exhaustion due to constant camouflaging of social deficits within social contexts, sensory-environmental challenges, and co-occurring mental health challenges. This chapter also notes increased rates of nonbinary gender and non-heterosexual orientation in girls and women with autism.

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Chapter 13: Conclusion By Nicholas Gelbar In chapter 13, Nicholas Gelbar provides a conclusion to the book by highlighting two commonly occurring themes: 1) the autism diagnosis is widely heterogeneous and 2) tools for supporting adolescents with autism exist but additional research is needed. The wide variety of symptoms and developmental skills of individuals with autism presents many challenges when conducting research and applying evidence-based concepts within clinical practice. When conducting research with individuals with autism, it is important to articulate a clear definition of the participants. It is also important to note adaptations for treatment modalities to accommodate the great variety of needs and abilities existing with individuals with autism.

overall, Adolescents with Autism Spectrum Disorder: A clinical handbook provides a thorough and important overview of the unique needs of adolescents and young adults with autism. Each chapter is sequenced to first introduce concepts and then provide in-depth information on these topics through a review of current research and evidence-based practices. Although music therapy is not mentioned in this text, it is essential for music therapists to be knowledgeable of the unique needs and evidence-based treatment strategies for adolescents with autism to inform goal-directed practice. The final message in the conclusion of this book focuses on a need for further research on adolescents with autism. In addition to further research on adaptations to the behavioral strategies described in this text, there is a need for research on the efficacy of music therapy and other relationship-based, humanistic treatments to support the specific and unique needs of adolescents with autism.

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About the Author

Lindsay Markworth is a board-certified music therapist and founder of Twin Cities Music Therapy Services, LLC in Minneapolis, MN. She specializes in working with individuals with autism through a relationship-based, music-centered approach. She has a Bachelor’s degree in Music Therapy from Augsburg University and a Master of Music Therapy degree from Temple University. Lindsay is a Nordoff-Robbins Music Therapist, completing training at the NordoffRobbins Center at New york University. She teaches clinical improvisation at Augsburg University and supervises the clinical training of practicum students and interns through her private practice.

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Addendum

Sato, K. & Sonoyama, S. (2018). Implementing a song as a reward for transition from free-play time to a group activity. Music Therapy, 14(1), 37-51. Sato and Sonoyama published the above referenced article in the 2018 issue of Music Therapy Today. The authors did not reference the following article in their review: Sato, K., & Sonoyama, S., (2017). A behavioural study exploring the use of originally composed songs to encourage children at a Japanese day treatment facility to transition between activities. New Zealand Journal of Music Therapy, 15, 95-116. Retrieved from https://www.musictherapy.org.nz/journal/2 017-2

They extend their apologies for this oversight and want to ensure that this is noted in the journal.

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